Sample Case Study

METROPOLITAN HOSPITAL COLLEGE OF NURSING
# 1357 Masangkay cor. Mayhaligue Sta. Cruz Manila
TABLE OF CONTENTS
INTRODUCTION
SCOPE AND LIMITATION
I. REVIEW OF ANATOMY AND PHYSIOLOGY OF AFFECTED ORGANS
II. PATHOPHYSIOLOGY
III. ASSESSMENT
1. Personal Data
2. Family Background
a. Demographic Data
3. Health History
a. Family Health History
b. Past Health History
c. Present Health History
d. OB History
4. Developmental Data
a. Erik Erickson
b. Robert Havighurst
5. Patterns of Functioning
6. Levels of Competencies
7. Review of Systems
8. Physical Exam
9. On-going Appraisal
10. Laboratory Works
11. Diagnostic Procedures
IV. MEDICAL MANAGEMENT

a. Treatment
b. Drug Study
V. NURSING CARE PLAN
VI. DISCHARGE PLAN

INTRODUCTION
Hernias. Most people have heard of them, but few know exactly what they are, how to
detect them or how to treat them
An estimated 5 million Americans develop hernias each year, according to the National
Center for Health Statistics. A hernia is an organ or tissue – often a segment of intestine –
protruding through a weakness in the abdominal wall. These protrusions are similar to an
inflated inner tube bulging through a worn-out bicycle tire. Hernias are not necessarily
hereditary, but a family history of weak abdominal wall will make people more likely to
develop hernias. Activities that can cause or aggravate hernias include coughing, heavy lifting,
straining during bowel movement, prior surgery/incisions and, for overweight people,
everyday activities that add strain to abdominal walls. There is no sure-fire way to prevent
hernias, but you can lower the risk through healthy eating, not smoking, exercising regularly,
and using proper lifting techniques.
Hernias can be detected by both sight and touch. Many people who have a hernia will
notice a lump in their groin or abdomen, and hernia sufferers often develop dull aches that
become more acute when they are active, coughing or lifting heavy objects. Hernias in the groin
are are more common in men but can also occur in women. Once a hernia has developed,
surgical treatment is usually necessary to repair it. The hernia will not get better on its own;
rather, as more tissue or more of the organ push through the abdominal wall, the size of the
hernia will usually increase. Some selected asymptomatic hernias can be treated non-
operatively with careful observation following complete surgical evaluation. Hernias are
divided into two categories: congenital (from birth), also called indirect hernias, and acquired,
also called direct hernias.
There are many different types of hernias. The most familiar type are those that occur in
the abdomen, in which part of the intestines protrude through the abdominal wall. This may
occur in different areas and, depending on the location, the hernia is given a different name.
An inguinal hernia appears as a bulge in the groin and may come and go depending on
the position of the person or their level of physical activity. It can occur with or without pain. In
men, the protrusion may descend into the scrotum. Inguinal hernias account for 80% of all
hernias and are more common in men.
Femoral hernias are similar to inguinal hernias but appear as a bulge slightly lower.
They are more common in women due to the strain of pregnancy.
A ventral hernia is also called an incisional hernia because it generally occurs as a bulge
in the abdomen at the site of an old surgical scar. It is caused by thinning or stretching of the
scar tissue, and occurs more frequently in people who are obese or pregnant.
An umbilical hernia appears as a soft bulge at the navel (umbilicus). It is caused by a

weakening of the area or an imperfect closure of the area in infants. This type of hernia is more
common in women due to pregnancy, and in Chinese and black infants. Some umbilical hernias
in infants disappear without treatment within the first year.
A hiatal or diaphragmatic hernia is different from abdominal hernias in that it is not

visible on the outside of the body. With a hiatal hernia, the stomach bulges upward through the
muscle that separates the chest from the abdomen (the diaphragm). This type of hernia occurs
more often in women than in men, and it is treated differently from other types of hernias.
In the light of the foregoing statements, the researchers would like to investigate deeper
into the facts about Umbilical Hernia and understand its etiology and physiology by focusing
on a specific case chosen in the Annex of Metropolitan Medical Center. The study will discuss
the patient’s clinical summary, clinical background, nursing care plan done and discharge plans
for the patient for her fast recovery.
SCOPE AND LIMITATIONS
The client was admitted at the Metropolitan Medical Center on February 06, 2009 at
03:25 direct to room with the chief complaint of umbilical pain and was discharged on February
11, 2009. The client was interviewed and asked for a permission to be the case that will be
presented as per requirement in Nursing Care Management 202 for four consecutive days
starting on February 6, 2009 until February 9, 2009.
Our case presentation focuses on Post – operative from Umbilical Herniorrhapy. We will
be dealing with the condition after the surgical procedure wherein the assessment and all
necessary information about health were obtained.
We requested for the permission ever since she was admitted to room and sign a letter
the day after her operation on February 09, 2009. Physical assessment was done at night one day
after her surgery.
The information gathered came primarily from the client. The client was coherent and
alert at the time of the interview was conducted as well as from her children who happen to be
there to care and support her. The client spoke fluently in Filipino language
The Nursing Care Plans were formulated during the time the client was handled. Most
of subjective information, objective cues, and clinical manifestations are visible and shown in
the on going appraisal from February 06 – February 9 and post-op physical assessment.
The case was approved on February 09, 2009 as noted by our beloved 3 rd year level
coordinators Miss Baldonado BSN RN and Miss Ong BSN RN.
I. Review of Anatomy and Physiology of Affected Organs

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral
cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach and
intestines to the rectum and anus, where food is expelled. There are various accessory organs
that assist the tract by secreting enzymes to help break down food into its component nutrients.
Thus the salivary glands, liver, pancreas and gall bladder have important functions in the
digestive system. Food is propelled along the length of the GIT by peristaltic movements of the
muscular walls.
The
primary purpose
of the
gastrointestinal
tract is to break
down food into
nutrients, which
can be absorbed
into the body to
provide energy.
First food must
be ingested into
the mouth to be
mechanically
processed and
moistened. Secondly, digestion occurs mainly in the stomach and small intestine where
proteins, fats and carbohydrates are chemically broken down into their basic building blocks.
Smaller molecules are then absorbed across the epithelium of the small intestine and
subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess
water. Finally, undigested material and secreted waste products are excreted from the body via
defecation (passing of feces). In the case of gastrointestinal disease or disorders, these functions
of the gastrointestinal tract are not achieved successfully. Patients may develop symptoms of
nausea, vomiting, diarrhea, malabsorption, constipation or obstruction. Gastrointestinal
problems are very common and most people will have experienced some of the above
symptoms several times throughout their lives.
Basic structure
The gastrointestinal tract is a muscular tube lined by a special layer of cells, called
epithelium. The contents of the tube are considered external to the body and are in continuity
with the outside world at the mouth and the anus. Although each section of the tract has
specialised functions, the entire tract has a similar basic structure with regional variations. The
wall is divided into four layers as follows:
Mucosa: The innermost layer of the digestive tract has specialised epithelial cells
supported by an underlying connective tissue layer called the lamina propria. The lamina
propria contains blood vessels, nerves, lymphoid tissue and glands that support the mucosa.
Depending on its function, the epithelium may be simple (a single layer) or stratified (multiple
layers).
Areas such as the mouth and oesophagus are covered by a stratified squamous (flat)
epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) or
glandular epithelium lines the stomach and intestines to aid secretion and absorption. The inner
lining is constantly shed and replaced, making it one of the most rapidly dividing areas of the
body! Beneath the lamina propria is the muscularis mucosa. This comprises layers of smooth
muscle which can contract to change the shape of the lumen.
Submucosa: The submucosa surrounds the muscularis mucosa and consists of fat,
fibrous connective tissue and larger vessels and nerves. At its outer margin there is a specialized
nerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and
submucosa.
Muscularis externa: This smooth muscle layer has inner circular and outer longitudinal
layers of muscle fibres separated by the myenteric plexus or Auerbach plexus. Neural
innervations control the contraction of these muscles and hence the mechanical breakdown and
peristalsis of the food within the lumen.
Serosa/ Mesentery: The outer layer of the GIT is formed by fat and another layer of
epithelial cells called mesothelium.
Stomach
The stomach is a J shaped expanded bag, located just left of the midline between the
oesophagus and small intestine. It is divided into four main regions and has two borders called
the greater and lesser curvatures. The first section is the cardia that surrounds the cardiac orifice
where the oesophagus enters the stomach. The fundus is the superior, dilated portion of the
stomach that has contact with the left dome of the diaphragm. The body is the largest section
between the fundus and the curved portion of the jejunum This is where most gastric glands are
located and where most mixing of the food occurs. Finally the pylorus is the curved base of the
stomach. Gastric contents are expelled into the proximal duodenum via the pyloric sphincter.
The inner surface of the stomach is contracted into numerous longitudinal folds called rugae.
These allow the stomach to stretch and expand when food enters. The stomach can hold up to
1.5 liters of material. The functions of the stomach include:
1. The short-term storage of ingested food.
2. Mechanical breakdown of food by churning and mixing motions.
3. Chemical digestion of proteins by acids and enzymes.
4. Stomach acid kills bugs and germs.
5. Some absorption of substances such as alcohol.

The secretion of stomach juices achieves most of these functions by gastric glands in the
body and fundus. Some cells are responsible for secreting acid and others secrete enzymes to
break down proteins.
Small Intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It averages
approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileo-
caecal valve separating the ileum from the caecum. The small intestine is compressed into
numerous folds and occupies a large proportion of the abdominal cavity. The duodenum is the
proximal C-shaped section that curves around the head of the pancreas. The duodenum serves
a mixing function as it combines digestive secretions from the pancreas and liver with the
contents expelled from the stomach. The start of the jejunum is marked by a sharp bend, the
duodenojejunal flexure. It is in the jejunum where the majority of digestion and absorption
occurs.
The final portion, the ileum, is the longest segment and empties into the caecum at the
ileocaecal junction. The small intestine performs the majority of digestion and absorption of
nutrients. Partly digested food from the stomach is further broken down by enzymes that came
from the pancreas and bile salts from the liver and gallbladder. These secretions enter the
duodenum at the Ampulla of Vater. After further digestion, food constituents such as proteins,
fats, and carbohydrates are broken down to small building blocks and absorbed into the body's
blood stream. The lining of the small intestine is made up of numerous permanent folds called
plicae circulares. Each plica has numerous villi (folds of mucosa) and each villus is covered by
epithelium with projecting microvilli (brush border). This increases the surface area for
absorption by a factor of several hundred. The mucosa of the small intestine contains several
specialised cells. Some are responsible for absorption, whilst others secrete digestive enzymes
and mucous to protect the intestinal lining from digestive actions.
Large Intestine
The large intestine is horseshoe shaped and extends around the small intestine like a
frame. It consists of the appendix, caecum, ascending, transverse, descending and sigmoid
colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm. The caecum
is the expanded pouch that receives material from the ileum and starts to compress food
products into faecal material. Food then travels along the colon. The wall of the colon is made
up of several pouches (haustra) that are held under tension by three thick bands of muscle
(taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold faecal matter before
it passes through the anorectal canal to the anus. Thick bands of muscle, known as sphincters,
control the passage of faeces. The mucosa of the large intestine lacks villi seen in the small
intestine. The mucosal surface is flat with several deep intestinal glands. Numerous goblet cells
line the glands that secrete mucous to lubricate faecal matter as it solidifies. The functions of the
large intestine can be summarised as:
1. The accumulation of unabsorbed material to form faeces.
2. Some digestion by bacteria. The bacteria are responsible for the formation of
intestinal gas.
3. Reabsorption of water, salts, sugar and vitamins.
Surface Anatomy of the Abdominal Wall

The abdomen can be divided into quadrants or nine abdominal regions. Pain felt in
these regions may be considered to be direct or referred. The midline in the sagittal plane is the
linea alba. The lateral edge of the rectus sheath is the linea semilunaris. The lower costal margin,
the iliac crest and public tubercle can be palpated.
The abdominal wall is divided into four quadrants by a vertical and a horizontal line
bisecting the umbilicus. An older more complicated scheme divided the abdomen into nine
regions. Although the old system generally is not used, some regional names persist, such as
epigastric for the area between the costal margins, umbilical for the area around the umbilicus,
and hypogastric or suprapubic for the area above the pubic bone.
Anatomic Location of Organs by Quadrant

RIGHT UPPER QUADRANT (RUQ ) LEFT UPPER QUADRANT (LUQ)
Liver Stomach
Gallbladder Spleen
Duodenum Left lobe of liver
Head of pancreas Body of pancreas
Right kidney and adrenal Left kidney and adrenal

Hepatic flexure of colon Splenic flexure of colon
Part of ascending and transverse colon Part of transverse and descending colon
RIGHT LOWER QUADRANT (RLQ) LEFT LOWER QUADRANT (LLQ)
Cecum Part of descending colon
Appendix Sigmoid colon
Right ovary and tube Left ovary and tube
Right ureter Left ureter
Right spermatic cord Left spermatic cord
Abdominal Fascia
Below the skin the superficial fascia is divided into a superficial fatty layer, Camper's
fascia, and a deeper fibrous layer, Scarpa's fascia. The deep fascia lies on the abdominal muscles.
Inferiorly Scarpa's fascia blends with the deep fascia of the thigh. This arrangement forms a
plane between Scarpa's fascia and the deep abdominal fascia extending from the top of the thigh
to the upper abdomen. Below the innermost layer of muscle, the transverses abdominis muscle
lays the transversalis fascia. The transversalis fascia is separated from the parietal peritoneum
by a variable layer of fat. Fascias are sheets of connective tissue covering or binding together
body structures.
Other internal fascia with relation to surrounding structures

Cremasteric fascia: Intermediate covering layer of the spermatic cord.

External spermatic fascia: Outermost covering of the spermatic cord that is derived from a
layer of the abdominal wall.
Iliacus fascia: Part of the transversalis fascia that covers the iliacus muscle.
Internal spermatic fascia: Innermost covering of the spermatic cord.
Periureteric fascia: Fascia that surrounds the ureter.
Psoas fascia: Part of the transversalis fascia that covers the psoas minor muscle.
Quadratus lumborum fascia: Part of the transversalis fascia that covers the quadratus
lumborum muscle.
Renal fascia: A fascial pouch derived from extra peritoneal connective tissue that contains the
kidneys, the suprarenal glands, the renal vessels and perirenal fat
Transversalis fascia: The deep fascia lining the inner surface of the abdominal wall.
The Anterior Abdominal Wall

Anatomical landmarks: Linea alba, semilunar line, linea semicirculoris, Umbilicus, inquinal
ligament
Bony landmarks: Iliac crest, anterior superior iliac spine, pubic crest and tubercle and xiphoid
process.
Skin and subcutaneous tissue:
Skin: thickerPrecipitating
in lumbar regions; scrotum and labia majora are outpouchings of the abdomen.
Factors:
-Obesity -Trauma
Camper's-Pregnancy
Fascia: outer fatty layer of superficial fascia
-Ascites
Predisposing Factors:
-Previous -Sneezing
Scarpas fascia: membranous
Abdominal layer of superficial fascia in lower two-thirds of abdomen;
-Coughing -Congenital
specialization – fundiform
Surgery ligament of the penis.
-Smoking
-Heavy -Old Age
Lifting
Weakening of abdominal wall Increased Abdominal

II. Pathophysiology Pressure
Protrusion of bowel to the

hernial ring, the umbilicus
Decreased blood supply to Obstruction of the

the herniated segment of bowel loop
bowel
Impede venous
return
Wall of intestine become

congested and bright red
Congestion increases,
intestine becomes purple
Increased intestinal pressure
Further impede
venous return
Venous stasis increases
Abdominal
STRANGULATION Distention
Nausea
Ischemia Decreased intestinal viability Vomiting
Abdominal
Pain
Necrosis Bacterial transudation
Infection
Pain
Fever
Tachycardia
Defects in the muscular wall may congenital and due to weakened tissue or may be
caused by trauma. This muscle weakness can be inherited or acquired due to previous
abdominal surgery or as part of the aging process. As client ages, muscular tissues become
infiltrated and are replaced by adipose and connective tissues. Intra abdominal pressure
increases with pregnancy, obesity, heavy lifting, coughing, sneezing, abdominal distention or
ascites, and traumatic injuries from blunt pressure. When two of these factors coexist with some
tissue weakness, a hernia may occur. Then, a protrusion of the bowel to the weakened area, the
umbilicus, is manifested. Increased pressure without weakness is not likely to cause hernia.
The intestine is obstructed and its blood supply impaired. Initially, only the venous
return is impeded, the wall of the intestine becoming congested and bright red with the
transudation of serous fluid into the sac. As congestion increases, the wall of the intestine
becomes purple in colour. The intestinal pressure increases distending the intestinal loop and
impairing venous return further. As venous stasis increases, the arterial supply becomes more
and more impaired. Blood is extravasated under the serosa and is effused into the lumen. The
fluid in the sac becomes blood stained and the shining serosa dull due to a fibrinous, sticky
exudate. A hernia becomes strangulated when the blood supply of its contents is seriously
impaired, rendering the contents ischaemic. At this stage the walls of the intestine have lost their
tone and become friable. Bacterial transudation occurs secondary to the lowered intestine
viability and the sac fluid becomes infected. Clinical features. Sudden pain at first situated over
the hernia is followed by generalised abdominal pain, colicky in character and often located
mainly at the umbilicus. Nausea and subsequently vomiting ensue. And as it progresses,
abdominal distention may also occur. The patient may complain of an increase in hernia size.
III. Assessment
Personal Data
Name : Leonora Ruiz Vitug
Age : 76 y/o
Sex : Female
Nationality : Filipino
Origin : Tagalog
Religion : Catholic
Address : 1145 Int. G. Vargas, New Antipolo Tondo, Manila
Date of Birth : February 15, 1932
Place of Birth : Gapan, Nueva Ecija
Educational Attainment : Grade 1
Date & Time of Admission : 02/05/09 03:25 PM
Room No. : 101-B
Attending Medical Doctor : Dr. Ricardo Dy M.D
Chief Complaint : Umbilical Pain
Admitting Diagnosis : Umbilical Herniorrhapy
Contact Person/ Informant : Cesar Vitug Jr.
Percentage Reliability of the Resource Person: 100%
Family Background
Family Age Gender Educational Occupation Position Relationship

Member Attainment to the patient
1. Mr. Deceased Male Secondary None Father Husband
Rolando at the
age of 75
2. Mrs. 56 Female Secondary Helper at UST Eldest Daughter
Teresita
3. Mrs. 49 Female College Domestic 2nd Daughter
Corazon Graduate Helper
4. Mr. Cesar 47 Male Secondary Mimeographic 3rd Son
at UST
5. Mr. 46 Male College National 4th Son
Chanito Graduate Bookstore
(Department
head)
6. Mrs. 45 Female College Professor at 5th Daughter
Clarita Graduate UST
7. Mrs. 43 Male College Librarian at 6th Daughter
Conception Graduate UST
8. Ciseteta 42 Male College Teacher at 7th Daughter
Graduate Dubai
9. Mr. Carlos 39 Male Secondary No present job Youngest Son
Genogram
? ?
75 76
60 49 47 46 45 43 42 39
Legend:
- Male - Deceased male ? - Unknown cause of death
- Female - Decease female - with present illness
Family Health History

Ms. Vitug grew up as an orphan because her parents died after she was born. The age
and the cause of death of her parents are unknown to her. Even her brothers and sisters are
unknown to her. Despite of all these, she grew independently and married her husband
Ronaldo Vitug. Ronaldo Vitug died on the age of 75 years old due to fall. Mr. Ronaldo Vitug
didn’t have any illnesses as Ms. Vitug said. Ms. Vitug have 8 children naming Teresita (56 years
old), Corazon (49 years old), Cesar (47 years old), Charito (46 years old), Clarito (45 years old),
Conception (43 years old), Criseta (42 years old), and Carlos (39 years old). Madame Vitug said
that all of her children are healthy except Cesar who has a heart disease. All of them have no
noted allergies. Still, all of them are living.
Past Health History

Ms. Vitug had chicken pox, measles, mumps, and rubella. And she has no records of
vaccination during childhood. She did not have any allergies to any foods and medications.
Other than umbilical hernia, she was also diagnosed of hypertension and rheumatoid arthritis
that is manifested by BP of 150/90 and nape pain, and swan neck deformities, respectively for
over ten years. She is taking Mefenamic acid whenever pain ensued for RA and Amvasc once a
day for hypertension. On last June 18, 2008, she brought to the hospital and scheduled at the
same day for surgery as an emergency case. She was operated due to umbilical hernia. After her
operation, she was given Buscopan as a maintainance for her pain. She is also taking Caltrate as
her calcium supplement.
Present Health History

2 months before her admission to Metropolitan Medical Center, Ms. Vitug suddenly
experienced pain in the umbilicus area scaling 5/10. Before Christmas, Ms. Vitug consulted at
MMC to know what she was experiencing that time. Then she was diagnosed of Umbilical
Hernia, which implies that her past condition recurs. She was then advised for Herniorrhapy on
January 2, 2009 but she didn’t come because of financial insufficiency. Then she was scheduled
again in January 14, 2009 to consult to Dr. Ricardo Dy. His physician ordered the patient to have
an ultrasound on January 26, 2009 to visualize her abdomen. Then she was scheduled for
herniorrhapy last February 2, 2009 but she still didn’t come because of financial problem. Dr.
Ricardo Dy rescheduled the surgery on February 7, 2009 and she was requested to be admitted
on February 6, 2009 and hence was admitted.
OB history
Ms. Vitug gave birth to 8 children. All of them grew healthy. They were delivered
normally at Fabella Public Hospital. No noted complications were experienced as Ms. Vitug
stated. Until last June 2008, she was diagnosed of Umbilical Hernia due to multi parity. She is
also menopause for 20 years.
Developmental Data
In the theory of Erik Erikson

Erikson described 8 stages of life cycle. The stages are marked by one or more internal
crises that are defined as turning points. When the person is in a state of increase vulnerability,
ideally, a crisis is mastered successfully; and the person gains strength and is able to move on to
the next stage. Development is continuous even though a particular stage may dominate at a
certain time; the person may have residual problems carried over from one stage to the next or
maybe under severe stress and regress to an earlier stage in whole or in part.
State Late Adulthood: Integrity vs. Despair

A. Physical Development
At the age of 76 years old, Ms. Vitug’s physical development revealed usuals signs of aging such
as facial wrinkles with formation of white hair. Signs of diminishing skin elasticity and loss of
muscle mass as evidenced by sagging of muscle in upper extremities where noted. She stands
5’0” and weighs 154 lbs.
-Ms. Vitug is wearing dentures as replacement to normal teeth
-Visual Acuity is blurred because of cataract “Malabo na ang mata ko dahil sa katarata”
-Ms. Vitug can hear clearly and readily answers our questions whenever we ask her.
-Motor Ability has slowed because of aging. But she likes doing household chores but
sometimes with difficulty due to backaches and because of rheumatoid arthritis.
-Performance of ADL are bad when it comes to doing washing and doing household chores
Because of having slow and limited movements due to pain.
B. Psychosocial Development
-Ms. Vitug, during childhood, rarely has friends because of working so much. But when
she started to have her own family when she was 20 years old, she started to have many
friends and became well known in their place. She made people in their neighborhood love
her.
-Ms. Vitug goes to her community “The Children of Life” every weekend. Sometimes,
she goes to Nueva Ecija to visit her family and friends there. She likes to going to birthday
parties. She is a socialized person.
-Right now, her source of strength is her family. They are the one who is by her side all the
time especially Cesar and Carlos. They gave her joy in times of her problems. They gave her
the support she needs.
C. Cognitive Development
-It has been observed that Ms. Vitug didn’t had a hard time replying to some questions
that we asked about her family. All of her answers are sure and constant as we validate it.
-With regards to present situation, she is coherent and consistent with her answers about her
children and grandchildren. She likes to watch TV and hear the news and this improves her
mental alertness.
D. Moral Development
-Ms. Vitug was able to maintain harmonious relationship with her family. She taught the
importance of close family ties and generosity to the needy. All her effort in teaching her
children to be a god-fearing and good person paid off as she noticed how she was being taken
cared of by her children and how they were able to relate to other people. She was proud that
her children grew up to be a good person now that she is old, she’s glad that she is being ableto
guide in raising her grandchildren.
Area of Resolution:
The final stage of Erik Erikson’s theory is late adulthood. The crisis presented by last stage is
integrity versus despair. Erikson proposes that this stage begins when the individual
experiences a sense of mortality. This maybe in the response to retirement, the death of a spouse
or a close friend, or may simply result from hanging social roles. The final crisis manifest itself
as review of the individual life, career, if it was a success or failure. Ego integrity is viewed as
the harmonious personality development. The individual view his/her whole life with
contentment and satisfaction. If this stage where not resolved, it will lead to despair.
Analyzing the life of Ms. Vitug, it can be said that she had completed her task. She had the
sense of satisfaction that one feels in reflecting on life productivity lived. She is contented and
enjoyed bonding with her grandchildren and was able to see the fruit on harbor being put to
good used by younger generation.
Ms. Vitug was fulfilled to have a meaningful life that she has made a contribution in
producing happy children. She also faces death without fear for now she understands the
meaning of life with all the things that she had gone through.
In the theory of Robert Havighurst

Later Maturity Task: Coping Activities of Mrs. Analysis:
Vitug:
-Adjusting to decreasing -Due to her illness, Ms. -Task achieved
physical strength and health. Vitug seems to have adjusted
well to her decreased physical
strength. “ Mahina na ko
ngayon. Di na nga ako
pinagtatrabaho ng mga anak
ko eh. Hirap na rin ako
kumilos ng sobra kasi
sumasakit na ang mga tuhod
ko. Kaya lang makulit talaga
ako eh. Minsan Umaalis pa
din ako. Pero tanggap ko na
ganun na talaga ako kasi
matanda na ko.”
-Adjusting to retirement -Ms. Vitug knew the value -Task achieved
and decreasing /reduced of hard-earned money, which
income. was taught to her by her
auntie. She was able to save
for her future. Ms. Vitug
verbalized, “Nakapag-ipon
ako para sa sarili ko kahit
malaking pera ang nagastos
ko para sa pagpapaaral sa
kanila.”
-Adjusting to death of -Ms. Vitug has already -Task achieved
spouse. accepted the death of her
husband and although she
sometimes recalls all the good
memories they shared, she
focused her attention on her
children and grandchildren.

“Alam ko na mauuna na siya
saken kasi 27 years ang
pagitan namin eh.”
-Establishing satisfactory Ms. Vitug is living -Task achieved
physical living arrangement. comfortably with her son,
daughter-in-law and 4
grandchildren.
-Meeting social and civic Ms. Vitug, despite of her -Task achieved
obligation. illness, loves to go to Nueva
Ecija to meet with her
relatives. This gives her inner
sense of joy that keeps her
strong. However, she is not
active in joining in their
barangay project as before
illness.
Patterns of Functioning
EATING Before Illness During Illness After

PATTERN Hospitalization
Before During
Hospitalizatio Hospitalizatio
n n
Breakfast 1 bowl of 1 bowl of sopas, NPO 1 bowl of sopas,
sopas, cereal, cereal, cereal,
champorado or champorado or champorado or
2 pieces 2 pieces 2 pieces

pandesal, pandesal, pandesal,
oatmeal oatmeal oatmeal
Lunch 1 – 1 ½ cup of 1 – 1 ½ cup of NPO 1 – 1 ½ cup of
rice, 1 serving rice, 1 serving rice, 1 serving
of vegetables or of vegetables or of vegetables or
meat meat meat
Dinner 1 – 1 ½ cup of 1 – 1 ½ cup of NPO 1 – 1 ½ cup of
rice, 1 serving rice, 1 serving rice, 1 serving
of vegetables or of vegetables or of vegetables or
meat meat meat
DRINKING Before Illness During Illness After

Before During
n n
Water 1000 mL 1000 mL NPO 1200 mL
Juice 200 mL 200 mL NPO 250 mL
Milk 450 mL 450 mL NPO 500 mL
Total Intake 1,650 mL 1650 mL 1950 mL
SLEEPING Before Illness During Illness After

Before During
n n
Arising Time 12 MN, 1, or 12 MN, 1, or Every 5 hours 12 MN, 1, or
2am 2am 2am
Sleeping Time 9pm; continued 9pm; continued Every 5 hours 9pm; continued
at 9am or 10am at 9am or 10am at 9am or 10am
Duration 4 hours 4 hours 15 hours 4 hours
BATHING Before Illness During Illness After

Before During
n n
Time 12-1pm 12-1pm Any time of the 12-1 pm
day
Frequency 1 1 2-3 1
With assistance None None By her son or None
daughter
(sponge bath)
ELIMINATION Before Illness During Illness After

Before During
Hospitalization Hospitalization
Time Anytime of the Anytime of the Foley Catheter Anytime of the
day day To Urinary Bag day
Amount Approx. 700 cc Approx. 700 cc a 30 – 40 cc/hr Approx. 700 cc
a day day Approx. 720 – a day
960 cc a day
Characteristic Yellowish to Yellowish to Yellowish Yellowish to
amber amber amber
Frequency 12-14x 12-14x Every Hour 12-14x
BOWEL Before Illness During Illness After

ELIMINATION Hospitalization
Before During
Hospitalization Hospitalization
Time 8 am 8 am No Bowel 8 am
Frequency 1x a day 1x a day No Bowel 1x a day
Consistency Soft Soft No Bowel Soft to
Color Brown to Dark Brown to Dark No Bowel Brown to Dark
Brown Brown Brown

Amount Moderate Moderate No bowel Moderate
Levels of Competencies
A. Physical
Before Illness During Illness Analysis

Before During After
Hospitalization Hospitalizatio Hospitalization
n
Ms. Vitug is She can still do She was A few days after Ms. Vitug is
still active at her activities, scheduled for discharge she is physically
her age, as she she’s still active repair of required to take active in spite
verbalize “ in spite of her herniorrhapy a rest for her of her age. She
Malakas pa age, she found 0710H on fast recovery. felt body
ako kahit it enjoyable February 7, No strenuous weakness and
ganito na edad doing her daily 2009 thus she activities should fatigue after
ko” she does routine, as she was not be done. Which the surgical
her daily verbalized “ allowed to eat the patient was procedure
activities like masaya ako or drink able to follow thus; advise to
performing her pag may anything, since she have a full bed
personal ginagawa ako, before and after understood the rest during and
hygiene, going parang surgery until purpose. after her
out for a walk nanghihina kasi her bowel hospitalization.
and doing a ako pag movement has
household nakatigil lang.” returned. And
chores even Although, since she needs
her children a few months rest, she cannot
stops her to do after her do her personal
these things, as operation at hygiene thus,
she verbalized UST she felt she needs
“ gumagawa pain on the assistance from
pa din ako sa umbilical area her children.
bahay kahit again. She takes And she was
ayaw ng mga Buscopan 1 tab advised to take
anak ko, gusto 10mg every a rest.
nila time her
magpahinga abdomen aches.

nalang daw
ako”
B. EMOTIONAL

Before During After
Hospitalization Hospitalization Hospitalizatio
n
Ms. Vitug was Ms. Vitug doesn’t She felt anxious Observing the Although the
very concern pay attention to the of having patient, she was patient has
with her pain she felt on the surgery as she seen with undergone
children and affected site, as she stated “ medyo happiness. She another
grandchildren. stated “ di ko kabado pa din was glad that operation, the
She gives masyado iniinda, ako sa the operation family was
advice to them ayokong bigyan pa operasyon pero was a success supportive which
and they ng problema ang kailangan and she can gives her the
support each mga anak ko…” lakasan ang return to her strength and
other. She has “Medyo nag-alala loob ko tsaka daily activities courage to get
good family rin ako nung andyan yung with still ready for it.
ties, as she sumakit ulit yung pamilya sabi limitations. Therefore, her
verbalized “ tyan ko kaya nung nila sa ‘kin… fear and
mahal na December relax lang kaya apprehension has
mahal ko sila nagpacheck-up mo yan..love subsided. And
yung mga apo ko.” you.” she was currently
ko,” happy of the
result on the
operation.
C. SOCIAL

Before During After
Hospitalizatio Hospitalization Hospitalizatio
n n
Ms. Vitug is The patient still The client still The client’s The client’s social
easy to deal managed to managed to social life is still life was not
with, interact with interact with healthy even affected by her
cooperative others despite her family, though she is illness. She does
and responsive her age and relatives and inside the still manage to
She spent most condition as friends who hospital. Her interact with the
of her time she verbalized, visited her very friends and people around
bonding with “ umaalis pa often during family calls her her, but during
her rink o ng her stay in the every now and her illness, she
grabdchildren bahay..sa hospital, as she then just to limits herself
and watching Nueva ecija ko verbalized “ check her going out to
television as madalas madami ako condition. avoid more
she mentioned. pumunta.” And laging bisita, “Tumawag nga complication.
‘Wowowie’ is as added by her masaya ako at saken yung
her favorite son Mr. Cesar madami nag- pamangkin ko
noon time “makulit talga aalaga sakin, tsaka yung
show. She also yan lagging palagi nila ako kumara ko
loves to travel wala sa bahay.” dinadalaw” kanina eh.
and visit her Kinukumusta
friends and nila ako. Sabi
relatives in her din kase nila eh
province at pupunta sila
Gapan Nueva dito.”
Ecija as she
verbalized,
“marami ako
varicose veins
sa binti…
mahilig kasi
ako bumyahe…
sa nueva ecija
sa gapan…
tsaka sa ibang
kamag-anak..”
D. MENTAL

Before During After

Hospitalizatio HospitalizationHospitalizatio
n n
The client has a The patient still The client The client is During
positive have a positive become anxious better than she hospitalization,
outlook in life, outlook in life, because of her was in the the client has
she’s more but whenever illness as she hospital. She been mentally
concern about she feel some stated “ medyo answers us pre-occupied by
the present, she pain, she divert kabado pa din directly to the her illness and
thinks how to it into ako sa point unlike she thinks that
live life in the something else operasyon, when she was the operation
fullest, but she so that her hindi ko alam in the hospital, might have some
also have plans children do not magiging she’s a little effects to her
ahead for a worry so much epekto nito disoriented. body and to her
better life about her sakin ngayon, lifestyle.
especially for condition as pati sa araw-
her children she stated “ araw ko na
and nilalakasan ko Gawain”
grandchildren ang loob ko pag
may
nararamdaman
akong di
maganda”
E. SPIRITUAL

Before During After
Hospitalizatio Hospitalization Hospitalizatio
n n
The client is a The client’s The client’s The client went .the client’s faith
firm catholic faith remain faith remains to her in God became
and her faith to strong as she strong as she community in stronger during
the Lord is verbalized “ verbalized “ the Children of her illness. She
strong. She kahit may edad nagdarasal ako Light to thank always ask for
regularly go to na ako, bihira lagi sa gabi at God for her help from God
church every lang akong lagi akong successful and his mercy
first Friday and magkasakit nagrorosaryo sa operation and
Sunday and kaya malaki panginoon na giving her the
actively ang sana’y strength to
attending a pasasalamat ko malagpasan ko surpass her
religious sa diyos” ang operasyon” problems.
affilations like “
Children of
light
Community”
as her way of
serving the
Lord
Review of Systems
Body Systems Past state of health Present state of Analysis

health
General Health “Okay naman, “Ngayon…eto Since Ms. Vitug is a
malakas pa ako noon. matanda na. geriatric patient, she
Kaya ko pa Nanghihina di pa is becomes weak as
magtrabaho.” daw ako pwede part of the aging
kumaen sabi kasi ng process.
doctor. Kahapon pa
ako walang kaen.”
Integumentary Systen “Noong bata ako “kaya ngayon may Signs of aging were
namumulot ako ng mahaba kong peklat seen as manifested by
mga palay kaya sa binti pati sa tuhod. wringkled face, poor
madalas ako ” skin turgor, and
magkasugat, “tsaka eto matanda na increase skin
magasgasan yung ako kulubot na balat pigmentation.
paa...” ko.”
Respiratory System “Nagkakaubo, sipon “di naman ako hirap The resistance of the
din pero di naman huminga. patient to disease
madalas…’pag yung Nagkakasipon pa rin decreases as part
panahon iba…’pag tsaka ubo” again of the aging
malamig ganun. ” process.
Cardiovascular “meron ako “hanggang ngayon Ms. Vitug develops
System highblood…matagal mataas pa rin blood hypertension, as she
na ‘to mga 60 pa lang pressure ko. gets older and on
ako mataas na blood Umiinom pa rin ako maintinance of

pressure ko…BP ko ng gamot. Bumababa antihypertensive
madalas 160/110. naman siya…Di drug, Amvasc.
Meron ako iniinom na naman sumasakit Furthermore,
gamot amvasc once a batok ko ngayon. ” although she is old,
day tuwing umaga… “marami ako varicose she is fond of
Minsan sumasakit veins sa binti… traveling to and from
yung batok ko.” mahilig kasi ako Nueva Ecija and other
bumyahe…sa nueva places to visit her
ecija sa gapan…tsaka relatives. As a result,
sa ibang kamag- she has varicose veins
anak..” on both legs.
Gastrointestinal “Nakakadumi ko. “Eto ngayon… After months from
System Isang beses sa isang bumalik yung hernia her operation at UST,
araw. Pero noong ko kaya andito ko the hernia recurs. She
nagkahernia ko sumakit kasi yung felt pain at the
sumasakit yung tyan tyan ko. Nagpacheck- umbilical area
ko madalas. May up ako…dapat nga without any
parang nakaumbok sa nung January 2 pa ko untoward patterns of
pusod ko tapos ooperehan ulit eh wla her defecation
meron nang itim… pa pera kaya di
umiinom ako ng natuloy…yaw na ng
buscopan ‘pag mga anak ko bumalik
sumakit kami sa UST kasi
lang..nawawala parang…nawalan na
naman pero ng tiwala “
bumabalik din. “sa pagdumi..wala
“Inoperahan ako… naman nakakatae pa
nung june last year sa rin ako sa isang
UST…” araw.”
Genitourinary System “nakakaihi ako ng “ganun din..okay There is no significant
maayos. Wala naman ako…wala difference from the
namang sumasakit sa akong nararamdaman past state to the
puson ko…di naman kakaiba sa pagihi.” present state of health
ako nagkaron ng sakit with regards to the
sa pagihi. ” genitourinary system
of the patient.
Musculoskeletal “di naman ako “di naman sumasakit The patient develops
System naksidente kahit yung mga binti ko arthritis as manifested
noon. Wala akong ‘pag galing sa biyahe by swan neck
mga pilay…meron parang ngalay…yung deformities seen on
akong arthritis mga dalari ko her fingers and toes.
matagal na din ‘to. nakabaluktot na…

Umiiinom ako ng sumasakit siya
caltrate isang beses sa palagi…ang hirap
isang araw. Umiinom nang igalaw yung
din ako ng Anleen kamay ko.”
tuwing umaga tsaka
gabi.
Neurologic System “sa paglalakad… “di ako hirap sa The patient’s vision
mahilig ako umalis paglalakad mahilig pa degenerates, as she
puro kalyo n nga paa nga ako bumyahe gets old. She is
ko eh.. ” wearing eyeglasses
“dati di naman ako “ nagsosuot na ko and has cataract on
nagsusuot ng ngayon ng salamin… both eyes.
salamin. Kaya ko pa 250 yung grado…
makakita.” meron din ako
katarata sa
mata..parehas meron
”
Endocrine System “tama lang sa “ganun pa din nakaen There is no significant
pagkain…wala ako tatlong beses sa difference from the
naman sa lahi namin isang araw madalas past state to the
na merong may meryienda sa present state of health
diabetis…’pag mainit hapon tsaka gabi… with regards to the
pinagpapawisan..” pinagpawisan pag endocrine system.
mainit…wala ako
diabetes o kahit sa
pamilya namin.”
“”
Physical Examination
Physical Examination was conducted last February 8, 2009 at 2000H room 101B of Annex
Metropolitan Medical Center. Patient was informed of the procedure and its purpose as consent.
Ms. Vitug was assessed in a lying position with well-lighted room and provided her with
privacy. The Physical examination was done as a head-to-assessment that will help determine
the objective data of the characteristics of the condition of the patient by using the inspection,
palpation, and percussion and auscultation technique. Other pars of the patient was not assess
as requested and for privacy purposes.
General Survey
Ms. Vitug was wearing a clean and kempt hospital gown. She is conscious and coherent,
cooperative, and responsive to verbal and non-verbal. Speech is understandable. Obvious sign
of weakness and restlessness were noted.
Vital Signs
Blood Pressure = 160/ 110 mmHg
Pulse Rate = 88 bpm
Cardiac Rate = 92 bpm
Respiratory Rate = 20 cpm
Temperature = 38. 2 OC (Febrile)
Height = 5 feet
Weight = 154 lbs
Body Technique Normal Actual Findings Remarks

Part Findings
Head
Skull Palpation  Symmetrical  Rounded, Normal
and intact smooth
Inspection  Rounded, contour; no
smooth skull masses or
contour lumps or
 Absence of depressions
nodules/ mass
Scalp and Inspection  Evenly  Evenly Abnormal

hair Palpation distributed hair distributed
and no presence hair and is
of white hair colored dark
 No dandruff red with
and not oily presence of
few white
hair
 Oily, no
dandruff
Face Inspection  Symmetrical  Symmetrical Normal

facial features facial
 Symmetrical features
facial  Symmetrical
movement facial
movement
Eyelids Inspection  Skin intact No lesions, Normal
 Closes closes
symmetrical symmetrica
lly
Eyebrows Inspection  Evenly  Evenly Normal
distributed and distributed
symmetrically and
aligned and symmetrical
moves equally aligned and
moves
equally
Eyelashes Inspection  Equally  Equally Normal
distributed distributed;
 Curled slightly Curl slightly
outward outward
Conjunctiva Inspection  Shiny, smooth  Shiny, Normal
 Pink Palpebral smooth
conjunctiva  Pink
Palpebral
conjuctiva
Sclera Inspection  White and clear  White and Normal
clear sclera
Iris Inspection  Brown, flat and  Brown, flat Normal
round and round
Pupils Inspection  Black in color  Black in Abnormal
and round color and
 Smooth borders round
 Smooth
borders
 (+) cataract
on both
pupils
Eye Inspection  Both eyes  Coordinated Normal
Movement coordinated, eye
moves in movements,
unison with moves in

parallel unison with
alignment parallel
alignment
Visual Inspection  Able to view  Unable to Abnormal
Acuity things clearly view things
clearly;
wearing eye
glasses
(grade 250+)
Ears Inspection  Color same as  Color same Normal
Palpation facial skin as facial
 Symmetrical skin
auricle aligned  Symmetrical
with outer auricle
canthus of the aligned with
eye outer
 Pinna folds canthus of
the eye
 Pinna folds
Nose Inspection  No discharge  No Normal
Palpation  Symmetrical discharge
and straight  Symmetrical
 No lesions and straight
 No lesions
Lips Inspection  Pinkish  Dark Abnormal
 Moist, smooth  Dry and
texture cracked lips
 Symmetry of  Symmetry
contour of contour
 Ability to purse  Ability to
lips purse lips
Teeth Inspection  32 permanent  With upper Abnormal
teeth and lower
 Never use false dentures
teeth  Dark and
 Smooth and dry gums
white teeth
 Gums are pink
and moist
Tongue Inspection  Central position  Central Normal
 Moves freely position
 Pink color  Moves

 No lesions freely
 Raised papillae  Dark color
 No lesions
Raised
papillae
Neck Inspection  Same color to  Same color Normal
facial to facial
Palpation  Coordinated  Coordinated
movement movement
 No lesion and  No lesion
non-palpable and non-
lymph nodes palpable
lymph
nodes
Thorax Auscultation  Normal  RR = 20 cpm Normal

breathing with no
sound and untoward
pattern breath
 Transverse sound or
diameter is pattern
greater than noted
anterio-  Transverse
posterior diameter is
diameter greater than
anterio-
posterior
diameter
Heart Auscultation  Heart beat of  CR of 92 Normal
60-120 bpm bpm
normal  No
range for murmur
adults  Normal
 No murmur pattern
 Normal pattern and
and rhythm rhythm
Abdomen Inspection  Flat and  With skin Abnormal
Auscultation rounded stapler
Percussion  Hyperactive covered
bowel sounds with simple
Palpation  No masses or dressing @
lesions umbilical
area and
rounded
 No bowel
sounds
heard
Upper Extremities
Arms Inspection  Equal size on  Equal size
Palpation both sides of on both Normal
the body sides of the
 Muscle are firm body
 Smooth  Muscles are
coordinated saggy
movement  Smooth
 Good skin coordinated
turgor, no movement
lesions  Poor skin
 No evidence of turgor w/o
swelling and lesions
tenderness  No evidence
 Color same at of swelling
both side and
 No bone tenderness
deformities  Color same
at both side
 No bone
deformities
Palms Inspection  No lesions  Warm to Abnormal

Palpation  Good skin touch, no
turgor lesion, pale
 Pinkish with
 Smooth presence of
callus
Fingers Inspection  No lesions  No lesions Abnormal
Palpation  Good skin  (+) Swan
turgor neck
 No cyanosis or deformity
jaundice  Warm to
 Complete touch
 Complete
Lower Extremities
Legs Inspection  Equal size  Equal size Abnormal

Palpation  Good skin  Poor skin
turgor, no turgor, no
lesions lesions
 No tremors  Smooth
 Smooth coordinated
coordinated movement
movement  Warm to
 Warm to touch touch
 No bone  No bone
deformities deformities
 Varicose
veins on
both legs
Sole Inspection  Smooth  Callus, dry Abnormal
Palpation  No lesions and skin is
intact
Toes Inspection  No evidence of  Warm to Abnormal
Palpation cyanosis/ touch,
jaundice complete
 Complete and intact
 No lesions skin
 (+) Swan
neck
deformity
On-going Appraisal
DATE TIME TREATMENT NURSES OBSERVATION

2/6/09 1500H-2300H
1610H Admitted DTR with order from AMD
partially carried out
Place on bed
Full diet
Cardiac clearance by Dr. M. Gan-aware
For CBC -requested
For ECG -requested
SQ Pen G _____IVT ANST(-) stat given
Low pressure_______
D5NM IL x KVO- started
Add Cal gluconate + BNC ANST(-) to IVF OD- incorporated
For umbilical hernioraphy Tom 0710H(2/7/09)
Consented
OR request sent
OR Marilyn
Dra. S. Gan for anesthesia
Dr. Escudero aware
Dr. De vivas aware
AMD aware OR admission
Dr. aware
1730H Dr. M. Gan in and seen patient with order
1800H Give patient amvasc @ 6 Pm then recheck BP- given @ 8 pm to
result
2000H BP 130/90- Dr. M. Gan aware thru text
Dr. Escudero aware
2115H Dr. M. Gan with telephone order and may
go ahead with operation
2145H Dr. S. Gan with phone order made and
carried out
NPO post- midnight- instructed
2300H No pre-op meds
Endorsed
2/6/09 2300H-0700H
2300H Received pt on bed with an IVF of D5NM
1L +BNC + cal gluconate @ 700 cc level
On full diet
For umbilical hernioraphy tom 0700H
2/7/09
Consented OR request sent OR Marilyn
Dr. M. Gan x clearance- aware and seen
patient
Dr. S. Gan x anesthesia aware
NPO post midnight Maintained
No pre- op meds
May go ahead with symptoms
V/S taken and recorded
Kept comfortable
Needs attended
Conscious
2/7/09 0633H Endorsed
0700H-1500H
Received from hard per stretcher;
conscious and coherent; with ongoing IVF
of D5NM 1L 1 amp BNC + 1 amp cal
gluconate
Ca gluconate @ 150 cc level infusing well
@ left metacarpal vein.
0755H Positioned to OR bed safely and
comfortable;
Hooked to WIBP, pulse oxymeter o2 via
nasal canula and ECG
0810H Spinal preparation Done- spinal anesthesia induced by Dr.
M. Santos for Dra. S. Gan
0820H Foley catheter aseptically Connected to urine bag prepared and
draped aseptically and systematically.
Initial counting of instrument, syringes
Procedure started initial incision done by
Dr. R. Dy assisted by Dr. R. Chua and
SIOD
1020H Hooked an IVF of PNSS 1L as follow up to above consumed IVF;
umbilical hernioraphy with mesh repair
done by Dr. R. Dy.
Equipped counting of instrument,
syringes and needle done and complete
Incision sutured by layers to close.
Pen G 2,000,000 “u” Instilled @ preoperative site @procedure
ended with skin stapler covered with
simple dressing.
1050H In patient from OR awake per stretcher
with an IVF of PNSS 1L @ 250 cc level
going on @ 31 gtts/min
With O2 inhalation @ 3lpm via cannula
With skin stapler cover with simple
dressing @ umbilical area intact with
Foley catheter to urine bag

V/S q15 min until stable Taken and recorded
I and O q1 measured & Recorded
Dr. R. Dy / SROD to be Notify if urine output is < 30cc/hr
NPO maintained
FOB until 2000H
Kefox 750mg IVT q8 ANST(-) given @
1100H
Nalbuphine ½ cc IVT q4 PRN x pain
Ulcin 50 mg IVT q8 while on NPO
Next dose @1500H.
1100H 0.9 cc x sterile water + 0.1 cc kefox injected as skin test at right
inner forearm due @ 1130H ANST(-)
given @ 1200H
1300H D5NR 1Lx 12-14 hooked as follow up to above consumed
IVF and regulated @ 21 gtts/min
Dr. Tomines in seen patient with order may refer back to room
needs attended
Due meds given
Afebrile
Conscious and Coherent
Endorsed
1430H In from PACU per stretcher with an IVF
of D5 NR 1L @ 900 cc level going on and
place comfortably
Vital signs taken and recorded
With skin stapler covered with simple
dressing @ umbilical area
With Foley catheter to urine bagOn
hourly urine output refer to Dr. R. Dy/
SROD if urine output is <30 cc/hr
NPO
Flat on bed until 8pm
Afebrile
Endorsed
2/7/09 1500H – 2300H

1500H Received on bed with an IVF of D5 NR 1L
@ 800cc level on going
NPO – reinstructed
Flat on bed until 2000H

With Foley catheter to urine bag
On hourly urine output refer to Dr. R. Dy/
Due meds given
Afebrile
Endorsed
2/7/09 2300H – 0700H

2/8/09 SROD if urine output is <30 cc/hr
2400H BP = 160/100 mmHg – Dra. Guzman
aware
2430H Patient complaitnt of pain – Dra. Guzman
aware
2440H Nalbuphine ½ cc IVT given as PRN meds for pain
0100H D5 NM 1L hooked as follow up to the
above consumed IVF – regulated
0400H Temperature = 37.8 C
Cooling measures rendered
0600H Latest temp = 37.8 C
Cooling measures rendered and
instructed
0700H – 1500H
1015H Seen by Dr. Caloyan/Dr. K. Chua with
orders made and carried out

May wet lips
May turn side to side
Deep breathing exercises
(+) headache, abdominal pain – SROD Dr.
Cabigas aware
1030H (+) headache Dr. M. Gan in with order
May give Nalbuphine ½ cc IVF given as
PRN meds
With BP = 120/90 mmHG
2/8/09 0700H-1500H
0700H Received asleep on bed in semi fowlers
position: with an IVF of D5 NMILx12 @
680 cc level infusing well and regulated @
21 gtts/min
On NPO- may wet lips
dressing @ Umbilical area dry and intact
With Foley catheter to Urine bag-
draining to yellowish
Urine moderate in amount
Intake and Output Q1 refer to
AMD/SROD if urine output <30cc/
May turn side to side, deep breathing
exercise- encouraged
0830H Dr. Parinas seen and examined with
orders made and carried out
0845H Dr. Lim seen and examined with orders
made and carried out
May clear liquids- instructed
May sit up if tolerated- instructed
1100H Nalbupine ½ cc Q4/ IVT given as PRN meds for pain by
nurse on duty
Encourage deep breathing
1215H Vomited 1x in small amount, clear in
color- Dr. Parinas aware
BP taken= 150/90
Left awake on bed on side lying position
1400H with an IVF of D5NM ILx12 @ 200cc level
infusing well and regulated @ 21gtts/min
Due meds given

1400H D5 NM x 12-14 Hooked as follow up to above consumed
IV
2/8/09 1500H-2300H
1500H Received on bed with an IVF of D5NM1L
@ 900cc level going on
On NPO; May wet lips
dressing @ Umbilical area
With Foley catheter to urine bag; I & O
hourly
Turned to side; deep breathing exercise-
encouraged
Afebrile
2/8/09 2300H- 0700H

2300H D5 NM x 12 hooked as the follow up IVF to above
consumed @ (+) phlebitis
IVF reinserted by SROD (Dr. Balergas)
V/S taken & recorded
Medicated
Endorsed
1500H-2300H
1500H Received on bed with an IVF of D5NM 1L @
150cc level on going
Clear liquid
Turn to sides
Encourage deep breathing
May sit up if tolerated
With Skin Stapler covered with simple
dressing at umbilical area
With FCTUB; q1° refer if u.o <30 cc/hr.
1700H hooked to above consumed IV
2000H D5NM 1L x 12 Dr. N. Lim seen patient with order
May have General liquid to soft diet
Foley Catheter removed
CV due 0200-0400
Voided = 1x 150cc amount
May ambulate with assistance if tolerated
Needs attended
2300H Endorsed
2200H Dr. R. Dy with order
May have diet as tolerated
IE
Vital Signs Monitoring

Date / BP PR RR CR Temperature
Time
02/6/09
1800H 160/90 80 20 36.6 OC
1830H 130/80 82 20 36.6 OC
2000H 130/80 72 20 36.6 OC
2200H 130/80 72 20 36.6 OC
02/7/09
2400H 120/90 77 20 36.7 OC
0200H 130/70 63 19 36.7 OC
0400H 130/80 65 19 36.5 OC
0600H 130/80 70 20 36.5 OC
0700H 130/90 64 19 36.5 OC
Post –
operative
02/7/09
1050H 120/80 81 16 36.5 OC
1100H 120/70 77 16 36.5 OC
1115H 130/70 84 17 36.5 OC
1130H 130/70 80 16 36.5 OC
1145H 130/70 79 16 36.5 OC
1200H 130/70 77 16 36.5 OC
1215H 130/80 78 18 36.5 OC
1230H 120/80 78 18 36.5 OC
1245H 130/90 80 17 36.5 OC
1300H 130/90 82 17 36.5 OC
1330H 130/80 84 18 36.5 OC
1400H 130/90 82 18 36.5 OC
1500H 130/70 83 19 36.5 OC
02/7/09
1600H 130/80 80 19 82 37.8 OC
1700H 130/90 88 19 90 37.7 OC

Intake and Output Monitoring

Date/Time Intake Output
IVF Oral Urine Vomit

02/7/09 7 # 1357 Masangkay cor. Mayhaligue Sta. Cruz Manila
8 OR OR
9 1,000 mL 200
10 NPO
11
12
250 mL 170
13
130
14
100 mL 130
Total 1350 630
15 50 200
16 40
17 60 150
18 40 100
19
30 150
20
60 180
21
40 130
22
50 140
Total 370 1050
2/08/09 23 40 210
24 50
1 40 55
2 30 40
3
40 NPO 40
4
60 45
5
50 35
6
40 60
Total 350 480
7 30 90
Laboratory Works
1. Blood Chemistry
Normal Values SI UNIT Normal Values

Blood Sugar 114* (70-100 mgs/dL) 6.27 (3.85-6.05 mmol/L)
Total Cholesterol 231* (150-200 mgs/dL) 6.01 (3.90-5.20 mmol/L)
Triglycerides 110 (40-150 mgs/dL) 1.21 (0.44-1.65 mmol/L)
LDL 149* (60-130 mgs/dL) 3.87 (1.56-3.38 mmol/L)
HDL 60 (30-75 mgs/dL) 1.56 (0.78-1.95 mmol/L)
Uric Acid 7.2* (3-7 mgs/dL) 0.42 (0.17-0.4 mmol/L)
BUN 14 (6-20 mgs/dL) 5.00 (2.14-7.14 mmol/L)
Creatine (0.8-1.5 mgs/dL) (71-133 mmol/L)
SGPT 22 (5-38 RF unit) 10.56 (2.4-18.2U/L)
SGOT (10-40 RF unit) (4.8-19.2 U/L)
According to the results above, the patient has increased reults from the following: Blood sugar,
total cholesterol, LDL, and uric acid. The blood sugar is 114 mgs/dL, which may imply risk for
diabetes. The Cholesterol level is 231 mgs/dL may be evaluated as risk for heart disease as well as
LDL with a result of 149 mgs/dL. And lastly, uric acid is 7.2 mgs/dL which may indicate kidney
disease.
Blood Chemistry
Blood Chemistry is a test to assess a wide range of conditions and the function of organs. It
measures the levels of a number of chemical substances that are released from various tissues in
the body. The amounts of these chemicals in the blood may reflect abnormalities in the tissues
secreting them. In addition, it check electrolytes, the minerals that help keep the body's fluid
levels in balance, and are necessary to help the muscles, heart, and other organs work properly.
To assess kidney function and blood sugar, blood tests measure other substances.
Procedure
Blood is drawn from a vein, usually from the inside of the elbow or the back of the hand. The
puncture site is cleaned with antiseptic, and a band is placed around the upper arm to apply
pressure and restrict blood flow through the vein. This causes veins below the band to fill with
blood.
A needle is inserted into the vein, and the blood is collected in an air-tight vial or a syringe.
During the procedure, the band is removed to restore circulation. Once the blood has been
collected, the needle is removed, and the puncture site is covered to stop any bleeding.
Pre-procedure:
The patient should try not to eat overnight before the test because it could alter the result.
Post – procedure:
Put pressure on the punctured site for 1 minute by using a dry cotton ball.
2. Hematology
Hematology Urinalysis
Hemoglobin 13.0 Gms/dL (F - 12-15) Spec. Gravity 1.015 (1.001-1.035)
(M – 13-16) Color Yellow
Hematocrit 39 % (F – 36-45) Charac. Slightly Turbid (Clear)
M – 39-48) Reaction 6.0 (4.5-8.0)
WBC 7,900 / cumm (5000-10000) Albumin - (negative)
RBC 4.3 / cumm (4.0-6.0 m) Sugar - (negative)
Platelet count (150,000-400,000)
Differential Count
Neutrophil 65% (40-60)
Stab cells % (2%-5%)
Lymphocytes 35 (20-40)
Eosinophils (1%-3%)
Monocytes (2%-5%)
Basophils (1%-3%)
Microscopic Exam
WBC 2-4 /hpf
RBC 8-10 /hpf
Bacteria Few /hpf
Cast None /hpf
Crystals None
Epithelial Cell 1+ /lpf
Mucus Thread 1+ /lpf
Others
Complete Blood Count
The CBC test may be performed under many different conditions and in the assessment of many
different diseases. It is a screening test used to diagnose and manage numerous diseases. The
results can reflect problems with fluid volume (such as dehydration) or loss of blood. The test can
reveal problems with red blood cell production and destruction, or help diagnose infection,
allergies, and problems with blood clotting.
MCV, MCH, and MCHC values reflect the size and hemoglobin concentration of individual cells,
and are useful in diagnosing different types of anemia.
It is actually a panel of tests that examines different parts of the blood and includes the following:
 The number of red blood cells (RBCs)

 The number of white blood cells (WBCs)
 The total amount of hemoglobin in the blood
 The fraction of the blood composed of red blood cells (hematocrit)
 The size of the red blood cells (mean corpuscular volume, or MCV)
Procedure
Blood is typically drawn from a vein, usually from the inside of the elbow or the back of the
hand. The site is cleaned with germ-killing medicine (antiseptic). The health care provider
wraps an elastic band around the upper arm to apply pressure to the area and make the vein
swell with blood.
Next, the health care provider gently inserts a needle into the vein. The blood collects into an
airtight vial or tube attached to the needle. The elastic band is removed from your arm.
Once the blood has been collected, the needle is removed, and the puncture site is covered to stop
any bleeding. There is no special preparation needed.
3. Urinalysis
Routine Urinalysis
Microscopic Results Microscopic Results
Physical Cast
Color: Light Yellow Hyaline:
Transparency: Hazy Granular:
Reaction: 6.5 Waxy
Specific Gravity: 1.025 Pus Cells
RBC
Fatty:
Chemical: Cells
Albumin(quali): Negative RBC: 5-10 / hpf

Sugar(quali): Negative Pus Cells: 0-1 / hpf
Acetone Yeast Cells:
Bilirubin Renal:
Urobilinogen Bacteria: Few
WBC Esterase Mucus Thread: Rare
Nitrate Epithelial Cells: Few
Trichomoniasis:
Crystals
Amorphorous Urates: None
Uric Acid: None
Calcium Oxalates: None
Amorphorous Phosphates: None
Triple Phosphate: None
Others
Remarks: *Some Are Crenated
Urinalysis
A urinalysis is a group of manual and/or automated qualitative and semi-quantitative tests
performed on a urine sample. A routine urinalysis usually includes the following tests: color,
transparency, specific gravity, pH, protein, glucose, ketones, blood, bilirubin, nitrite,
urobilinogen, and leukocyte esterase. Some laboratories include a microscopic examination of
urinary sediment with all routine urinalysis tests. If not, it is customary to perform the
microscopic exam, if transparency, glucose, protein, blood, nitrite, or leukocyte esterase is
abnormal.
Purpose
Routine urinalyses are performed for several reasons:
 General health screening to detect renal and metabolic diseases

 Diagnosis of diseases or disorders of the kidneys or urinary tract
 monitoring of patients with diabetes
In addition, quantitative urinalysis tests may be performed to help diagnose many specific
disorders, such as endocrine diseases, bladder cancer, osteoporosis, and porphyrias (a group of
disorders caused by chemical imbalance). Quantitative analysis often requires the use of a timed
urine sample. The urinary microalbumin test measures the rate of albumin excretion in the urine
using laboratory tests. This test is used to monitor the kidney function of persons with diabetes
mellitus. In diabetics, the excretion of greater than 200 μg/mL albumin is predictive of impending
kidney disease.
Pre-procedure:
To collect a sample using the clean-catch method:
Females should use a clean cotton ball moistened with lukewarm water (or antiseptic wipes
provided with collection kits) to cleanse the external genital area before collecting a urine sample.
To prevent contamination with menstrual blood, vaginal discharge, or germs from the external
genitalia, they should release some urine before beginning to collect the sample.
Post-procedure:
The patient may return to normal activities after collecting the sample and may start taking any
medications that were discontinued before the test.
Leonora Vitug January 27,2009

Coagulation
Prothrombin
Control : 13.0 secs
Patient’s Time:13.0 secs
Normal Values: 11-15 secs
%Activity: 100%
INR: 1.0
4. ECG
>ECG Interpretation
>Normal Tracing
Electrocardiogram
An electrocardiogram (ECG) is a test that records the electrical activity of the heart.
An ECG is used to measure:
 Any damage to the heart

 How fast your heart is beating and whether it is beating normally
 The effects of drugs or devices used to control the heart (such as a pacemaker)
 The size and position of your heart chambers
Procedure
You will be asked to lie down. The health care provider will clean several areas on your arms,
legs, and chest, and then attach small patches called electrodes to the areas. It may be necessary
to shave or clip some hair so the electrodes stick to the skin.
The number of patches used may vary.
You usually need to remain still, and you may be asked to hold your breath for short periods
during the procedure. It is important to be relaxed and relatively warm during ECG recording.
Any movement, including muscle tremors such as shivering, can alter the results.
The electrodes are connected by wires to a machine that converts the electrical signals from the
heart into wavy lines, which are printed on paper and reviewed by the doctor.
Pre-procedure:
Make sure your health care provider knows about all the medications you are taking, as some
can interfere with test results.
Exercising or drinking cold water immediately before an ECG may cause false results.
5. Chest X-ray
X-ray Report
Patient: Vitug, Leonora R. Age: 76 X-ray#: 09-296
Patient No.: 64517 Date: 01/24/2009
Physician: Ricardo Dy, M.D.
Chest PA view
Both lungs are clear
Heart is not enlarged
Thoracic Aorta is calcified
Diaphragm is intact
Impression:
 Artheromatous Thoracic Aorta
5. Abdominal Ultrasound
Report of Ultrasound Examination

Leonora Vitug January 26, 2009
76 years old OPD
Dr. Ricardo Dy
Upper Abdominal Sonography: There is a bulge with mobile re echoes in the umbilical
area. Liver is normal in size but hyperechoic. Gallbladder is undistended with normal anechoic
lumen. Biliary ducts are not dilated. Pancreas, spleen, and kidneys are normal in size and
echotexture. Remainder is unremarkable.
Abdominal Ultrasound
Abdominal ultrasound is an imaging procedure used to examine the internal organs of the
abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The blood vessels that
lead to some of these organs can also be looked at with ultrasound.
Procedure
An ultrasound machine creates images that allow various organs in the body to be examined.
The machine sends out high-frequency sound waves, which reflect off body structures to create
a picture. A computer receives these reflected waves and uses them to create a picture. Unlike
with x-rays or CT scans, there is no ionizing radiation exposure with this test.
You will be lying down for the procedure. A clear, water-based conducting gel is applied to the
skin over the abdomen. This helps with the transmission of the sound waves. A handheld probe
called a transducer is then moved over the abdomen.
You may be asked to change position so that the health care provider can examine different
areas. You may also be asked to hold your breath for short periods of time during the
examination.
The procedure usually takes less than 30 minutes.
Pre-procedure
Preparation for the procedure depends on the nature of the problem and your age. Usually
patients are asked to not eat or drink for several hours before the examination. Your health care
provider will advise you about specific preparation.
Post-procedure:
Once the imaging is complete, the gel will be wiped off your skin.
After an ultrasound exam, you should be able to resume your normal activities.
IV. Medical Management
A. Treatment
Umbilical Herniorrhapy
Surgical procedure to fix a hernia. A hernia is a weak spot or tear in the abdominal muscle that
allows a part of the intestine to bulge through. Hernias most frequently occur in the groin
(called inguinal), near the navel (called umbilical), or at the site of a prior surgery (called
incisional).
Prior to Procedure
Your doctor will likely do the following:
 Physical exam
 X-rays to check for intestinal blockages and the doctor will check this picture of your
lungs and heart to make sure you're ready for surgery.
 Blood tests. You may need blood taken for tests. It can be drawn from a vein in your
hand or from the bend in your elbow. Several samples may be needed.
 Heart Monitor. Typically, three to five sticky pads are placed on different parts of your
body. Each pad has a wire that is hooked to a TV-type screen or to a small portable box
(telemetry unit) that shows a tracing of each heartbeat.
Nursing Responsibilities: (pre-procedure)
 Review the regular medications; aspirin, anti-inflammatory medications, and anti-

coagulant (blood-thinning) drugs may need to be stopped for a period of time before the
procedure. Follow the surgeon's instructions about discontinuing these drugs.
 Just before surgery, you should not eat or drink anything (even water).
 Contact lenses, eyeglasses, and dentures must be removed before surgery.
 Secure consent
 Take of vital sign before transfer to OR
Open Herniorrhaphy: In this approach, the doctor makes a single long incision over the hernia,
removes the protruding sac if necessary, and sews the torn muscle closed. Man-made mesh may
be applied to the inside of the muscle wall to further strengthen it. The operation typically takes
between 1 and 2 hours. Anesthesia will be induced a painkiller during the operation.
Nursing Responsibilities: (post-procedure)
 Get up and walk around the day after surgery

 Keep the incision area clean and dry
 Instruct patient not to lift heavy objects
 Instruct patient to drink plenty of fluids and eat plenty of high-fiber foods (fruits,
vegetables, beans, and whole grains) to prevent constipation and straining during bowel
movements
 Move your bowels as soon as you feel the urge
B. Drug Study
BRANDNAME: Nubain
GENERIC NAME: Nalbuphine
Therapeutic Use/Indications:
Relief of moderate to severe pain; preoperative analgesia, postoperative and surgical anesthesia,
and obstetrical analgesia during labor and delivery; this medication is a narcotic pain reliever. It is used
to treat moderate to severe pain and to boost the effects of anesthesia
Mechanism of Action:
Agonist of kappa opiate receptors and partial antagonist of mu opiate receptors in the CNS,
causing inhibition of ascending pain pathways, altering the perception of and response to pain; produces
generalized CNS depression
Mode Route of Administration:
I.V. Detail
pH: 3.5-3.7
Common Side Effects:
Drowsiness, dizziness, sweating, headache ﾧ, nausea, restlessness, itching, vomiting, dry mouth ﾧ or
constipation ﾧ may occur. If these effects persist or worsen, contact your doctor or pharmacist
promptly. Tell your doctor immediately if any of these unlikely but serious side effects occur:
depression ﾧ , confusion, mood changes, hallucinations, trouble breathing, blurred vision, seizures. A
serious allergic reaction to this drug is unlikely, but seeks immediate medical attention if it occurs.
Symptoms of a serious allergic reaction include: rash ﾧ , itching, swelling, severe dizziness, trouble
breathing. If you notice other effects not listed above, contact your doctor or pharmacist
Nursing Responsibilities:
Contraindications
Hypersensitivity to nalbuphine or any component, including sulfites; pregnancy (prolonged use or high
dosages at term)
Client Teaching
If self-administered, use exactly as directed; does not increase dose or frequency. Drug may cause
physical and/or psychological dependence. While using this medication, do not use alcohol and other
prescription or OTC medications (especially sedatives, tranquilizers, antihistamines, or pain medications)
without consulting prescriber. Maintain adequate hydration (2-3 L/day of fluids) unless instructed to
restrict fluid intake. May cause hypotension, dizziness, drowsiness, impaired coordination, or blurred
vision (use caution when driving, climbing stairs, or changing position - rising from sitting or lying to
standing, or when engaging in tasks requiring alertness until response to drug is known); loss of appetite,
nausea, or vomiting (frequent mouth care, small, frequent meals, chewing gum, or sucking lozenges may
help); or constipation (increased exercise, fluids, fruit, or fiber may help; if unresolved, consult prescriber
about use of stool softeners). Report chest pain, slow or rapid heartbeat, acute dizziness or persistent
headache; changes in mental status; swelling of extremities or unusual weight gain; changes in urinary
elimination or pain on urination; acute headache; back or flank pain or muscle spasms; blurred vision;
skin rash; or shortness of breath. Pregnancy/breast-feeding precautions: Inform prescriber if you are or
intend to become pregnant. If you are breast-feeding, take medication immediately after breast-feeding
or 3-4 hours prior to next feeding
Measures That Potentiate the Action of the Drug:
Abrupt discontinuation after sustained use (generally >10 days) may cause withdrawal
symptoms.
Mixed agonist-antagonist: Incidence of psychomimetic effect is lower than with pentazocine;
may precipitate withdrawal in narcotic-dependent patients.
BRANDNAME: Ulcin
GENERIC NAME: Ranitidine HCL
Therapeutic Use/Indications:
-Short-term and maintenance therapy of duodenal ulcer, gastric ulcer, gastroesophageal reflux,
active benign ulcer, erosive esophagitis, and pathological hypersecretory conditions; as part of a
multidrug regimen for H. pylori eradication to reduce the risk of duodenal ulcer recurrence. Relief of
heartburn, acid indigestion, and sour stomach
Recurrent postoperative ulcer, upper GI bleeding, prevention of acid-aspiration pneumonitis during
surgery, and prevention of stress-induced ulcers
Mechanism of Action:
Competitive inhibition of histamine at H2-receptors of the gastric parietal cells, which inhibits gastric
acid secretion, gastric volume, and hydrogen ion concentration are reduced. Does not affect pepsin
secretion, pentagastrin-stimulated intrinsic factor secretion, or serum gastrin.
Oral
Should not be chewed, swallowed whole, or dissolved on tongue: 25 mg tablet: Dissolve in at least 5 mL
(1 teaspoonful) of water; wait until completely dissolved before administering

Serious Side Effects: Chest pain, fever, feeling short of breath, coughing up green or yellow
mucus; easy bruising or bleeding, unusual weakness; fast or slow heart rate; problems with
your vision; fever, sore throat, and headache with a severe blistering, peeling, and red skin rash;
or nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice
(yellowing of the skin or eyes).
Less Serious Side Effects: Headache (may be severe); drowsiness, dizziness; sleep problems
(insomnia); decreased sex drive, impotence, or difficulty having an orgasm; or swollen or tender
breasts (in men); nausea, vomiting, stomach pain; or diarrhea or constipation.
Contraindications
Hypersensitivity to ranitidine or any component of the formulation
Warnings/Precautions
• B12 deficiency: Long-term therapy may be associated with vitamin B12 deficiency.
• Confusion: Reversible confusional states (rare), usually clearing within 3-4 days after discontinuation,
have been linked to use. Increased age (>50 years) and renal or hepatic impairment are thought to be
associated.
Disease-related concerns:
• Gastric malignancy: Relief of symptoms does not preclude the presence of a gastric malignancy.
• Hepatic impairment: Use with caution in patients with hepatic impairment.
• Porphyria: Avoid use in patients with a history of acute porphyria; may precipitate attacks.
• Renal impairment: Use with caution in patients with renal impairment; dosage adjustment
recommended.
Adverse Reactions
Cardiovascular: Atrioventricular block, bradycardia, premature ventricular beats, tachycardia, vasculitis
Central nervous system: Agitation, dizziness, depression, hallucinations, headache, insomnia, malaise,
mental confusion, somnolence, vertigo
Dermatologic: Alopecia, erythema multiforme, rash
Endocrine & metabolic: Increased prolactin levels

Gastrointestinal: Abdominal discomfort/pain, constipation, diarrhea, nausea, pancreatitis, vomiting
Hematologic: Acquired hemolytic anemia, agranulocytosis, aplastic anemia, granulocytopenia,
leukopenia, pancytopenia, thrombocytopenia
Hepatic: Hepatic failure, hepatitis
Local: Transient pain, burning or itching at the injection site
Neuromuscular & skeletal: Arthralgia, involuntary motor disturbance, myalgia
Ocular: Blurred vision
Renal: Serum creatinine increased
Respiratory: Pneumonia (causal relationship not established)
Miscellaneous: Anaphylaxis, angioneurotic edema, hypersensitivity reactions
Client Teaching
Do not take any new medication during therapy without consulting prescriber. Take exactly as
directed; do not increase dose - may take several days before you notice relief. Allow 1 hour between any
other antacids (if approved by prescriber) and ranitidine. Avoid excessive alcohol. Follow diet as
prescribed recommends. May cause drowsiness, dizziness, or fatigue (use caution when driving or
engaging in tasks requiring alertness until response to drug is known). Report chest pain or irregular
heartbeat; skin rash; CNS changes (mental confusion, hallucinations, somnolence); unusual persistent
weakness or lethargy; yellowing of skin or eyes; or change in color of urine or stool. Breast-feeding
precaution: Consult prescriber if breast-feeding.
Nursing: Physical Assessment/Monitoring

Use caution in presence of renal or hepatic impairment. Assess potential for interactions with
other pharmacological agents patient may be taking (eg, increased or decreased levels/effects and
toxicity). Evaluate results of laboratory tests, therapeutic effectiveness, and adverse reactions (eg,
bradycardia, PVCs, tachycardia, CNS changes [depression, hallucinations, confusion, and malaise], rash,
gynecomastia, GI disturbance, hepatic failure). Teach patient appropriate use, possible side
effects/appropriate interventions, and adverse symptoms to report.
Measures That Potentiate the Action of the Drug:
Geriatric Considerations
Ulcer healing rates and incidence of adverse effects are similar in the elderly, when compared to
younger patients; dosing adjustments not necessary based on age alone. Always adjust dose based upon
creatinine clearance. Serum half-life is increased to 3-4 hours in elderly patients. H2 blockers are the
preferred drugs for treating PUD in the elderly due to cost and ease of administration.
Dietary Considerations
Oral dosage forms may be taken with or without food.
Dosage
Children 1 month to 16 years:
Duodenal and gastric ulcer:
Oral:
Treatment: 2-4 mg/kg/day divided twice daily; maximum treatment dose: 300 mg/day
Maintenance: 2-4 mg/kg once daily; maximum maintenance dose: 150 mg/day
I.V.: 2-4 mg/kg/day divided every 6-8 hours; maximum: 200 mg/day
Adults:
Duodenal ulcer: Oral: Treatment: 150 mg twice daily, or 300 mg once daily after the evening meal or at
bedtime; maintenance: 150 mg once daily at bedtime
GENERIC NAME: Metronidazole - ORAL (meh-troh-NID-uh-zole)

BRAND NAME(S): Flagyl
Therapeutic Use for Patient:
Metronidazole is an antibiotic used to treat a variety of infections.
Mechanismofaction/Effect:
The exact mechanism of action has not been completely established. Metronidazole is thought
to be microbicidal against most obligate anaerobic bacteria and protozoa. To be active, it must
undergo intracellular chemical reduction via mechanisms unique to anaerobic metabolism. The
short-lived reduced forms are cytotoxic and interact with DNA to cause a loss of helical
structure and strand breakage resulting in inhibition of nucleic acid synthesis
andcelldeath.Metronidazole may produce a local antioxidant and anti-inflammatory effect on
inflamed tissue by affecting neutrophil function.

Oral
May be taken with food to minimize stomach upset; extended release tablets should be taken on an
empty stomach (1 hour before or 2 hours after meals).
Dizziness, headache, diarrhea, nausea, stomach pain, change in taste sensation or dry
mouth may occur. If these effects persist or worsen, contact your doctor. Unlikely but report:
seizures, loss of consciousness, tingling of hands or feet. Very unlikely but report: unsteadiness,
mood/mental changes, rash, itching, sore throat, fever, severe stomach pain, vomiting, vaginal
irritation. This drug may cause urine to darken in color. This is not harmful. In the unlikely
event you have an allergic reaction to this drug, seek immediate medical attention. Symptoms of
an allergic reaction include: rash, itching, swelling, dizziness, trouble breathing.
Contraindication
Hypersensitivity to metronidazole, nitroimidazole derivatives, or any component of the formulation;
pregnancy (1st trimester - found to be carcinogenic in rats)
Client Teaching
Alcoholic beverages should be avoided while taking Metronidazole and for at least one day
afterward.
Patients should be counseled that antibacterial drugs including Metronidazole tablets should
only be used to treat bacterial infections. They do not treat viral infections (e.g., the common
cold). When Metronidazole tablets are prescribed to treat a bacterial infection, patients should
be told that although it is common to feel better early in the course of therapy, the medication
should be taken exactly as directed. Skipping doses or not completing the full course of therapy
may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood
that bacteria will develop resistance and will not be treatable by Metronidazole tablets or other
antibacterial drugs in the future.
Measures that Potentiate the Action of the Drug
Metronidazole has been reported to potentiate the anticoagulant effect of warfarin and
other oral coumarin anticoagulants, resulting in a prolongation of prothrombin time. This
possible drug interaction should be considered when Metronidazole is prescribed for patients
on this type of anticoagulant therapy.
The simultaneous administration of drugs that induce microsomal liver enzymes, such
as phenytoin or phenobarbital, may accelerate the elimination of Metronidazole, resulting in
reduced plasma levels; impaired clearance of phenytoin has also been reported.
The simultaneous administration of drugs that decrease microsomal liver enzyme

activity, such as cimetidine, may prolong the half-life and decrease plasma clearance of
Metronidazole. In patients stabilized on relatively high doses of lithium, short-term
Metronidazole therapy has been associated with elevation of serum lithium and, in a few cases,
signs of lithium toxicity. Serum lithium and serum creatinine levels should be obtained several
days after beginning Metronidazole to detect any increase that may precede clinical symptoms
of lithium intoxication.
Alcoholic beverages should not be consumed during Metronidazole therapy and for at least one
day afterward because abdominal cramps, nausea, vomiting, headaches, and flushing may
occur.
Psychotic reactions have been reported in alcoholic patients who are using Metronidazole and
disulfiram concurrently. Metronidazole should not be given to patients who have taken
disulfiram within the last two weeks.
7 Identified Nursing Diagnoses: Post-operation
1. Acute Pain related to surgical incision in the umbilical area secondary to surgery
2. Impaired skin integrity related to surgical incision in the umbilical area
3. Impaired physical mobility related to pain secondary to surgery
4. Risk for infection related to skin break secondary to surgery
5. Risk for imbalanced nutrition: less than body requirement
6. Risk for alteration in bowel elimination related to postoperative immobilization.
7. Knowledge deficit related to the recurrence of condition

Cues/Data Nursing Rationale Goals of Care Nursing Rationale Evaluation

Diagnosis Interventions
Subjective Data: P: Acute Pain The source of Short Term: Independent Short Term:
Ms. Vitug E: Related to postoperative After 15-30 Intervention: After 15-30
verbalized, surgical incision pain in the minutes, the -Anticipate -One can most minutes, the
“Kakatapos pa in the umbilical injury induced patient will: need for pain effectively deal patient was able to
lang ng operation area secondary to release of 1. Follow relief. with pain by identify the
ko kahapon… surgery chemical prescribe preventing it. indication of the
kaya masakit As manifested by: mediators that pharmacological Early intervention prescribed
pa…nanghihina Ms. Vitug occurs with the regimen may decrease the pharmacological
pa din ko.” verbalized, acute 2. Verbalize total amount of regimen. She had
“Ang hirap “Kakatapos pa inflammatory non- analgesic required. recognized the use
tumawa kasi lang ng operation response. pharmacologic of
kumikirot yung ko kahapon… Bradykinin, methods that -Respond -In the midst of nonpharmacologic
sugat.” kaya masakit substance P, and provide relief to immediately painful methods that
“Masakit pa…nanghihina prostaglandins pain. to complaint experiences a provide relief and
talaga..nasa 7 pa din ko.” “Ang are released 3. Demonstrate of pain. patient’s demonstrated use
ganun…di ko p hirap tumawa from the injured use of relaxation perception of time of relaxation skills
nga kaya kasi kumikirot cells. Pain skills and may become and diversional
kumilos.” yung sugat.” stimuli sensitize diversional distorted. Prompt activities, as
“Masakit pain receptors activities, as responses to indicated for her.
Pain Scale = 7/10 talaga..nasa 7 so that once the indicated, for complaints may Goal met.
ganun…di ko p brief period of individual result in decreased
Objective Data: nga kaya injury is over; situation. anxiety in the Long Term:
 Grimacing kumilos.” long-standing patient. After 3-4 days of
 Guarding charges on the Long Term: nursing
or neurons After 3-4 days of -Eliminate - Patients may intervention, the
protective Pain Scale = 7/10 maintain the nursing additional experience an patient used the
behavior  Grimacing pain post- intervention, the stressors or exaggeration in non-
on her  Guarding operatively. patient will: sources of pain or a pharmacological
abdomen or Presentation of 1. Show discomfort decreased ability way to decrease

 Self- protective intra-operative improvements whenever to tolerate painful and control pain
focusing behavior pain in handling pain possible. stimuli if by means of
BP – 160/110 on her transmission 2. Decrease environmental, listening to radio
mmHg abdomen may reduce post independence intrapersonal, or while taking a
RR – 20 cpm  Self- operative pain on taking intrapsychic rest. Therefore,
PR – 88 bpm focusing perception analgesics factors are further she was able to
CR – 92 bpm BP – 160/110 Focus on 3. Maintain stressing them. manage and
mmHg Pathophysiology relief from pain handled it and the
RR – 20 cpm by Barbara L. without -Provide rest -The patient’s patient verbalized
PR – 88 bpm Bullock and Reet pharmacological periods to experiences of relief of pain.
CR – 92 bpm L. Henze regimen facilitate pain may become
p. 1056 4. Report pain is comfort, exaggerated as the Goal Met
relieved/ sleep, and result of fatigue.
controlled relaxation.
-Encourage -Listening to
diversional music, radio,
activities watching T.V can
along with help draw out the
breathing attention from the
exercises and pain felt and can
other reduce muscle
relaxation tension as a
skills method to
alleviate it, non-
pharmacologically,
which can
minimize the use
of
pharmacological
regimen
Dependent
Intervention:
-Nalbuphine -Administer
HCL ½ cc medication
IVF as PRN whenever the pain
medication is beyond
tolerance as stated
by the patient.
Cues/Data: Nursing Rationale Goals of Care Nursing Rationale Evaluation

Diagnosis Intervention
Subjective: P: Impaired Skin Injury to the Short Term: Independent Short Term:
“Medyo masakit Integrity skin and After 15- 30 Intervention: The patient
pa nga kasi E: Related to surrounding minutes of -Assess incision -This provides understands
kahapon lang surgical incision soft tissue can nursing site and evidence of the indication of
natapos…mga in the umbilical occur from intervention, the dressing every effectiveness of avoiding
alas tres…” area sharp object, patient will: shift. Describe skin care prolonged
“Nangangati pero As manifested by: blunt force 1. Communicate and document regimen pressure, and
kaya naman tiisin. injury, scraping understanding its condition using skin
” As verbalized  History of mechanisms or of skin and report protective
by Ms. Vitug past bites resulting protection changes. measures and
abdominal in lacerations, measures was able to
Objective: surgery contusions, 2. Demonstrate -Assist with - The patient is demonstrate
 History of  Disruption abrasions, skin inspection general hygiene immobile and skin inspection
past of the skin avulsions, or technique and comfort personal techniques.
abdominal integrity punctured measures hygiene is Goal met.
surgery at the wounds essential for
 Disruption umbilicus Long Term: skin care Long Term:
of the skin  With skin Reference: After 3-4 days of protection and After 3-4 days
integrity stapler Medical- nursing providing of nursing
at covered Surgical intervention, the comfort intervention the
umbilicus with Nursing 6th patient will: - Always patient was able
 With skin simple Edition by Black 1. Demonstrate provide and -In order to to apply the
stapler dressing @ et. al skill in caring of keep the area prevent any skills in caring
covered Umbilical Page 2279 incision, clean and dry complication, for the incision
with area dry perform skin the surrounding site with
simple and intact care routine must be kept dressing

dressing @ 2. Report clean and dry without
Umbilical “Medyo masakit discharges and -Warn against tampering it
area dry pa nga kasi changes in the tampering with and seen as dry
and intact kahapon lang dressing the wound or -Instruct the and intact. Goal
natapos…mga immediately. dressing patient never met
alas tres…” alter the
“Nangangati pero dressing to
kaya naman tiisin. encourage
” As verbalized compliance and
by Ms. Vitug protect wound
-Instruct the
patient or -Any untoward
family member changes in the
to report any condition of the
changes to the patient must be
condition of the reported to
incision site or address the
the dressing. problem
immediately
Dependent
Intervention:
-Nalbuphine ½
cc IVF as PRN -Administer
medication pain medication
as a way of
comfort
measure and
relief. Because
muscle tension
may potentiates
stress on the
site.
Cues/Data: Nursing Rationale Goals of Care Nursing Rationale Evaluation

Diagnosis Intervention
Subjective: P: Impaired Short Term: Independent Short Term:
“Kakatapos pa physical After 30 Intervention: After 3o minutes of
lang ng mobility minutes of -Observe the -Changes may nursing intervention
operation ko E: Related to nursing patient’s indicate the patient was able
kahapon…kaya pain secondary intervention, functional ability progressive to recognize and
masakit pa… to surgery the patient daily. decline or verbalize the need
nanghihina pa As manifested will: improvement and willingness to
din ko.” by: 1. Verbalize from the surgery. participate in the
“Masakit  Unable understanding treatment and
talaga..nasa 7 to sit or of the activities. Goal met.
ganun…di ko p stand treatment -Provide comfort -Using of side
nga kaya  Needs regimen and and safety rails to prevent
kumilos.” assistanc safety measures. any injury.
As verbalized by e with measures.
Ms. Vitug ADL 2. Verbalize -Discuss the use of -There are many
 Difficulty willingness to diversional ways to divert
turning participate in activities and one’s attention in
Objective: performing other order to handle
 Unable “Kakatapos pa care and nonpharmacologic pain. This will
to sit or lang ng activities way to relief pain. help the patient
stand operation ko indicated for achieve a sense of
 Needs kahapon…kaya the patient control. Long Term:
assistanc masakit pa… After 3-4 days of
e with nanghihina pa Long Term: nursing intervention
ADL din ko.” After 3-4 days -Encourage to -This prevents a the patient used
 Difficulty “Masakit of nursing participate in self- decrease in both the
turning talaga..nasa 7 intervention, care and activities muscle tone and nonpharmacological
ganun…di ko p the patient if tolerated promotes sense of and
nga kaya will: well-being pharmacological

kumilos.” 1. State a relief -Provide a stress- -Any stimulus way to relief from
from pain free surrounding that can catch the pain but unable to
through non- attention will increased in
pharmacologic cause tension thus mobility. Goal
and always provide a partially met.
pharmacologic quite
regimen. environment.
2. Show
increased in
mobility Dependent
Intervention:
- Nalbuphine ½ -Administer
cc IVF as PRN analgesics to
meds alleviate pain and
maintain patient’s
functional activity
level if
nonpharmacologic
treatment was not
successful
Cues/Data Nursing Rationale Objectives of Care Nursing Rationale Evaluation

Risk Factors: P: Risk for Open wounds, Short term: Independent: Short term:
Infection traumatic or surgical, After 15-30 -Assess for the
E: Related to can be sites for minutes of integrity of -Each of these After 15-30
skin break, infection; soft tissues nursing wound dressing examples minutes of
indwelling (cells, fat, muscle) and interventions, the and presence of represents a nursing
catheter and organs (kidneys, lungs) patient will be indwelling break in the interventions, the
intravenous can also be sites for able to: catheter, and
body’s normal patient was able
device infection either after 1. Verbalize intravenous lines
trauma, invasive understanding of first lines of to verbalize
procedures, or by individual -Maintain or defense. understanding of
invasion of pathogens causative/risk teach asepsis for individual
carried through the factors of dressing changes causative/risk
bloodstream or infection and wound care, factors of
lymphatic system. 2. Demonstrate catheter care and infection and
Infections can be techniques to handling, and
-Most antibiotics demonstrated
transmitted, either by reduce infection peripheral IV and
contact or through central venous work best when a techniques to
airborne transmission, Long Term: access constant blood reduce infection
sexual contact, or After 2-3 days of management. level is
sharing of intravenous nursing maintained; a
(IV) drug paraphernalia. interventions, the constant blood
patient will be Long Term:
level is
Reference: able to:
maintained when After 2-3 days of
http:// 1. Remain free of
www1.us infection, as medications are nursing
.elsevierhealth evidenced by taken as interventions, the
.com normal vital signs prescribed. The patient was able
/MERLIN and absence of absorption of to
/Gulanick purulent drainage -Review some antibiotics
/Constructor from wounds, laboratory studies
/index.cfm?plan=32 incisions, and for systemic is hindered by remain free of

tubes. infection certain foods; infection, as
patient should be evidenced by
-Maintain
instructed normal vital signs
dependent
accordingly. and absence of
gravity drainage
of indwelling purulent drainage
catheters, tubes, from wounds,
and/or positive -Increased WBC incisions, and
pressure of tubes.
count may
parenteral or
irrigation lines indicate ongoing
infection
-Apply sterile
dressing
-Prevents stasis
and reflux of body
Collaborative: fluids
-Provide and
document
copious wound
irrigations; e.g.,
saline, water,
antibiotics or anti
septic
-Administer
antibiotics as
indicated
-Prevents
environmental
contamination of
fresh wound
-Wash hands and
teach other
caregivers to
wash hands
before contact
with patient and -May be used
between post operatively
procedures with
to reduce
patient.
bacterial counts
-Teach patient to at surgical site
take antibiotics as and cleanse the
prescribed. wound of debris
-Teach patient
and caregiver the
signs and -May be given
symptoms of
infection, and
when to report
these to the
physician or
nurse.
Cues/Data Nursing Rationale Goals of care Nursing Rationale Evaluation

Risk Factors; P: Risk for Many Severely Short Term: Independent: Short Term:
 Restriction Imbalanced illed or After 15-30 minutes -Provide oral -Prevents After 15-30
of fluids Nutrition: Less hospitalized of nursing hygiene on a discomfort of dry minutes of
and food than body clients interventions, the regular, frequent mouth and nursing
 Change in requirements experiencing patient will be able basis, including cracked lips interventions,
digestive E: Related to trauma are at to: petroleum jelly for caused by fluid the patient is
process/ Change in diet risk for protein- 1. Understand lips restrictions able to
absorption secondary to calorie the purpose understands the
of nutrients surgery malnutrition of restricting -Auscultate for
-Peristalsis can be purpose of
(PCM), also her diet resumption of
expected to restricting her
known as protein 2. Verbalize any bowel sounds andreturn about the diet and
energy changes in note passage of third post op day, verbalized any
malnutrition her body flatus signaling changes in her
(PEM). This readiness to body
problem Long Term: resume oral
presents After 2-3 days of intake Long Term:
clinically when nursing interventions, After 2-3 days of
metabolic stress the patient will be -Monitor nursing
is imposed on a able to: tolerance to fluid interventions,
chronically 1. Maintain and food intake the patient is

starved client. stable weight (when resumed), able to maintain
The outcome of with noting abdominal stabled weight
unrecognized or normalization distention, report with normal of
untreated PCM is of lab. values of increased lab. values and
often 2. Be free of pain/cramping, showed free of
dysfunction or signs of Nausea and signs of
disability and malnutrition vomiting malnutrition
increased
morbidity or -Note admission
mortality. weight and -Provides
compare with information
subsequent about adequacy
reading of dietary intake/
determination of
Collaborative: nutritional needs
-Administer IV
fluids, parenteral, -Meets
or enteral fluid/nutritional
nutrition as needs until oral
indicated intake can be
resumed
-Progress diet as
tolerated,
advancing from -Intake is
clear liquid to advanced
bland diet with gradually to
several small prevent gastric
feedings irritation /
distention
VI. Discharge Planning

Sample Case Study

Загружено:

Сведения о документе

Исходное описание:

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Sample Case Study

Загружено:

Авторское право:

Доступные форматы

METROPOLITAN HOSPITAL COLLEGE OF NURSING

# 1357 Masangkay cor. Mayhaligue Sta. Cruz Manila

SCOPE AND LIMITATION

I. REVIEW OF ANATOMY AND PHYSIOLOGY OF AFFECTED ORGANS

IV. MEDICAL MANAGEMENT

V. NURSING CARE PLAN

VI. DISCHARGE PLAN

An umbilical hernia appears as a soft bulge at the navel (umbilicus). It is caused by a

A hiatal or diaphragmatic hernia is different from abdominal hernias in that it is not

SCOPE AND LIMITATIONS

I. Review of Anatomy and Physiology of Affected Organs

5. Some absorption of substances such as alcohol.

Surface Anatomy of the Abdominal Wall

Anatomic Location of Organs by Quadrant

Right kidney and adrenal Left kidney and adrenal

Other internal fascia with relation to surrounding structures

Cremasteric fascia: Intermediate covering layer of the spermatic cord.

The Anterior Abdominal Wall

Skin and subcutaneous tissue:

Weakening of abdominal wall Increased Abdominal

Protrusion of bowel to the

Decreased blood supply to Obstruction of the

Wall of intestine become

Increased intestinal pressure

Venous stasis increases

Family Age Gender Educational Occupation Position Relationship

- Male - Deceased male ? - Unknown cause of death

- Female - Decease female - with present illness

Family Health History

Past Health History

Present Health History

In the theory of Erik Erikson

State Late Adulthood: Integrity vs. Despair

In the theory of Robert Havighurst

children and grandchildren.

EATING Before Illness During Illness After

2 pieces 2 pieces 2 pieces

DRINKING Before Illness During Illness After

SLEEPING Before Illness During Illness After

BATHING Before Illness During Illness After

ELIMINATION Before Illness During Illness After

BOWEL Before Illness During Illness After

Brown Brown Brown

Before Illness During Illness Analysis

magpahinga abdomen aches.

Before Illness During Illness Analysis

Before Illness During Illness Analysis

Before Illness During Illness Analysis

Before During After

Before Illness During Illness Analysis

Body Systems Past state of health Present state of Analysis

ako mataas na blood Umiinom pa rin ako maintinance of

matagal na din ‘to. nakabaluktot na…

Body Technique Normal Actual Findings Remarks

Scalp and Inspection  Evenly  Evenly Abnormal

Face Inspection  Symmetrical  Symmetrical Normal

unison with moves in

 Pink color  Moves

Thorax Auscultation  Normal  RR = 20 cpm Normal

Palms Inspection  No lesions  Warm to Abnormal

Legs Inspection  Equal size  Equal size Abnormal

DATE TIME TREATMENT NURSES OBSERVATION

Foley catheter to urine bag