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College of Nursing
Capitol Site, Batangas City
Presented By:
Karen Michelle B. Lecaroz
BSN 3-5
Presented To:
Annabelle Iturralde MD, RN
(clinical Instructor)
11. Enumerate all the references used to make the case more
effectively and much clearer.
PATIENT’S PROFILE
NAME: Patient X
AGE: 13 years old
SEX: Female
DATE OF BIRTH: January 5, 1995
CIVIL STATUS: Child
ADDRESS: Balibago, Rosario, Batangas
NATIONALITY: Filipino
RELIGION: Roman Catholic
DATE OF ADMISSION: December 8, 2008
ATTENDING PHYSICIAN: Dr. Tenorio/ Lanting/ Ilagan
CHIEF COMPLAINT: high fever and abdominal pain
ADMITTING DIAGNOSIS: Blunt abdominal Injury secondary to
fall
FINAL DIAGNOSIS: Hemoperitoneum secondary to jejunel
perforation secondary to blunt
abdominal injury.
CLINICAL APPRAISAL
Past Health History
The patient’s immunization was completed during
childhood. She has no known allergies to any drugs and
foods. She was never been involved in any accident and
serious injuries. It is her 1st time to be admitted at Batangas
Provincial Hospital. She takes over the counter drugs for
simple illnesses that she usually acquires. Paracetamol for
fever and Neozep for colds.
Family History
She have 2 siblings ages 21 and 25 both working at the
mango farm near to their house. There is no known family
history of heart disease, cancer, diabetes, mental disorders,
PTB, HPN or any communicable disease.
Personal history
She is a 2nd year High school student and fond of
playing with her cousins during weekends. According to her,
she usually eats egg, fish and vegetables and rarely eats pork
and beef. She sleeps for 8 hours a day.
Social History
They lived in a community in which, according to her, can
be considered safe. Their house is made up of cement but
mostly wood and it is located near the mango farm her family is
working. According to her father, their income is just enough to
meet their daily needs.
Psychological History
The major stressor they experience is financial problem,
because their family job is seasonal and sometimes they didn’t
know where to get money to buy food.
History of Present Illness
>Absence of >Normal.
masses or
nodules.
>Head >Normal.
circumference of
52 cm.
Face >Inspection >Facial features >Normal.
and facials
movements are
symmetrical.
BODY PART METHOD FINDINGS ANALYSIS
Eyes
>Eyebrow >Inspection >symmetrically aligned. >Normal.
>Symmetric >Normal.
movements caused by
respiration
>Abnormal.
Decrease
Hematocrit level
indicates massive
blood loss.
December 9, 2008
ULTRASOUND
The upper portion includes the pylorus, the opening at the lower part of
the stomach, through which the contents of the stomach pass into the
duodenum.
The middle part of the small intestine, extending from the duodenum to
the ileum, is called the jejunum, and the terminal portion is the ileum, which
leads into the side of the first part of the large intestine, the cecum.
The lining membrane, or mucosa, of the small intestine is especially
suited for the purpose of digestion and absorption.
The mucosa is folded; the folds are covered with minute mucosal
projections called villi.
Tiny glandular pits, called the crypts of Lieberkühn, open at the bases
of the villi; these pits secrete the enzymes necessary for intestinal
digestion.
Digested carbohydrates and proteins pass into the capillaries of the villi
and then to the portal vein, which enters the liver; digested fats are
absorbed into the lacteals in the villi, and they are transported through the
lymphatic system into the general bloodstream.
FEMALE
EATING PATTERN
DEFORM HOLLOW ORGANS AND TRANSIENT TEARS AND SUBCAPSULAR HEMATOMA TO THE
INCREASE INTRALUMINAL PRESSURE SOLID VISCERA
ACUTE
JEJUNAL PERFORATION ABDOMINAL PAIN
HEMORRHAGE
HEMOPERITONEUM
SUMMARY OF PATHOPHYSIOLOGY
Eating and playing pattern as well as the environment and Socio-
economic status are under modifiable factor. Age, gender and
compression or concussion forces are factors that cannot be modify.
Compression or concussive forces may result from direct blows or
external compression against a fixed object. The force cause tears
and subcapsular hematomas to the solid viscera. These forces also
may deform hollow organs and transiently increase intraluminal
pressure, resulting in rupture. This transient pressure increase is a
common mechanism of blunt trauma to the small intestine. Acute
hemorrhage, jejunal perforation and abdominal pain was felt by my
patient having Hemoperitoneum.
NURSING CARE
PROCESS
ASSESSMENT NURSING SCIENTIFIC PLANNING
DIAGNOSIS EXPLANATION
S> “Ang init po Elevated body Is usually caused After 3 hours of
ng pakiramdam temperature by bacterial nursing
ko ngayon!” related infection invasion as a intervention the
secondary to result of patient will
O> 39°C intra abdominal contamination of maintained body
bleeding. the peritoneum temperature from
>Hot skin through the 39°C to 37°C.
vascular system.
>Irritable (Medical-Surgical
Nursing, Critical
Thinking for
>Poor skin turgor collaborative care,p.
1341)
>tachypneic– 30
breaths per
minute
INTERVENTION RATIONALE
>Determined >Identification and management of underlying cause
precipitating factors. are essential to recovery.(Nursing Care Plan 6th edition,
Gulanic/Myers)
>Provided Tepid >May reduce fever. (Delmar’s Pediatric NCPs 3rd edition,
Luxner)
Sponge Bath.
INTERVENTION RATIONALE EVALUATION
>Set short-range goals with the >Assisting the patient to set realistic
patient. goals will decrease frustration.
(Nursing Care Plan 6th edition,
Gulanic/Myers)
INTERVENTION RATIONALE
Dressing / grooming >Patients may take longer to
> Provided privacy during dress and may be fearful of
dressing. breaches in privacy.
(Nursing Care Plan 6th
edition, Gulanic/Myers)
Route:
IV
Frequency:
Q8
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >Assess patient for >May increase
patients hypersensitive to abdominal pain. Note creatinine and ALT
drug and those with acute presence of blood in levels.
porphyria. emesis, stool or gastric
aspirate. >May cause false-
>Use cautiously in positive results in urine
patients with hepatic >Drug may be added to protein test using
dysfunction. Adjust total parenteral Multistix.
dosage in patients with solutions.
renal function.
NORMAL VALUES:
Creatinine=18-35
ALT=10-35 u/L
NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION
Generic Name: >Non-Steroidal >Short term >Headache
Ketorolac Anti-inflammatory management of
Tromethamine Drugs. moderately >Dizziness
severe, acute
Brand Name: >May inhibit pain for single >Drowsiness
Toradol prostaglandin dose treatment.
synthesis, to >Sedation
Dose: produce anti-
15mg inflammatory, >GI pain
analgesic and
Route: antipyeretic >Constipation
IV effects.
>Vomitting
Frequency:
Q8 >Pain at injection
site
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >Correct hypovolemia >May increase ALT and
patients hypersensitive before giving. AST levels.
to drug and in those
with active peptic >ALERT: the maximum >May increase bleeding
disease; recent GI combined duration of time.
bleeding or perforation, parenteral and oral
advance renal therapy for 5 days.
impairment,
cerebrovascular >When appropriate,
bleeding, hemorrhagic give by deep IM
diarthresis, or injection. Patient may NORMAL VALUES
incomplete hemostasis, feel pain at injection ALT= 10-35 unit
and in those at risk for site. Put pressure on Bleeding Time= 3-10
renal impairment from site for 15-30 seconds minutes
volume depletion or at after injection to
risk for bleeding. minimize local effects.
NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION
Generic Name: >Peri-operative >Fever
Cefotaxime Cephalosporins prevention in
Sodium contaminated >Headache
3rd generation surgery
Brand Name: cephalosporin that >Dizziness
Claforan inhibits cell wall
synthesis,
Dose: promoting osmotic
500 mg instability; usually
bactericidal.
Route:
IV
Frequency:
Q8
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >Before giving drugs, >May increase alkaline
patients hypersensitive ask the patient if he is phosphate, ALT, AST,
to drug or other allergic to penicillins or bilirubin, GGT and LDH
cephalosporin. cephalosporins. levels.
NORMAL VALUES
ALT=10-35 unit
AST=15- 30 U/L
Prognosis
The prognosis is fair although the client’s pain
has subsided, there is still a risk for infection at the
incision site.
M Instructed the significant others to give home medications that the physician
will prescribe upon discharge.
T Advised client and significant others to clean the incision site to prevent
further complications.
D Advised relatives to have the client eat foods that are good for her health
and need for her body requirements.
S Advised the client and significant others to keep her faith in GOD and