Diverticulitis

Caro, Nyco - Leader

Anchos, Madelaine
G.
Lara, Myrlanie
Flores, Marimar
Nadal, Denise
Patricia

Diverticulitis
A common digestive disease
which involves the formation
of pouches (diverticula)
within the bowel wall.
Typically occurs within the
large intestine, or colon,
although it can occasionally
occur in the small intestine
as well.
Is acute inflammation and
infection caused by trapped
fecal material and bacteria.

Patients Information

Patient's Name: Mrs. E. M.

Gender: Female
Age: 65
Birthdate: 05/04/1949

Date Admitted: 06/20/2014

Chief of Complaint: Pain in the anal area with constipation

History of present illness:

4 days PTA, patient was noted to have tenesmus, with
feeling of bloatedness. Symptoms persisted, now with
abdominal pain described as crampy sought consult at
Angono Medical Hospital, given Hemostan and Tramadol.

Patients Information
Past Health History:
- May 30, 2014- +UTI
- June 04, 2014- + Complicated UTI
S/P ureteral stenting
+ PTB
History of present illness:
The patient is E.M., non-hypertensive, nondiabetic, a housewife, previously fully
functional with urinary incontinence problem,
who is referred for geriatric evaluation

Patients Information
Present illness started 2 months PTA, when she was
admitted twice at Baras Rizal Hospital initially
because of chills and second for vomiting: the
relatives were not sure if she was diagnosed to
have UTI for those confinements. After those
confinements the patients was noted to be weak,
needing assistance in walking, transferring/ getting
up and bathing.
A week PTA, the patient was admitted at Queen
Mary Hospital for ureteral stenting.
3 days PTA, the patient had been complaining of
constipation.
1 day PTA, the patient had an episode of abdominal
pain and melena.
On the day of the Admission, the patient was

Patients Information
Physical Examination
General: Weak-looking
VS: BP: 140/80 HR: 82
RR:18
Skin: grayish skin, dry skin, pressure sore Grade 1
Sacral area
HEENT: pale conjunctiva, anicteric scheral, (-) neck
vein engorgement
CVS: NRRR, (-) murmur
C/L: (+) ralesmid to base right lung and (+) basal
rates left lung,
(-) wheeze
Abdomen: soft, non-tender, (-) ornagomegaly
Extremities: (+) bipedal edema, (+) edematons

Patients Information
Mental status Examination:

The patient was quiet during the interview. Most of the

information was given by the husband and the patients
daughter, affect is appropriate. When she saw her
visitor, she smiled and greeted her cheerfully, saying the
visitors name. She was hesitant in answering the
questions in the geriatric Depression Scale (GDS). She
answered it in a soft voice and a hurt feeling was
observed during that time. After finishing the GDS, it
was noted that she could no longer focus during the Mini
Mental Status Examination. Questions need to be
repeated and she would suddenly doze off during
question. When asked if she was sleepy, she answered
NO

Patients Information
During the MMSE, the patient was
able to identify that is in Lourdes
Hospital, at the ground floor and that
Lourdes Hospital is in Manila. When
asked what the date was, she
answered July 5, which was correct,
but failed to say the right year. The
MMSE was not completed because
the patient could not focus for a long
time

Phatophysiology

Anatomy & Physiology

Hematology (Previous)

Hematology (Latest)

CT Scan

Urinalysis PTA

Urinalysis

Colonoscopy

Cholesterol

ABG

ABG

Bacteriology

X-ray Report

BUN (latest)

Drug Analysis

Drug Analysis

Drug Analysis

Drug Analysis

Drug Analysis

Drug Analysis

Drug Analysis

Drug Analysis

Nursing Care Plan (Actual)

Nursing Care Plan

(Potential)

Discharge Planning
Medications
Exflem 600mg/tab 1/2glass of water
(8am) OD
Pantoprazole 20mg, 40mg/ tab (8am) OD
Dilantin 100mg/cap (8am) TID
Calmoseptine ointment (as needed)

Environment
Foods should be prepared properly and
clean.
Avoid exposed food to prevent spoilage
and to decrease bacterial growth
Go to places that are not crowded and
well ventilated
Maintain humid environment

Discharge Plan
Treatment
Work with the physical therapist to
practice reflex
Talk to someone to verbalize feelings
or concerns
Apply ointment for bedsores to
moisten wound
Turn position every 2 hours
Health Teaching
Adequate fluid intake
Encourage exercise
Encourage deep breathing
Encourage to visit health care provider
Educate relatives on how to perform
proper NGT feeding

Discharge Plan
Outpatient
Seek physician for monthly/
follow-up check-up.
Diet
Folllow diet plan prescribed
by the doctor.
OF (1,500 Kcal)
6 equal feeding + 50 cc
flushing
Spiritual
Pray everyday
Ask for assistance in the

Thank you
&
God bless you!!! =))