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METROPOLITAN HOSPITAL COLLEGE OF NURSING

#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

INTRODUCTION

Amoebiasis is due to invasion of the intestinal wall by the protozoan parasite Entemoeba
histolytica. Amoebic colitis results from ulcerating mucosal lesions caused by the release of
parasite-derived hyaluronidases and proteases. It refers to infection of man by Entamoeba
hystolytica initially involving the colon but which may spread to other soft tissues organs by
contiguity or by hematogenous or lymphatic dissemination most commonly to the liver and lungs.

It is a worldwide parasitic disease. It creates many medical and surgical problems. About
15 to 20 per cent of Indians are affected by the parasite. It can be acute and chronic and can have
intestinal and extra-intestinal manifestations. The causative organism is a protozoa which remains
in the large intestine and can be transmitted to other organs like liver, lungs, brain, spleen and skin
etc. It is transmitted through contaminated food, water and infected human feaces.

Amoebiasis can occur at any age. There is no gender or racial difference in the occurrence
of the disease. It is a household infection and the human being is responsible for spreading the
disease. Most of the infected people remain asymptomatic (without symptoms) and are called as
healthy carriers. If one person in a family gets infected with the parasite, other family members are
at the great risk of infection. The human carrier can discharge up to 1.5x107 cysts per day.

Pathogenic amoeba which produce condition of a great clinical variation:

Acute Amoebic Dysentery


- stools contain blood and mucus which may give rise to amoebic hepatitis or liver abscess

Chronic Amoebic Dysentery


- with recurrent attack of diarrhea or relatively mild dysentery

Amoebic Colitis
- characterized by periods of constipation and diarrhea and episodes of abdominal discomfort
frequently stimulating appendicitis

History of Discovery

Human infections of the parasite are not a recent phenomenon. The earliest record of
symptoms of the disease—bloody, mucose diarrhea—was from the Sankskrit document Brigu-
samhita, written at around 1000BC. Assyrian and Babylonian texts also have references to the
diseases, with descriptions of blood in the feces, thus suggesting that amoebiasis occurred in the
Tigris-Euphrates basin before the sixth century BC. Later records were able to distinguish bacterial
infections with those of amoebic origin: epidemics of dysentery by itself are more likely to result
from bacterial infections, while dysentery that is associated with disease of the liver is more likely
to be caused by amoeba. Thus, around the second century AD, there was clearer understanding of
the association between liver abscesses and amoebas.
Around the 16th century, amoebiasis became more widespread in the developed world, mostly due
to the growth of European colonies and increased world trade. There had been many clear
descriptions of the hepatic and intestinal forms of amoebiasis, considered as the cause of a “bloody
flux” spreading through Europe, Asia, Persia, and Greece. The first accurate description of both
forms of the disease came from the book Researches into the Causes, Nature and Treatment of the
More Prevalent Diseases of India and of Warm Climates Generally by James Annersley, written in

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

the 19th
century.

Considering their small size, protozoans were difficult to identify before the invention of
the microscope in the 17th century. The causal agent, Entamoeba histolytica, was discovered in
Russia in 1873 by Friedrich Losch. His early observations came from the case of a young farmer
who had from been suffering chronic dysentery. In his diagnosis, Losch found large numbers of of
amoeba in his feces and associated the amoebas to be the cause of the dysentery.

Causative Agent
Entamoeba histolytica

Entamoeba histolytica is an anaerobic parasitic protozoan, part of the genus Entamoeba. It


infects predominantly humans and other primates. It is estimated that about 50 million people are
infected with the parasite worldwide.

The active (trophozoite) stage exists only in the host and in fresh loose feces; cysts survive
outside the host in water, soils and on foods, especially under moist conditions on the latter. The
cysts are readily killed by heat and by freezing temperatures, and survive for only a few months
outside of the host.[1] When cysts are swallowed they cause infections by excysting (releasing the
trophozoite stage) in the digestive tract. The trophozoite stage is readily killed in the environment
and cannot survive passage through the acidic stomach to cause infection.

E. histolytica, as its name suggests (histo–lytic = tissue destroying), causes disease;


infection can lead to amoebic dysentery or amoebic liver abscess. Symptoms can include
fulminating dysentery, diarrhea, weight loss, fatigue, abdominal pain, and amebomas. The amoeba
can actually 'bore' into the intestinal wall, causing lesions and intestinal symptoms, and it may
reach the blood stream. From there, it can reach different vital organs of the human body, usually
the liver, but sometimes the lungs, brain, spleen, etc. A common outcome of this invasion of
tissues is a liver abscess, which can be fatal if untreated. Ingested red blood cells are sometimes
seen in the amoeba cell cytoplasm.

Trophozoites are amorphous and range from 20-40um in diameter, and contain one
nucleus. They use a well-defined pseudopodium for their rapid, gliding locomotion. This
pseudopodium is often extended greatly, such that there is no conspicuous differentiation between
ecto- and endoplasm. It was originally thought to lack mitochondria, but recent evidence of
nuclear-encoded mitochondrial genes and a remnant organelle proves otherwise.

The cyst, which is capable of surviving in harsh environments as well as in the human
stomach and small intestine; thus it is the cyst form that transmits the disease
The trophozoite, which is involved in the actual infection of the host by invading the host
epithelial cells
Infection begins through fecal-oral contamination. Initially, a person ingests fecallly contaminated
food or water that contains the E. histolytica cysts. The cysts then pass through the stomach and
small intestine (if any trophozoites were ingested, they would die from the acidic gastric juices of
the stomach) and travel to the bowel lumen, where they excyst (with the help of the enzyme
trypsin). Thus, the potentially invasive trophozoite form is released into a safer environment in
which they can exist and cause infection. A total of four trophozoites emerge from each cyst.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Most
asymptomatic
colonization (90% of all infections) arise because the trophozites end up aggregating in the
intestinal mucin layer and form new cysts, thus leading to a self-limited and asymptomatic
infection. But in some cases (which accounts for the 10% of those who are both infected and
symptomatic), the trophozoites adhere to and lyse the colonic epithelium, mediated by the GalNAc
lectin that initiates invasion of the colon. Further damage at the site of invasion is caused by the
presence of neutrophils that comes in as a response to the invasion. In the process of invasion in
the large intestine, the trophozoites also interact with enteric bacteria, adapt to the changing
oxygen environment, and ingest erythrocytes. Once the trophozoites have invaded the intestinal
epithelium, they may pass through damaged blood vessels and travel extraintestinally to invade the
peritoneum, liver, lung, brain, and other sites.

Trophozoites are often carried in feces along with mucous and red blood cells. But what
continues the cycle of infection from human to human is that most of the trophozoites encyst
(convert into the cyst form) at the end of the large intestine and are passed through feces and
contaminate soil, grass, fruits and vegetables, dirty hands, water and food. Since the cysts can
survive the harsh environment outside, they go on to spread the infection. Through all these
sources, the cyst can once again enter the digestive tract and continue the infectious cycle. The
amoeba goes through asexual reproduction by binary fission

Mode of Transmission
Fecal-Oral Route

Amoebiasis occurs when E. histolytica parasites are somehow ingested—either taken in by


mouth, eaten or swallowed something infected with the parasite, or through person-to-person
spread. Those infected (though not necessarily symptomatic), pass the parasite through their
stools, and their contaminated hands can spread the parasites to surfaces and objects which will be
touched by other people. In some situations, the disease can also spread sexually by oral-anal
contact. The most common mode of transmission is through water contaminated by feces or from
food served by contaminated hands. As well, vegetables that were grown in feces-contaminated
soil may lead to transmission of the disease. As well, geophagy (“the practice of eating earthy
substances such as clay, chalk, and laundry starch, often to augment a mineral-deficient diet”) is a
common route of transmission in some cultures .

Since E. histolytica can exist in two forms, both forms are present in contaminated food and
drinks:
• Trophozoites (free amoeba)
• Infective cysts (which are surrounded by a protected wall

Ingesting the trophozoite form is not harmful—the trophozoites usually die in the acidic
stomach of a person. However, the cysts form are quite resistant to various environmental
conditions, and are thus able to survive in the acidic contents of the stomach and go on to cause
infection. When the cysts reach the intestine, the trophozoite forms are released in this safer
environment where it can invade the epithelial cells of the large intestine, causing flask-shaped
ulcers. Trophozoites can also penetrate the intestinal mucous layer and lead to colitis. The
intestinal mucous layer serves an important role in providing a barrier to invasion by blocking
amoebic adherence to the underlying epithelium and also by slowing motility of trophozoites.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Thus, the
trophozoites
gain a strong advantage for infection when it is able to invade this layer. It does this by killing
epithelial cells, neutrophils and lymphocytes—thus limiting the immune system’s response. It can
also invade the venous system of the intestine and spread to other organs, including the liver, lungs
and brain. When it reaches end of the large intestine, most of the trophozoites are converted back
to its cyst form and released into the environment through passage of stool, and a new cycle of
infection begins.

It is important to note that although amoebic dysentery may not demonstrate any symptoms
for long periods of time (months, even years), the infected individuals still excrete cysts and, in
thus, infect their surroundings and aid in the spread of the disease.

The motile trophozoile is not an infected form whereas non-motile cyst is the infected one.
The infection is transmitted by cyst through ingestion. People discharge cyst in the stool. The cyst
remains live outside the body for days to weeks. It will die quickly if it is not kept cool and moist.
So the infection is transmitted from one person to another through contaminated water. Food
handlers are also the immediate source of infection, if they are the healthy carriers. While handling
the food, they transmit the cyst in the food.

Incubation period

After infection, it may take from a few days up to two to four weeks before developing
overt symptoms. However, some people may carry the parasite for several months or even years
before they become ill. Thus, due to the slight variations in incubation period, tracing the cause of
the illness requires that one knows what he/she ate and drank and the places traveled in the
weeks/months before becoming ill.

Amoebiasis is caused by protozoa. Amoebiasis is commonly spread by water contaminated


by faeces or from food served by contaminated hands. It can also spread to other organs like the
liver, and brain by invading the venous system of the intestines. Asymptomatic carriers pass cysts
in the faeces. Contaminated drinking water can also spread infection. The disease may also spread
y oral-anal contact.

Risk factors
• Eating contaminated food.
• Anal or directly from person to person contact.
• Eating Non-veggie foods.
• Unhygienic conditions and Poor sanitation areas.
• Eating vegetables and fruits which have been contaminated by the harmful bacteria.

The most common symptoms of amoebiasis are diarrhoea, stomach cramps and fever. Rarely,
amoebiasis can cause an abscess in the liver. Entamoeba histolytica parasites are only found in
humans. After infection, it may take a few days, several months or even years before you become
ill but it is usually about two or four weeks.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Signs and
symptoms
• Abdominal cramps.
• Nausea.
• Painful passage of stools.
• Loss of Weight.
• Severe stomach pain.
• Loss of Appetite.
• Profuse diarrhoea.

Treatment and Diagnostic Exams

Consultation of a physician gastroentrologist; stool specimen - Three fresh stool specimens


help diagnosis of 90 per cent of patients; sigmoidos copy:

Treatment for carriers: idoquinot 650 mg x eight times a day for 20 days; furamide 500
mg x eight times a day for 10 days; and paromomycin 25-30 mg/kg/day in divided three doses for
seven days.

Mild to moderate: metronidezole 750 mg thrice a day x 10 days. No medicine should be


taken without the prescription of the physician/gastroentrologist. Self-medication is harmful than
cure.

Prevention

1. Improvement of sanitary conditions: The sanitary conditions should be improved. As mentioned


earlier, the cyst can survive days to weeks in cool and moist conditions. Proper disposal of human
excreta should be there.

2. Control of flies: Flies should be controlled at living places. The flies must be eradicated from
the house as they are responsible to transmit the disease from one place to another. Foods and
eatables should be covered and properly cooked before eating.

3. Safe drinking water: Drinking water should be boiled. If one can afford, water filter should be
used.

4. Hand washing: Hand washing practices are also very helpful to control the infection. Hands
should be properly washed with soap and water after defecation. Especially before eating and
preparing the food, hands should be washed properly.

5. Washing of vegetables: Ground grown vegetables like carrot, turnip, radish, should be washed
thoroughly by running water. During infection, these vegetables should be avoided because these
may be contaminated with human feaces.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

ANATOMY
AND PHYSIOLOGY

AN OVERVIEW ON THE DIGESTIVE SYSTEM

Digestion is the breaking down of food in the body, into a form that can be absorbed. It is
also the process by which the body breaks down food into smaller components that can be
absorbed by the blood stream. In mammals, preparation for digestion begins with the cephalic
phase in which saliva is produced in the mouth and digestive enzymes are produced in the
stomach. Mechanical and chemical digestion begin in the mouth where food is chewed, and mixed
with saliva to break down starches. The stomach continues to break food down mechanically and
chemically through the churning of the stomach and mixing with enzymes. Absorption occurs in
the stomach and gastrointestinal tract, and the process finishes with excretion.

Digestion is usually divided into mechanical processing to reduce the size of food particles and
chemical action to further reduce the size of particles and prepare them for absorption. In most
vertebrates, digestion is a multi-stage process in the digestive system, following ingestion of the
raw materials, most often other organisms. The process of ingestion usually involves some type of
mechanical and chemical processing. Digestion is separated into four separate processes:

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

1. Ingesti
on:
The first activity of the digestive system is to take in food through the mouth. This process
has to take place before anything else can happen.
2. Mechanical Digestion: The large pieces of food that are ingested have to be broken into
smaller particles that can be acted upon by various enzymes. This is mechanical digestion,
which begins in the mouth with chewing or mastication and continues with churning and
mixing actions in the stomach.
3. Chemical Digestion: The complex molecules of carbohydrates, proteins, and fats are
transformed by chemical digestion into smaller molecules that can be absorbed and utilized
by the cells. Chemical digestion, through a process called hydrolysis, uses water and
digestive enzymes to break down the complex molecules. Digestive enzymes speed up the
hydrolysis process, which is otherwise very slow.
4. Movements: After ingestion and mastication, the food particles move from the mouth into
the pharynx, then into the esophagus. This movement is deglutition, or swallowing. Mixing
movements occur in the stomach as a result of smooth muscle contraction. These repetitive
contractions usually occur in small segments of the digestive tract and mix the food
particles with enzymes and other fluids. The movements that propel the food particles
through the digestive tract are called peristalsis. These are rhythmic waves of contractions
that move the food particles through the various regions in which mechanical and chemical
digestion takes place.
5. Absorption: movement of nutrients from the digestive system to the circulatory and
lymphatic capillaries through osmosis, active transport, and diffusion
6. Elimination: The food molecules that cannot be digested or absorbed need to be
eliminated from the body. The removal of indigestible wastes through the anus, in the form
of feces, is defecation or elimination

Underlying the process is muscle movement throughout the system, swallowing and peristalsis.

Human digestion process


Phases of Gastric Secretion

• Cephalic phase - This phase occurs before food enters the stomach and involves
preparation of the body for eating and digestion. Sight and thought stimulate the cerebral
cortex. Taste and smell stimulus is sent to the hypothalamus and medulla oblongata. After
this it is routed through the vagus nerve and release of acetylcholine. Gastric secretion at
this phase rises to 40% of maximum rate. Acidity in the stomach is not buffered by food at
this point and thus acts to inhibit parietal (secretes acid) and G cell (secretes gastrin)
activity via D cell secretion of somatostatin.
• Gastric phase - This phase takes 3 to 4 hours. It is stimulated by distention of the stomach,
presence of food in stomach and increase in pH. Distention activates long and myentric
reflexes. This activates the release of acetylcholine which stimulates the release of more
gastric juices. As protein enters the stomach, it binds to hydrogen ions, which raises the pH
of the stomach to around pH 6. Inhibition of gastrin and HCl secretion is lifted. This
triggers G cells to release gastrin, which in turn stimulates parietal cells to secrete HCl.
HCl release is also triggered by acetylcholine and histamine.
• Intestinal phase - This phase has 2 parts, the excitatory and the inhibitory. Partially-
digested food fills the duodenum. This triggers intestinal gastrin to be released.
Enterogastric reflex inhibits vagal nuclei, activating sympathetic fibers causing the pyloric
sphincter to tighten to prevent more food from entering, and inhibits local reflexes.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

The
digestive
system includes the digestive tract and its accessory organs, which process food into molecules
that can be absorbed and utilized by the cells of the body. Food is broken down, bit by bit, until the
molecules are small enough to be absorbed and the waste products are eliminated. The digestive
tract, also called the alimentary canal or gastrointestinal (GI) tract, consists of a long continuous
tube that extends from the mouth to the anus. It includes the mouth, pharynx, esophagus, stomach,
small intestine, and large intestine. The tongue and teeth are accessory structures located in the
mouth. The salivary glands, liver, gallbladder, and pancreas are major accessory organs that have a
role in digestion. These organs secrete fluids into the digestive tract

Digestion begins in the oral cavity where food is chewed. Saliva is secreted in large
amounts (1-1.5 litre/day) by three pairs of exocrine salivary glands (parotid, submandibular, and
sublingual) in the oral cavity, and is mixed with the chewed food by the tongue. There are two
types of saliva. One is a thin, watery secretion, and its purpose is to wet the food. The other is a
thick, mucous secretion, and it acts as a lubricant and causes food particles to stick together and
form a bolus. The saliva serves to clean the oral cavity and moisten the food, and contains
digestive enzymes such as salivary amylase, which aids in the chemical breakdown of
polysaccharides such as starch into disaccharides such as maltose. It also contains mucin, a
glycoprotein which helps soften the food into a bolus. the tongue which tastes and manipulates the
food

Swallowing transports the chewed food into the esophagus, passing through the oropharynx
and hypopharynx. The mechanism for swallowing is coordinated by the swallowing center in the
medulla oblongata and pons. The reflex is initiated by touch receptors in the pharynx as the bolus
of food is pushed to the back of the mouth.

Pharynx, leads to both the trachea and the esophagus. The Esophagus, a narrow, muscular tube
about 25 centimeters (11 inches) long, starts at the pharynx, passes through the larynx and
diaphragm, and ends at the cardiac orifice of the stomach. The wall of the Esophagus is made up of
two layers of smooth muscles, which form a continuous layer from the Esophagus to the oten and
contract slowly, over long periods of time. The inner layer of muscles is arranged circularly in a
series of descending rings, while the outer layer is arranged longitudinally. At the top of the
Esophagus, is a flap of tissue called the epiglottis that closes during swallowing to prevent food
from entering the trachea (windpipe) while. The uvula blocks off the nose. The chewed food is
pushed down the Esophagus to the stomach through peristaltic contraction of these muscles. It
takes only seconds for food to pass through the Esophagus, and little digestion actually takes place.

The stomach is a pear shaped pouch and it is also described as a thick walled elastic bag. The
food enters the stomach after passing through the cardiac orifice. In the stomach, food is further
broken apart, and thoroughly mixed with gastric acid and digestive enzymes that break down
proteins. The acid itself does not break down food molecules; rather, the acid provides an optimum
pH for the reaction of the enzyme pepsin. The parietal cells of the stomach also secrete a
glycoprotein called intrinsic factor which enables the absorption of vitamin B-12. Other small
molecules such as alcohol are absorbed in the stomach as well by passing through the membrane
of the stomach and entering the circulatory system directly. The form of the food in the stomach is
in semi-liquid form.

The transverse section of the alimentary canal reveals four distinct and well developed layers
called serosa, muscular coat, submucosa and mucosa. Serosa: It is the outermost thin layer of

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

single cells
called
mesothelial cells. Muscular coat: It is very well developed for churning of food. It has outer
longitudinal, middle smooth and inner oblique muscles. Submucosa: It has connective tissue
containing lymph vessels, blood vessels and nerves. Mucosa: It contains large folds filled with
connective tissue. The gastric glands have a packing of lamina propria. Gastric glands may be
simple or branched tubular secreting mucus, hydrochloric acid, pepsinogen and renin. The cardiac
sphincter which closes off the top end of the stomach and the pyloric sphincter, which closes off
the bottom.

Small intestine which has a length of about 6 m. The surface of the small intestine is wrinkled
and convoluted to produce a greater surface area for absorption. the sections of the small intestine
include the duodenum, jejunum, ileum.

After being processed in the stomach, food is passed to the small intestine via the Pyloric
sphincter. The majority of digestion and absorption occurs here as chyme enters the duodenum.
Here it is further mixed with three different liquids:

1. bile, which emulsifies fats to allow absorption, neutralizes the chyme, and is used to
excrete waste products such as bilin and bile acids (which has other uses as well). It is not
an enzyme, however. The bile juice is stored in a small organ called the gall bladder.
2. pancreatic juice made by the pancreas.
3. intestinal enzymes of the alkaline mucosal membranes. The enzymes include: maltase,
lactase and sucrase, to process sugars; trypsin and chymotrypsin are also added in the small
intestine.

Most nutrient absorption takes place in the small intestine. As the acid level changes in the
small intestines, more enzymes are activated to split apart the molecular structure of the various
nutrients so they may be absorbed into the circulatory or lymphatic systems. Nutrients pass
through the small intestine's wall, which contains small, finger-like structures called villi, each of
which is covered with even smaller hair-like structures called microvilli. The blood, which has
absorbed nutrients, is carried away from the small intestine via the hepatic portal vein and goes to
the liver for filtering, removal of toxins, and nutrient processing.

The small intestine and remainder of the digestive tract undergoes peristalsis to transport food
from the stomach to the rectum and allow food to be mixed with the digestive juices and absorbed.
The circular muscles and longitudinal muscles are antagonistic muscles, with one contracting as
the other relaxes. When the circular muscles contract, the lumen becomes narrower and longer and
the food is squeezed and pushed forward. When the longitudinal muscles contract, the circular
muscles relax and the gut dilates to become wider and shorter to allow food to enter. In the
stomach there is another phase that is called Mucus which promotes easy movement of food by
wetting the food. It also nullifies the effect of HCl on the stomach by wetting the walls of the
stomach as HCl has the capacity to digest the stomach. If the form of food in the stomach is semi-
liquid form, the form of food in the small intestine is liquid form. It is in the small intestine where
the digestion of food is completed.

After the food has been passed through the small intestine, the food enters the large intestine.
The large intestine is roughly 1.5 meters long, with three parts: the cecum at the junction with the
small intestine, the colon, and the rectum. The colon itself has four parts: the ascending colon, the
transverse colon, the descending colon, and the sigmoid colon. The large intestine absorbs water

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

from the bolus


and stores
feces until it can be egested. Food products that cannot go through the villi, such as cellulose
(dietary fiber), are mixed with other waste products from the body and become hard and
concentrated feces. The feces is stored in the rectum for a certain period and then the stored feces
is egested due to the contraction and relaxation through the anus. The exit of this waste material is
regulated by the anal sphincter. The large intestine functions to re-absorb (resorb) water and in the
further absorption of nutrients. The bacterial flora of the large intestine includes such things as
Escherichia coli, Acidophilus spp., and other bacteria, as well as Candida yeast (a fungus). These
bacteria produce methane (CH4), hydrogen sulfide (H2S), and other gases as they ferment their
food. Occasionally, some of this gas is released as flatus. As these bacteria digest/ferment left-over
food, they secrete beneficial chemicals such as vitamin K, biotin (a B vitamin), and some amino
acids, and are our main source of some of these nutrients.

the rectum is the terminal portion of the large intestine and functions for storage of the feces,
the wastes of the digestive tract, until these are eliminated. The external opening at the end of the
rectum is called the anus. The anus has two sphincters, one voluntary and one involuntary. The
pressure of the feces on the involuntary sphincter causes the urge to defecate and the voluntary
sphincter controls whether a person defecates or not.

Carbohydrate digestion

Carbohydrates are formed in growing plants and are found in grains, leafy vegetables, and
other edible plant foods. The molecular structure of these plants is complex, or a polysaccharide;
poly is a prefix meaning many. Plants form carbohydrate chains during growth by trapping carbon
from the atmosphere, initially carbon dioxide (CO2). Carbon is stored within the plant along with
water (H2O) to form a complex starch containing a combination of carbon-hydrogen-oxygen in a
fixed ratio of 1:2:1 respectively.

Plants with a high sugar content and table sugar represent a less complex structure and are
called disaccharides, or two sugar molecules bonded. Once digestion of either of these forms of
carbohydrates are complete, the result is a single sugar structure, a monosaccharide. These
monosaccharides can be absorbed into the blood and used by individual cells to produce the
energy compound adenosine triphosphate (ATP).

The digestive system starts the process of breaking down polysaccharides in the mouth
through the introduction of amylase, a digestive enzyme in saliva. The high acid content of the
stomach inhibits the enzyme activity, so carbohydrate digestion is suspended in the stomach. Upon
emptying into the small intestines, potential hydrogen (pH) changes dramatically from a strong
acid to an alkaline content. The pancreas secretes bicarbonate to neutralize the acid from the
stomach, and the mucus secreted in the tissue lining the intestines is alkaline which promotes
digestive enzyme activity. Amylase is secreted by the pancreas into the small intestines and works
with other enzymes to complete the breakdown of carbohydrate into a monosaccharide which is
absorbed into the surrounding capillaries of the villi.

Nutrients in the blood are transported to the liver via the hepatic portal circuit, or loop,
where final carbohydrate digestion is accomplished in the liver. The liver accomplishes
carbohydrate digestion in response to the hormones insulin and glucagon. As blood glucose levels
increase following digestion of a meal, the pancreas secretes insulin causing the liver to transform
glucose to glycogen, which is stored in the liver, adipose tissue, and in muscle cells, preventing

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

hyperglycemia
. A few hours
following a meal, blood glucose will drop due to muscle activity, and the pancreas will now
secrete glucagon which causes glycogen to be converted into glucose to prevent hypoglycemia.

Note: In the discussion of digestion of carbohydrates; nouns ending in the suffix -ose
usually indicate a sugar, such as lactose. Nouns ending in the suffix -ase indicates the enzyme that
will break down the sugar, such as lactase. Enzymes usually begin with the substrate (substance)
they are breaking down. For example: maltose, a disaccharide, is broken down by the enzyme
maltase (by the process of hydrolysis), resulting in a two glucose molecules, a monosaccharide.

Fat digestion

The presence of fat in the small intestine produces hormones which stimulate the release of lipase
from the pancreas and bile from the gallbladder. The lipase (activated by acid) breaks down the fat
into monoglycerides and fatty acids. The bile emulsifies the fatty acids so they may be easily
absorbed.

Short- and medium chain fatty acids are absorbed directly into the blood via intestine capillaries
and travel through the portal vein just as other absorbed nutrients do. However, long chain fatty
acids are too large to be directly released into the tiny intestinal capillaries. Instead they are
absorbed into the fatty walls of the intestine villi and reassembled again into triglycerides. The
triglycerides are coated with cholesterol and protein (protein coat) into a compound called a
chylomicron.

Within the villi, the chylomicron enters a lymphatic capillary called a lacteal, which
merges into larger lymphatic vessels. It is transported via the lymphatic system and the thoracic
duct up to a location near the heart (where the arteries and veins are larger). The thoracic duct
empties the chylomicrons into the bloodstream via the left subclavian vein. At this point the
chylomicrons can transport the triglycerides to where they are needed.

Digestive hormones

There are at least four hormones that aid and regulate the digestive system:

• Gastrin - is in the stomach and stimulates the gastric glands to secrete pepsinogen(an
inactive form of the enzyme pepsin) and hydrochloric acid. Secretion of gastrin is
stimulated by food arriving in stomach. The secretion is inhibited by low pH .
• Secretin - is in the duodenum and signals the secretion of sodium bicarbonate in the
pancreas and it stimulates the bile secretion in the liver. This hormone responds to the
acidity of the chyme.
• Cholecystokinin (CCK) - is in the duodenum and stimulates the release of digestive
enzymes in the pancreas and stimulates the emptying of bile in the gall bladder. This
hormone is secreted in response to fat in chyme.
• Gastric inhibitory peptide (GIP) - is in the duodenum and decreases the stomach churning
in turn slowing the emptying in the stomach. Another function is to induce insulin
secretion.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Significance
of pH
in digestion

Digestion is a complex process which is controlled by several factors. pH plays a crucial


role in a normally functioning digestive tract. In the mouth, pharynx, and esophagus, pH is
typically about 6.8, very weakly acidic. Saliva controls pH in this region of the digestive tract.
Salivary amylase is contained in saliva and starts the breakdown of carbohydrates into
monosaccharides. Most digestive enzymes are sensitive to pH and will not function in a low-pH
environment like the stomach. Low pH (below 5) indicates a strong acid, while a high pH (above
8) indicates a strong base; the concentration of the acid or base, however, does also play a role.

pH in the stomach is very acidic and inhibits the breakdown of carbohydrates while there. The
strong acid content of the stomach provides two benefits, both serving to denature proteins for
further digestion in the small intestines, as well as providing non-specific immunity, retarding or
eliminating various pathogens.

In the small intestines, the duodenum provides critical pH balancing to activate digestive
enzymes. The liver secretes bile into the duodenum to neutralise the acidic conditions from the
stomach. Also the pancreatic duct empties into the duodenum, adding bicarbonate to neutralize the
acidic chyme, thus creating a neutral environment. The mucosal tissue of the small intestines is
alkaline, creating a pH of about 8.5, thus enabling absorption in a mild alkaline in the environment.

COLON (LARGE INTESTINE)

The colon is approximately 4.5 feet long, 2.5 inches wide, and is a muscular tube
composed of lymphatic tissue, blood vessels, connective tissue, and specialized muscles for
carrying out the tasks of water absorption and waste removal. The tough outer covering of the
colon protects the inner layer of the colon with circular muscles for propelling waste out of the
body in an action called peristalsis. Under the outer muscular layer is a sub-mucous coat
containing the lymphatic tissue, blood vessels, and connective tissue. The innermost lining is
highly moist and sensitive, and contains the villi- or tiny structures providing blood to the colon.
The location of the parts of the colon is either in the abdominal cavity or behind it in the
retroperitoneum. The colon in those areas is fixed in location.

The colon is actually just another name for the large intestine. The shorter of the two
intestinal groups, the large intestine, consists of parts with various responsibilities. The names of
these parts are: the transverse colon, ascending colon, appendix, descending colon, sigmoid colon,
and the rectum and anus.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

PARTS OF
THE COLON

Several parts make up the continuous tube of the colon. Each part contributes to the
movement of materials and the formation of stools. The parts include:

Illeocecal Valve:
The illeocecal valve is a fold of mucus membrane at the entry way to the colon. It is
located where the small intestine meets the colon. Materials from the small intestine pass into the
colon through this valve.

Vermiform Appendix:
The appendix is attached to the bottom of the cecum. This is a twisted coiled tube that is
about 3 inches long. The function of the appendix is not known.

Cecum:
It is located below the illeocecal valve at the base of the colon. The upper part of the
cecum is open to the colon. The muscles of the cecum and the colon advance feces upward out of
the cecum.

Ascending Colon:
The ascending colon is located on the right side of the abdomen above the cecum. Here,
most of the water is absorbed from the feces as it moves upward through the ascending colon. The
ascending colon “ends” at the hepatic flexure where the colon bends to the left and connects to the
transverse colon.

Transverse Colon:

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

The
transverse
colon runs laterally across the abdomen below the belly button. As feces move across the
transverse colon, stools begin to take form. The transverse colon “ends” at the splenic flexure
where the colon bends again and connects to the descending colon which heads down the left side.

Descending Colon:
The descending colon runs down the left side of the abdomen. Stools move down the
descending colon. Stools are now more solid in form. Here, stools may be stored for a time. The
descending colon “ends” where it continues into the sigmoid colon.

Sigmoid Colon:
The sigmoid colon angles to the right, curving down and inward to about the midline, then
it curves slightly upward where it connects to the top of rectum. Stools continue their descent as
they move through sigmoid colon. Stools may also be stored here for a time before they are moved
into the rectum.

Rectum and Rectal Sac:


The rectum is a passageway about 8 inches long that leads to the anus. The rectum is
usually empty until mass peristalsis drives the stools into the rectum. When stools fill the rectum,
the elastic qualities of the walls permit the rectum to expand, creating a sac to accommodate stools
just prior to elimination.

Anal Canal and Anus:


The last inch of the rectum is called the anal canal. The mucus membrane of the canal has
folds called anal columns that contain arteries and veins. The opening of the anal canal to the
exterior is called the anus. The anus is guarded by internal and external sphincters (muscles) that
keep the anus closed except during elimination of a stool.

The colon has no villi (multiple, minute projections of the intestinal mucous layer which serve to
absorb fluids and nutrients) as compared to the small intestine and produces no digestive enzymes.
It is like a tube of circular muscle lined with a layer of moist mucous cells that lubricate the
contents. The smooth folds of the colon are speckled with glands that resemble skin pores.

These glands extract the fluids and electrolytes from the passing food residue. Between 1/3 -1 liter
of water (which is recycled and eventually filtered and excreted by the kidneys as urine),
electrolytes, and some vitamins, are absorbed daily through the colon. If colon bacteria are normal,
vitamins B-1, B-2, B-12 and K are produced by them, and all with the possible exception of B-12
are absorbed and used by the body traveling first to the liver via the portal circulation.

Absorption and storing fecal material are the colon's two main functions.

The colon does secrete mucus to help the digested food along and hold the fecal material together.
It also plays a role in protecting the walls of the colon from bacterial activity and neutralizes some
of the fecal acids.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

After
processed
matter from the small intestine enters the colon much absorption occurs in the cecum and
ascending colon. Mixing movements called haustrations occur every few minutes and last about
one minute apiece.

They roll and mix the matter to expose most of it to the colon’s surface for absorption. Over 80%
of the material reaching the colon is reabsorbed.

There are no peristaltic waves in the colon but a few times daily (usually after meals) a segment of
the colon usually eight inches long will constrict (usually in the transverse or descending colon) to
force the fecal material along. Our Feces are usually 75% water, 7-8% dead bacteria, 2-7% fat, .5-
10% protein, 5-10% roughage, byproducts, digestive juices, etc.

Once the stool moves out of the sigmoid colon into the rectum, a parasympathetic reflex is set up
and the brain gets the signal that nature is calling, and so we go.

The external sphincter is under voluntary control and we can mentally overcome this reflex and
prevent defecation if we desire to.

Of all the vital organs in the body, the one that suffers the most abuse from modern dietary habits
is the colon.

Large Intestine Microscopic Cross Section

Mucosal layer on the surface is made up simple columnar cells and a mucosal muscularis on the deep
side .
Submucosa contains fibrous connective tissue and blood vessels.
The muscularis externa is made up of a circular and a longitudinal muscle layer with a myenteric plexus

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

in between the
layers.
A very thin layer of Serosa is also present .

PROCESSING AND ACTIVITY OF THE COLON

Aided by enzymes and muscular action, the mouth, stomach and small intestine perform
their individuated jobs of breaking down and absorbing nutrients. The liquid that these organs
generate is called chyme. However, when it passes to the colon, the liquid that is leftover is mostly
waste matter. This liquid waste matter is called feces. It is passed to the colon for further
processing and elimination. In the colon, instead of the enzymatic action that occurs in other
organs of the G.I. tract, further breakdown of fecal matter and the production of substances occur
by way of bacterial fermentation. Cellular exchanges, bacteria, and muscular actions all play a part
in processing the feces as it passes through the colon:

Fluid Absorption:
The colon lining contains epithelial cells that absorb fluids and other substances such as
vitamins and electrolytes. It is the absorption of fluids and bacterial processing that transforms the
soupy fecal matter into a stool.

Secretion of Mucus:
The colon lining contains epithelial cells that secrete mucus. This mucus moisturizes and
lubricates the colon lining. This lining protects the colon wall and nerve tissues.

Bacterial Growth:
Bacteria live and grow along the colon lining. Using the fluids and foods you intake,
bacteria actually manufacture the nutrients that sustain their environment and their food supply.

Manufacture of Some Vitamins & Electrolytes:


Bacteria change proteins into amino acids and break these amino acids down further into
indole and skatole (which gives stools their odor), hydrogen sulfide, and fatty acids. Bacterial
action also synthesizes some vitamins (K and some B), electrolytes, and breaks down bilirubin into
a pigment that gives stools their brown color.

Production of Lubrication:
Bacteria ferment soluble fiber into a lubricating gel that is incorporated into the stool mass
as it is formed. This gel helps to make stools soft and flexible. Some of this gel also coats the
exterior of the stools and is used by the colon to moisturize the colon lining. This lubrication helps
to ease stool passage through the colon.

Defense against Infection:


Healthy intestinal bacteria help to groom the colon and keep it clean so that infections do
not develop. They also help to fight the growth of infectious bacteria.

Stool Formation:
To form stools, muscles in the colon churn the soupy liquid fecal matter as fluids are
extracted until the particles have the consistency to form a stool.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

PATHOPHYSIOLOGY OF AMOEBIASIS

Predisposing Factors
Precipitating Factors
Developing countries
Unsanitary food handling
Tropical and subtropical
Ingestion of contaminated food and
countries
drinks
Urban areas
Poor environmental sanitation
Socioeconomic status
Crowded areas

Etiologic Agent
Entamoeba histolytica

Mode of Transmission
Fecal-Oral route

Ingestion of cyst of the


infecting microorganism

Enters the
stomach

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Survives the acid environment


of the stomach

Enters the small intestine

Excsytation occurs

Emergence of trophozoites

Trophozoites migrate in the large intestine

Trophozoites multiply by
means of binary fission

Contact with the intestinal mucosa

Lytic digestion occurs

Invades the epithelium


cells of the colon

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Release of enterotoxins Decrease integrity of thee


intestinal wall

Increase secretion of water


and electrolytes
(Chloride and Bicarbonate)
Stimulation of the
Decrease
symphatetic/parasymphatetic
absorption
responses
Inhibits sodium
reabsorption
Increase Gastrocolic
Stimulation of the reflex
emetic center
Large amount of
CHON rich fluids
Increase
Nausea/ peristalsis
Vomiting

Diarrhea

Abdominal pain

Deficient fluid volume

Dehydration

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Damage of Burrows deeper invading


intestinal tissues the sub mucosa

Formation of lesions
Increase vascular Chemotaxis Activation of
permeability occurs prostaglandin

Flask shaped
Swelling Mobilization of Stimulates the ulceration
leukocytes and goblets cells in
macrophages the colon

Edema Squeezed out /


contraction
Migration of Increase mucus
RBC and WBC production
Compression of
nerve endings Carried to lower
portion of the colon
Blood and pus
formation
Abdominal
pain Progressive
ulceration

Irritation of the
intestine

Hematochezia Ulcerative
Colitis

Blood streaked feces

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

PATHOPHYSIOLOGY OF AMOEBEASIS

Normally human intestinal flora protects the bowel from colonization of pathogens;
however, the intestinal flora can be disrupted by harmful bacteria and viruses that cause tissue
damage and inflammation or depressed by antibiotic c therapy.

Amoeba cause tissue damage and inflammation by releasing toxins (enterotoxins) that
stimulates the mucosal lining of the intestine, resulting greater secretion of water and electrolytes
into the intestinal lumen. The active secretion of chloride and bicarbonate ions in the small bowel
leads to inhibition of sodium reabsorption. To balance the excess sodium, large amounts of protein
rich fluids are secreted in the bowel, leading to diarrhea

The metacystic trophozoites or their progenies reach the cecum and those that cone contact
with cecal mucosa penetrate or invade the epithelium by the lytic digestion if condition is
favorable. The trophozoites burrow deeper with tendency to spread laterally by flask shape
ulcers. There may several points of penetration. From the primary site of invasion, secondary
lesions may be produced at the lower levels of the large intestines. Progenies of the initial colonies
are squeezed out of the neck of the ulcer and carried to the lower portion of the bowel, thus have
opportunity to invade and produce additional ulcers. Eventually the whole colon may be involved.

When the integrity of the GIT impaired its ability to carry out digestive and absorptive
functions can be affected as well as the sympathetic and parasympathetic afferent nerve will be
stimulated thru the vagus, glossopharyngeal, vestibular and splanhnic nerves, which is located at
the proximal duodenum, thus stimulates emetic center resulting to vomiting.

As inflammation occurred, inflammatory response happened, chemical mediators are


released in he injured tissue causing blood dilation of the blood vessels which is beneficial because
it increases the speed with which blood cells and other important for r fighting infections and
repairing the injury and brought to the injury site.It also increase permeability of the blood vessels
and fluid leaves the capillaries, producing swilling of the tissue. WBC and RBC leave the dilated
and move to the site of infection, where they begin to phagocytize foreign microorganisms and
other debris.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

BIOGRAPHICAL DATA

Name : Ms. L.G.


Age : 33 years old
Address : Lim Compound, San Dionisio, Paranaque City
Birthday : January 21, 1975
Birthplace : Bohol
Gender : Female
Nationality : Filipino
Religion : Roman Catholic
Marital Status : Single
Educational Attainment : 2 yrs. Vocational Graduate (Sewer)
Occupation : Businesswoman
Informant : Patient and patient’s mother
Reliability : Total 95%

HOSPITAL DATA

Admission No. : 78256


Ward Room/Bed : Station Annex Room 105C
Admitting Diagnosis : Amoebiasis
Chief Complaint : Loose bowel movement and abdominal pain
Final Diagnosis : Amoebiasis T/C Amoebic Colitis
AMD : Dr. William Hoping Gan
Date of Admission : August 16, 2008
Discharge Date : August 28, 2008

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

FAMILY
BACKGROUND

Family Position Date of Age Sex Civil Place of Educational Occupation Salary
Members Birth Status Residence Attainment
Davao City High School Unemployed N/A
Mr. R.G Father 01/05/42 66 y/o Male Married Graduate

Binondo, Sta.
Mrs. D.G Mother 02/02/47 61 y/o Female Married Cruz, Manila High School House helper 3,500/
Graduate month

Ms. L.G Eldest 01/21/75 33 y/o Female Single San Dionosio, 2-yr. Store vendor 15,000/
(patient) sibling Paranaque Vocational month
City Course

Mrs. C.G Middle 09/04/78 30 y/o Female Married Davao City High School Unemployed N/A
sibling Graduate
20,000/
Mr. J.G Youngest 07/24/81 27 y/o Male Single Qatar College Factory month
sibling Undergraduate Worker
Currently, Ms. L.G is residing alone at San Dionisio, Paranaque City. She rents a small
house and has a sari-sari store as her means of income. Her father and middle sibling lives together
in Davao City together with their relatives. While her mother is a stay in house helper at Binondo,
Sta. Cruz, Manila. Ms. L.G’s youngest sibling works as a factory worker in Qatar.

Ms. L.G finished a 2-year vocational course in Bohol and had previously worked as a
sewer and dressmaker at Africa and Brunei for almost three years from 2003-2006. She went back
here in the Philippines last May 2006 since her contract to the agency she was employed already
expired. She then decided not to return again abroad to work and started to invest on a ‘sari-sari’
store which provided her with sufficient income. Her youngest sibling is a college undergraduate
and works as a factory worker in Qatar for almost two years.

SOCIO-ECONOMIC BACKGROUND

Ms. L.G lives in a typical urban community set-up situated at Lim Compound, San
Dionisio, Paranaque City. The surroundings in which her house is situated consists of compressed
households and was quite unsafe. Her mother verbalized, “ Medyo delikado nga dito sa lugar
namin, Minsan may mga gulo at nag-aaway pero kahit papaano ligtas naman, may mga barangay
tanod naman dito.” While transportation, public and commercial establishments are accessible
within her house. She lives alone in a small bungalow type of household which she rents every
month. But due to her recent health condition, her mother presently stays with her temporarily. The
household comprises of a single bedroom, comfort room and a small space that serves as their
living room and dining area. The space of the household is approximately enough for two to three
persons only. In front of the house is a space provided for Ms. L.G’s small ‘sari-sari’ store. The
structure of the house is of mixed type built with wood and cement and two medium size windows
as a means of ventilation. The cleanliness of the house is maintained by the client herself. Ms.
L.G’s water supply is from NAWASA. She pays for it monthly.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Ms.
L.G. has her
income through her small ‘sari-sari’ store. Her income every month comprises of about 15,000
pesos. This income supports her alone with her basic needs. However, part of it is given to her
nephews and niece to support them with their daily needs. The client verbalized, “ Sapat lang din
para sa akin yung kinikita ko sa tindahan pero sinusuportahan ko din yung mga pamangkin ko kasi
wala naman trabaho yung pangalawa kong kapatid, kaya talagang nagigipit din ako.” On the other
hand, the youngest sibling of Ms. L.G. works abroad earning 20,000 pesos a month which is given
to support their family needs. While Ms. L.G’s mother earns 3,500 a month as a house helper
which is also contributed to the family’s basic needs.

LIFESTYLE

The client’s usual daily activity is more on housekeeping and watching her ‘sari-sari’ store.
She is not smoking and drinks alcohol occasionally. The patient used to consider cleaning the
house as a form of exercise and spends 7-8 hours of sleep per day. She seldom watches TV
programs and prefers to read magazines and newspaper as well as listening to OPM music. She
seldom goes to malls and public places except when she needs to buy groceries for her ‘sari-sari’
store. Ms. L.G. goes to church regularly every Sunday morning. She is not involved to any
organizations or social institutions and spends a lot of her time at home.

FAMILY HEALTH HISTORY

The only recognized familial disease is hypertension, all other hereditary diseases (e.g.
diabetes mellitus, lung diseases, cancer etc.) was not traced back to the client’s family generation.
With her father side, both grandparents are still alive with no alteration in their health condition.
While her father is of good health status except that he smoked for almost 40 years from now and
denies any health problems. Hypertension is identified to the maternal side. As evident, the client’s
grandmother and mother were hypertensive and maintain a regular dose of antihypertensive drugs.
However, the client herself is not hypertensive in spite of having a family history of hypertension.
The family seeks medical consultation whenever they need to, but as for common health problems
such as flu, cough, fever and colds that are manageable, they practice self-medication.

PAST MEDICAL HISTORY

Medical History

The patient had no previous medical records that are significant to her health condition
prior to her recently diagnosed disease. The patient was never been admitted to a hospital and
consider herself healthy prior to her sickness. She only consults medical advice for purposes of
going abroad as a requirement since the client previously worked outside the country. The client
verbalized, “Hindi pa naman ako na-ospital dati, ngayon lang talaga nung nagkasakit ako. Nung
umpisa pa nga, ayoko din talaga magpa confine, kaso hindi ko na din talaga kaya. Nagpupunta
lang ako sa ospital kapag magpapa- medical kasi kailangan kapag mag-aabroad ako.” The patient
had no surgical procedures done from the past. The client seldom take a dose of multivitamins and
ascorbic acid. Uses Paracetamol (Biogesic) for fever, analgesic (Alaxan) for muscle or body pain,
Diphenhydramine HCL (Neozep) for common colds and to relieve symptoms of flu, and
Guaifenessin (Robitussin) for coughs and colds.
The patient acquired chicken pox and measles during her childhood years. No other
communicable disease noted from the past. The patient also have no allergic reactions to any

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

chemicals,
foods or
medications.
The patient had an injury during an earthquake attack on 1991 when she accidentally fell
off the ground due to the intensity of the earthquake and obtained a fracture in the wrist. Medical
consultation was sought after the incident and was treated appropriately through anti inflammatory
medications and X-ray imaging. No complications was noted and complete bone healing was
achieved.
The patient had an Oral Polio vaccination during her childhood. Other immunizations were
not remembered by the client.

HISTORY OF PRESENT ILLNESS

Patient was in usual state of good health until April 2008 prior to confinement at the
Metropolitan Medical Center. Four months prior to confinement, the patient had experienced mild
abdominal pain and loose bowel movement. She had 3-6 times of bowel movement per day
characterized with mucoid consistency, brownish yellow in color and about 1 to ½ cup per bout.
The onset of these symptoms begun after the client ate from a usual ‘carinderia’ near her place.
The client verbalized, “ Pagkatapos ko kumain ng kaldereta dun sa karinderya malapit sa amin,
sumama na yung timpla ng tiyan ko. Tapos nagsimula na akong magtae, maaaring sa tubig din na
ininum ko dun sa karinderya kaya sumama yung timpla ng tiyan ko.” After which, the client
experienced persistent loose bowel movement and a gradual increase in the abdominal pain for
consecutive days. Due to above symptoms, the client took an over the counter medication. She
took ‘Imodium’ 1 tablet which offers a quite relief to her loose bowel movement. Eventually, 1
month after the onset of the symptoms, the client continuously experienced loose bowel movement
for 3-4 times per day with absence of the abdominal pain. She continues to take ‘Imodium’ as
needed and still offers relief to her condition. In this time, the consistency of her feces is still of
mucoid, foul odor, brownish yellow with blood streaked. This prompted the client to seek for
medical consultation. Since the client is alone while experiencing the above signs and symptoms,
she contacts her mother to accompany her to the hospital for consultation.

By late of May 2008, the client went to San Juan de Dios Medical Center as an out patient.
She was attended by Dr. Mariano and was prescribed for a fecalysis immediately during the time
they consulted. Based on the result of the fecalysis, the attending medical doctor diagnosed that the
client has an Amoebiasis. She was then prescribed to take a daily dose of Flagyl for 7 days 750mg
as a treatment regimen. After the consultation, the treatment that was given to the client offered a
great relief as compared to her recent condition prior to medical consult. She had a frequency of 2-
3 bowel movements per day but with same characteristics except with the presence of blood streak
and amounts for about ½- 1 cup per bout. Still symptoms persist but with decrease in severity.

However, by early June 2008, the client experienced severe abdominal cramping and
aggravated loose bowel movements with a frequency of 3-5 times per day still with mucoid
consistency, foul odor, brownish yellow with blood streak, 1 ½ -2 cups per bout. This onset of
aggravated symptoms was attributed when the client had stopped taking her medication after
experiencing a relief from her previous conditions. Due to persistent above signs and symptoms,
the client once again consulted for a medical advice and was rushed to the emergency room of
Makati Medical Center. Upon the client’s confinement on the ER, she was again prescribed to
have fecalysis as well as CBC and urine analysis. She was also given another set of antibiotics and
advised to resume taking Flagyl for 7 days 750mg. Once result of fecalysis was done, the client

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

was still
diagnosed
with Amoebiasis and was advised to continue medications. The client was not admitted to the
hospital since they preferred to went home and just take the prescribed medications.

From July 2008, the client’s condition stabilized and symptoms were alleviated. There was
a gradual improvement on client’s bowel movement. Normal bowel movement decreases from 1-2
times per day, semi formed, brownish in color and 1 cup per bout. The abdominal pain was also
relief. No follow up consultation took place after symptoms was alleviated.
By early August 2008, the client felt a sudden body weakness and loss of appetite with decrease
energy levels. This was accompanied again with loose bowel movements of at least 2-3 times per
day, mucoid consistency, brownish yellow, foul odor and amounting to 1 to 1 ½ cup per bout.
These symptoms persist for almost a five days before the client started to consult for the third time.
By August 13, 2008, the client consulted for medical advice at Metropolitan Medical
Center under the service of Mr. William Hoping Gan, a specialist on internal medicine. The
physician was referred to client’s mother by her superior on the house she works. Another set of
laboratory test was prescribed to the client including fecalysis with culture and sensitivity. They
were advised to continue taking the medications previously prescribed and was advised to go back
at his clinic after 3 days and reports if symptoms still persist.

By August 16, 2008, two hours prior to client’s admission, they went back to Dr. Gan’s
clinic for follow up consultation. The result of the following test including fecalysis with culture
and sensitivity revealed that the client still suffered from a chronic Amoebiasis and considering the
client of having a complication of amoebic colitis. This prompted the physician to advise the client
to be confined at the hospital institution for further medical management and treatment modalities.
She was admitted at Metropolitan Medical Center at station Annex room 105A.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

DEVELOPMENTAL DATA

Psychosocial Development Theory by Erik Erickson


Stage 7: Middle Adult (late 20’s to 50’s years)
Psychosocial Crisis: Generativity vs. Stagnation
Psychosocial Virtue: Care
Maladaption and Malignancies: Overextension, Rejectivity

Erik Erickson adapts and expands Freud’s theory of development to include the entire life
span, believing that people continue to develop throughout life. He believed in the massive
influence of culture on behavior and placed more emphasis on the external world such as
depression and was according to his theory, each stage signals a task that must be achieved. The
resolution of task can be complete, partial and successful. He believes that the greater the task
achievements the healthier the personality of the person. Failure to achieve a task influences the
person’s ability to achieve the next tasks. Erickson emphasizes that people must change and adapt
their behavior to maintain control over their lives.

The seventh stage is that of middle adulthood. It is hard to pin a time to it, but it would
include the period during which we are actively involved in raising children. For most people in
our society, this would put it somewhere between the middle twenties and the late fifties. The task
here is to cultivate the proper balance of generativity and stagnation.

Generativity is an extension of love into the future. It is a concern for the next generation
and all future generations. As such, it is considerably less "selfish" than the intimacy of the
previous stage. Generativity on Erikson considers teaching, writing, invention, the arts and
sciences, social activism, and generally contributing to the welfare of future generations to be
generativity as well -- anything, in fact, that satisfies that old "need to be needed."

Stagnation, on the other hand, is self-absorption, caring for no-one. The stagnant person
ceases to be a productive member of society. It is perhaps hard to imagine that we should have any
"stagnation" in our lives, but the maladaptive tendency Erikson calls overextension illustrates the
problem: Some people try to be so generative that they no longer allow time for themselves, for
rest and relaxation. The person who is overextended no longer contributes well. I'm sure we all
know someone who belongs to so many clubs, or is devoted to so many causes, or tries to take so
many classes or hold so many jobs that they no longer have time for any of them

More obvious, of course, is the malignant tendency of rejectivity. Too little generativity
and too much stagnation and you are no longer participating in or contributing to society. And
much of what we call "the meaning of life" is a matter of how we participate and what we
contribute.

This is the stage of the "midlife crisis." Sometimes men and women take a look at their
lives and ask that big, bad question "what am I doing all this for?" Notice the question carefully:
Because their focus is on themselves, they ask what, rather than whom, they are doing it for. In
their panic at getting older and not having experienced or accomplished what they imagined they
would when they were younger, they try to recapture their youth. Men are often the most
flambouyant examples: They leave their long-suffering wives, quit their humdrum jobs, buy some
"hip" new clothes, and start hanging around singles bars. Of course, they seldom find what they are
looking for, because they are looking for the wrong thing.

27
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

But if
you are
successful at this stage, you will have a capacity for caring that will serve you through the rest of
your life.

Ms. L.G, a 33 year old single woman lives most of her life alone and is independent as with
regards to making decision. She finished a two-year vocational course and became a sewer in
South Africa from 2004-2006 but had resigned last mid 2006 and went home. Now she owned a
sari-sari store from which she managed alone. The income she gets from her sari-sari store
provides her needs and allows her to somehow support her nephew and niece with their basic
needs as well. Her usual activities are primarily focused on household chores, watching her store
and house keeping. She likes sewing most especially when she had nothing so important to do. Ms.
L.G. is not affiliated or involved to any organizations or institutions within their community or the
society as a whole. However, she is able to interact with her neighbors and mingled with them
during free her free time.

Physical Development
Mrs. L.G.weighs 42.7 kg or 94 lbs and stands 5 foot or 1.524m and is conscious but
appears irritable and less pleasant. She appears younger than her chronological age. She has no
deformities noted. According to her mother,“Hindi siya malakas kumain pero hindi naman siya
mapili sa pagkain”. Neuromuscular skills are refined and eye-hand coordination is facilitated. Mrs.
L.G can dress herself, is able to wash her own face and hands, brush teeth and attend to her own
toilet needs. She is able to write and read. In essence, she is able to do the usual activities of daily
living with no limitations. Her menstruation period start at age 13 and she is regular since then.

Psychosocial Development
For many women in midlife, sexuality has achieved a degree of stability. A sense of
femininity and comfortable patterns of behavior has been established. This increased security in
identity can promote greater intimacy in sexual and social relationships. This may also be the time
when adults allow themselves more freedom in exploring and satisfying sexual needs.

Menopause alters reproductive functioning; it does not physically inhibit sexual


functioning. Generally, a woman with a strong self- image, positive sexual and social relationship
and knowledge regarding her body and menopause is more likely to progress thru this natural
biological stage without problems and remain sexually active and satisfied.

Midlife is often a time. When women reexamine life goals, careers, accomplishments,
values systems and familial and social relationships, as a result some people adapt, whereas, other
experience stress or a crisis. This reexamination can positively or negatively affect individual
gender identity and sexuality.
As with regards to Ms. L.G’s developmental assessment, she remains single up to her
present age and does not have any affair with anyone. In this stage, it can be considered that
through this time where she is at her midlife, Ms. L.G. had already achieved a sense of stability as
with regards to her sexuality. However, exploring and satisfying sexual needs might be a problem
to Ms. L.G. This is of the reason that she was not able to experience intimate relationship from her
past as with regards to the opposite sex as to build her own family. Another reason is that she had
lived most of her life alone and independent that such support system coming from friends, family
and other significant others is less achieved.

28
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Ms.
L.G. is also
experiencing current issues and problems that involve her family and immediate relatives. These
issues involve supporting her relatives, financial constraints and conflicts that arises among family
members. This had become her stressor through this stage of her development which has greater
impact to the way she thinks and make decisions. Such stressors and crisis might affect the way
Ms. L.G. reexamines her goal and value system as part of her task on her age now.

She is also at risk of failing her developmental task for the reason that generating goals and
values that focus on unselfish desires are hindered resulting to stagnation and becoming self
absorbed. This is evident to Ms. L.G. since she happened to live alone and independent, limited
support system and social functioning is quite unmet and might result to rejectivity.

Robert Havighurts

Developmental Task

The idea of "developmental task" is generally credited to the work of Robert Havighurst who
indicates that the concept was developed through the work in the 1930s and 40s of Frank, Zachary,
Prescott, and Tyron. Others elaborated and were influenced by the work of Erik Erikson in the
theory of psychosocial development. Havighurst states:.

The Developmental Task Concept

From examining the changes in your own life span you can see that critical tasks arise at certain
times in our lives. Mastery of these tasks is satisfying and encourages us to go on to new
challenges. Difficulty with them slows progress toward future accomplishments and goals. As a
mechanism for understanding the changes that occur during the life span.

Robert Havighurst(1952, 1972, 1982) has identified critical developmental tasks that occur
throughout the life span. Although our interpretations of these tasks naturally change over the
years and with new research findings. Havighurst's developmental tasks offer lasting testimony to
the belief that we continue to develop throughout our lives.

Middle Age (Ages 30-60)

Achieving adult social and civic responsibility. * Reaching and maintaining satisfactory
performance in one’s occupational career. * Developing adult leisure time activities. * Relating
oneself to one’s spouse as a person. * To accept and adjust to the physiological changes of middle
age. * Adjusting to aging parents.

Ms. L.G. is able to achieve this stage of her life as evidence by the following aspects. First Ms.
L.G. has finished a 2 year vocational course and is currently owning a small sari-sari store that she
is currently managing, also the client is able to have her time for relaxation and she has a good
relationship with her parents. The client has not complained any emotional aspects regarding the
state of her parents but there is no sign on her that she is not coping with the physiological changes
of her life.

29
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

LEVEL OF
COMPETENCIES

PHYSICAL COMPETENCY

BEFORE DURING HOSPITALIZATION


ILLNESS ANALYSIS
( BEFORE DURING PRIOR
APRIL 2008) HOSPITALIZATION DISCHARGE
PRIOR ONSET ( APRIL 2008- DATE
OF SIGNS AND AUGUST 2008) DISCHARGE:
SYMPTOMS DATE OF AUGUST 28, 2008
CONFINEMENT:
AUGUST 16-28, 2008
The client is of During the onset of After hospitalization, Client’s physical
healthy condition. signs and symptoms the client regained competency was
She was able to and the time he was some energy and was altered during
perform activities diagnosed of having a able to tolerate her illness state;
of daily living disease and confined in activities such as there was a
with no limitation the hospital, the client walking, preparing her gradual decrease
and with no experience body meals, managed her on her physical
alterations on weakness and decrease ‘sari-‘sari’ store. competency that
energy levels. She energy levels. There However, there are still includes activity
was able to was a gradual decrease limitations on her intolerance in
managed her on activities that were activities such as those some degree and
‘sari-sario’ store. previously performed that are strenuous in decrease energy
The client by the client. The client nature (e.g. lifting, levels. Previous
verbalized, “ verbalized, “ Sobra pushing etc.) The client activities that
Masigla at yung panghihina na verbalized, “Mas ok na were done prior
malakas ako bago naramdaman ko noong ako ngayon. Mas illness were not
ako magkasakit. nagkasakit ako, nagagawa ko yung mga tolerated by the
Wala akong nanghihina at wala Gawain sa bahay at client. However,
nararamdaman na talaga akong ganang nakakapagbantay uli after illness
kakaiba sa magkikilos, kahit nga ako ngb tindahan. Pero state, the client
katawan ko.” maglakad, hirap ako.” medyo nanghihina pa was able to
din ako lalo na kapag regain energy
nagbubuhat.” levels and
tolerate activities
previously
performed but
still with little
limitations on
task that induce
force or stress to
client’s physical
attributes.

30
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

MENTAL
COMPETENCY

BEFORE DURING HOSPITALIZATION


ILLNESS ANALYSIS
( BEFORE DURING PRIOR
APRIL 2008) HOSPITALIZATION DISCHARGE
PRIOR ONSET ( APRIL 2008- DATE OF
OF SIGNS AND AUGUST 2008) DISCHARGE:
SYMPTOMS DATE OF AUGUST 28, 2008
CONFINEMENT:
AUGUST 16-28, 2008
Client finished a During her After hospitalization, As regards to
two year confinement, the the client presently client’s mental
vocational primary decision maker lives with her mother, competency, the
graduate. She is as with regards to she was able to make client is
capable of client’s condition was decisions again on her independent with
making her own her mother, the client own but her mother’s regards to
decisions and was irritable, loses her opinion is of great decision making
expressing her focus and decrease influence in making prior to illness
own opinions. attention span during decisions. The client state. This is
She is quite her confinement. She verbalized, “ Sa primarily
independent with allows her mother to ngayon, sinasanguni ko affected since
her decision take decisions for the na din kay mama yung client lives alone
makings since she plan of care mga desisyon ko, for almost a long
lives alone. There appropriate to her pinaguusapan na time making
were no condition. The client namin.” Decisions of responsible with
significant others verbalized, “ Nung na the client where first all her decisions
that influences ospital ako, si nanay informed made. But
her decisions. The talaga ang through the
client verbalized, nagdedesisyon para sa course of her
“ Wala naman akin. Syempre, hindi illness up to her
akong problema talaga maganda yung discharge, the
pagdating sa pakiramdam ko.” mother of the
pagdedesisyun, client plays a
madalas ako significant role
talaga ang on the client’s
nagdedesisyun decisions which
kasi hindi ko din heightens during
kasam ang her
pamilya ko hospitalization.
simula ng to her mother
nagtrabaho ako and together they
hanggang sa make a decision.
pagbalik ko.”

31
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

EMOTIONAL COMPETENCY

BEFORE DURING ILLNESS


ILLNESS ANALYSIS
( BEFORE DURING PRIOR
APRIL 2008) HOSPITALIZATION DISCHARGE
PRIOR ONSET ( APRIL 2008- DATE OF
OF SIGNS AND AUGUST 2008) DISCHARGE:
SYMPTOMS DATE OF AUGUST 28, 2008
CONFINEMENT:
AUGUST 16-28, 2008
The client is quite The client was After hospitalization, Due financial
unhappy and is emotionally distress the client was still quite problems within
burden on how to during her emotionally distressed the client’s
support his family hospitalization; this but is relief from being family, the client
and significant was manifested by the discharge to the was unhappy and
relative. Since client by becoming hospital. The client feels burden on
their clan has irritable, frowns all the verbalized, “ Syempre how she could
problems with time and refrain from masaya ako na manage to
their finances, this talking to others. The nakalabas na ako sa support the basic
serves as major patient verbalized, “ ospital at wala na ako needs of her
problem to the Sobrang nahirapan din nararamdaman na family and
client which talaga ako nung na- masama sa katawan significant
affects her ospital ako. Ang dame ko.” relatives. She is
emotionally. The kong iniisip lalo na emotionally
client verbalized, yung gastos tapos affected with this
“ Mahirap talaga sabayan pa ng situation and was
ang buhay masamang aggravated when
ngayon. Hindi din pakiramdam.” she was confined
naman kami to the hospital.
mayaman, Her peak of
maraming emotional
panahon na disturbances
medyo nagigipit reaches it’s
talagga kami. height when she
Tapos ako din had a disease.
kasi yung But felt relief
tunutulong sa when she was
mga kamag-anak healed and
ko.” discharged from
the hospital.
Still, existing
problems within
the client’s
family affects
the client
emotionally.

32
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

SOCIAL
COMPETENCY

BEFORE DURING ILLNESS


ILLNESS ANALYSIS
( BEFORE DURING PRIOR
APRIL 2008) HOSPITALIZATION DISCHARGE
PRIOR ONSET ( APRIL 2008- DATE OF
OF SIGNS AND AUGUST 2008) DISCHARGE:
SYMPTOMS DATE OF AUGUST 28, 2008
CONFINEMENT:
AUGUST 16-28, 2008
The client is of During her The client was able to The patient
good confinement, the client return her good experienced an
interpersonal interpersonal interpersonal interrupted
relationship with relationship was relationship with others interpersonal
her friends and interrupted. This is immediately after her relationship
neighbors. This is manifested during discharge to the during her illness
evident with nurse-patient hospital. She was state; this is
client having interaction. The client visited by her possibly related
conversation with was irritable and neighbors and friends with client
neighbors during refrains from speaking after hospitalization. experiencing an
mid-afternoon in to others. The client The client verbalized, alteration in
front of her ‘sari- verbalized, “ Ayoko “Naging ok naman na comfort that
sari’ store. She talaga makipagusap sa yung pakikitungo ko sa results to client’s
had good kahit kanino nung nasa mga kaibigan at kapit becoming
relationships with ospital ako. Hindi kasi bahay ko simula nung irritable and
her previous co- talaga maganda yung na-discharge ako, wala refrain
workers at Africa pakiramdam ko at naman nagbago.” interacting with
and Brunei. The irritable pa talaga ako.” others.
client verbalized,
“ Wala naman
akong problema
sa mga kaibigan
ko at sa mga
katrabaho ko dati,
marunong naman
kasi ako
makisama.”

SEXUAL COMPETENCY

33
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

BEFORE DURING ILLNESS


ILLNESS ANALYSIS
( BEFORE DURING PRIOR
APRIL 2008) HOSPITALIZATION DISCHARGE
PRIOR ONSET ( APRIL 2008- DATE OF
OF SIGNS AND AUGUST 2008) DISCHARGE:
SYMPTOMS DATE OF AUGUST 28, 2008
CONFINEMENT:
AUGUST 16-28, 2008
The client’s civil There was no There was still no The client has no
status is single significant change on significant changes to significant
and has no recent the client’s sexual client’s sexual changes with
sexual affairs. competency during her competency as regards to her
The patient illness state since the compared before her sexual
verbalized, “ client is single and illness state. competency. The
Wala akong does not have any client was single
asawa, medyo affairs to anyone. and no recent
pihikan ako sa sexual affairs.
lalake eh. Pero
dati may mga
nanliligaw sa
akin.”

SPIRITUAL COMPETENCY

34
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

BEFORE
ILLNESS DURING ILLNESS
( BEFORE DURING PRIOR ANALYSIS
APRIL 2008) HOSPITALIZATION DISCHARGE
PRIOR ONSET ( APRIL 2008- DATE OF
OF SIGNS AND AUGUST 2008) DISCHARGE:
SYMPTOMS DATE OF AUGUST 28, 2008
CONFINEMENT:
AUGUST 16-28, 2008
The client is a During her After hospitalization, The client was
Roman Catholic confinement, the client the client resumed her unable to attend
and attends was unable to attend regular attendance with her
Sunday mass on a Sunday mass but was during Sunday mass religious activity
regular basis and able to pray anytime and prays regularly such as attending
practices religious she wants. The client anytime she wants. The church mass
beliefs. The client verbalized, “ Syempre client verbalized, “ every Sunday
verbalized, “ nung nasa hospital ako, Nung makalabas na when she was
Palage ako hindi ako ako ng ospital at hospitalized.
nagsisimba nakakapagsimba. Pero medyo ok na yung However, was
tuwing lingo. kahit papaano pakiramdam ko, able to resume
Pinapraktis nagdadasal ap din ako nagsisimba na uli ako.” again after
naming yung mga lalo pa at may sakit hospitalization.
prusisyon, ako.” The clients have
penitensya kapag an aptitude on
mahal na araw.’ attending regular
church mass and
have faith and
believe to the
Lord Almighty.
She presented
personal, health
and family
problems to God
through prayers
and religious
activities.

PATTERNS OF FUNCTIONING

EATING PATTERN (Consists only of samples of what the patient usually consumes.)

35
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

DURING ILLNESS
Prior to Hospitalization During Hospitalization
Before Illness (Early April 2008-Early (August 16 2008-August 28, Analysis
(Daily Basis) August 2008 ) 2008)
Onset of recurrent signs and
symptoms
BREAKFAST (7 am- BREAKFAST (7 am-varies) DIET UPON ADMISSION: There is a decreased in
varies) Usually consumes 1-2 pcs. Of Low fat diet food intake of the
Usually consume 3-4 medium size pandesal, at least patient prior to
pcs. of medium size 2 thin slices of dairy cream, ½ hospitalization. During
pandesal, 3-4 thin cup coffee with creamer Succeeding Diet: the onset of signs and
slices of dairy cream BRAT diet and Bland Diet symptoms, the client
and 1 cup of coffee LUNCH without dairy products has a gradual decrease
with creamer (12:00 NN – time varies ) • Usual meal of the on servings of her
Usually consumes a cup of client during previous meals eaten.
LUNCH rice, approximately ¼ portion hospitalization varies This could be related to
(12:00 NN – time of meat or fish, and 1-2 to the hospital food client’s altered comfort
varies ) glasses of water being given. This primarily by her
Usually consumes a includes 1 cup of recurrent loose bowel
1- 1 1/2 cup of rice, SNACK rice, a portion of fish movements and
a portion of meat or (4:00 pm) or meat without abdominal pain. Once
fish,1 cup of soup Usually 3-4 pcs. Of crackers spices, side the client was
and 2 glasses of or biscuits and a glass of vegetables, banana hospitalized, there is a
water or sometimes water. and apple. However sudden change on
12oz. of soft drinks. the client only client’s food
DINNER consumes 3-6 tbsp. of preferences as ordered
SNACK (8:00 – 8:30 pm) rice, ¼ portion of the by her physician.
(4:00 pm) Usually consumes a ¾ to 1 viand, 2 tbsp. of the Previously eaten food
Usually just a glass cup of rice, a portion of meat side vegetables, ¼ to such as dairy products,
of water or juice and or fish, and a glass of water. half servings of either coffee and soft drinks
bread or banana cue. banana or apple, 1-2 are prohibited for her.
glasses of water per There is a remarkable
DINNER meal loss of appetite by the
(7:30 – 8:00 pm) client during
Usually consumes a Patient verbalized, “Wala hospitalization that
cup of rice, a portion akong ganang kumain nung leads her to some
of meat or fish, and a nasa ospital ako. Sobrang degree of weakness and
glass of water. nanghihina din talaga ako.” decrease energy levels.

DRINKING PATTERN

DURING ILLNESS
Prior to Hospitalization During Hospitalization

36
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Before Illness Analysis


(Daily Basis) (Early April 2008-Early (August 16 2008-August 28,
August 2008 ) 2008)
Onset of recurrent signs and
symptoms
 Consumes 4-5  Consumes 4 glasses of  Consumes 3-4 glasses of The client
glasses of water water per day water per day drinks insufficient
per day (approximately 840 ml (approximately 630- 840 amount of oral fluids
(approximately per day) ml per day). required per day
840-1050 ml per  ½ cup of coffee ( 50-60 even before illness
day). ml of per day) state. Prior to
 1 cup of coffee ( hospitalization, a
approximately gradual decrease on
110 ml per day) fluid intake was
 12 oz. soft noted. This decrease
drinks ( 360 on the client’s fluid
ml.) but is intake persisted until
seldom the time she was
hospitalized. There
was a decrease of
approximately 210
ml or 1 glass of
water from the
client’s fluid intake
during
hospitalization as
compared before her
illness state.

ELIMINATION PATTERN
URINATION

DURING ILLNESS

37
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Before Illness Prior to Hospitalization During Hospitalization Analysis


(Daily Basis) (Early April 2008-Early (August 16 2008-August 28,
August 2008 ) 2008)
Onset of recurrent signs and
symptoms
Urinary frequency Urinary frequency - Urinary frequency – The patient’s
– 3x/day – 4x/day 3x/day – 4x/day 2x/day – 3x/day urine output before
Color – amber Color – amber yellow Color – amber yellow illness state is within
yellow Amount – scanty to moderate Amount- moderate the normal range.
Amount- moderate Odor – aromatic Odor – aromatic However, during the
Odor – aromatic onset of signs and
APPROXIMATE TOTAL = symptoms, the client
650- 700 ml/day APPROXIMATE TOTAL = had a decrease in
APPROXIMATE 700-750 ml/day urine output
TOTAL = approximately 100-
850- 900 ml/ day 200 ml. This
significant drop on
the client’s urine
outputs make her at
risk to have a
deficient fluid
volume since during
this time, the client
had episodes of
loose bowel
movements. The
decrease in urine
output was gradually
corrected during
hospitalization
where the client is
within the minimum
normal urine output
but is still
insufficient since
client still had
episodes of loose
bowel movements.

BOWEL MOVEMENT

DURING ILLNESS
Prior to Hospitalization During Hospitalization

38
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Before Illness Analysis


(Daily Basis) (Early April 2008-Early (August 16 2008-August 28,
August 2008 ) 2008)
Onset of recurrent signs and
symptoms
Bowel Bowel Bowel Before
Frequency – once a Frequency – Frequency- illness, client had a
day early in the 3-6x/day recurrent in nature 2-3x/ day usual bowel
morning Color – brownish yellow with Color- brownish yellow with movement with
Color – yellowish to blood streak blood streak normal characteristic
light brown Consistency - loose and Consistency – loose and and amount of feces.
Consistency – mucoid mucoid As soon as signs and
semi-formed; soft Amount- 1- 1 ½ cup per bout Amount- 1 cup per bout symptoms occur
bowel prior to her
Amount- 1- 1 ½ cup hospitalization, the
per bout client had a
frequency of 3-6
times of loose bowel
movement that occur
recurrently. The
feces is brownish
yellow in color,
loose and mucoid in
consistency and at
least 1- 1 ½ cup per
bout. This episodes
of loose bowel
movement happened
for almost 3-4
months even the
client is under
medications.
However, during
client’s
hospitalization, a
decrease of 1-2x per
day was observed
but still with same
characteristics of
feces.

BATHING PATTERN

DURING ILLNESS
Prior to Hospitalization During Hospitalization

39
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Before Illness Analysis


(Daily Basis) (Early April 2008-Early (August 16 2008-August 28,
August 2008 ) 2008)
Onset of recurrent signs and
symptoms
Complete bath twice Complete bath once a day in Sponge or bed bath once a The patient’s
a day in the morning the morning day in the morning c/o bathing pattern has
and afternoon. relative or student nurse. not changed except
that the patient was
not able to bathe by
herself during
hospitalization. This
can be related to
client’s feeling of
weakness, decrease
energy levels and
unable to tolerate
some activities.

SLEEPING PATTERN

DURING ILLNESS
Prior to Hospitalization During Hospitalization
Before Illness (Early April 2008-Early (August 16 2008-August 28, Analysis
(Daily Basis) August 2008 ) 2008)
Onset of recurrent signs and
symptoms
Duration : 7-8 Duration : 5-6 hrs/day Duration : Irregular The client has
hrs/day = Time of sleep is usually but reaches 5-6 hours a day. enough sleeping
= Time of sleep is 11:00 in the evening and hours before her
usually 11:00 in the awakens by 7:00 in the illness. But prior to
evening and morning. Interruption of sleep her hospitalization,
awakens by 7:00 in is experienced whenever the she experienced a
the morning. client experienced defecating decrease on the
= Does not take naps due to episodes loose bowel duration of her sleep
during mid- movement. and was interrupted
afternoon since the = Does not take naps during whenever she felt the
client watches her mid-afternoon since the client urge to defecate due
‘sari-sari’ store. watches her ‘sari-sari’ store. to her loose bowel
movement. Once the
client was
hospitalized, she had
still insufficient time
of sleep. This
interruption on
client’s sleeping
pattern is related to
alteration in comfort
due to illness state.

40
METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

DAY TO
DAY APPRAISAL

DATE/ TIME NURSE’S OBSERVATION

08/17/08
0700H-1500H • The client was scheduled for colonoscopy and
proctosigmoidoscopy c/o gastro point of view by 08/19/08
early in the morning
• With orders to give lemonada purgante 720 ml on
08/18/08 to start at 7pm to 10pm
• To give dulcolax 2 tabs at 6pm on 08/18/08
• Client was instructed to have clear liquid diet on 08/18/08
after dinner until 5am of 08/19/08 the nothing per orem
prior the procedure
• With an on going IVF of D5LR 1L + 20meqs KCl as
follow up to above consumed IVF.
• Flagyl discontinued- Dr. Gan aware
• Metronidazole 750mg/ tab every 8 hours if not ok.
• To start Diloxamide Furoarte 500mg/tab 1 tab OD

• Requested for Acid Ether concentration technique of the


stool with modified Kinyoun Acid fast stain- laboratory
personnel aware
• For biopsy noted plan for proctosigmoidoscopy- Dr.
Acuesta aware
• (+) blood streaked stool- Dr. Escalona aware

1500H-2300H
• For stool culture and sensitivity with specimen bottle
• For acid either concentration tech. of the stool with SB.
• Client defered modified Kinyoun acid fast stain of the
stool with blue form and med. abstract with chart
• (+) blood streaked stool, water with some particles,
moderate in amount, mucoid in consistency, 1x
• Client has 3 episodes of vomiting of previously ingested
food.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

DATE/TIME NURSES OBSERVATION

08/17/08 • Client was awake in supine position with on going IVF


of D5LR 1l + 20meqs KCl at 31gtts/min
2300H- 0700H • Client was instructed to have nothing per orem
temporarily
• Scheduled for upper abdominal ultrasound on 08/19/08
early in the morning- not requested
• For proctosimoidoscopy with biopsy scheduled on
8/19/08 early in the morning on call-no consent,
endoscopy request not yet sent
• Dulcolax 2tab. @ 6pm tom. 8/18 night
• May have clear liquid post dinner 8/18 up to 5am (tues.)
8/19 then NPO thereafter
• Advised client’s relative to inquire at DOH if
Diloxamide Furgante is not commercially available in
the pharmacy- Dr. escalona aware
• Afebrile

08/19/08
0700H-1500H
• Client was on pulse oximeter
• Dormicum 2.5mg given as stat dose given prior
procedure
• Demerol 12.5 mg given prior procedure
• Proctosigmoidoscopy done
• Biopsy taken from sigmoid colon to rectum and was
sent to the laboratory
• With results of histopathology and biopsy report to be
follow up

DATE/TIME NURSES OBSERVATION

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

08/19/08
1500H-2300H • Seen
patient by Dr. Cuaresma with suggestion- Dr. P. Te
aware
• Vomited once; previously ingested food
• Dr. P. Te with orders to give:
• Metronidazole tab shifted to 500mg IVT q8
• Metronidazole 1g/supp. OD/rectum
• Imodium 2mg/tab given now then q4 PRN for loose
stool
2300H-0700H
• BM-1x mucoid, brown in color, with blood streaked
moderate in amount.
• Dr. P. Te ordered same IVF as follow up to above
consumed IVF
• Afebrile

ASSESSMENT FINDINGS

GENERAL SURVEY

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

The patient
was conscious and coherent. However, she appears to be irritable and uncomfortable and avoids
conversing to others. She also appears to be ill with thin and frail body. Her stated chronological
appearance is not proportion with her present appearance. The client appears to be younger than
her age.

PHYSICAL ASSESSMENT

Body Part Technique Normal Assessment Analysis


Findings Findings
Skin
a. Color Inspection Whitish pink or Pale and dull Abnormal
brown in color; skin; no evidence Pale and dull
dark skin tone of discoloration skin can be
depending on related to a
patients race; no decrease in
evidence of fluid volume in
discoloration the body and
decrease levels
of oxygen
carrying
capacity of the
blood
b. Bleeding, Inspection No areas of No bleeding, Normal
Ecchymosis and increased ecchymosis and
Vascularity vascularity, increased
ecchymosis and vascularity was
bleeding noted
c. Lesions Inspection & No skin lesions No evident skin Normal
Palpation present except lesions noted
freckles,
birthmarks or
nevi which may
be flat or raised
d. Moisture Palpation Dry with Skin feels dry; Normal
minimum with minimal
perspiration. perspiration
Moisture varies
with changes in
environment,
stress, activity
and body
temperature
e. Tenderness Palpation Skin surface Non tender with Normal
should be no evident
nontender inflammation
f. Texture Palpation Feel smooth, Smooth and firm, Normal
even and firm minimal
with rough roughness on

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

surfaces elbows and knees


g.Turgor/Edema Palpation Skin should No edema Normal
return to it’s present; with fair
original contour skin turgor
rapidly when
released; no
edema present
Hair Inspection & Color varies Thin, dry, Abnormal
Palpation from dark black straight dark Dryness and
to pale blonde; black; evenly hair fall can be
evenly distributed with acquired both
distributed; pale moderate hair genetic and
white to light fall noted, pale nutritional
brown scalp white scalp with imbalances due
with no lesions; no lesions noted to lack of
thin, straight, collagen, a
coarse, thick or protein than
curly; shiny and nourishes the
resilient hair for growth
Nails Inspection & Pink to brown Pale nail beds; Abnormal
Palpation cast; 2-3 seconds with normal This is due to
capillary refill; capillary refill; decrease
smooth, flat and smooth, flat and oxygen supply
slightly rounded; round; 160ͦ angle in the body. An
160ͦ angle early sign of
oxygen
desaturation
Head Inspection & Normocephalic Normocephalic Normal
Palpation and and symmetrical;
symmetrical; nontender; no
smooth, masses and
nontender depression noted
without masses
and depression
Face Inspection & Facial features Symmetrical Normal
Palpation should be facial features;
symmetrical; oval in shape; no
shape can be involuntary
oval, round or movements,
slightly square; edema and
no involuntary disproportion
movements; no noted
edema and
disproportion
Mandible Palpation No discomfort No pain or Normal
with movement; discomfort
no clicking or experienced
crepitus heard upon movement
of the

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

tempomandibular
joint; articulates
smoothly

Neck/Thyroid Inspection & Symmetrical Symmetrical


gland/ Lymph Palpation neck muscles; neck muscles Abnormal
Nodes able to move with head in a Palpable lymph
head in full central position; nodes are
ROM without able to move attributed to
discomfort; no head in full infectious
palpable masses ROM without process in
or enlargement discomfort; no which the
of thyroid glands thyroid gland lymph drains
and lymph nodes enlargement and filters such
noted; with foreign bodies
palpable anterior and
cervical lymph accumulates on
nodes the lymph
nodes
Eyes
a. Visual Acuity Inspection 20/20 vision; Unable to read Abnormal
able to read within a distance Decrease visual
within a near of 14 inches; acuity is related
distance of 14 to degenerative
inches or hereditary
factors with
some risk
factors on
nutritional
intake
b. Eye Cover/Uncover Eyes are aligned No movements Normal
Alignment Test if no movements noted; eyes are
of either eyes aligned
c. Eye Inspection Both eyes move Able to move Normal
Movement smoothly and both eyes in six
symmetrically in field of gaze
each of the six smoothly and
field of gaze symmetrical
Eyelids Inspection Symmetrical; no Asymmetrical; Abnormal
drooping(ptosis), right eyelid with Ptosis is related
infections or mild ptosis noted to cranial nerve
tumors damages that
affects the
neuromuscular
attributes of the
eye.
Lacrimal Inspection & No enlargement, No enlargement Normal
Apparatus Palpation swelling, or swelling

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

redness, noted; with


exudates; no minimal
excessive tearing discharges
or discharge
from the
punctum
Conjunctiva Inspection Pink and moist; Pale palpebral Abnormal
no swelling, conjunctiva Pale palpebral
lesions or noted conjunctiva is a
foreign bodies sign of decrease
fluid volume
and oxygen in
the blood
Pupil Inspection Deep black, Deep black; Normal
round, equal in equal in
diameter ( 2- diameter; equally
6mm), constrict reactive to direct
briskly to direct light; 2-3mm;
light brisk in reaction
Ears
a. Hearing Voice-Whisper The patient Able to repeat Normal
Acuity Test should be able to words whispered
repeat words from a distance
whispered from of 2 feet
a distance of 2
feet
b. External Ear Inspection & Match the flesh Flesh in color; Normal
Palpation color of the proportional to
entire skin; head; non tender
proportional; no auricles; no pain
pain or experienced
tenderness upon palpation
during palpation
c. Ear Canal Inspection No redness, No redness, Normal
swelling, swelling, lesions
lesions, and drainage
drainage, foreign noted; with
bodies or scaly minimal non-dry
surface cerumen noted
Sinuses Inspection & No evidence of No swelling and Normal
Palpation swelling around discomfort upon
nose and eyes; palpation noted
no discomfort
during palpation
Nose
a. External Inspection Symmetrically Located midline Normal
in the midline of to the face; no
the face; no lesion, swelling,

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

lesion, swelling, masses or


bleeding and bleeding noted;
masses; no patent nostril
occlusion to air
passage
b. Internal Inspection Nasal mucosa Pale nasal Abnormal
should be pink mucosa without Pale nasal
or dull red swelling or mucosa is
without swelling polyps; septum is related to
or polyps; no at midline; with decrease
deviation in minimal thick, oxygen supply
septum; with whitish discharge in the blood
small amount of noted
clear watery
discharge
Mouth
a. Lips Inspection Pink and moist Pale and dry lips; Abnormal
with no evidence no swelling and Pale and dry
of lesion or inflammation lips is related to
inflammation noted fluid volume
deficit or
dehydration
b. Tongue Inspection Midline in the Midline in the Normal
mouth; pink, mouth; pink,
moist and rough moist and rough;
( from taste can move freely
buds), no lesions and stick out
and swelling; tongue
moves freely
c. Buccal Inspection Pinkish in color; Mildly pale; Abnormal
Mucosa moist, smooth smooth and Related to fluid
and absence of moist; no lesions volume deficit
inflammation or inflammation or decrease
and lesions noted oxygen in the
blood
d. Gums Inspection Pale-red stippled Pale-red stippled Abnormal
surface; well surface; well Related to fluid
defined gum defined gum volume deficit
margins; no margins; mildly or decrease
swelling or retracted from oxygen in the
bleeding the teeth blood
e. Teeth Inspection 32 set of teeth, Incomplete set of Abnormal
white with teeth with areas Dental carries
smooth edges, of tooth can be acquired
properly aligned extraction; if oral hygiene
and without improperly is inadequate
caries aligned; with and with
black patches decrease in

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

and erosion on calcium and


the surface of fluoride intake
certain teeth that makes teeth
strong and free
from carries
f. Palate Inspection Hard and soft Concave and Normal
palate are pinkish; hard
concave and palate with
pink; hard palate ridges and soft
with many palate is smooth.
ridges; soft No lesion or
palate is smooth; malformations
no lesion and noted
malformations
Throat Inspection Pink, vascular Pink, vascular Normal
and without with no swelling
swelling, or exudates
exudates or noted; Uvula is
lesions; Uvula is at midline:
midline; tonsillar Tonsillar size is
size is 1+ to 2+; 2+ with (+) gag
(+) gag reflex reflex
Breast Inspection Flesh colored; Flesh in color; Normal
areolar area and darker
nipples with pigmentation on
darker areolar areas and
pigmentation; nipples; convex
No thickening or and symmetrical
edema; with breast on
symmetrical; the side of the
convex; no dominant arm
lesions or being larger
masses ( right side); no
thickening,
lesions or
dimpling noted.
Thorax and
Lungs
a. Shape and Inspection Elliptical in Thorax is Abnormal
Symmetry shape; shoulders elliptical in Related to
should be at the shape; left misalignment
same height; shoulder is lower of the spinal
scapula should in height cord.
be the same compared to
height bilaterally right shoulder;
with no masses right scapula
higher in height
bilaterally
b. Muscles of Inspection No accessory Eupnea; no Normal

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Respiration
muscles are used accessory
in normal muscles being
breathing used; no
exaggerated
respiratory effort
upon breathing
noted
c. Tactile Palpation Normal Fremitus Buzzing is felt Normal
Fremitus is felt as buzzing on the ulnar
on the ulnar aspect of the
aspect of the hand upon
hand palpation; no
increase or
decrease
Fremitus was
observed
c. Breath Auscultation Blowing or Fine crackles Abnormal
Sounds hollow sound, (rales) heard Heard when
high in pitch upon there is fluid
( Bronchial); auscultation accumulation
gentle rustling or on the alveoli
breezy, low in of the lungs
pitch
( Vesicular); no
adventitious
breath sounds
should be heard
Heart
a. Precordium Inspection & Symmetrical; no Adynamic Normal
Palpation vibrations, thrills precordium; PMI
and expansions at 5th Intercostal
noted space, left
midclavicular
line
b. Heart Sounds Auscultation Rhythm is Regular heart Normal
regular; sounds; S1 and
distinguishable S2 are
S1 and S2; no distinguishable
murmurs heard upon
auscultation
Peripheral Inspection No pallor, No discoloration Normal
Vasculature cyanosis or and complains of
ulceration noted; pain or
no complaints of discomfort noted
pain or
discomfort
Abdomen
a. Contour, Inspection Flat or rounded; Flat abdomen; Normal

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Symmetry
and symmetrical non tender;
Pigmentation bilaterally; no symmetrical;
discoloration uniform in color
and
pigmentation; no
scars, striae or
lesions noted
b. Umbilicus Inspection Should be Umbilicus at Normal
depressed and lower midline of
beneath the abdomen;
abdominal depressed and
surface beneath
abdominal
surface
c. Bowel Sounds Auscultation Intermittent Normoactive to Abnormal
gurgling sounds hyperactive
throughout bowel sounds
abdominal prominent at
quadrants; high right lower
pitched and quadrant
occurs 5 to 30
times per minute
Musculoskeletal
System
a. Muscle size Inspection Muscle shape Reduced muscle Abnormal
and shape may be size; thin and Decrease in
accentuated in flabby muscles; muscle size and
certain body contour is less shape is due to
areas but should distinct; no nutritional
be symmetrical; involuntary imbalances and
no involuntary movement noted lack of
movement movements
leading to
atrophy
b. Muscle Inspection Complete Decrease muscle Normal
Strength voluntary range strength was
of joint motion observed on
against gravity upper
and moderate to extremities;
full resistance; complete range
strength is of joint motion
equally bilateral; against both
no involuntary gravity and
muscle moderate manual
movements resistance; good
muscle strength

c. Upper Inspection & Able to perform Can perform full


Extremities Palpation full ROM; no range of motion

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

swelling or but with slowed


inflammation movements; no Normal
noted; digital clubbing
symmetrical; observed; with
with five fingers five fingers on
on each hand; each hand;
aligned; no symmetrical;
numbness or equally aligned;
paralysis noted no inflammation
and swelling
noted
d. Lower Inspection & Able to perform Can perform full Abnormal
Extremities Palpation full range of range of motion; Slowed body
motion; no with slowed gait movements
swelling or observed; no may be
inflammation swelling or attributed to
noted; inflammation pain or
symmetrical; noted; alteration in
with five toes on symmetrical; discomfort.
each foot; with five toes on Numbness is
aligned; no each foot; no due to slowed
numbness or complains of calf or blockage of
paralysis noted pain and nerve impulse
intermittent from the axon
claudication; to another
with numbness neuron through
on toes both right the pre synaptic
and left foot to post synaptic
noted
e. Spinal cord Inspection Cervical Cervical is Abnormal
concavity; concave; thoracic Related to
thoracic has increased curvature of the
convexity; convexity ( slight spinal cord such
lumbar hump); lumbar is as scoliosis,
concavity; with concave; with lordosis etc.
full ROM full ROM

REVIEW OF SYSTEM

The review of system is the client’s subjective response to a series of body system related
questions. It follows a head-to-toe approach and includes the signs and symptoms related to
disease. Mentioned among are the positive findings assessed from the client.

Body Parts/System Positive Findings

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

General
Subjective:
“Hindi maganda ang pakiramdam ko,
medyo sumasakit ang tiyan ko at hindi at
mapalagay. Nararamdaman ko din na
nanghihina ako at para bang palage akong
walang lakas.”

Integumentary Subjective:
“Wala naman ako mga peklat o sugat.
Medyo ‘dry’ nga lang ang balat ko, di kasi
akon nakakapag lotion madalas”

Respiratory Subjective:
“ Medyo inuubo ako ngayon pero hindi
naman ako nahihirapan huminga.”

Cardiovascular and Peripheral Vasculature Subjective:


“ Yung nanay ko pati lola ko sa mother
side, parehas silang high blood, pero ako
naman sa awa ng Diyos, hindi naman.”

Gastrointestinal Subjective:
“Madalas ako nadudume na may kasamang
dugo at medyo basa. Nakaramdam din ako
ng pagsusuka. Pabalik balik ang pananakit
ng tiyan, humihilab at para bang umiikot
yung sikmura ko,”

Urinary Subjective:
“ Wla naman akong problem sa pag-ihi o
sakit na nararamdaman. Dalawa hanggang
tatlong beses ako umiihi. Medyo mahina
din kasi ako uminom ng tubig eh.”

Musculoskeletal Subjective:
” Nahihirapan ako maglakad at magkikilos
ngayon, nanghihna kasi ako at madaling
mahapo.’

Neurological Subjective:
“Medyo nahihirapan ako magsalita ngayon,
nauutal ako. Masakit din ang tiyan ko.
“Nagmamanhid nga din yung mga daliri ko
sa paa, para bang hindi ako
nakakaramdam.”
Female Reproductive ( no positive findings)

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Nutrition
Subjective:
“Wala talaga akong ganang kumain. Mga
3-4 na subo lang ayoko na agad. Sumasakit
kasi ang tiyan ko at masama talaga ang
pakiramdam ko”
Endocrine ( no positive findings)

Lymph Nodes Subjective


“ Masakit yung leeg ko, para bang may
bukol. Masakit kapag hinahawakan.”

Hematological Subjective:
“ Medyo nanghihina ako at walang gana.
Madali ako mapagod at mahapo.’

DIAGNOSTIC PROCEDURES

LABORATORY EXAMINATION

COMPLETE BLOOD COUNT (CBC). Done to assess if the patient has increase or decrease
WBC due to detect infection.

Requested By: Dr. William Hoping Gan


Date received: 08/16/08 10; 09 AM

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Date released: 08/16/08 10:54 AM

Result Normal Values


Hemoglobin 100 112-157 g/L
Hct 0.31 0.34-0.3510^12/L
RBC 3.72 3.93-5.22 x 10 ^ 12/L
WBC 6.2 4.7810^9/L
Platelet Adequate 150-400

Differential Count
Results Normal Values
Segmenters 0.58 0.55- 0.70
Lymphocytes 0.29 0.25- 0.40
Monocytes 0.08 0.02- 0.08
Eosinophils 0.04 0.01- 0.06
Basophils 0.01 0.00- 0.05

ANALYSIS:
The result of e exam of hemoglobin 100 g/L show a decrease in number of circulating
hemoglobin iron-protein compound in red blood cells which transport oxygen for to the body
tissue thus implicate a poor tissue perfusion. This also show a decrease number of RBC TO
3.72.Thus decreasing the percentage of a blood sample that consists of red blood cells, measured
after the blood has been centrifuged and the cells compacted called Hematocrit to 0.31.
Differential counts are within normal values.

Hematology
It is a series of screening test, which consists of hemoglobin and hematocrit measurement for the
detection of certain diseases. It provides complete evaluation of all the formed elements of the
blood. It can supply a great deal of information to diagnose hematopoietic system and helps to
evaluate these stages and prognosis of certain diseases.

Differential Count
The differential count measures the percentage of each type of leukocytes. An increased of
percentage of one type of leukocyte, maybe a decreased in percentage of the other type. The
leukocyte type can be identified easily by their morphology in venous blood smear.

Red Blood Cells


The red blood cells are the cells that carry oxygen to all parts of the body through the hemoglobin.

White Blood Cells


It refers to the blood cells that do not contain hemoglobin. White blood cells are made by bone
marrow and help body fight infections and other diseases as part of immune system. The white
blood cell count also used to suggest the presence of infections, allergy, and leukemia. It is also
used to monitor the body's response to various types of treatments and to monitor bone marrow
function.

Platelet
Platelets are part of cytoplasm that are involved in the coagulation process. Platelet attach or

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

adhere to the
walls of
injures blood vessels, where they clump together or aggregate to form platelet plugs necessary for
coagulation. It is produced by bone marrow and processed and removed by the spleen when they
are damaged or old.
Lymphocytes
Is a class of leukocytes produced in a variety of lymphoid organs throughout the body and is
responsible for cellular and normal immune responses. Leukocytes are often seen in sites of
chronic inflammation. They produce many secretory products that modulate the functional of a
wide variety of cell types.

Eosinophils
It is a variety of white blood cells distinguished by the presence of cytoplasm. It is capable of
ingesting foreign particles.

Monocytes
It is the largest cell of a normal blood that transforms into macrophages and become responsible
for phagocytosis of unwanted particular matter.

Hematocrit and Hemoglobin Levels

Requested by: Dr. William Hoping gan


Date Received: 08/17/08 05:00 AM
Date Released: 08/17/08 5:39 AM

Exam Results Normal Values


Hemoglobin 105 120-160 g/L
Hematocrit 0.32 0.37-0.47

Analysis:
The result of the exam for hemoglobin 105 g/L shows decrease in number of circulating
hemoglobin contained entirely in the red blood cells, amounting to perhaps 35 percent of their
weight. To combine properly with oxygen, red blood cells must contain adequate hemoglobin.
Hemoglobin, in turn, is dependent on iron for its formation. A deficiency of hemoglobin caused by
a lack of iron in the body leads to anemia. Thus decreasing red blood cells in a blood sample in
order to determine the percentage of the blood that consists of cells Decrease in hemoglobin,
Hematocrit, and RBC shows the relation to amoebiasis in a way that trophozoites a parasite that
invade tissue found in liquid colonic contents burrow deeper with tendency to spread laterally by
continous lysis of cell until they reach the muscalaris mucosae frequently erode the lymphatic or
walls of the mesenteric venules in the floor of ulcers, which may enter , and in carried into
intraheptic portal veins. If thrombi occur in small branches of the portal vein, the trohozoites held
in the thrombi cause lytic necrosis of the wall of vessel and digest s pathway into the lobules
Date received: 08/22/08 02:25 PM
Date released: 08/22/08 03:55PM
Requested by: William Hoping Gan, MD

Exam Results Normal Values


Hemoglobin 114 120-160 g/L
Hematocrit 0.35 0.37-0.47

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Analysis:
The result of e exam of hemoglobin 114 g/L show a slightly decrease in number of
circulating hemoglobin. In addition alterations in the structure of hemoglobin can lead to life-
threatening illnesses. The most important of these conditions is sickle-cell anemia, which involves
a hereditary change in one of the amino acids that make up hemoglobin. The thalassemias are a
group of hereditary diseases of similar origin. A decrease in the fraction of blood occupied by
erythrocyte or hematocrit.

Hemoglobin
Hemoglobin is the main components of red blood cells. The main function is to carry
oxygen from the lungs to the tissue and transport carbon dioxide, the product of metabolism, back
to the lungs. It is often ordered as part of complete blood count. Red blood cells are complete with
hemoglobin.

Hematocrit
The hematocrit is the percent of whole blood that is comprised of red blood cells. It is
compound measures how much space in the blood is occupied by red blood cells. It is useful when
evaluating a person with anemia.

ACTIVATED PARTIAL PROTRHOMBIN TIME/ PROTHROMBIN TIME

Requested by: William Hoping Gan, MD


Date received: 08/16/08 07:25 PM
Date released: 08/16/08 08:09PM

Exam Results Normal Values


APTT 39.0 25-27 seconds
Control 27.4 27-35 seconds

PROTHROMBIN PT
Protime 14.6
% activity 84.4 sec
INR 1.15 %
ISI 1.21
Control 13.0 sec

Analysis
An increase in APTT indicates a decrease clotting time which initiates bleeding tendency
and a blood-clotting factor in blood platelets that converts prothrombin to thrombin to promote
scar formation and wound healing. Normal prohrombin activity in the blood depends on adequate
absorption of Vitamin K from the GI tract and adequate liver function. Therefore deficiency may
arise from factor that affects vitamin K absorption such as diarrhea. Increase in APTT is related in
a amoebiasis in a way that it may affect the liver decreasing production of several clotting factors
may be due to deficient vitamin K from the gastrointestinal tract. This probably is caused by the

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

inability of
liver cells to
use vitamin K to make prothrombin. Absorption of the other fat-soluble vitamin (vitamin A, D,
and E) as well the dietary fats may also be impaired because of the decreased secretion of bile salt
in the intestine. The production of blood clotting factor of the liver is also reduced, leading in an
increased incidence of bruising, nosebleed, bleeding from wounds and gastrointestinal bleeding.

BLOOD CHEMISTRY

Requested by: Dr William Hoping Gan


Date Received: 08/16/08
Date Released: 08/16/08
Conventional Unit SI Unit
TEST
Results Reference Results Reference
BUN L 5.25 mg/dL 7.79- 21.40 1.97 mmol/.L 2.78- 7.64
Creatinine 0.61 mg/dL 0.50- 1.20 55.02 umol/L 44.0- 106.0
SGPT (ALT) 8 u/L 0-41 8 u/L 0- 41
Sodium 139 meq/L 135- 145.0 139 mmol.L 135.0- 145.0
Potassium 3.4 meq/L 3.80- 5.50 3.4 mmol/L 3.80- 5.50

Analysis
A decrease in BUN indicates a decrease in index of renal excretory capacity. Serum urea
nitrogen is dependent on the body’s urea production and on urine flow. Urea’s are nitrogenous end
product of protein metabolism and are also affected by protein intake. A decrease in potassium
which can cause such problems as thirst, fatigue, low blood pressure, muscle cramps, nausea, and
irregular heartbeat. Some diuretics (medications that increase urination) and heart drugs, as well as
certain diseases, can cause potassium deficiency. SGPT, Creatinine, Sodium are at normal range.
Decrease in BUN and potassium due to slight attack of diarrhea eructations after eating and slight
nausea partly because potassium is actually lost when gastric fluid is lost; but more so because
potassium is lost through the kidneys in association with metabolic alkalosis. Relatively large
amounts of potassium are contained in intestinal fluid for example diarrheal fluid may contain as
much as 30 mEq.L. Therefore potassium deficit occurs frequently with diarrhea that may cause
cardiac dysrythmias as a complication. A decrease in BUN indicates a low index in renal excretory
capacity and is associated in low protein intake therefore decrease protein metabolism causing by
product urea to decrease.

Date received: 08/22/08 02:25 PM


Date released: 08/22/08 04:12PM
Requested by: William Hoping Gan, MD

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TEST Conventional Unit SI Unit


Results Reference Results Reference
Potassium L 3.6 meq/L 3.80- 5.50 3.6 mmol/L 3.80- 5.50

Analysis
The test show a slightly decrease in potassium which plays an important role in normal
muscle activity symptoms of deficiency include muscle weakness. Potassium chloride works by
controlling the body’s water balance and regulating such processes as nerve transmission, muscle
contraction, and normal heart rhythm. Laboratory chemistry branch of science dealing with the
structure, composition, properties, and reactive characteristics of substances, especially at the
atomic and molecular levels.

BLOOD EXTRACTION

Nursing responsibilities:
Before:
1. Greet client by name and validate client’s identification. Check full name and ID band –
for verification purposes.
1. Explain the procedure and its importance.
2. Tell the patient that no special diet or fasting is required.
3. Give details about the collection of the blood sample which is brief but if causes some
discomfort.
4. Notify the patient that pressure will be applied to the puncture site for few minutes.
5. Hand washing – to prevent contamination of microorganisms.
During:
1. Inform the patient to avoid closing and opening the hand after the tourniquet is applied.
2. Position client’s arm to form a straight line from the shoulder to wrist. Place pillow under
upper arm to enhance extension. Client should be in supine or semi-fowler’s position – to
facilitate easy blood drawing.
3. Indicate on the laboratory slip any drugs that can affect the result.
After:
1. Apply pressure or a pressure dressing area to the venipuncture site.
2. Assess the venipuncture site for bleeding.
3. Dispose the needles, syringe and soiled equipments to proper container – to prevent
contamination.
4. Hand washing – to prevent contamination.
5. Validate client’s reaction – to assess feelings and reactions of patient after the procedure.
6. Send specimen into the laboratory with the client’s complete identification – inaccurate
identification on the specimen container can lead to errors of diagnosis or therapy.
7. Follow up the result and report to AMD.

COMPLETE URINALYSIS

Requested by: Dr. William Hoping Gan


Date released: 08/16/2008 01:35 PM
Date received: 08/16/2008 02:56 Pm

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MACROSCOPIC

Physical/Macroscopic Result
Color Amber
Transparency Slightly hazy
Specific Gravity 1.010
Ph 7.5 Alkaline
Protein Negative
Glucose Negative

MICROSCOPIC

RBC 0-1/ HPF


WBC 1-2/ HPF
Epithelial cells Occasional
Bacteria Many
Mucous Threads Moderate
Amorphous Urates Moderate

Analysis
Urinalysis shown normal urine color amber and slightly hazy a decrease urine specific gravity
it is less precise than urine osmolality and reflects both the quantity and the nature of particles.
Therefore, protein, Glucose, and intravenous contrast agent specific gravity than osmolality. Urine
is a good medium for growth of bacteria that’s why urine ideally performed on fresh specimen
preferably the first voiding. If left standing at room temperature urine become alkaline because of
contamination of urea-splitting bacteria.
Mucous thread moderates in amount, Bacteria many in amount A. Phosphate moderate epithelial
cell occasional. The normal urinary tract is sterile above the urethra bacteria may be due to
incomplete emptying of the bladder and urinary stasis. Decreased natural host defense and
instrumentation of the urinary tract including catheterization and cystoscopic procedure
MACROSCOPIC

Physical/Macroscopic Result
Color Yellow
Transparency Slightly hazy
Specific Gravity 1.030
Reaction 6.0
Protein Negative
Glucose Negative

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MACROSCOPIC

RBC 0-1/ HPF


WBC 1-2/ HPF
Epithelial cells Occasional
Bacteria Moderate
Mucous Threads Few
Renal Cells None

Analysis
Show normal urine color and transparency increase specific gravity indicate presence of
substances found in urine. Negative for protenuria and glycosuria. In addition urinalysis may
provide important clinical information. Although urinalysis is usually performed routinely it
evaluates urine color, clarity and odor. Measurement urine acidity and specific gravity. Test for
presence of protein, glucose and ketone, hematuria, cast (cylinduria), crystals (crystalluria), pus
(pyuria) and bacteria (bacteriuria).

NOTE:
Hematology-Specimen rechecked
Results verified
Chem: Specimen rechecked. Abnormal results verified.
Clinical microscopy verified. Specimen rechecked. Results verified

FECALYSIS

Requested by: William Hoping Gan


Date received: 08/15/ 08
Date released: 08/16/08 4: 09 PM

MACROSCOPIC MICROSCOPIC
Color Red RBC 70- 80/ HPF
Consistency WATERY/MUCOID Pus cells 12-20/ HPF

Others
SPECIAL TEST
Occult blood: NOT REQUESTED

Entamoeba histolytica
Cyst 1-3L/LPF
Trophozoite 1-2/LPF

Parasites
Ascariasis ova: NONE SEEN

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Hookworm ova: NONE SEEN


Trichiuris ova: NONE SEEN

Analysis:

Stool exam show a red in color which is an indicator of blood entering the lower portion of
the GI tract or passing rapidly through it. Carrots and beets may cause a red stool. A normal
mucoid consistency no presence of ascariasis ova, hookworm ova, trichiuris ova a parasite usually
found in stool. Color red watery mucoid in consistency in relation to amoebiasis that a watery
mucoid stool are characteristics of small bowel disease whereas loose, semisolid stool are
associated more often in the disorder of the colon it denotes inflammatory enteritis or colitis. Color
red stool may indicate a blood entering the lower portion of the gastrointestinal tract or passing
rapidly through it will appear bright or dark red that is associate4d in amoebiasis an a way that
there is ulceration in lymphatic vessel of the gastrointestinal tract.

STOOL ACID- ETHER CONCENTRATION TECHNIQUE


Requested by: Dr. William Hoping Gan
Date received: 08/18/08
Date released: 08/18/08 04:05 PM

RESULT: NONE FOUND FOR OVA, PARASITES & AMOEBA

Analysis

Stool acid indicates no found for ova, parasites and amoeba no changes noted. In addition
there are factors that interfere with the sensitivity and specificity of the test. Careful assessment of
diet and mediation regimen is necessary to eliminate the chance of false-positive results.

BACTERIOLOGY
STOOL CULTURE AND SENSITIVITY
Date received: 08/18/ 08
Date released: 08/21/0808
Requested by: William Hoping Gan

Result: No enteric Pathogen Isolated

Analysis
Stool culture shown no presence of enteric pathogen it include inspection of the specimen
for its amount, consistency, and color, and a screening test for occult blood. The test done to
patient is a special test which includes for pathogen and collected in a random basis. In addition
bacteriology is the scientific study of bacteria, especially in relation to medicine

Computed Tomography Scan Report


Date: 08/23/2008

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Clinical
history:
slurring speech
Canial CT scan: with delayed conttrast

Findings:
Tiny parenchymal is note in the left pareital lobe
The gray white matter interface is well defined
Te ventricles, sulci, and cisterns are normal
No evidence of hydrocephalus, acute parenchymal hemorrhage of midline shift
Posterior fossa structure are intact
Visualized paranasal sinises petromastoid are clear
No abnormal enhancementis seen contrast study

Impression:
Tiny parenchymal calcification with adjacent edema, left lateral lobe.
This may relate to vascular abnormal, previous injection or less likely peoplastic process

Indication:
The test is done to the patient to see if there is mass, cyst,
inflammatory lesions, abscess of the chest, abdomen, pelvis and extremities.

ULTRASOUND REPORT
Date: 08/19/2008

Findings:
The liver is normal in size and echo pattern
There is no dilation of the intra-hepatic ducts
No mass seen
The gallbladder5 measuring 6.1 x 2.0cm with anaerobis lumen. The wall is not thickened
The pancreas is normal in size and echo pattern
No mass seen in at or near the region of the pancreas
The spleen is not enlarged. Negative for intrasplenic mass.

Indication:
This test is done to see if there is any problem like mass or cyst regarding the liver, gallbladder
pancreas and spleen.

Impression:
Essentially there is normal
COLONOSCOPY
Date: 09/19/08

Findings:
Seen Finding Biopsy
Anus / / /
Rectum / / /

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Sigmoid
/
Descending colon /
Sple flexure /
Trans colon /
Hop. Flexure /
Ascending colon /

Scope was inserted until terminal ileum. Normal terminal ileal mucosa. From level 40cm, there are
multiple white base mucosa erosion with erythematotous border seen. Circumferential mucosa
erosion with whitish mucous seen from level 35cmdown to the rectum. Multiple biopsies taken
from erosion and normal mucosa to send for hiatopath. The rest of the examination are
unremarkable.

Indication:
This test is done to see if client is at high risk of having colon cancer. Patient with a history
of diarrhea and constipation, persistent rectal bleeding or lower abdominal pain.

Impression:
There is normal ileal mucosa
There is multiple whtie base matter erosion with erythematotous

Pathology Report

Referring physician; Dr. Purwanta


Specimen: Normal and abnormal mucosa, sigmoid down to rectum

Diagnosis:
A. Fragments of unremarkable mucosa
B. Consistent with chronic active colitis with ulceration

Description of notes:

Received in two parts


A. The specimen labeled “ normal mucosa sigmoid down to rectum” consist of tan gray tissues
with an aggregate diameter all of 0.3cm. block
B. The specimen labeled “abnormal mucosa sigmoid down to rectum” consist of tan gray tissues
with an aggregate diameter all of 0.5cm. blocd.

MEDICAL MANAGEMENT

INTRAVENOUS THERAPY

Initial Intravenous Fluid upon admission:


• D5LR 1 liter to run for 10 hours, 25 gtts/min, 100 cc/hr

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Succeeding
Intravenous
Fluid:

Date Ordered Time Name of IVF


8/19/08 2:20 pm D5NM 1L X 8 hours
8/20/08 6 am D5NM 1L + 20 meqs Kcl x
12 hours
8/20/08 1:30 pm D5NM 1L X 12 hours
8/22/08 7:30 am D5 NSS 1L X 10 hours TF:
D5LR 1L X 10 hours
8/23/08 7am D5LR 1L X 10 hours
8/23/08 12 MN D5NM 1L X 14 hours
8/26/08 6:35 am D5NM 1L X 16 hours
8/26/08 7:37 am PLR X 14 hours

Intravenous therapy or IV therapy is the giving of liquid substances directly into a vein. It
can be intermittent or continuous; continuous administration is called an intravenous drip. The
word intravenous simply means “within a vein”, but is most commonly used to refer IV therapy.
Therapies administered intravenously are often called specialty pharmaceuticals.

Compared with other routes of administration, the intravenous route is the fastest way to
deliver fluids and medications throughout the body. Some medications, as well as blood
transfusions and lethal injections, can only be given intravenously.

D5LR/ PLR

Lactated Ringer's solution is a solution that is isotonic with blood and intended for
intravenous administration. Veterinary administration may also be subcutaneous.

Lactated Ringer's solution is abbreviated as "LR" or "RL". It is also known as Ringer's


lactate solution (although Ringer's solution technically refers only to the saline component,
without lactate). It is very similar - though not identical to - Hartmann's Solution, the ionic
concentrations of which differ.

Lactated Ringer

Lactated Ringer's Solution is often used for fluid resuscitation after a blood loss due to
trauma, surgery, or a burn injury. Previously, it was used to induce urine output in patients with
renal failure.Lactated Ringer's Solution is used because the byproducts of lactate metabolism in the
liver counteract acidosis, which is a chemical imbalance that occurs with acute fluid loss or renal
failure.

The intravenous dose of Lactated Ringer's Solution is usually calculated by estimated fluid
loss and presumed fluid deficit. For fluid resuscitation the usual rate of administration is 20 to 30
ml/kg body weight/hour. Lactated Ringer's Solution is not suitable for maintenance therapy
because the sodium content (130 mEq/L) is considered too high, particularly for children, whereas
the potassium content (4 mEq/L) is too low, in view of electrolyte daily requirement.

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Other
commonly
used intravenous solutions include normal saline and hespan (used in hypovolemic shock).
Lactated Ringer's is also used as a conduit for the delivery of drugs. Lactated Ringer's is usually
given intravenously, but if a suitable vein is not found, it can be taken orally (although it has an
unpleasant taste).

D5NS

The amount of normal saline infused depends largely on the needs of the patient (e.g.
ongoing diarrhea or heart failure) but is typically between 1.5 and 3 litres a day for an adult.

Other concentrations of saline are frequently used for other medical purposes, such as
supplying extra water to a dehydrated patient or supplying the daily water and salt needs
("maintenance" needs) of a patient who is unable to take them by mouth. Because infusing a
solution of low osmolality can cause problems, intravenous solutions with reduced saline
concentrations typically have dextrose (glucose) added to maintain a safe osmolality while
providing less sodium chloride. As the molecular weight (MW) of dextrose is greater, this has the
same osmolality as normal saline despite having less sodium. Because the dextrose used in these
preparations is dextrose monohydrate (a commercial form having MW 198 in contrast to MW 180
for glucose), 5% dextrose is equivalent to 4.5% glucose.

NURSING RESPONSIBILITIES:

• Regulate the flow rate accurately.


• Check IVF insertion site and take note for any possible infection if is still inserted
in vein.
• Maintain patent tube and assess for formation of bubbles.
• Instruct patient not to move the site vigorously.

DIET
• Initial diet upon admission: low fat diet

Succeeding diet:

Date Ordered Time Diet

8/16/08 10:30 am BRAT diet ,no dairy


products
8/16/08 6:00 pm Banana per meal TID
8/17/08 9:25 am BRAT, free of dairy
products
8/17/08 11:35 am Clear liquids after dinner up
to 5 am Tuesday then NPO
thereafter.
8/18/08 5:45 am Bland diet, no dairy
products
8/19/08 6:00 am BRAT diet
8/28/08 1:15 am Light meal, then NPO 5 am.

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In
nutrition, the diet is the sum of food consumed by a person or other organism Dietary habits are
the habitual decisions an individual or culture makes when choosing what foods to eat. Although
humans are omnivores, each culture holds some food preferences and some food taboos.
Individual dietary choices may be more or less healthy. Proper nutrition requires the proper
ingestion and equally important, the absorption of vitamins, minerals, and fuel in the form of
carbohydrates, proteins, and fats. Dietary habits and choices play a significant role in health and
mortality, and can also define cultures and play a role in religion.

BRAT DIET

The BRAT diet is a historically prescribed treatment for patients with various forms of
gastrointestinal distress such as diarrhea, dyspepsia, and/or gastroenteritis. The BRAT diet consists
of foods that are relatively bland, easy to digest, and low in fiber. Low-fiber foods are
recommended because foods high in fiber may cause gas, possibly worsening the gastrointestinal
upset. The foods from the BRAT diet may be added, but should not replace normal, tolerated
foods. Sugary drinks and carbonated beverages should be avoided.A well-balanced diet is best
even during diarrhea, but studies have found that incorporating foods from the BRAT diet can
reduce the severity of diarrhea (see Contrary medical advice). Applesauce provides pectin, as does
toast with grape jelly.

The BRAT diet should include additional protein supplements such as tofu or protein pills.

BLAND DIET

Purpose: The bland or soft diet is designed to decrease peristalsis and avoid irritation of the
gastrointestinal tract.

Use: It is appropriate for people with peptic ulcer disease, chronic gastritis, Reflux esophagitis or
dyspepsia. It may also be used in the treatment of hiatal hernia.

Description: The soft/ bland diet consists of foods that are easily digestible, mildly seasoned and
tender. Fried foods, highly seasoned foods and most raw or gas-forming fruits and vegetables are
eliminated. Drinks containing Xanthine and alcohol should also be avoided.

DIAGNOSTIC PROCEDURES:

COLONOSCOPY

A colonoscopy is an internal examination of the colon (large intestine), using an instrument


called a colonoscope.

Colonoscopy is a procedure that enables an examiner (usually a gastroenterologist) to


evaluate the appearance of the inside of the colon (large bowel). This is accomplished by inserting
a flexible tube that is about the thickness of a finger into the anus, and then advancing it slowly,
under visual control, into the rectum and through the colon. It is performed with the visual control
of either looking through the instrument or with viewing a TV monitor.

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Why is
colonoscopy done?

This test may be done for a variety of reasons. Most often it is done to investigate the finding
of blood in the stool, abdominal pain, diarrhea, a change in the bowel habits, or an abnormality
found on colon x- ray or a CT scan. Certain individuals with previous history of polyps or colon
cancer and certain individuals with family history of particular malignancies or colon problems
may be advised to have periodic colonoscopies because they are at a greater risk of polyps or colon
cancer.

NURSING RESPONSIBILITIES:

Client preparation

1. Ensure presence of a signed informed consent for the procedure.


2. A liquid diet may be prescribed for two days prior to the procedure and the client is
usually NPO for 8 hours, just before the procedure.
3. Administer or instruct the client in bowel preparation procedures such as taking citrate
or magnesia or polyethylene glycol the evening before.
4. Sedation is usually given during the procedure.

Client and Family teaching:

Before procedure

• Explain dietary restrictions and their purpose.


• The procedure takes 30 minutes to 1 hour.
• The scope is inserted through the anus and advanced to the cecum.

After procedure

• You may have increased flatus as air is instilled into the bowel during the
procedure.
• Report any abdominal pain, chills, fever, rectal bleeding or mucopurulent discharge.
• If polyps have been removed, avoid heavy lifting for 7 days and avoid high fiber
food foe 1-2 days.

UPPER ABDOMINAL ULTRASOUND

Abdominal ultrasound (US) is an important diagnostic method for evaluation of many


structures in the abdomen, such as the liver, gallbladder, biliary tract, pancreas and kidneys.
Indications include abdominal, flank and/or back pain, palpable abnormalities, abnormal laboratory
values suggestive for abdominal pathology, follow-up of known or suspected abnormalities and
search for metastatic disease or occult primary. Abdominal US are frequently performed in Western
societies.

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The
frequency
with which even relatively inexpensive and non-invasive diagnostic tests are performed clearly
places a burden on health care.

Therefore it is important that their influence on patient management is assessed.


Unnecessary diagnostic investigations may lead to incidental findings, or to additional unnecessary
diagnostic procedures or even over treatment.

NURSING RESPONSIBILITIES:

Client preparation

1. Ask patient to wear comfortable, loose-fitting clothing for ultrasound exam. The patient
will need to remove all clothing and jewelry in the area to be examined. You may be asked to wear
a gown during the procedure.

2. Ask patient to inform the doctor if he/she have had a barium enema or a series of upper
GI (gastrointestinal) tests within the past two days. Barium that remains in the intestines can
interfere with the ultrasound test.

Other preparations depend on the type of ultrasound you are having.


• For a study of the liver, gallbladder, spleen, and pancreas, you may be asked to eat a fat-
free meal on the evening before the test and then to avoid eating for eight to 12 hours
before the test.
• For ultrasound of the kidneys, you may be asked to drink four to six glasses of liquid about
an hour before the test to fill your bladder. You may be asked to avoid eating for eight to
12 hours before the test to avoid gas buildup in the intestines.
• For ultrasound of the aorta, you may need to avoid eating for eight to 12 hours before the
test.
DURING AND AFTER THE PROCEDURE

Most ultrasound examinations are painless, fast and easy.

1. Inform the patient that after he or she positioned on the examination table, the radiologist, or
sonographer will spread some warm gel on his/her skin and then press the transducer firmly
against the body, moving it back and forth over the area of interest until the desired images are
captured. There may be varying degrees of discomfort from pressure as the transducer is pressed
against the area being examined.

2. If scanning is performed over an area of tenderness, the patient may feel pressure or minor pain
from the procedure.

3. If a Doppler ultrasound study is performed, the patient may actually hear pulse-like sounds that
change in pitch as the blood flow is monitored and measured.

• Once the imaging is complete, the gel will be wiped off on skin.

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• After an ultrasound exam, the patient should be able to resume your


normal activities.

PROCTOSIGMOIDOSCOPY/ SIGMOIDOSCOPY

Sigmoidoscopy is the minimally invasive medical examination of the large intestine from
the rectum through the last part of the colon. There are two types of sigmoidoscopy, flexible
sigmoidoscopy, which uses a flexible endoscope, and rigid sigmoidoscopy, which uses a rigid
device. Flexible sigmoidoscopy is today generally the preferred procedure. Sigmoidoscopy is a
very effective screening tool. Sigmoidoscopy is similar but not the same as colonoscopy.
Sigmoidoscopy only examines up to the sigmoid, the most distal part of the colon, while
colonoscopy examines the whole large bowel.

Client Preparation:

The colon and rectum must be completely empty for flexible sigmoidoscopy to be thorough
and safe, so the physician will probably tell the patient to drink only clear liquids for 12 to 24
hours beforehand. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water,
plain coffee, plain tea, or diet soft drinks. The night before or right before the procedure, the
patient receives a laxative and an enema, which is a liquid solution that washes out the intestines.

No sedation is required during this procedure as long as the examination does not exceed
the level of the splenic flexure

COMPUTED TOMOGRAPHY SCAN

CT imaging is particularly useful because it can show several types of tissue with great
clarity, including organs such as the liver, spleen, pancreas and kidneys. Using specialized
equipment and expertise to create and interpret CT scans of the lower gastrointestinal (GI) tract,
the colon and rectum, an experienced radiologist can accurately diagnose many causes of
abdominal pain, such as an abscess in the abdomen, inflamed colon or colon cancer, diverticulitis
and appendicitis. Often, no additional diagnostic work-up is necessary and treatment planning can
begin immediately.

What are some common uses of the procedure?

Because it is a non-invasive procedure that provides detailed, cross-sectional views of all


types of tissue, CT is becoming the preferred method for diagnosing many diseases of the bowel
and colon, including diverticulitis and appendicitis, and for visualizing the liver, spleen, pancreas
and kidneys.

In cases of acute abdominal distress, CT can quickly identify the source of pain. Especially
when pain is caused by infection and inflammation, the speed, ease and accuracy of a CT
examination can reduce the risk of serious complications caused by a burst appendix or ruptured
diverticulum and the subsequent spread of infection.

CLIENT PREPARATION

1. The client should wear comfortable, loose-fitting clothing for the CT exam.

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2. Metal
objects
can affect the image, so avoid clothing with zippers and snaps. The client may be asked to
remove hairpins, jewelry, eyeglasses, hearing aids and any removable dental work that
could obscure the images.
3. The client may also be asked to refrain from eating or drinking anything for an hour or
longer before the exam.
4. Women should always inform their doctor or x-ray technologist if there is any possibility
that they are pregnant.

How is the procedure performed?

The technologist begins by positioning the patient on the CT table. The patient's body may
be supported by pillows to help hold it still and in the proper position during the scan. As the study
proceeds, the table will move slowly into the CT scanner. Depending on the area of the body being
examined, the increments of movement may be so small that they are almost undetectable, or large
enough that the patient feels the sensation of motion.

A CT examination of the gastrointestinal tract requires the use of a contrast material to


enhance the visibility of certain tissues. The contrast material may be swallowed or administered
by enema. Before administering the contrast material, the technologist will ask whether the patient
has any allergies, especially to medications or iodine, and whether the patient has a history of
diabetes, asthma, a heart condition, and kidney problems. These conditions may indicate a higher
risk of reaction to the contrast material. A CT examination usually takes from five minutes to half
an hour.

NURSING RESPONSIBILITIES:

DURING THE CT SCAN

1. The client will lie on a table that will pass slowly through a large opening in the scanner as
x-rays are taken.
2. The client will be asked to lie perfectly still throughout the procedure, so that blurring does
not occur. Even though the client will be alone in the room, the client will be closely
observed at all times. If contrast is used, it will be injected into the client’s arm through an
IV line.
3. At the time of injection, client may have a momentary feeling of warmth and flushing, a
salty taste in the mouth, and possibly some mild nausea.

AFTER THE SCAN

1. After the scan, inform the client that he/she should be able to resume his/her normal diet
and activities.
2. Encourage to drink at least 5 to 6 glasses of water a day for 2 days after the scan. The water
helps flush the contrast media from the system. If the client must limit fluid intake because
of a heart problem or for any other reason, he/she should inform doctor about how much
water he/she can safely drink.
3. If the client is diabetic who takes any medication that contains metformin, the client must
have a blood test to check kidney function before he/she can start taking metformin again.

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Call
thedoctor for the results of the blood test and for instructions about resuming metformin.
This is to prevent kidney damage and a serious reaction called lactic acidosis

PHARMACOLOGICAL INTERVENTIONS

Date Ordered: August 17, 2008

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Date
Discontinued:
August 21, 2008
Generic Name: Metronidazole
Brand Name: Flagyl
Drug Classification: Amebicides and antiprotozoals
Dosage: 750mg 1 tab per orem
Frequency: every 8 hours
Mechanism of Action:
To exert bactericidal effects, metronidazole must first be taken up by cells and then converted into
its active form; only anaerobes can perform the conversion.the active form interacts with DNA to
cause strand breakage and loss of helical structures, effects that result in inhibition of nucleic acid
synthesis and,ultimately cell death.
Indication: Intestinal amoebiasis
Adverse Reaction:
CNS: headache, seizures
GI: nausea,
GU: vaginitis,
Hematologic: transient leucopenia, neutropenia
Respiratory: Upper respiratory tract infection
Skin: rash
Contraindications:
Contraindicated in patients with:
• hypersensitive to drug or other nitroimidazole derivatoives
• first trimester of pregnancy
• history of blood dyscrasia
• CNS disorder
• Retinal or visual field changes

Drug Interactions:
Cimetidine: May increase risk of metronidazole toxicity because of inhibited hepatic
metabolism.
Disulfiram: May cause psychosis and confusion.
Lithium: May increase lithium level, which may cause toxicity.
Oral anticoagulants: May increase anticoagulant effects.
Phenobarnital, phenytoin: may decrease metronidazole effectiveness; may reduce total
phenytoin resistance

Nursing Considerations:
• Monitor liver function test results carefully in elderly patients
• Give oral forms with meals
• Observe patient for edema, especially if taking corticosteroids; Flagyl IV may cause
sodium retention
• Record number and character of stool.

Patient Teaching:
• Instruct patient to take extended-release tablets from at least 1 hour before or 2 hours
after meals but to take all other oral forms with food to minimize GI upset.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

• Tel
l
patient to avoid alcohol and alcohol containing drugs during and for atleast 3 days after
treatment course.
• Tell patient he may experience a metallic taste and have dark or red-brown urine
• Tell patient to report to prescriber any neurologic symptoms.

Date ordered: August 19, 2008


Date Discontinued: August 21, 2008
Generic Name: Hyoscine Butylbromide
Brand Name: Buscopan
Drug Classification: Antispasmodic
Dosage: 10 ml 1 tab per orem
Frequency: every 4 hours PRN
Mechanism of Action:
Inhibits muscarinic action of acetylcholineon autonomic effectors innervated by postganglionic
cholinergic neurons. May affect neural pathways originating in the inner ear to inhibt nausea and
vomiting.
Indication: Spasmodic state
Adverse Reactions:
CNS: disorientation, restlessness, irritability
GI: constipation, dry mouth, nausea, vomiting, epigastric distress
GU: urinary retention
Respiratory: depressed respiration
Skin: rash, dryness

Contraindications:
Contraindicated in patients with:
• Angleclosure glaucoma, obstructive uropathy, obstructive disease of the GI
tract, asthma, Chronic pulmonary disease, myasthenia gravis, paralytic ileus,
intestinal atony, unstable CV status.
Drug Interactions:
Antacid: May decrease oral absorption of anticholinergics. Separate doses by 2 or 3 hours
CNS Depressants: May increase risk of CNS depression
Digoxin: May increase digoxin level
Ketoconazole: May interfere with ketoconazole absorption

Nursing Considerations:
• Raise side rails as a precaution because some patients become temporarily
excited or disoriented and some develop amnesia or become drowsy. Reorient
patient as needed.
• Tolerance may develop when therapy is prolonged
• Atropine-like toxicity may cause dose-related adverse reactions
• Overdose may cause curarelike effects, such as respiratory paralysis.

Patient Teaching:

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

• Warn
patient
to avoid activities that require alertness until CNS effects of drug are known.
• Urge the patient to report urinary hesitancy or urine retention.

Date Ordered: August 17, 2008


Date Discontinued: August 21, 2008
Generic Name: Loperamide
Brand Name: Imodium
Drug Classification: Antidiarrheals
Dosage: 2 mg I tab
Frequency: every 4 hours PRN
Mechanism of Action:
Inhibits peristaltic activity prolonging transit of intestinal contents.

Indication: Acute, non-specific diarrhea


Adverse Reactions:
CNS: drowsiness, fatigue, dizziness
GI: dry mouth, abdominal pain, distention, constipation, nausea
Skin: rash
Contraindications:
Contraindicated in patients with:
• hypersensitive to drug
• bloody diarrhea
• diarrhea with fever greater than 101F
• breastfeeding women
Drug Interactions:
• Saquinavir: May increase loperamide levels and decrease saquinavir
levels.ildren younger than 2

Nursing Considerations:
• If clinical symptoms don’t improve within 48 hours, stop therapy and consider other
alternatives
• Drug produces antidiarrheal action similar to that of diphenoxylate but without as many
adverse CNS effects.

Patient Teaching:
• Advise patient not to exceed recommended dosage
• Tell patient with acute diarrhes to stop drug abd seek medical attention if no
improvement occurs within 48 hours.
• Advise patient with acute colitis to stop drug immediately and report abdominal
distention.
• Tell patient to report nausea, abdominal pain or abdominal discomfort.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Date
Ordered:
Auguts 17, 208
Date Discontinued: August 23, 2008
Generic Name: Prednisone
Brand Name: Deltasone
Drug Classification: Corticosteroids
Dosage: 10 mg 1 tab per orem
Frequency: three times a day
Mechanism of Action:
Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses
immune response; stimulates bone marrow; and influences protein, fat and carbohydrate
metabolism.
Indication: Sever inflammation, immunosuppression
Adverse Reactions:
CNS: euphoria, insomnia, pseudotumor cerebri, headache, seizures
CV: heart failure, arrhythmias, thromboembolism
GI: peptic ulceration, pancreatitis, nausea,
GU: menstrual irregularities, increased urine calcium level
Skin: hirsutism, delayed wound healing
Contraindications:
Contraindicated in patients with:
• hypersensitive to drug
• systemic fungal infection
• client receiving immunosuppressive doses with live virus vaccines
Drug Interactions:
Aspirin: May increase risk of GI distress and bleeding
Barbiturates, rifampin, phenytoin: may decrease corticosteroid effect
Cyclosporine: May increase toxicity
Oral anti coagulants: May alter dosage requirements
Skin-test antigens: may decrease response

Nursing Considerations:
a.) Determine whether patient is sensitive to other corticosteroids
b.) Drug may be used for alternate-day therapy
c.) Always adjust to lowest effective dose
d.) For better results and less toxicity, give a once-daily dose in the morning
e.) Give oral dose with meal to reduce GI irritation
f.) Monitor patient’s blood pressure, sleep pattern and sodium level.
g.) Report sudden weight gain
h.) Monitor patient for Cushingoid effects
i.) Drug may mask or worsen infections. Including latent amoebiasis.

Patient Teaching:
• Tell patient not to stop drug abruptly or without prescriber’s consent
• Instruct patient to take the drug with food or milk
• Teach patient signs and symptoms of early adrenal insufficiency
• Tell patient to report slow healing

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Generic Name: hydrocortisone sodium succinate


Brand Name: Solucortef
Drug Classification: Corticosteroid
Dosage: 100ml IV
Frequency: every 8 hours
Mechanism of Action:
Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses
immune response; stimulates bone marrow; and influences protein, fat and carbohydrate
metabolism.
Indication: ulcerative colitis
Adverse Reactions:
CNS: euphoria, insomnia, pseudotumor cerebri, headache, seizures
CV: heart failure, arrhythmias, thromboembolism
GI: peptic ulceration, pancreatitis, nausea,
Hematologic: easy bruising
GU: menstrual irregularities, increased urine calcium level
Skin: hirsutism, delayed wound healing
Contraindications:
Contraindicated in patients with:
• hypersensitive to drug
• systemic fungal infection
• client receiving immunosuppressive doses with live virus vaccines
Drug Interactions:
Aspirin: May increase risk of GI distress and bleeding
Barbiturates, rifampin, phenytoin: may decrease corticosteroid effect
Cyclosporine: May increase toxicity
Oral anti coagulants: May alter dosage requirements
Skin-test antigens: may decrease response

Nursing Considerations:
j.) Determine whether patient is sensitive to other corticosteroids
k.) Drug may be used for alternate-day therapy
l.) Always adjust to lowest effective dose
m.) For better results and less toxicity, give a once-daily dose in the morning
n.) Give oral dose with meal to reduce GI irritation
o.) Monitor patient’s blood pressure, sleep pattern and sodium level.
p.) Report sudden weight gain
q.) Monitor patient for Cushingoid effects
r.) Drug may mask or worsen infections. Including latent amoebiasis.

Patient Teaching:
• Tell patient not to stop drug abruptly or without prescriber’s consent
• Instruct patient to take the drug with food or milk
• Teach patient signs and symptoms of early adrenal insufficiency
• Tell patient to report slow healing

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Date Ordered: August 17, 2008


Date Discontinued: August 23,2008
Generic Name: Rabeprazole sodium
Brand Name: Aciphex
Drug Classification: Anti ulcerant ( Proton pump inhibitor)
Dosage: 20 mg 1 tab per orem
Frequency: twice a day
Action of the Drug:
Blocks proton pump activity and gastric acid secretion by inhibiting gastric hydrogen-potassium
adenosine triphosphate at secretory surface of gastric parietal cells.
Indication: healing of duodenal ulcers
Adverse Reactions:
CNS: headache
Contraindications:
Contraindicated in patients with:
• hypersensitive to drug or other benzimidazoles
Drug Interactions:
Clarithromycin: May increase rabeprazole level
Cyclosporine: May inhibit cyclosporine metabolism
Digoxin, ketoconazole, other pH-dendent drugs: May decrease or increase drug absorption
at increased pH values
Warfarin: May inhibit warfarin matebolism

Nursing Considerations:
• Consider additional courses of therapy if duodenal ulcer isn’t healed after
first course therapy
• Amoxicillin may trigger anaphylaxis in patients with a history of penicillin
hypersensitivity
• Symptomatic response to therapy doesn’t preclude presence of gastric
malignancy

Patient Teaching:
 Explain importance of taking drugs exactly as prescribed
 Advice patient to swallow delayed release tablets whole and to crush, shew or split it
 Inform patient that drug may be taken without regard to meals

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

Generic Name: Ciprofloxacin


Brand Name: Cipro
Drug Classification: Fluoroquinolones
Dosage: 500mg 1 tab per orem
Frequency: twice a day
Action of the Drug:
Inhibits bacterial DNA synthesis mainly by blocking DNA gyrase; bactericidal
Indication: Complicated intra-abdominal infection
Adverse Reactions:
CNS: headache, seizures
GI: nausea, diarrhea, pseudomembranous colitis
Hematologic: leukopenia, neutropenia, thrombocytopenia
Skin: rash

Contraindications:
Contraindicated in patients with:
• hypersensitive to fluoroquinolones

Drug Interactions:
Aluminum hydroxide, aluminum-magnesium hydroxide, calcium carbonate
Magnesium hydroxide: may decrease ciprofloxacin absorption and effects
Cyclosporine: May increase risk for cyclosporine toxicity

Nursing Considerations:
• Obtain specimen for culture and sensitivity before giving first dose.
• Some drugs require waiting up to 6 hours after giving this drug to avoid decreasing its
effects
• Monitor patient’s intake and output and observe patient for sign and symptoms of
crystalluria.

Patient Teaching:
5. Tell patient to take drug as prescribed, even after he feels better.
6. Advise patient to drink plenty of fluids to reduce risk of urine crystals
7. Advise patient not to chew, crush or split the extended-release tablets
8. Instruct patient not to take caffeine while taking drug because of potential increase
caffeine effects
9. Breastfeeding should be stop while taking the drug

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

TEN
IDENTIFIED
PROBLEMS

1. Diarrhea
2. Fluid Volume Deficit
3. Acute Pain
4. Altered Sensory Perception
5. Imbalance Nutrition less than Body Requirements

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

NURSING CARE PLAN

CUES NURSING DIAGNOSIS SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATION


RATIONALE INTERVENTION
Release of
SUBJECTIVE: Diarrhea related to enterotoxins SHORT INDEPENDENT: SHORT TERM
invasion of the lining of by invading TERM GOAL GOAL
“Madalas ako nadudume the colon secondary to microorganism - Observe and -To note for
na may kasamang dugo at infectious processes as After 30-45 record amount, degree of fluid After
medyo basa. Nakaramdam manifested by: minutes of characteristics and losses implementation
din ako ng pagsusuka Increase nursing frequency of bowel of appropriate
kung minsan at pananakit ACF of stool secretion of intervention the movement. nursing
ng tiyan” • 2-3X/ day water and client will be intervention, the
• brownish electrolytes able to - Increase oral -To replace client was able
OBJECTIVE: yellow with promptly fluid intake fluid losses to promptly
ACF of stool blood streak, replace fluids due to frequent replaced fluids
• 2-3X/ day loose and and vowel and electrolyte
• brownish mucoid Inhibits the electrolyte movement losses through
yellow with • 1 cup per bout sodium losses through - Monitor intake hydration and
blood streak, • Hyperactive bowel reabsorption hydration and and output - To assess for electrolyte
loose and sounds electrolyte decrease in supplement as
mucoid supplement as fluid volume evidenced by
• 1 cup per bout • Abdominal cramps evident by resulting to increased in oral
Large amount increasing oral dehydration intake and
• Hyperactive bowel of CHON rich fluid intake and maintained
sounds With patient verbalization, fluids electrolyte - Assess for signs -To determine electrolyte
“Madalas ako nadudume balances of dehydration client’s balance
• Abdominal cramps na may kasamang dugo at hydration
medyo basa. Nakaramdam Diarrhea LONG TERM status and - Goal fully met
Inferences: din ako ng pagsusuka GOAL determine
Fecalysis (08/16/08) kung minsan at pananakit dehydration
Presence of Entamoeba ng tiyan” After 3-4 hours
histolytica Reference: nursing DEPENDENT:

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

LONG TERM
Result: Medical intervention the -To replenish GOAL
Cyst = 1-3L/LPF Surgical client will be -Administer IV and establish
Trophozoite= Nursing by able to fluids as indicated hydration and After
1-2/LPF Black and reestablish with electrolyte maintain implementation
Hokanson hydration supplements (KCl) electrolyte of appropriate
Pg 1078-1079 status as to balance nursing
prevent intervention, the
dehydration client was able
through -Inhibits partially
physical -Administer nucleic acid of reestablished
assessment and antiprotozoal the bacteria hydration status
careful medication there by as to prevent
monitoring of (Flagyl) eliminating dehydration
intake and spread of through absence
output. infection of signs of
dehydration
minimum intake
and output

- Goal is partially
met

CUES NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATION

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

DIAGNOSIS RATIONALE INTERVENTION


Fluid Volume Deficit
SUBJECTIVE: related to active fluid Infectious SHORT INDEPENDENT SHORT TERM
volume loss ( diarrhea) process TERM GOAL > Encourage client > To replenish GOAL
“Nararamdaman ko din secondary to infectious to increase oral patient with
na nanghihina ako at process as manifested After 1-2 hours fluid intake fluid volume After 1-2 hours
para bang palage akong by Invades the of nursing losses of implementing
walang lakas.” lining of the intervention, appropriate
ACF of Bowel intestines the client will nursing
OBJECTIVES: movement maintain intervention, the
ACF of Bowel • Frequency- adequate fluid > Provide > To moisten client maintained
movement 2-3x/ day Stimulation of volume versus meticulous oral the mucous adequate fluid
• Frequency- • Color- the SNS/PNS active fluid care (toothbrush membrane and volume versus
2-3x/ day brownish and decrease volume loss and mouthwash) prevent injury active fluid
• Color- brownish yellow with water through fluid from dryness volume loss as
yellow with blood streak reabsorption hydration and evidenced by an
blood streak • Consistency – monitoring of increase in oral
• Consistency – loose and intake and > Check voiding > To check for fluid intake from
loose and mucoid mucoid Increase output as and record amount an increase or 840ml to at least
• Amount- 1 cup • Amount- 1 cup gastrocolic evidence by decrease fluid 1000ml with
per bout per bout reflex moist mucous losses moistened
membranes, mucous
• Decrease in urine • Decrease in good skin > Promote a quiet > To decrease membrane, good
output urine output Diarrhea turgor, and environment and oxygen skin turgor and
results increase in oral bed rest demand increase urine
• ( 700-750ml) • Decrease oral
( Active fluid fluid intake thereby output of 800 cc
• Decrease oral fluid intake
volume loss) from 840 ml to resulting from
fluid intake • Fair skin turgor at least 1000ml weakness - Goal partially
( 630-840 ml) • Pale nail beds and urine met
• Fair skin turgor • Pale palpebral output of at
• Pale nail beds conjunctiva Fluid Volume least 850cc > Regularly assess > To assess
• Pale palpebral • Slightly pale Deficiency client for changes for signs of LONG TERM

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

conjunctiva dehydration GOAL


• Slightly pale nasal and buccal in conditions (e.g. and monitor
nasal and buccal mucosa LONG TERM mental status, progress of After 4-6 hours
mucosa Reference: client. of implementing
GOAL fatigability,
• Dry and cracked Medical appropriate
INFERENCES restlessness etc.)
lips Surgical nursing
After 4-6 hours
Nursing by >To measures intervention, the
• Thready/weak • Slight increase of nursing
Black and if client had client reported a
pulse in urine specific intervention, > Strictly monitor
Hokanson enough fluid slight increase in
gravity- 1.030 the client will I/O
Pg. 1078-1079 intake and energy level and
INFERENCES have an
With client’s increase in output absence of
• Slight increase in verbalization, energy levels complications as
urine specific “Nararamdaman ko din and prevent verbalized by
gravity- 1.030 na nanghihina ako at further the client, “
• Fecalysis para bang palage akong complication DEPENDENT > For Medyo ok na
(08/16/08) walang lakas.” as evident by > Administer IV replacement of ang pakiramdam
client’s fluids as indicated fluids and ko, hindi na ako
• Presence of
verbalization of electrolytes gaano
Entamoeba
an increase in nanghihina.”
histolytica
energy levels > To assess for
> Monitor client’s hydration - Goal partially
urine specific status of the met.
gravity client

CUES NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATION


DIAGNOSIS RATIONALE INTERVENTION
INDEPENDENT:
SUBJECTIVE: Acute pain related to Damage to the SHORT SHORT TERM
inflammatory intestinal TERM GOAL >Encourage adequate >To promote GOAL

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

“Pabalik balik yung response relaxation as to


sakit ng tiyan ko. secondary to tissue rest periods prevent fatigue After 15-30
Humihilab at para compression of After 15-30 minutes of
bang umiikot yung nerve endings minutes of implementing
sikmura ko” • Recurrent Increase nursing > To decrease appropriate
abdominal pain vascular intervention the >Provide comfort pain through nursing
• Pain scale of permeability patient will be measures (e.g. back stimulation of intervention the
7-8 out of 10 • Guarding able report a rub, proper release of patient was
behavior decrease in pain positioning etc.) endorphins reported a
OBJECTIVES: during Vasodilation perception decrease in pain
episodes of through scale from 7-8 to
• Recurrent pain providing 6 out of 10
abdominal pain Swelling methods to > To assist in
• Slight facial alleviate pains muscle and Goal fully met
• Guarding grimace as evident by a > Encourage deep generalized
behavior Edema decrease in pain breathing exercise relaxation LONG TERM
during • Irritable and scale from 7-8 GOAL
episodes of less pleasant to at least 6 >To lessen
pain • Narrowed Compression preoccupation After 1-2 hours
focus ( less of nerve > Provide diversional to pain and of implementing
• Slight facial interested endings LONG TERM activities such as lessen it appropriate
grimace with GOAL listening to music and nursing
conversing to watching television >To reduce intervention the
others) Pain After 1-2 hours stimulation patient
Perception of nursing >Provide quiet and that may demonstrated
• Normal to
• Irritable and hyperactive intervention the calm environment and trigger pain behavioral
less pleasant Reference: patient will be cluster nursing care perception modifications
bowel sounds
Medical able that has lessened
• Narrowed
Surgical demonstrate pain perception
focus ( less With verbalization
Nursing appropriate > To release through
interested of patient, “Pabalik
By: Brunner behavioral > Encourage right endorphins and relaxation skills
with balik yung sakit ng
and Suddarths modifications to sided brain enhance well and other
conversing to tiyan ko. Humihilab
Pg. 810-812 lessen pain stimulation such as being comfort
others) at para bang umiikot

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

• Normal to yung measures as


hyperactive sikmura ko” perceived love, laughter and > To decrease evidenced by
bowel sounds through music inflammation decrease
• Pain scale of relaxation skills that may cause irritability and
7-8 out of 10 and comfort Dependent: pain decrease
measures as preoccupation to
evident by >Administer anti pain
decrease inflammatory drugs
irritability and ( Prednisone)
preoccupation -Goal fully met
to pain

CUES NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATION


DIAGNOSIS RATIONALE INTERVENTION
SUBJECTIVE: Altered Sensory Prolonged used SHORT TERM INDEPENDENT SHORT TERM
Perception; Tactile of GOAL GOAL

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

“Nagmamanhid nga related to >To prevent


yung mga daliri ko prolonged Metronidazole After 30-45 >Provide client with injury ( e.g. After 30-45
sa paa, hindi ako use of medication minutes of shoe wear or slippers punctured minutes of
nakakaramdam.” (Flagyl) secondary nursing when ambulating wound) while implementing
to chronic bacterial Damage nerve intervention, the ambulating appropriate
OBJECTIVES: infection of the endings client will be nursing care, the
colon as manifested safe from any > To prevent client had been
• Positive (+) by cause of dangers > Remove sharp or falls, slipping safe from any
numbness of Altereation on that may unnecessary objects or wound to cause of dangers
toes both in • Positive (+) the axonal precipitate injury ( needles, clutters get unnoticed that may
right and left numbness of regions of the due to altered etc.) within client’s precipitate injury
feet toes both in neurons tactile area due to altered
• Change in right and left perception > To protect tactile perception
usual feet through > Monitor use of from as evidenced by
response to • Change in Decrease measures that heating pads as well thermal/cold absence of
tactile usual amplitude on will promote as cold packs and damage or injury, trauma or
stimuli response to nerve safety to the temperature of water burns hazards caused
• Unable to tactile conduction client to as use for sponge bath by sensory
feel touch or stimuli velocity evident by deficit.
object • Unable to absence of
applied to feel touch or Altered nerve injury or trauma > To aid in -Goal fully met
both toes object transmission to caused by maintaining
applied to periphery sensory deficit > Assist during balance and
both toes ambulation avoid
With client’s unwanted
verbalization, injury LONG TERM
““Nagmamanhid GOAL
nga yung mga Altered LONG TERM > To allow
daliri ko sa paa, sensory GOAL easy access to After 1-2 days of
hindi ako perception After 1-2 days of >Place call bell when client implementing
nakakaramdam.” ( Tactile) nursing within client’s reach needs help and appropriate
intervention, the when nursing care, the
Reference: client will emergency client had

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

cases happen recognized


Neurologyindia recognize alteration in
website alteration on > To promote tactile perception
tactile stimulation of and learned
perception other sense independent
through health >Provide diversional unaffected and skills as a
teaching and be activities for the avoid client’s compensatory
able to client (e.g. watching preoccupation technique which
compensate to it TV, listen to music, to sensory aided her in
by providing read etc.) deficit making
measures or necessary
ways of dealing activities.
with perceptual > It
deficit as evident communicate -Goal fully met
by client able to connection to
make > Provide tactile other people
independent stimulation (cotton and provide
compensatory ball, pin, feather , stimulation to
techniques that pinching etc.) sense of touch
will aid in
making > To presume
necessary path to be
activities taken is free
> Instruct client to from harm
check her path during
ambulation > To assist
client when
ambulating if
decrease tactile
> Use assistive device deficit is
as necessary (e.g. severe
wheelchair, cane etc.)
> To recognize

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

and understand
the reason of
sensory deficit
> Discuss with the and allow
client the cause of the client to make
alteration in tactile appropriate
perception and ways to deal
measures to deal with with it
it

> To promote
stimulation of
COLLABORATIVE tactile
perception and
> Advice client to regain it
undergo physical
rehabilitation or
therapy

CUES NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATION


DIAGNOSIS RATIONALE INTERVENTION
SUBJECTIVE: Chronic INDEPENDENT SHORT TERM
Imbalance nutrition damaged of SHORT GOAL
“Wala talaga akong less than body intestinal tissue TERM GOAL > Give a health >To determine After 45-60

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

ganang kumain. requirements health minutes of


Mga 3-4 na subo related to After 45-60 teaching on the knowledge of implementing
lang ayoko na agad. loss of appetite due minutes of importance of a client that appropriate
Sumasakit kasi ang chronic illness state Inflammatory nursing balanced diet and needs to be nursing
tiyan ko at masama secondary to response intervention, adequate hydration modified or to intervention, the
talaga ang abdominal pain as the client will that it helps in enhance client
pakiramdam ko” manifested by be able to building strong regarding food understood the
Compression of understand the immune system. management. need to eat a
• Reports of • 94 lbs nerve endings need to eat a well balance diet
abdominal ( ABW) well balanced both in quality
pain • Stands 5’0 diet both in > Prepare food >Stimulates and quantity by
feet Pain perception quality and samples that are the client’s means of health
OBJECTIVES: • IBW vs. quantity as to nutritious and desire to teaching as
ABW improved demonstrations of initiate ways in evidenced by
• 94 lbs 104lbs = 94 Narrowed focus nutritional food preparations that how to achieve client’s desire to
( ABW) lbs status through is an optimum make
• Stands 5’0 • BMI = 18.6 health teaching within client’s health. appropriate diet
feet ( Underweight) Preoccupation and income modification
• IBW vs. • Appears thin to pain demonstration with
ABW and frail perceived as evidence >Assess client’s > To verbalization of,
104lbs =94 with client’s condition such as determine “ Gusto ko
• Decrease
lbs desire to make energy levels and client’s talaga maging
subcutaneou
• BMI = 18.6 Loss of appetite appropriate diet feeling of body physiologic masustansya ang
s and muscle
( Underweight) ( Anorexia) modifications weakness response to kinakian ko para
mass
of improving food intake as makaiwas sa
• Appears thin • Pale
general health with regards to sakit. At least
and frail conjunctiva
status quality and ngayon alam ko
• Decrease • Moderate quantity na ang mga
subcutaneou hair loss was LONG TERM
Imbalanced GOAL >Encourage to eat a dapat kong
s and muscle observed >Balanced diet piliing pagkain.”
mass Nutrition less well balanced meal
• Weak and and adequate
• Pale than body After 1-2 days and proper hydration
decrease hydration are -Goal fully met
conjunctiva requirements of nursing by citing some health
energy level known to
intervention the benefits that could
• Moderate

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

hair loss was With contribute to a LONG TERM


observed verbalization Reference: patient will be build strong line of good nutrition. GOAL
• Weak and of the client, “Wala Pathophysiology able to increase defense.
decrease talaga akong ganang by Carol food intake After 1-2 days of
energy level kumain. Mga 3-4 na Mattson Porth both in quality implementing
subo lang ayoko na and quantity > Encourage bed rest > Decrease appropriate
agad. Sumasakit appropriate to during acute phase of metabolic nursing
kasi ang tiyan ko at her illness illness needs aids in intervention, the
masama talaga ang status through preventing client had a
pakiramdam ko” proper caloric gradual increase
preparation of depletion and in food intake
food to serve conserves both in quantity
with client energy and quality
reports on an appropriate to
increase in >Provide foods that >To provide her illness state
energy levels are high in calories, client nutrients through proper
and decrease proteins and that will boost preparation of
body weakness carbohydrates energy levels food to serve
during illness with client
state and repair verbalized,
bodily tissues “Medyo hindi na
ako nanghihina
at mas maganda
ang pakiramdam
ko ngayon kesa
dati. Mas
> Provide the client > To facilitate madame na din
with adequate time to adequate food ako nakakain
eat and prepare food intake and ngayon.”
aesthetically make food
attractive -Goal fully met

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

> To enhance
> Prepare foods that mechanical
are easy to chew and digestion of
palatable food and
promote
client’s
appetite

DEPENDENT
>Administer vitamins > To build
and supplements as strong immune
per doctors order system and
body
resistance to
COLLABORATIVE diseases
> Refer to dietician
for diet regimen > To
determine
appropriate
dietary
regimen

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

DISCHARGE PLANNING

TAKE HOME MEDICATIONS


• daily large baking soda enemas followed with flax seed enemas
• Psyllium husks - treatment of mild to moderate hypercholesterolemia.
• Steroids for relief of inflammation
• Drugs that suppress the immune system
• Drugs that relieve diarrhea
• Medication is necessary

DIETARY MANAGEMENT
• clear liquids such as water, juice, tea
• oral rehydrating or electrolyte solutions
• Drinking small amounts at frequent intervals is better accepted in cases of nausea.
• Avoid solids because they can cause cramps
• Light soups, toast, rice and eggs are good foods

ACTIVITIES
• bed rest upon arrival from the hospital
• light exercise every morning
• eventually the patient can return to its normal activities of daily living

HYGENIC PRACTICES
• wash hands with soap after going to the toilet and before eating or preparing food
• Avoiding sexual practices that may lead to fecal-oral contact
• Proper hand washing is necessary
• Cut and keep your nails clean
• Avoid sharing towels with infected persons
• Avoid alcohol for preventing intestinal complications
• Take care of drinking water - either opt for mineral water or water boiled for 20 minutes

SPECIAL CARE
• Never use any soap or chemical that are not specifically stated by your doctor
• Eating slippery elm will usually ease ulcer pain in less than twenty minutes with no
negative side effects
• Specifically no water containing chlorine
• No milk or milk products should be taken as this could cause irritation

SCHEDULE CLINIC
• Continuous follow-up care - a schedule of follow-up care
• Return again after a month for follow up check- up

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

HOME
PREVENTION
• Avoidance of drinking unboiled or unbottled water in endemic areas.
• Uncooked food such as fruit and vegetables that may have been washed in local water
should also not be consumed.
• Amoebic cysts are resistant to chlorine at the levels used in water supplies, but
disinfection with iodine may be effective.
• Wash hands with soap and warm water after going to the toilet and before eating or
preparing food.
• Proper food storage and preventing its contamination with faeces, flies, and contaminated
water
• Avoiding sexual practices that may lead to fecal-oral contact

PUBLIC HEALTH PREVENTION


• One important public health strategy is to make sure to treat infected individuals who
appear asymptomatic, since these people also pass cysts in their stool and thus
contributed to spreading the disease.
• Good sanitation and water facilities are also important in preventing the disease.
• Food handlers, child care workers, and health care workers with amoebiasis should not be
allowed to work until their symptoms are gone.
• If children have symptoms, they should not attend child care centers or schools until their
symptoms are gone.
• In general, people should practice good hygiene, since the fecal matter from those
infected could contaminate food and water that is then transferred to others. This
includes careful hand washing with soap and hot running water for at least 10 seconds
after going to the toilet, as well as practice frequent hand washing in general to eliminate
any parasite that one may have picked up throughout the day.
• Travelers should take precaution
• Clean bathrooms and toilets often.
• Boil water
• Avoid uncooked foods
• Practice safe food storage and handling: thoroughly cook all raw foods, thoroughly wash
raw vegetables and fruits, and reheat food until the internal temperature of food reaches at
least 167°F.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING
#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

BIBLIOGRAPHIES

Joyce M. Black, et al. Study Guide for Medical-Surgical Nursing -- Clinical Management for
Positive Outcomes. Saunders: 2004

Marilynn E. Doenges, et al. Nursing Care Plans: Guidelines for Individualizing Client Care
Across the Life Span. F. A. Davis Company: 2006

Marilynn E. Doenges, et al. Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and
Rationales. F. A. Davis Company: 2006

Meg Gulanick, et al. Nursing Care Plans: Nursing Diagnosis and Intervention. Mosby: 2006

Sue Huether, et al. Study Guide and Workbook to Accompany Understanding Pathophysiology.
Mosby: 2003

Suzanne C Smeltzer, et al. Brunner and Suddarth's Textbook of Medical-Surgical Nursing.


Lippincott Williams & Wilkins: 2006

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