1

I. Introduction
A stabbing is the penetration with a sharp or pointed object at close range. Stab connotes purposeful action, as by an assassin or murderer, but it is also possible to accidentally stab oneself or others, although such stabbings are rarely serious and still more rarely fatal. Stabbing differs from slashing or cutting in that the motion of the object used in a stabbing generally moves perpendicular to and directly into the victim's body, rather than being drawn across it. Stabbings today are common among gangs and in prisons because knives are cheap, easy to acquire (or manufacture), and highly concealable. The threat of stabbing is perhaps the most common form of robbery. The human skin has a somewhat elastic property as a self-defense; when the human body is stabbed by a thin object such as a kitchen knife, the skin often closes tightly around the object and closes again if the object is removed, which can trap some blood within the body. Some have speculated that the fuller, an elongated concave depression in a metal blade, functions to let blood out of the body in order to cause more damage. This misconception has led to fullers becoming widely known as "blood grooves". The fuller is actually a structural reinforcement of the blade similar in design to a metal "I" beam used in construction. However, internal bleeding is just as dangerous as external bleeding; if enough blood vessels are severed to cause serious injury, the skin's elasticity will do nothing to prevent blood from exiting the circulatory system and accumulating uselessly in other parts of the body. Death from stabbing is caused by shock, severe blood loss, infection, or loss of functioning of an essential organ such as the heart or lungs. Complications associated with open wounds may include infection, cellulitis, overgrowth of scar tissue (keloid formation), gangrene, bleeding (wound hemorrhage), overwhelming systemic infection (sepsis), and tetanus, a potentially fatal infection of the nervous system. Treatment of stabbed wound includes thoroughly cleaned, nonviable tissue and debris removed (debridement), and the wound closed with stitches. Wounds with a high-risk of infection (puncture wounds, human and animal bites) or wounds 12 to 24 hours old are left open and then closed with stitches, if needed, in 5 to 7 days (delayed primary closure). In larger wounds which are more than 24 hours old, the area is cleansed, dbrided and then packed with wet to dry dressings. The wound is then either allowed to heal naturally, allowing scar formation, or it may be closed surgically in 5 to 7 days. The repaired wounds are covered with an antibiotic ointment and appropriate bandage. A tetanus shot (tetanus toxoid) may be given if over 10 years has passed since the individual's last booster shot, or if there is a question about when the individual was last vaccinated. If the individual has never been immunized against tetanus, human tetanus immune globulin may be given. In serious injuries, the first step is to ensure an adequate airway. An artificial airway (endotracheal intubation) may be necessary. Supplemental oxygen is administered. Intravenous fluid and blood may be administered to help maintain an adequate blood pressure if there is

2 evidence of shock or excessive bleeding. A tube may be placed in the stomach (nasogastric tube) to decompress and drain excess stomach contents, and a bladder catheter may be necessary to drain and monitor urine output. Impaled or embedded objects are left in place until the individual has a stable blood pressure. These objects are then removed in the operating room (removal of foreign body).

II. OBJECTIVES
General Objective This case study aims to identify and determine the general heath problems, needs and interventions given of a patient with an admitting diagnosis of Stab Wound. Specific Objectives This case study specifically aims to:
y y y y y

To determine what interventions given to a patient with stab wound. To determine complications that might occur with stab wounds. To determine the process of wound healing. To determine what is a stab wound. To determine operative procedures given to patients with specified site of stab wound

4 PERSONAL INFORMATION A. BIOGRAPHIC DATA Patients Name: Chaba Age: 51 years old Sex: Male Address: Mibantang, Quezon, Bukidnon Birthdate: October 10, 1959 Birth place: Bohol City Civil Status: Married Nationality: Filipino Religion: Roman Catholic Occupation: Farmer Educational Attainment: Grade V Ward: Male Surgical Ward Date of Admission: September 16, 2010 Admitting Physician: Dr. Ramil Dy Admitting Diagnosis: (1) SW 2 cm Intraumbilical Area with Intestinal Evisceration (L) LW 4 cm Posteromedial Aspect P/3RD (L) Thigh (3) LW 6 cm P/3RD (R) Thigh Informant: Patient, Patients chart

B. CHIEF COMPLAINT Patient Chaba was admitted with the chief complaint of stabbed wound at the upper umbilical area (epigastric area) last September 16, 2010. Vital signs: Height: 52 Weight: 59 kgs. BP: 100/80 mmHg Heart rate: 82 bpm RR: 16 cpm T: 37.2 C

5 C. HISTORY OF PRESENT ILLNESS On September 16, 2010(six days prior to initial assessment), patient Chaba was hurriedly rushed to Bukidnon Provincial Medical Center-Malaybalay to seek immediate medical attention due to a stabbed wound in the upper umbilical area (epigastric area) that happened at Mibantang, Quezon, Bukidnon, while he was trying to come in between two (2) drunk persons who were fighting. Upon arrival at the hospital unit, he was then attended by the Nurse on Duty at the Emergency Room. Patient Chaba drinks alcoholic beverages, and have last taken this on September 16, 2010, with the amount of three (3) glasses. He does not smoke, and have not used any recreational drugs. D. FAMILY HISTORY Patient Chaba, a 51-year old Male, was born in Bohol City on October 10, 1959. He currently resides at Mibantang, Quezon, Bukidnon, and lives with his family, which is composed of 5 members. His highest educational attainment is Grade V, and at present, he is a farmer by occupation. The patient is married, with three (3) children. E. DEVELOPMENTAL TASK (Eriksons developmental stages) STAGES PSYCH CENTRAL POSITIVE EGO OSOCIA OUTCOME QUALITY TASK L CRISIS Trust Receiving Trust in Hope vs. care people and Mistrust the environment DEFINITI ON Enduring belief that one can attain ones deep and essential wishes DEVELOPM ENTAL TASK

Infancy (Birth-18 Months)

Younger Years (18 Months-3 Years)

Autonom Imitation y vs. Shame & Doubt

Pride in Will self; Assertion of will in the face of danger

Social attachment; Maturation of sensory, perceptual, and motor functions; Primitive causality Determinat Locomotion; ion to Fantasy play; exercise Language free choice development; and self Self-control control

Early

Initiative

Identificati

Sense

of Purpose

Courage to

Sex-role

6 Childhood (3-6 Years) vs. Guilt on purpose and ability. imagine and pursue valued goals identification; Early moral development; Self-esteem; Group play; Egocentrism

Middle Childhood (6-12 Years)

Industry vs. Inferiorit y

Education

SelfCompetenc confidence e by doing and achieving.

Adolescen ce (12-20 Years)

Identity vs. Role confusio n

Young adult (20-30 years)

A strong Loyalty group identity; Ready to plan for the future Intimacy Intimate Establish Stability vs. relationship long-lasting Rejection relationship s

Peer group

Free exercise of skill and intelligence in completion of tasks Ability to freely pledge and sustain loyalty to others

Friendship; Skill learning; Selfevaluation; Team play

Physical maturation; Emotional development; Membership in peer group Maintain Ability to established relate well relationship with other and people to form commitme long-lasting nts. relationships.

Middle adult(3060 years)

Generati vity vs. Stagnatio n

Concern for the family,com munity, and the world

SelfInvolveme confident nt and are able to juggle their various lives.

Participatio n in any community activities and programs.

Become politically active, work to solve environmental problems, or participate in far reaching community or world-based decisions.

7 PHYSICAL ASSESSMENT Functional Assessment DESCRIPTION INITIAL DAY 1 ASSESSMENT (Sept. 21,2010) (Sept. 22,2010) y Patient believes y Patient is in albularyo submissive to (binisaya) and pharmacologic uses herbal regimen medicines (e.g. (IVTT meds) Lagundi,Bayaba s) for treatment of common health alterations (e.g.Cough, colds, Fever). y Patient is given medications IVTT (antibiotics) DAY 2 (Sept. 23, 2010) y Patient is submissive to pharmacologic regimen (IVTT)

Health Perception and Health Management

Perceived level of health and wellbeing, and practices for maintaining health. Habits that may be detrimental to health are also evaluated, including smoking and use of alcohol or other drugs.

Nutrition and Metabolism

Pattern of food and fluid intake relative to metabolic needs. The adequacy of local nutrient supplies is evaluated.

On general liquids (NGT was removed that day)

y On DAT with fair appetite y Eats 3 meals a day y Patient does not follow a prescribed or special diet. y Voided twice during our shift(7am-3pm) with approximately 240 cc per urination y Defecated once during our shift(7am-3pm)

y On DAT with fair appetite y Eats 3 meals a day y Patient does not follow a prescribed or special diet. y

Elimination

Excretory patterns y Voided 4 times (GI, GU, skin). since morning Incontinence, with constipation, approximately diarrhea, and 150 cc per urinary retention urination may be identified. y Have not yet defecated until the time of assessment(11 AM) y diaphoresis

Voided twice during our shift(7am3pm) with approximately 240 cc per urination Did not defecate during our shift(7am3pm)

Activity and Exercise

Activities of daily living (ADLs) requiring energy expenditure including selfcare activities, exercise, and leisure activities. Assess major body systems involved with activity and exercise including the respiratory, cardiovascular, and musculoskeltal systems.

to Cognition and Ability comprehend and Perception use information. Assess sensory functions. Sensory experiences such as pain and altered sensory input may be identified and evaluated.

y Dependent to SO in performing ADLs y Cannot move freely due to surgical incision y No shortness of breath noted upon exertion y Often lying on bed y Does not ambulate due to complaints of weakness of both right and left leg y Does not experience headache, seizures, blackouts, dizziness as assessed y Patient is well oriented as to time, place and person y Patient is alert, awake and coherent y Able to follow directions y Speech is clear y Vision is not impaired y Patient experiences sharp stabbing pain at the surgical site with pain scale of 8/10,0 as no

y Able to perform ADLs independently y Passive ROM exercises y No shortness of breath noted upon exertion y Often lying on bed y Limited physical movements y Ambulates less with assistance

y y

y y y

Able to perform ADLs independently Passive ROM exercises No shortness of breath noted upon exertion Often lying on bed Limited physical movements able to ambulate independently maintaining balance and steady gait

y Does not experience headache, seizures, blackouts, dizziness y Patient is well oriented as to time, place and person y Patient is alert, awake and coherent. y Able to follow directions y Speech is clear y Vision is not impaired y Patient experiences sharp stabbing pain at the surgical site upon exertion with pain scale of 6/10,0 as no

y Does not experience headache, seizures, blackouts, dizziness as assessed y Patient is well oriented as to time, place and person y Patient is alert, awake and coherent. y Able to follow directions y Speech is clear y Vision is not impaired y Patient experiences sharp stabbing pain at the surgical site with pain scale of 3/10,0 as no pain and 10 as excruciating pain y Patient is willing to learn

9 pain and 10 as excruciating pain y Patient is willing to learn Sleep, rest, and y Patients usual relaxation bedtime: 9pmpractices. 5am) Dysfunctional y No difficulty sleep patterns and falling asleep fatigue may be identified. pain and 10 as excruciating pain y Patient is willing to learn y Patients usual bedtime: 9pm6am) y No difficulty falling asleep

Sleep and Rest

y Patients usual bedtime: 9pm-5am) y No difficulty falling asleep

SelfPerception and SelfConcept

Roles and Relationships

Attitudes toward self, including identity, body image, and sense of self-worth. Level of selfesteem and response to threats of selfconcept. Roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated.

y Accommodating y Accommodating y Accommodating and kind and kind and kind y Identifies selfy Identifies selfy Identifies self-worth worth as a worth y Established selfesteem y Established self- y Established selfesteem esteem

y Patient is a farmer by occupation y Five (5) members in the family. y Nuclear family y Close family relationships

y Patient is a farmer by occupation y Five (5) members in the family. y Nuclear family y Close family relationships y Patient is married y Does not perform Testicular Self Exam and does not know how to perform the procedure

y Patient is a farmer by occupation y Five (5) members in the family. y Nuclear family y Close family relationships

Sexuality and Reproduction

Satisfaction or y Patient is dissatisfaction married and has with sexuality 3 children patterns and y Does not reproductive perform functions. Testicular Concerns with Self Exam sexuality may be and does not identified. know how to

y Patient is married y Does not perform Testicular Self Exam, but already knows how to perform the procedure because health teachings

10 perform the procedure y Strong family support y Patient drinks only for enjoyment or leisure because health teachings were provided y Strong family support were provided

Coping and Stress Tolerance

Values and Beliefs

Perception of stress and coping strategies. Support systems are evaluated, and symptoms of stress are noted. The effectiveness of coping strategies in terms of stress tolerance may be evaluated. Values, beliefs, and goals that may guide choices or decisions.

Strong family support

y Patient is a Roman Catholic y Mentions about spirituality with regards to his present condition

y Patient is a Roman Catholic y Mentions about spirituality with regards to his present condition

y Patient is a Roman Catholic y Mentions about spirituality with regards to his present condition

*Based on Gordons Functional Health Patterns developed by Dr. Marjory Gordon

11 REVIEW OF SYSTEMS System Subjective General Sakit akong samad Maam. Kanang murag hait nga klase sa sakit,as verbalized by the patient.

y y y y y y y Integumentary system y Skin

Objective Pain scale of 8/10, 0 as no pain and 10 as excruciating pain Facial grimace guarding behavior Diaphoresis Temperature=37.20C PR= 82 bpm RR= 16 cpm BP= 100/80 mmHg

Sa kinatulan man ni akong mga pali, as verbalized by the patient. Sa nadunggaban gyud ni nga samad, as verbalized by the patient.

(+) Scars on upper and lower extremities (+) surgical wound at upper umbilical area(epigastric area) (+) sutured lacerated wound at posterior left thigh

y y

Hair Nails Wala na lagi ni nailcutter akong mga kuko Maam, as verbalized by the patient. (+) long, dirty fingernails and toenails

Head Eyes Ears Mouth and throat Neck Respiratory system Cardiovascular y Central y Peripheral Gastrointestinal system Urinary system Genitalia Musculoskeletal system Neurologic system Hematologic

(+) dental carries Gi-ubo ko pero wala may plemas, as verbalized by the patient. (+) non-productive cough RR= 16 cpm

Luya ni akong duha ka tiil. Kanang dili kayo kapangusog ba, as verbalized by the patient.

(+) cannot sustain prolonged standing or ambulation (+) often lying on bed

12 Endocrine system

IV. VITAL SIGNS MONITORING SHEET September 21, September 22, 2010 September 23, 2010 2010 Initial Vital 10 am 2 pm Signs Taking 10 am 2 pm Temperature 37.20C 36C 36.8C 36.80C 36.10C Pulse Rate 82 bpm 68 bpm 70 bpm 68 bpm 62 bpm Respiratory Rate 16 cpm 16 cpm 16 cpm 20 cpm 20 cpm Blood Pressure 100/80 mmHg 100/80mmHg 90/70 mmHg 90/60 mmHg 100/80 cpm Pain 8/10* 6/10* 5/10* 3/10* 2310* *Sharp stabbing pain quality using pain scale with 0 as no pain and 10 as excruciating pain.

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IV. Review of Anatomy and Physiology

The Integumentary System

The integumentary system is the organ system that protects the body from damage, comprising the skin and its appendages including hair, scales, feathers, and nails. The integumentary system has a variety of functions; it may serve to waterproof, cushion, and protect the deeper tissues, excrete wastes, and regulate temperature, and is the attachment site for sensory receptors to detect pain, sensation, pressure, and temperature. In humans the integumentary system also provides vitamin D synthesis. olopongities The integumentary system is the largest organ system. In humans, this system accounts for about 16 percent of total body weight and covers 1.5-2m2 of surface area.[4] It distinguishes, separates, protects and informs the animal with regard to its surroundings. Small-bodied invertebrates of aquatic or continually moist habitats respire using the outer layer (integument). This gas exchange system, where gases simply diffuse into and out of the interstitial fluid, is called integumentary exchange. subcutaneous tissue. Functions The integumentary system has multiple roles in homeostasis. All body systems work in an interconnected manner to maintain the internal conditions essential to the function of the body. The skin has an important job of protecting the body and acts as the bodys first line of defense against infection, temperature change, and other challenges to homeostasis. Functions include:
y y y y y

Protect the bodys internal living tissues and organs Protect against invasion by infectious organisms Protect the body from dehydration Protect the body against abrupt changes in temperature Help excrete waste materials through perspiration

14
y y y y y

Act as a receptor for touch, pressure, pain, heat, and cold (see Somatosensory system) Protect the body against sunburns Generate vitamin D through exposure to ultraviolet light Store water, fat, glucose, and vitamin D Participate in temperature regulation

Layers of the Skin Epidermis

This is the top layer of skin made up of epithelial cells. It does not contain blood vessels. Its main function is protection, absorption of nutrients, and homeostasis. In structure, it consists of a keratinized stratified squamous epithelium comprising four types of cells: keratinocytes, melanocytes, Merkel cells, and Langerhans' cells. The major cell of the epidermis is the keratinocyte, which produces keratin. Keratin is a fibrous protein that aids in protection. Millions of dead keratinocytes rub off daily. The majority of the skin on the body is keratinized, meaning waterproofed. The only skin on the body that is non-keratinized is the lining of skin on the inside of the mouth. Non-keratinized cells allow water to "sit" atop the structure. The epidermis contains different types of cells: The most common are squamous cells, which are flat, scaly cells on the surface of the skin; basal cells, which are round cells; and melanocytes, which give the skin its color. The epidermis also contains Langerhan's cells, which are formed in the bone marrow and then migrate to the epidermis. They work in conjunction with other cells to fight foreign bodies as part of the body's immune defense system. Granstein cells play a similar role. Melanocytes create melanin, the substance that gives skin its color. These cells are found deep in the epidermis layer. Accumulations of melanin are packaged in melanosomes (membrane-bound granules). These granules form a pigment shield against UV radiation for the keratinocyte nuclei. The epidermis itself is made up of four to five layers. From the lower to upper epidermis, the layers are named: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum (the extra layer that occurs in places such as palms and soles of the feet), and the stratum corneum. The stratum basale is the only layer capable of cell division, pushing up cells to replenish the

15 outer layer in a process called terminal differentiation. The stratum corneum is the most superficial layer and is made up of dead cells, proteins, and glycolipids. The protein keratin stiffens epidermal tissue to form fingernails. Nails grow from thin area called the nail matrix; growth of nails is 1 mm per week on average. The lunula is the crescent-shape area at the base of the nail, this is a lighter colour as it mixes with the matrix cells. Dermis The dermis is the middle layer of skin, composed of loose connective tissues such as collagen with elastin arranged in a diffusely bundled and woven pattern. These layers serve to give elasticity to the integument, allowing stretching and conferring flexibility, while also resisting distortions, wrinkling, and sagging. The dermal layer provides a site for the endings of blood vessels and nerves. Many chromatophores are also stored in this layer, as are the bases of integumental structures such as hair, feathers, and glands. The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors (nerve endings) that provide the sense of touch and heat. It contains the hair follicles, sweat glands, sebaceous glands, apocrine glands, lymphatic vessels and blood vessels. The blood vessels in the dermis provide nourishment and waste removal from its own cells as well as from the Stratum basale of the epidermis. The dermis is structurally divided into two areas: a superficial area adjacent to the epidermis, called the papillary region, and a deep thicker area known as the reticular region. Papillary region The papillary region is composed of loose areolar connective tissue. This is named for its fingerlike projections called papillae, that extend toward the epidermis. The papillae provide the dermis with a "bumpy" surface that interdigitates with the epidermis, strengthening the connection between the two layers of skin. Reticular region The reticular region lies deep in the papillary region and is usually much thicker. It is composed of dense irregular connective tissue, and receives its name from the dense concentration of collagenous, elastic, and reticular fibres that weave throughout it. These protein fibres give the dermis its properties of strength, extensibility, and elasticity. Also located within the reticular region are the roots of the hair, sebaceous glands, sweat glands, receptors, nails, and blood vessels. Subdermis (aka subcutaneous layer, hypodermis, or superficial fascia)

16 Although technically not part of the integumentary system, the subdermis is the layer of tissue directly underneath the dermis. It is composed mainly of connective and adipose tissue or fatty tissue. Its physiological functions include insulation, the storage of energy, and aiding in the anchoring of the skin, attach the skin to underlying bone and muscle as well as supplying it with blood vessels and nerves. It consists of loose connective tissue and elastin. The main cell types are fibroblasts, macrophages and adipocytes (the hypodermis contains 50% of body fat). Fat serves as padding and insulation for the body. Another name for the hypodermis is the

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Wound Healing
Wound healing, or wound repair, is an intricate process in which the skin (or another organ) repairs itself after injury. In normal skin, the epidermis (outermost layer) and dermis (inner or deeper layer) exists in a steady-state equilibrium, forming a protective barrier against the external environment. Once the protective barrier is broken, the normal (physiologic) process of wound healing is immediately set in motion. The classic model of wound healing is divided into three or four sequential, yet overlapping, phases: (1) hemostasis (not considered a phase by some authors), (2) inflammatory, (3) proliferative and (4) remodeling. Upon injury to the skin, a set of complex biochemical events takes place in a closely orchestrated cascade to repair the damage. Within minutes post-injury, platelets (thrombocytes) aggregate at the injury site to form a fibrin clot. This clot acts to control active bleeding (hemostasis). In the inflammatory phase, bacteria and debris are phagocytosed and removed, and factors are released that cause the migration and division of cells involved in the proliferative phase. The proliferative phase is characterized by angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction. In angiogenesis, new blood vessels are formed by vascular endothelial cells. In fibroplasia and granulation tissue formation, fibroblasts grow and form a new, provisional extracellular matrix (ECM) by excreting collagen and fibronectin. Concurrently, re-epithelialization of the epidermis occurs, in which epithelial cells proliferate and 'crawl' atop the wound bed, providing cover for the new tissue. In contraction, the wound is made smaller by the action of myofibroblasts, which establish a grip on the wound edges and contract themselves using a mechanism similar to that in smooth muscle cells. When the cells' roles are close to complete, unneeded cells undergo apoptosis. In the maturation and remodeling phase, collagen is remodeled and realigned along tension lines and cells that are no longer needed are removed by apoptosis. However, this process is not only complex but fragile, and susceptible to interruption or failure leading to the formation of chronic non-healing wounds. Factors which may contribute to this include diabetes, venous or arterial disease, old age, and infection. Wound Healing Process

Approximate times of the different phases of wound healing, with substantial variation depending on wound size and healing conditions.

18 V. Nursing Theories Dorothea Orems Self-Care Theory Defined Nursing: The act of assisting others in the provision and management of self-care to maintain/improve human functioning at home level of effectiveness. Orems model focuses on each individuals ability to perform self-care, defined as the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being. The basic premise of the model is that individuals can take responsibility for their health and the health of others. In a general sense, individuals have the capacity to care for themselves or their dependents The Orem model is based upon the philosophy that all "patients wish to care for themselves". They can recover more quickly and holistically if they are allowed to perform their own self cares to the best of their ability. It also identified 3 related concepts: Self-care activities an Individual performs independently throughout life to promote and maintain personal well-being. Self-care deficit results when self-care agency (Individuals ability) is not adequate to meet the known self-care needs. Nursing System nursing interventions needed when individual is unable to perform the necessary self-care activities: Wholly compensatory nurse provides entire self-care for the client. Partial compensatory nurse and client perform care; client can perform selected self-care activities, but also accepts care done by the nurse for needs the client cannot meet independently. Supportive-educative nurses actions are to help the client develop/learn their own self-care abilities through knowledge, support and encouragement. y Jean Watson: Theory of Human Caring

Jean Watsons Theory of Transpersonal Caring also called Theory of Human Caring or The Caring Model was developed in 1979. This theory has evolved over the years but the basic premise remains the same. It emphasizes the humanistic aspects of nursing in combination with scientific knowledge. Watson designed this theory to bring meaning and focus to nursing as a distinct health profession. Watson believes that: y Caring is an endorsement of professional nurses identity y Medicines identity is that of caring y Florence Nightingale appeared to agree in her statement: It is the surgeon who saves a persons life .it is the nurse who helps this person live According to Watson, the nurses role is to: y Establish a caring relationship with patients y Treat patients as holistic beings (body, mind and spirit) y Display unconditional acceptance y Treat patients with a positive regard y Display unconditional acceptance y Treat patients with a positive regard y Promote health through knowledge and intervention y Spend uninterrupted time with patients: caring moments Watson defines interactions or caring moments as follows: y The nurse and patient make contact.

19 y The nurse enters the patients room, a feeling of expectation is created. Watson believes that through the nurses attitude and competence, a patients world can become: y Larger or smaller y Brighter or drab y Rich or dull y Threatening or secure Watson also believes these moments transform both the patient and nurse and that they are linked together. y Hildegard Peplaus Interpersonal Relations Theory

Defined Nursing: An interpersonal process of therapeutic interactions between an Individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help and a maturing force and an educative instrument Identified 4 phases of the Nurse Patient relationship: 1. Orientation individual/family has a felt need and seeks professional assistance from a nurse (who is a stranger). This is the problem identification phase. 2. Identification where the patient begins to have feelings of belongingness and a capacity for dealing with the problem, creating an optimistic attitude from which inner strength ensues. Here happens the selection of appropriate professional assistance. 3. Exploitation the nurse uses communication tools to offer services to the patient, who is expected to take advantage of all services. 4. Resolution where patients needs have already been met by the collaborative efforts between the patient and the nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away from identifying with the nurse as the helping person.

20 VI. PATHOPHYSIOLOGY Stabbed wound- it is a wound with fine edges caused by a sharp and blunt force, it is rather deeper than long Modifiable: Non-modifiable . Lifestyle: farmer Age: 51 years old Behavior: mediator between Gender: male two persons fighting

Accidentally got stabbed by a knife for trying to become a mediator between two drunken men fighting Hypoxia, ATP production decreases, Sodium and water move into cell Potassium moves out of the cell, osmotic pressure increases. More water moves into cell, cristernae of endoplasmic reticulum distended, ruptured

Injury

Laceration at the intraumbilical region

Hydropic degeneration Signals brain to release antiinflammatory agents Constriction of vascular circulation Trauma and force

Kinins, bradykinins, prostaglandins

Inflammation of the site

There is intestinal evisceration and multiple jejunal perforations

If unoperated

Infection o BP, PR, RR, T (local ly)

Pain with a scale of 8/10

Has undergone operation

Sepsis

Intervened by

Jejunal resection and closure of wounds

Death

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Wound healing Ketorolac 30 mg IVTT q 60

Intervened by Pre-operative medications: -Ranitidine 1 amp IVTT q 80 Anti-bacterials: -Cefuroxime 750 mg IVTT q 80 -Metronidazole 500 mg IVTT q 80

Legends: Pathophysiologic process

Pharmacologic interventions

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VII. DOCTORS ORDER

ORDER
September 16, 2010 5:08am k Pls. admit to surgical ward k Consent k TPR q6 o k NPO k LABS: CBC, Blood typing, U/A stat k IVF: 1. D5LR iL @ 30 gtts/min 2. PNSS iL @ 20 gtts/min k MEDS:  Metronidazole 500mg IVTT q8 o  Cefuroxime 750mg IVTT q8 o    ATS 3000cc IVTT ANST Ketororac 30mg IVTT q6o Ranitidine 1amp IVTT q8 o

RATIONALE
For management of pts. condition For legality purposes To monitor pts. v/s closely and determine any deviation from normal range Preparation for surgery, to prevent aspiration, pt undergone emergency operation To establish baseline data for further comparison For fluid replacement and caloric supplementation Ordered earlier in preparation for blood transfusion. PNSS has the same salinity with the cells Ordered in preparation for surgery To prevent post operative infection To prevent bacterial infection, skin test is done to determine sensitivity to cephalosporin. To prevent tetanus since pt. was stabbed For pain reliever Reduce gastric acid secretions, in preparation for surgery To monitor/determine deviation from normal range. Referral is ordered for continuity of care. To inform for surgery of pt For immediate surgical intervention because of patients condition. This is to ensure that pt. understands and submits himself for surgery To inform for emergency surgery To prepare for blood trans To ensure that blood to be transfused is of pt blood type and Rh type FBC is done to empty the bladder and NGT is done so that the liquids/soft diet

k Monitor v/s q6 o , refer for unusualities k Inform Dr. Prantilla k Schedule for E exlap k Secure consent k Inform anesthesiologist k To secure iii u blood of pts BT. k Screened and cross matched for OR k FBC and NGT

23 will be given to the pt to prevent GI upset and workload For continuity of care Preparation for surgery, to prevent aspiration For legality purposes Reduce gastric acid secretion To prevent/reduce post-operation nausea and vomiting For continuity of care For relieve of pain For proper and close monitoring To prevent aspiration since anesthesia effects is still present For close monitoring of pt v/s postoperatively For fluid replacement and supplementation since pt undergone surgery For maintenance of fluid replacement For replacement of blood lost during operation. PNSS is the only IVF compatible with blood transfusion procedure since it has the same salinity with the cells. To determine and evaluate oxygen carrying RBC. To prevent infection post-op To prevent post-op infection For relief of pain For relief of pain Reduce gastric acid secretion To evaluate fluid status Pts condition is found to be stable/suitable for transfer to surgical ward. For continuity of care For maintenance therapy of fluid

k Refer accordingly September 16, 2010 k NPO for 6 o k Secure consent k MEDS:  Famotidine 20mg  Metoclopramide 1gm k Refer accordingly 6:45am k Tramadol 1amp slow IVTT POST-OP ORDERS k To pacu k NPO k Monitor v/s q15 mins. Until stable k Regulate IVF to 30 gtts/min k IVFTF: D5LR k Regulate BT to 30gtts/min to ff up PNSS @ KVO

k Hgb 6 o post BT k MEDS:  Cont cefuroxime 750mg IVTT q8 o  Metronidazol 30mg IVTT q8 o  Tramadol 80 mg slow IV now then q6 o  Ketorolac 30mg IV now  Cont. Ranitidine 50mg IV k I and O q shift k May transfer once fully awake k Refer accordingly k IVFTF: D5NM iL + 1 amp benutrex c

24 @ 30gtts/min k NPO k IVFTF: D5NM iL + 1 amp benutrex c @ 30gtts/min k Pls. change dressing k Ambulate patient k Remove fbc k Cont. meds k Strict NPO k D5LR iL @ 30gtts/min k Ambulate k IVFTF: D5NM iL + 1 amp benutrex c @ 30gtts/min k May have general liquid k Soft diet k Pls. change dressing k Ambulate pt k Cont. meds k Remove NGT supplementation To prevent GI upset/reduce GI workload because of the surgery undergone by pt. For maintenance of the fluid supplementation To prevent infection to surgical site To promote circulation, promoting faster healing and recovery To resume the normal activity of the bladder For maintenance of the therapeutic effect of meds given To prevent GI upset/reduce GI workload because of the surgery undergone by pt For maintenance of fluid supplementation To promote circulation, promoting faster healing and recovery For maintenance of fluid supplementation For gradually introduce content in the GI tract To prevent GI upset since pt is from strict NPO To prevent infection at surgical site To promote circulation, promoting faster healing and recovery To maintain the therapeutic effects of meds given. Pt. is able to take/ingest orally.

25

VIII. LABORATORY/DIANOSTIC EXAMS

Name of Exam
Complete Blood Count (CBC)

Description

Results

Normal Values
Male: 13.7-16.g/dL Female: 11.714.5g/dL Male: 40.549.7vols% Female: 34.1-44.3 vols% 150,000-500,000 mm3

Interpretation
Normal

Significant Findings
Normal

Determination of Hemoglobin the number of 14.1g/dL blood components performed Hematocrit manually by 42.3vols% staining a slide and counting the different types of Platelet cells under the Adequate microscope. To assess characteristics of urine, to determine the excretion of substance from the kidneys adrenal glands and the stomach Color -yellow Transparency -cloudy Sugar -negative Sp. Gravity -1.030 pH -6.0 RBC -0-1/hpf Pus cells -4-7/hpf Blood type -B Rh -+ Hgb -13.6g/dL

Normal

Normal

Normal

Normal

Urinalysis

Pale yellow- amber Clear Negative 1.010-1.030 7.35-7.45 0-2/hpf 2-4/hpf

Normal Abnormal Normal Normal Abnormal Normal Above normal

Normal Concentrated urine Normal Normal Slightly acidic Normal Possible infection

Blood typing

A procedure done to determine pts blood type and Rh Re-evaluation of hgb and hct level

Normal Normal Male: 13.7-16.g/dL Female: 11.7Below normal

Normal Normal May be due to blood loss during surgery

Hgb and hct ff-up count

26 post-operative Hct -41.0vols% 14.5g/dL Male: 40.549.7vols% Female: 34.1-44.3 vols% Normal Normal.

27 IX. DRUG STUDY Drug Classification Indication Mechanism of Adverse reaction Drug action Interaction Ranitidine H2 receptor y Heartburn Competitively CNS:headache,malai NONE hydrochlorid antagonist y Maintenan inhibits action se,vertigo, e ce therapy of histamine on EENT:blurred vision the h2 at Hepatic: jaundice for receptor site of Other:anaphylaxis,a duodenal and gastric parietal cells, ngioedema,burning decreasing and itching at ulcer gastric acid injection site secreations

Route/freq/ Nursing dosage considerations IVTT 1 y Assess pt. amp q 8 for hrs. abdominal pain y Advise pt. to report presence of blood in stool/emesis y Dont confuse ranitidine with rimantadine

28

Drug

Classification

Indication

Mechanism of action May inhibit prostaglandin synthesis,to produce antiinflamatory,an algesic and antipyretic effects.

Adverse reactions

Drug interaction NONE

Route/freq/ dosage IVTT 30 mg q 6 hrs.

Nursing consideration y NSAIDS may mask signs and symptoms of infection Serios g.i toxicity including peptic ulcer and bleeding can occur Instruct patient to report signs of bleeding

Ketorolac Non steroidal y tromethamine antiinflamatory drug

Short term manageme nt for moderatel y severe pain

CNS:headache,dizzi ness,drowsiness,seda tion CV:arrhythmias,ede ma,hypertension,pal pitations G.I:dyspepsia,g.i pain,nausea,constipa tion,diarrhea,vomitin ,flatulence Hema:prolonged bleeding time,decreased platelet adhesion Skin:diaphoresis,pru ritus,rash

29

Drug

Classification

Indication

Mechanism of action

Adverse reactions

Drug interaction

Route/freq/ dosage

Nursing considerations Reassess patient's level of pain at least 30 minutes after administration. Monitor CV and respiratory status. Withhold dose and notify prescriber if respirations decrease or rate is below 12 breaths/minute. Monitor bowel and bladder function. Anticipate need for laxative. For better analgesic effect, give drug before onset of intense pain. Monitor patients at risk for seizures. In the case of an overdose. Monitor patient for drug dependence.

Tramadol Analgesic hydrochloride

Moderate to Unknown. A moderately centrally acting severe pain synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin.

coordination disturbance, euphoria, nervousness, sleep disorder, seizures, malaise. CV: vasodilation. EENT: visual disturbances. GI: nausea, constipation, vomiting, dyspepsia, dry mouth, diarrhea, abdominal pain, anorexia, flatulence. GU: urine CNS: dizziness, vertigo, headache,confusion, retention, urinary frequency, proteinuria. Respiratory: respiratory depression. Skin: pruritus, diaphoresis, rash.

Carbamaze IVTT 50 pine: May mg q 6 hrs. increase tramadol metabolism . SSRIs: May increase risk of serotonin syndrome. Use cautiously and monitor patient for adverse effects. CNS depressants : May cause additive effects. Use together cautiously; tramadol dosage may need

30 to be reduced. Cyclobenza prine, MAO inhibitors, neuroleptic s, other opioids, tricyclic antidepress ants: May increase risk of seizures. Monitor patient closely. Quinidine: May increase level of tramadol Drug Cefuroxime sodium Classification Indication Antiinfectives Bacterial infection Mechanism of action Inhibits cell wall synthesis,prom oting osmotic instability,usu ally bactericidal Adverse reactions CV: phlebitis, thrombophlebitis. GI: pseudomembranous colitis, nausea, anorexia, vomiting, diarrhea. Hematologic: transient Drug interaction Aminoglyc osides: May cause synergistic activity against some organisms; may Route/freq/ Nursing dosage considerations IVTT 750 Before giving drug, mg q 8 ask patient if he is allergic to penicillins or cephalosporins. Obtain specimen for culture and sensitivity tests before giving first

31 neutropenia, eosinophilia, hemolytic anemia, thrombocytopenia. Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, temperature elevation, tissue sloughing at I.M. injection site. Other: hypersensitivity reactions, serum sickness, anaphylaxis. increase nephrotoxi city. Monitor patient's renal function closely. Loop diuretics: May increase risk of adverse renal reactions. Monitor renal function test results closely. Probenecid : May inhibit excretion and increase cefuroxime level. Probenecid may be used for this effect. Drug-food Any food: dose. Therapy may begin while awaiting results. For I.M. use, inject deep into a large muscle, such as the gluteus maximus or the side of the thigh. Absorption of oral drug is enhanced by food. Tablets may be crushed, if absolutely necessary, for patients who can't swallow tablets.

32 May increase absorption. Give drug with food.

33

Classification Drug Metronidazol e hydrochlorid e Antiinfectives

Indication

Mechanism of action To prevent Unknown.ma post-operative y cause infections bactericidal effect by interacting the bacterial DNA.

Adverse reactions CNS:headache,fever ,dizziness CV:edema EENT: rhinitis G.I:nausea,vomiting, constipation G.U:polyuria,darken ed urine Hema:neutropenia Musculoskeletal:tran sient joint pains Resp:URTI Skin:rash

Drug interaction None

Route/freq/ Nursing dosage considerations IVTT 500 y Caution pt. to mg q 8 avoid alcohol y Use carefully in patient with history of hepatic impairement.

34

X. Nursing Care Plans Actual Nursing Care Plans

CUES SUBJECTIVE: Sakit pa man ni akong samad, kanang ngutngot nga pagkasakit, as verbalized by the patient. NURSING DIAGNOSIS Acute pain related to release of prostaglandins secondary to surgical treatment at epigastric area OBJECTIVES STO: At the end of 8 hours duty,client will be able to: 1.follow prescribed pharmacologic regimen. 2.demonstrate use of relaxation skills such as deep breathing NURSING INTRVENTION Independent: 1. monitor skin color/temperature and vital signs 2. provide comfort measures (e.g touch ) 3. reposition patient every 2 hours   RATIONALE EVALUATION

OBJECTIVE: y Guarding y Facial grimace y Diaphoresis Pain scale of 8/10, 0 as no pain and 10 as excruciating pain

LTO: At the end of 2 days duty, the patient will be able to:

4. encourage use of relaxation techniques (e.g listening to music, deep breathing) 5. encourage diversional activities (e.g talking to others, music therapy, guided imagery)

STO: Objectives met. This can be Patient was able to altered in acute follow prescribed pain pharmacologic This can help in regimen and reducing demonstrated sensation of relaxation skills(e.g pain deep Promotes breathing)because circulation, health teachings promoting pain were provided. reduction To promote nonpharmacologic pain management. May promote LTO: relaxation or Objectives met. Patient reported redirect reduction in pain attention and scale from 8/10 to reduce 5/10, 0 as no pain analgesic

35 1.report pain is relieved from pain scale of 8/10 to 5/10, 0 as no pain and 10 as excruciating pain 2. demonstrate relaxed body posture and facial expression 6. encourage adequate rest periods. 7. encourage verbalization of pain dosage needs/ frequently .  To prevent fatigue.  To assess reports pain is a subjective experience. and 10 as excruciating pain because pharmacologic regimen was followed. And demonstrated relaxed body posture and facial expression.

8. accept clients description of pain

Collaborative: 1. administer ketorolac 30 mg q6 2. administer tramadol 50 mg q6

 For pain relief; or pharmacolog ic pain management  For relief of pain: for pharmacolog ic pain management

36

NURSING CARE PLAN

CUES NURSING DIAGNOSI S Risk for infection related to portal of bacterial invasion secondary to traumatized tissue at epigastric area OBJECTIVES NURSING INTRVENTION Independent: 1. observe for localized signs of infection (e.g itching, redness) 2. change wound dressing regularly as indicated 3. encourage early ambulation  To assess causative factor RATIONALE EVALUATIO N STO: Objective met. Patient demonstrated techniques to prevent infection(e.g participate in wound dressing, hand washing not exposing surgical site unnecessarily) and able to understand the importance of daily wound dressing.

SUBJECTIVE: magkatol ni akong samad usahay, as verbalized by the patient. OBJECTIVE:  Itching at surgical site  Surgical incision above the umbilical area

STO: At the end of 8 hours duty,client will be able to:  demonstrate techniques to prevent infection  Understand the importance of daily wound care and dressing.  Promote proper hygeine

 To prevent infection  To promote circulation, promoting faster wound healing  Facilitate/aids in wound healing

4. encourage adequate hydration, intake of fluids for at least 8-10 glasses a day 5. provide health teachings on proper wound care 6. stress the importance of hand hygiene

 To facilitate patients learning  This is a universal precaution in preventing infection/contamina LTO: tion Objective met. Patient

LTO: At the end of 2 days duty, the patient will

37 be able to: 1.achieve timely wound healing, and 2. be free of purulent drainage 7. use sterile dressing  To prevent infection and maintain aseptic technique achieved timely wound healing, without purulent drainage

Collaborative: 1. administer cefuroxime 750 mg IVTT q8 hours 2. administer metronidazol e 500 mg IVTT q8 hours  Pharmacologic therapy to prevent infection

 Pharmacologic therapy to prevent infection

38

NURSING CARE PLAN

CUES SUBJECTIVE: Mubinhod akong samad ug mosakit pud , as verbalized by the patient. NURSING DIAGNOSIS Impaired skin integrity related to skin trauma and surgery OBJECTIVES STO: At the end of 8 hours duty,client will be able to:  participate in prevention measures and treatment program NURSING INTRVENTION Independent: 1. Assess blood supply and sensation of affected area 2. note skin color, texture and turgor RATIONALE EVALUATION

 

OBJECTIVE:  Damaged skin 

3. periodically observe wound for complications 4. keep the surgical site clean/dry 5. dress the surgical site regularly 6. use appropriate wound dressings, wound coverings 7. reposition patient every 2 hours

 

LTO: At the end of 2 days duty, the patient will be able to: 1. display timely healing of wound without complications, and 2. maintain optimal nutririon

  

 8. encourage/assist patient with ambulation

STO: objective met. Patient contributing participated in factors prevention To assess extent measures and treatment of involvement/inj program(e.g wound dressing) ury To monitor progress of wound healing Moisture causes contamination To prevent infection To promote LTO: optimal healing Objective met. Patient displayed timely wound To promote healing without circulation, complications promoting and maintained faster healing optimal nutrition and recovery To promote circulation especially to affected part

39  Nutrition affects wound healing

9. provide health teachings about proper nutrition

Collaborative: 1.administer metronidazole 500 mg IVTT q8 hours 2. administer cefuroxime 750 mg IVTT q8 hours  For pharmacologic therapy, to prevent infection  For pharmacologic therapy, to prevent infection

40

NURSING CARE PLAN

NURSING DIAGNOSIS SUBJECTIVE: Impaired galisod ko ug lihokphysical lihok maam tungod sa mobility related akong tinahian tapos to surgical magsakit man gud pud intervention as siya as verbalized by evidenced by the patient limited range of motion OBJECTIVE:  Reluctance to attempt movement  Inability to move purposefully within bed  Limited range of motion  Decrease muscle control CUES OBJECTIVES STO: At the end of 8 hours duty, client will be able to:  Understand the importance of ROM exercises as tolerated.  Demonstrate appropriate ROM exercises NURSING INTRVENTION Independent: 1. Conduct health teaching with emphasis on ROM exercise as tolerated by the patient. 2. Promote and encourage self care activities. RATIONALE EVALUATION STO: Objectives met. Patient able to understand the importance of ROM exercises as tolerated and demonstrate appropriate ROM exercises.

 To impart knowledge to patient prior for understanding the procedure.  Improves muscle strength and circulation, also promotes self-directed wellness.  To promotes wellbeing and maximizes energy promotion.

3. Encourage adequate intake of LTO: At the end of 2 days fluids/nutritiou duty, the client will be s foods. able to:  Maintain Collaborative: mobility at the Collaborate with highest level as physical or occupational possible therapist as  Demonstrate techniques that indicated. enable resumption of

 Useful in creating aggressive individualized activity/ exercise

LTO: Objectives met. The patient able to Maintain mobility at the highest level as possible , demonstrate techniques that enable resumption of activities and maintain position of function.

41 activities  Maintain position function program. of

42

IDEAL NURSING CARE PLANS NURSING DIAGNOSIS Acute pain related to incision site OBJECTIVES NURSING INTERVENTION RATIONALE

STO: at the end of 3hours duty, the patient will be able to: 1.follow prescribed pharmacologic regimen. 2.demonstrate use of relaxation skills such as deep breathing

Independent: 1. monitor skin color/temperature and vital signs 2. provide comfort measures (e.g.,touch,change of position) 3. encourage use of relaxation techniques (e.g listening to music, deep breathing) 4. encourage diversional activities (e.g talking to others, LTO: At the end of 2 music therapy) days duty, the patient 5. encourage adequate rest will be able to: periods. 1.report pain is relieved 6. encourage verbalization of from pain scale of 8/10 to pain 5/10, 0 as no pain and 10 7. accept clients description of as excruciating pain pain

 This can be altered in acute pain  This can help in reducing sensation of pain and promotes circulation  To promote non pharmacologic pain management .  To focus pt.s attention to things other than pain

 To prevent fatigue.  To assess reports of pain  Pain is a subjective experience

Collaborative: 1. administer ketorolac 30 mg q6 2. administer tramadol 50 mg q6  For relief of pain: for pharmacologic pain management

43 NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION RATIONALE

Risk for infection related STO: At the end of 5 to traumatize tissue hours duty, the patient will be able to; 1.verbalize understanding of individual risk factors 2.identify interventions to reduce risk of infection LTO: At the end of 2 days duty, the patient will be able to: 1.achieve timely wound healing;be free of purulent drainage. 2. demonstrate techniques,lifestyle changes to promote safe environment

Independent: 1. observe for localized signs of infection (e.g itching, redness) 2. change wound dressing regularly as indicated 3. encourage early ambulation,deep breathing,position changes. 4. encourage adequate hydration, intake of fluids for at least 8-10 glasses a day 5. provide health teachings on proper wound care 6. stress the importance of hand hygiene 7. use sterile dressing Collaborative: 1. administer cefuroxime 750 mg IVTT q8 hours 2. administer metronidazole 500 mg IVTT q8 hours

 To assess causative factor  To prevent infection  To promote circulation  Facilitate/aids in wound healing  To facilitate patients learning  This is a universal precaution in preventing infection/contamination  To prevent infection and maintain aseptic technique  Pharmacologic therapy to prevent infection  Pharmacologic therapy to prevent infection

44 NURSING DIAGNOSIS Impaired skin integrity related to skin trauma and surgical incision OBJECTIVES STO: At the end of 5 hours, the patient will be able to participate in prevention measures and treatment program NURSING INTERVENTION Independent: 1. Assess blood supply and sensation of affected area 2. note skin color, texture and turgor 3. periodically observe wound for complications 4. keep the surgical site clean/dry 5. dress the surgical site regularly 6. use appropriate wound dressings, wound coverings 7. reposition patient every 2 hours 8. encourage/assist patient with ambulation 9. provide health teachings about proper nutrition RATIONALE

 To assess contributing factors  To assess extent of involvement/injury  To monitor progress of wound healing  Moisture causes contamination  To prevent infection  To promote optimal healing  To promote circulation,for faster recovery  To promote circulation especially to affected part  Nutrition affects wound healing

LTO: At the end of 2 days duty, the patient will be able to: 1. display timely healing of wound without complications, and 2. maintain optimal nutririon

Collaborative: 1. administer metronidazole 500 mg IVTT q8 hours 2. administer cefuroxime 750 mg IVTT q8 hours

 For pharmacologic therapy, to prevent infection  For pharmacologic therapy, to prevent infection

45 DIAGNOSIS Impaired physical mobility related to pain NURSING INTERVENTIONS STO:At the end of 5 Independent: hours duty the patient 1.Assess degree of will be able to: pain,listening to patients 1.Verbalize description. understanding of his 2.Monitor vital signs condition 3.Assist patient in repositioning 2.Cooperate during the 4.Encourage adequate intake of nursing care fluids/nutritious foods 5.Encourage use of relaxation technique(e.g.,deep breathing) 6.Encourage participation in LTO:At the end of 2 days self-care duty the patient will be 7.Identify energy-concerving able to: techniques for ADLs 1.Demonstrate behaviors that enable resumption of activities 2.Maintain strength and Collaborative: 1.Administer ketorolac 30 mg q function of the affected 6 hours area 2.Adminester tramadol 50 mg q 6 hours OBJECTIVES RATIONALE

 To identify causative factors  This can altered in acute pain  Promotes circulation  Promotes well-being and maximizes energy production  To promote non pharmacologic pain management  Promotes independence  Limits fatigue,maximizing participation

 For pain relief to permit maximal effort  For pain relief to permit maximal effort

46

XI. DISCHARGE PLAN

Name of patient: Chaba
Medication:  Cefuroxime 750 mg tablet every 8 hours for 7 days  Tramadol 50 mg tablet every 6 hours for pain  Ketorolac 30mg tablet every 6 hours for pain  Metronidazole 500mg tablet every 8 hours for 7 days Therapy: we all know that there is no specific treatment for dengue fever, but experts recommend  Water therapy- drinking lots of fluids, it should be optimal fluid therapy to maintain the function of the vital organs.  Getting plenty of bed rest- avoid stressful activities or activities that will require of use a lot of energy Health Teaching:  Proper hygiene: advise to follow proper body hygiene  Proper nutrition: Outpatient Teaching:  Return 7 days or 1 week after discharge for follow-up check-up.  Report immediately any unusualities.  Remind patient to take drugs according to dose and time. Diet:  Instruct patient to eat foods that are low fat, low fiber, non irritating and non carbonated foods (avoid soft drinks, increase eating vegetables)  Encourage patient to eat protein rich foods- egg, milk, dairy products Spirituality:  Provide spiritual support, remind patient to ask for Gods guidance and protection all the time. Encourage him to never loss hope that there is always a time for everything; encourage him not to give for all the challenges he experienced since God is really good all the time.  Encourage patient to attend Sunday mass.

47