Intestinal Obstruction (Volvulus) in Geriatric Patient

Intestinal Obstruction (Volvulus) in Geriatric Patient: 

Intestinal Obstruction (Volvulus) in Geriatric Patient CASE PRESENTATION: Reynel Dan L. Galicinao, RN Student, Master in Nursing Major in Nursing Educational Administration

Contents: 

Objectives Overview Nursing Health Assessment Gordon’s Assessment Contents Physical Examination and Review of Systems Pathophysiology Laboratory and Diagnostic Tests

Contents: 

Concept Map Discharge Plan Medical Management Contents Surgical Management Summary of Medications Drug Study Nursing Care Plan

OBjectives: 

OBjectives

General Objectives: 

General Objectives Within the case presentation session, the audience will be able to discuss the etiology , pathophysiology, and medical, surgical, and nursing interventions of intestinal obstruction.

Specific Objectives: 

Specific Objectives Within the case presentation session, the audience will be able to: Describe intestinal obstruction List the risk factors of intestinal obstruction Trace the pathophysiology of intestinal obstruction Determine the signs and symptoms associated with intestinal obstruction Identify diagnostic and laboratory procedures for intestinal obstruction and their corresponding nursing responsibilities Enumerate possible medical and surgical interventions for intestinal obstruction List the medications to be given for intestinal obstruction Identify possible nursing diagnoses for intestinal obstruction Plan appropriate independent and interdependent nursing interventions for intestinal obstruction Write a discharge plan for intestinal obstruction

Overview: 

Overview

Intestinal Obstruction : 

Intestinal Obstruction Interruption in the normal flow of intestinal contents along the intestinal tract The block: may occur in the small or large intestine may be complete or incomplete may be mechanical or paralytic may or may not compromise the vascular supply Obstruction most frequently occurs in the young and the old

Causes: 

Causes Intussusception - shortening of the colon by the movement of one segment of bowel into another Volvulus of the sigmoid colon - the twist is counter clockwise in most cases of sigmoid volvulus Hernia ( inguinal) - the sac of the hernia is a continuation of the peritoneum of the abdomen and that the hernial contents are intestine, omentum , or other abdominal contents that pass through the hernial opening into the hernial sac

Types of Intestinal Obstruction: 

Types of Intestinal Obstruction

Mechanical obstruction : 

Mechanical obstruction A physical block to passage of intestinal contents without disturbing blood supply of bowel Causes: Extrinsic—adhesions from surgery, hernia, wound dehiscence, masses, volvulus Intrinsic—hematoma , tumor , intussusception, stricture or stenosis, congenital, trauma, inflammatory diseases Intraluminal—foreign body, fecal or barium impaction, polyp, gallstones, meconium in infants .

Paralytic (adynamic, neurogenic) ileus: 

Paralytic ( adynamic , neurogenic) ileus Peristalsis is ineffective There is no physical obstruction and no interrupted blood supply Disappears spontaneously after 2 to 3 days Causes: Spinal cord injuries; vertebral fractures. Postoperatively after any abdominal surgery. Peritonitis, pneumonia. Wound dehiscence (breakdown). GI tract surgery.

Strangulation: 

Strangulation Obstruction compromises blood supply, leading to gangrene of the intestinal wall Caused by prolonged mechanical obstruction.

Nursing Health Assessment: 

Nursing Health Assessment

Demographic Data: 

Demographic Data Name : “Mr. William Lippincott” Address: Poblacion , Midsalip , Zamboanga del Sur Age: 77 years old Sex: Male Status: Widower Religion: Roman Catholic Occupation: Bookkeeper

Health History: 

Health History A . Chief Complaint/s: Abdominal pain B. Impression/Admitting Diagnosis: Acute abdominal problem secondary to volvulus; gangrenous ileum 35 cm from ileocecal valve with ileoileal anastomoses . C. History of Present Illness: One month prior to admission, patient had complaints of epigastric pain, described as crampy, graded at 8/10, intermittent, aggravated by eating solid foods, patient can only tolerate to eat porridge with flaked fish sprinkled on it, alleviated by application of Efficascent oil to abdomen, and rest. Patient had a feeling of strong urge to fart or expel flatus but was unable to do.

Health History (cont.): 

Health History (cont.) Patient had loose bowel movement for 3 days prior to admission, intermittent, brown-colored, unformed stool. Few hours prior to admission, pain became generalized and unrelieved with oral medications thus prompted admission; no fever, no vomiting, no tarry stool. Last bowel movement was the morning before admission (September 26, 2011) with mucoid stool. Patient is a bookkeeper and a regular member of parish church. D. History of Past Illness/es: Patient was hospitalized for 1 week last July 2008 due to Pneumonia. Patient reported he had “complete immunization”. Patient takes Centrum 500 mg 1 tablet, once a day. Patient had blood transfusion (1989) but he could not recall the details. No known allergies. Born via NSVD.

Health History (cont.): 

Health History (cont.)

Health History (cont.): 

Health History (cont.) G. Patient’s Perception of Present Illness: Pt reported, “ Nawala naman ang sakit sa akong tiyan karon , bag-o paman gud ko gitagaan ug tambal para mawala ang sakit .” Hospital Environment: Pt reported, “Ok raman ang kwarto dire aircon , komportable ra man.” H. Summary of Interaction Patient was sleeping upon nurse’s arrival. During physical assessment, patient woke up and nurse continued assessment. Patient appears weak but still answered the nurse’s interview questions and cooperated in the assessment.

Gordon’s assessment: 

Gordon’s assessment

Slide 21: 

Normal Pattern Before Hospitalization Clinical Appraisal Activities – Rest Activities Sleeping pattern Rest Pt usually sleeps at 9 pm, and then wakes up at 6 am. Pt takes a bath every day except for Tuesdays and Fridays r/t his cultural belief. Pt goes to work as a bookkeeper, and then goes to city hall, BIR, and then church. Few weeks PTA, pt usually takes naps in the afternoon. Pt has been lying on bed the whole day. Moves/ changes position with assistance. Pt was not able to sleep in the morning due to pain, but was able to sleep for 2 hours in the evening. Pt appeared very weak and sleepy. Nutrition – Metabolic Typical intake (food or fluid) Diet Diet restriction Weight Medication/Supplement food Few days PTA, pt only eats quaker oats, drinks water, coffee, and flaked fish on porridge. No diet restriction. Weight not taken, unknown. Takes Centrum 500 mg tab once a day. Pt is on NGT early this morning, but was removed later in the morning then diet changed to clear liquids limited to 15 ml/ hr Pt is taking Paracetamol 500 mg 1 tab every 4 hours, prn; Telmisartan ( Micardis ) 40 mg tab OD every HS.

Slide 22: 

Normal Pattern Before Hospitalization Clinical Appraisal Elimination Urine (frequency, color, transparency) Bowel (frequency, color) Pt was able to urinate approximately 1-2 times per day, with clear and yellow urine. Pt defecated > 3x for LBM with color brown, unformed, intermittent LBM for 3 days. Pt was able urinate once on his diaper, with clear and yellow urine, had changed diaper once. Pt has not been able to defecate this day. Ego Integrity Perception of Self Coping Mechanism Support Mechanism Mood/Affect Pt reported, “ok ra baya akong kinabuhi”. Pt has 8 children, has been living with his daughter. He goes to work, and a part of lay minister of parish church, he goes to church regularly. Pt has normal affect congruent to behavior c calm mood. Pt reported “ok ko ron ”. Pt has 8 children, with his whole family visiting him regularly, with friends also visiting him regularly. He prays for his health condition. Pt appears very weak but with normal affect congruent to behavior, with calm mood.

Slide 23: 

Normal Pattern Before Hospitalization Clinical Appraisal Neuro-Sensory Mental State Condition of 5 senses (sight, hearing, smell, taste, touch) Pt is in well mental being. Pt speaks clearly and logically with normal pace. Pt has intact senses: Able to read with aid, hear, feel, touch and discriminate, smell and taste. Pt is in well mental being, speaks clearly and logically within normal pace. Pt has intact senses as tested: Able to read with aid, hear, feel, touch and discriminate, smell and taste. Oxygenation and Vital Signs Respiratory rate Pulse rate Heart Rate Blood pressure Lung sounds History of respiratory problems VS not taken but has history of Pneumonia and was hospitalized for a week last 2007. RR: 22 cpm PR: 86 bpm HR: 86 bpm BP: 130/80 mmHg Pt has decreased breath sounds on lower lobes. Pt has history of pneumonia and was hospitalized for a week last July 2008.

Slide 24: 

Normal Pattern Before Hospitalization Clinical Appraisal Pain – Comfort Pain (location, onset, intensity, duration, associated symptoms, aggravation) Comfort measures/alleviation Medication/s Epigastric pain, graded 8/10, for 2 weeks already, with LBM for 3 days but intermittent with brown unformed stool, aggravated with solid foods; alleviated with Efficascent oil and rest. Pain – 0/10 upon assessment since pt has just been given an analgesic. Hygiene and activities of daily living Pt takes a bath everyday upon waking up except for Tuesdays and Fridays. Pt goes to work as bookkeeper, goes to City Hall, BIR, and church. He sleeps at 9 pm-6 pm Pt has not taken a bath since admission. Pt changes position with assistance lies on bed the whole day. Sleep is disturbed due to pain; was only able to sleep for 2 hours this evening for this day.

Slide 25: 

Normal Pattern Before Hospitalization Clinical Appraisal Sexuality Male (circumcision, civil status, number of children) Patient is a male, 77 years old, widower, with 8 children, circumcised at 6 years old. Patient is a male, 77 years old, widower, with 8 children, circumcised at 6 years old.

Physical examination and rreview of systems: 

Physical examination and rreview of systems

General: 

General Patient is male, 77 y/o, lying semi-fowler’s position in bed, sleeping, but later was awakened. Has mild body and breath odor. Conscious, and oriented to person, and place. Calm and with normal affect congruent to behavior, speaks clearly, logically, and with normal pace. Appears very weak and sleepy Has #17 D5 LR 1 L with 650 cc left, hooked at right arm, regulated at 30 gtts /min, patent and infusing well.

HEENT: 

HEENT H- Patient has wavy, white-streaked hair, equally distributed, no infestations, facial features are symmetric, slightly oval in shape. Skin is wrinkled at the forehead and cheeks. E- has moist, pink conjunctiva, anicteric sclera, able to read with aid, pupils are black, constricts 2 mm when lighted, 4 mm when not, PERRLA. E- able to hear adequately; ears have dry, brown cerumen, level with eyebrows N- able to smell adequately, patent and equal nostrils, no nasal flaring, nasal septum at midline, with dried up mucus. T- oral mucosa is pale and dry, lips are parched. Tongue is pink, dry, and parched. With dental carries, tonsils are not enlarged/flat. Has slight breath odor, able to swallow, and gag reflex present.

Integumentary System: 

Integumentary System Patient’s skin is dry, warm, rough in some parts, and brownish in color; Temperature is 37.8 ˚C. Skin in feet is dry, scaly, and pale has body hairs equally distributed on contralateral parts of the body Has good skin turgor, with nonpitting edema on dorsal part of both feet, but with a grade 1+ pitting edema on the ankles H as median incision on abdomen; open wound below the umbilicus, with length of 9 cm and width of 6 cm, yielding yellow-greenish drainage with foul odor. Nails are long, no clubbing, CRT 2-3 sec; nails are in normal angle and shape/ curvature, but with pale nail beds

Respiratory System: 

Respiratory System Patient has chest shape 1:2 anteroposterior to transverse. Chest movement is symmetric, diaphragmatic exursion is equal and symmetric, but restricted. Spine is vertically aligned. Chest expansion is slightly restricted. Tactile fremitus is palpated, symmetrical bilaterally. Breath sounds on the upper lung fields are clear, but decreased breath sounds on the lower fields. RR-22 cpm, and with effort Uses abdominal accessory muscles and internal intercostal muscles when breathing. Flaring nostrils noted. Pt breathes with open mouth. Respiration is rhythmic, with regular pattern and normal depth. No adventitious breath sounds Has moderate ascites that pushes the diaphragm upwards, thus restricting lung expansion, as reflected on UTZ , and physical assessment.

Cardiovascular System: 

Cardiovascular System Patient is pale, with pale extremities Anterior chest has symmetrical features Neck veins are flat on semi-fowler’s position. Skin is warm to touch. PMI is at fifth intercostal space, left midclavicular line Pulse is graded 1+ on all extremities, equal bilaterally, weak, and thready as palpated Nonpitting edema on both feet. CRT is 2-3 sec. HR-86 bpm, PR-86 bpm, resonant to dull at midclavicular line S1 is heard best on apex, S2 at base. No murmurs. Heart sounds have irregular pattern, with S4.

Digestive System: 

Digestive System Abdomen is flabby/globular, light brown, uniform all over. Umbilicus is at midline, with median incision on abdomen. Landmarks are palpated in appropriate places, liver borders, xiphoid process, and bladder. No signs of enlargement Chest rises on inspiration and deflates on expiration. Hypoactive bowel sounds of 3/min. dull on liver, tympany on intestine, flat on ribs upon percussion No pulsations or masses with thickness only on deep palpation. Abdominal girth is 107 cm Oral mucosa is pale and dry; tongue is pink, dry, and parched. With dental carries, has slight breath odor, able to swallow, and gag reflex present On clear liquid diet. Pt has moderate ascites.

Excretory System: 

Excretory System Patient has urinated on diaper, which was changed once for the whole day, with clear, yellow urine No burning sensation upon urination Bladder is slightly palpable Unable to defecate for 2 days already.

Musculoskeletal System: 

Musculoskeletal System Patient’s muscles on upper extremities are equal in size bilaterally, measures 24.5 cm thigh 23.5 cm on right and 27.5 cm on left, calf is 35 cm on right and 31.5 cm on left. Has firm tone, smooth and coordinated in movement graded 4+ on extremities PROM and AROM performed Patient is able to change position with assistance Patient is able to move toes Pt has nonpitting edema on both feet, pitting on the ankles grading 1++. Pt has moderate ascites.

Nervous System: 

Nervous System Patient is conscious, and oriented to person, place, but confusion noted at times Calm and with normal affect congruent to behavior, speaks clearly, logically, and with normal pace Cranial nerves tested and found functioning R eflexes are 2+ bilaterally, superficial reflexes present Able to contrast pain, temperature appropriately and able to differentiate temperatures A ble to move but slowly and with assistance. GCS=14, muscle strength 4+ on all extremities.

Slide 36: 

Endocrine System Patient has no history of hormonal/endocrine problems, thyroid is not enlarged, skin is dry and warm to touch. Patient has no known allergies. Reproductive System Patient is a widower, with eight children, was circumcised at age 6 y/o. no pain upon urination, no abnormal masses on his reproductive organ reported by patient.

Pathophysiology: 

Pathophysiology

Laboratory and diagnostic tests: 

Laboratory and diagnostic tests

Hematology : 

Hematology NORMAL VALUE Sep 26 Sep 27 Sep 28 Sep 29 Sep 30 Oct 1 IMPLICATIONS Hgb 135-160 g/L 133 136 105 103 116 110 Anemia, decreased 2° to blood loss 3° surgery Hct 0.40-0.48 0.4 0.4 0.31 0.21 0.34 0.32 Decreased, anemia 2° blood loss 3° surgery WBC 5-10 x10/L 11.3 12.8 13.1 12.8 Increased, indicates infection 2° current abdominal problem and surgical procedures Neutrophil 0.55-.65 0.79 0.84 0.88 0.8 Increased, indicates bacterial infection Lymphocyte 0.25-0.4 0.21 0.14 0.1 0.2 Decreased, indicates bacterial infection, decreased because outnumbered by neutrophils Monocyte 0.02-0.06 0.01 Indicates infection Eosinophil 0.01-0.05 0.01 0.02 Normal

Urinalysis (10/2/2011): 

Urinalysis (10/2/2011) NORMAL VALUE RESULT IMPLICATIONS Color yellow/amber dark yellow normal pH 4.5-8.0 6 normal Sp. Gravity 1.005-1.030 1.015 normal Sugar negative ++ normal Protein negative 8-10/hpf Indicates proteinuria Pus negative 8-10/hpf Indicates bacteriuria RBC negative 2.4/hpf Indicates hematuria Epithelial cells rare few normal Crystals negative moderate Indicates dehydration, or improper hydration Bacteria negative moderate indicates bacteriuria, UTI Granular cast (coarse) 2-4/ hpf 8-10/hpf indicates ineffective GRF

Blood Chemistry : 

Blood Chemistry NORMAL VALUE Sep 28 Oct 2 Oct 3 IMPLICATIONS SODIUM 135-148 mmol/L 143.4 mmol/L Normal POTASSIUM 3.5-5.3 mmol/L 4.88 mmol/L 5.19 mmol/L 4.83 mmol/L Normal

Chest X-ray AP view (9/30/2011): 

Chest X-ray AP view (9/30/2011) INDICATION NORMAL VALUE RESULT IMPLICATIONS Used to diagnose pulmonary diseases and disorder of mediastinum, and bony thorax, to evaluate heart condition. Normally appearing and positioned chest, bony thorax (all bones present, aligned, symmetrical, and normally shaped), soft tissues, mediastinum, lungs, pleura, heart, and aortic arch. Hazy densities at the right paracardiac aorta and left lung base suggestive of PNEUMONITIS. There is suspicious free-peritoneal air below the hemi- diaphragm suggestive of: pneumo-peritoneum cardiomegaly AP view Calcified aorta - cardiomegaly - calcified aorta - pneumonitis - pneumo -peritoneum

Ultrasound-Liver (10-5-2011): 

Ultrasound-Liver (10-5-2011) INDICATION NORMAL VALUE RESULT IMPLICATIONS Valuable in detecting a variety of pathologies, including fluid collections, masses, infections and obstruction. The size and shape of the abdominal organs appear normal. The liver, spleen, and pancreas appear normal in size and texture. No abnormal growths are seen. No fluid is found in the abdomen. Normal in size exhibiting homoenous parenchymal Echo pattern in relation to the system It has smooth outline No definite focal nor diffuse mass lesions No dilated intrahepatic vessels There is moderate amount of free- intraperitoneal fluid collection Ultrasonically normal size liver Moderate ascites Incidental small pleural fluid, right

Fasting Blood Sugar (9/29/2011): 

Fasting Blood Sugar (9/29/2011) INDICATION NORMAL VALUE RESULT IMPLICATIONS To monitor the blood glucose level of a patient and is vital component of diabetes management. 72-125 mg/dL 131 mg/dL Increased, possible for DM And advanced liver disease

Medical management: 

Medical management

Slide 49: 

IDEAL ACTUAL Diagnostic Evaluation Fecal material aspiration from NG tube Abdominal and chest X-rays May show presence and location of small or large intestinal distention , gas or fluid “Bird beak” lesion in colonic volvulus Foreign body visualization Contrast studies Barium enema may diagnose colon obstruction or intussusception. Ileus may be identified by oral barium or Gastrografin . Laboratory tests May show decreased sodium, potassium, and chloride levels due to vomiting Elevated WBC counts due to inflammation; marked increase with necrosis, strangulation, or peritonitis Serum amylase may be elevated from irritation of the pancreas by the bowel loop Flexible sigmoidoscopy or colonoscopy may identify the source of the obstruction such as tumor or stricture Nonsurgical Management Correction of fluid and electrolyte imbalances with normal saline or Ringer's solution with potassium as required. NG suction to decompress bowel. Treatment of shock and peritonitis. TPN may be necessary to correct protein deficiency from chronic obstruction, paralytic ileus, or infection. Analgesics and sedatives, avoiding opiates due to GI motility inhibition. Antibiotics to prevent or treat infection. Ambulation for patients with paralytic ileus to encourage return of peristalsis. Diagnostic Evaluation Hematology Chest X-ray -AP view Blood Chemistry Abdominal Ultrasound Urinalysis Abdominal X-ray flat plate and upright Treatment With oxygen inhalation at 2- 3L /min NGT removed Drainage of transudate fluid with suction Fluid taken for cell block, cell count Vital signs monitoring every hour Intake and output monitoring every shift Refer if urine output is less than 30mL /hr On general liquids diet Medication Tramadol 50mg IVTT q8h Ketorolac 30mg IVTT q6h RTC Cefuroxime 750mg IVTT q8h Metronidazole 500mg IVTT q8h Paracetamol 300mg IVTT for temp> 38°C Azithromycin Telmisortan Simvastatin Furosemide 20mg IVTT now IVF D 5 LR D5NM

Surgical Management: 

Surgical Management

Slide 51: 

IDEAL ACTUAL Surgery Consists of relieving obstruction. Options include: Closed bowel procedures: lysis of adhesions, reduction of volvulus, intussusception, or incarcerated hernia Enterotomy for removal of foreign bodies or bezoars Resection of bowel for obstructing lesions, or strangulated bowel with end-to-end anastomosis Intestinal bypass around obstruction Temporary ostomy may be indicated Surgical preparation is often lengthy, taking as long as 6 to 8 hours. It includes correction of fluid and electrolyte imbalances; decompression of the bowel to relieve vomiting and distention; treatment of shock and peritonitis; and administration of broad-spectrum antibiotics. Often, decompression is begun preoperatively with passage of a nasogastric (NG) tube attached to continuous suction. This tube relieves vomiting, reduces abdominal distention, and prevents aspiration. In strangulating obstruction, preoperative therapy also usually requires blood replacement and I.V. fluids. Postoperative care involves careful patient monitoring and interventions geared to the type of surgery. Total parenteral nutrition may be ordered if the patient has a protein deficit from chronic obstruction, postoperative or paralytic ileus, or infection. Exploratory Laparotomy Ileal Resection and Anastomosis Surgical preparation done. Postoperative care done.

Summary of Medications: 

Summary of Medications

Slide 53: 

DATE MEDICATION DOSAGE ROUTE FREQUENCY REMARKS 09/27-10/2 09/27-10/4 10/1-10/3 10/1-10/4 10/5 Tramadol Ketorolac Cefuroxime Metronidazole Paracetamol Azithromycin Telmisartan Simvastatin Metronidazole Cefuroxime Tramadol Ranitidine Ketorolac 100 mg 30 mg 750 mg 500 mg 500 mg tab 50 mg tab 40 mg tab 40 mg tab 500 mg 750 mg 50 mg 50 mg 30 mg IV PUSH IV PUSH IV PUSH IV PUSH PO PO PO PO IV PUSH IV PUSH IV PUSH IV PUSH IV PUSH q 8 hrs q 6 hrs RTC q 8 hrs q 8 hrs q 4 hrs, PRN OD OD q HS q 8 hrs q 8 hrs q 8 hrs q 8 hrs q 6 hrs Administered and tolerated well

Nursing care plan: 

Nursing care plan

Nursing Assessment: 

Nursing Assessment Assess the nature and location of the patient's pain, the presence or absence of distention, flatus, defecation, emesis, obstipation. Listen for high-pitched bowel sounds, peristaltic rushes, or absence of bowel sounds. Assess vital signs. Watch for air-fluid lock syndrome in elderly patients, who typically remain in the recumbent position for extended periods. Fluid collects in dependent bowel loops. Peristalsis is too weak to push fluid “uphill”. Obstruction primarily occurs in the large bowel. Conduct frequent checks of the patient's level of responsiveness; decreasing responsiveness may offer a clue to an increasing electrolyte imbalance or impending shock.

Nursing Diagnoses: 

Nursing Diagnoses Acute Pain related to obstruction, distention , and strangulation Risk for Deficient Fluid Volume related to impaired fluid intake, vomiting, and diarrhea from intestinal obstruction Diarrhea related to obstruction Ineffective Breathing Pattern related to abdominal distention , interfering with normal lung expansion Risk for Injury related to complications and severity of illness Fear related to life-threatening symptoms of intestinal obstruction

Nursing Interventions: 

Nursing Interventions Achieving Pain Relief Administer prescribed analgesics. Provide supportive care during NG intubation to assist with discomfort. To relieve air-fluid lock syndrome, turn the patient from supine to prone position every 10 minutes until enough flatus is passed to decompress the abdomen. A rectal tube may be indicated.

Nursing Interventions: 

Nursing Interventions Maintaining Electrolyte and Fluid Balance Measure and record all intake and output. Administer I.V. fluids and parenteral nutrition as prescribed. Monitor electrolytes, urinalysis, hemoglobin, and blood cell counts, and report any abnormalities. Monitor urine output to assess renal function and to detect urine retention due to bladder compressions by the distended intestine. Monitor vital signs; a drop in BP may indicate decreased circulatory volume due to blood loss from strangulated hernia.

Nursing Interventions: 

Nursing Interventions Maintaining Normal Bowel Elimination Collect stool samples to test for occult blood if ordered. Maintain adequate fluid balance. Record amount and consistency of stools. Maintain NG tube as prescribed to decompress bowel.

Nursing Interventions: 

Nursing Interventions Maintaining Proper Lung Ventilation Keep the patient in Fowler's position to promote ventilation and relieve abdominal distention . Monitor ABG levels for oxygenation levels if ordered.

Nursing Interventions: 

Nursing Interventions Preventing Injury Due to Complications Prevent infarction by carefully assessing the patient's status; pain that increases in intensity or becomes localized or continuous may herald strangulation. Detect early signs of peritonitis, such as rigidity and tenderness, in an effort to minimize this complication. Avoid enemas, which may distort an X-ray or make a partial obstruction worse. Observe for signs of shock—pallor, tachycardia, hypotension. Watch for signs of: Metabolic alkalosis (slow, shallow respirations; changes in sensorium; tetany ). Metabolic acidosis (disorientation; deep, rapid breathing; weakness; and shortness of breath on exertion).

Nursing Interventions: 

Nursing Interventions Relieving Fears Recognize the patient's concerns, and initiate measures to provide emotional support. Encourage presence of support person.

Patient Education and Health Maintenance: 

Patient Education and Health Maintenance Explain the rationale for NG suction, NPO status, and I.V. fluids initially. Advise the patient to progress diet slowly as tolerated once home. Advise plenty of rest and slow progression of activity as directed by surgeon or other health care provider. Teach wound care if indicated. Encourage the patient to follow-up as directed and to call surgeon or health care provider if increasing abdominal pain, vomiting, or fever occur prior to follow-up .

Evaluation: Expected Outcomes: 

Evaluation: Expected Outcomes Maintains position of comfort, states pain decreased to 3 or 4 level on 0-to-10 scale Urine output greater than 30 mL/hour; vital signs stable Passed flatus and small, formed brown stool, negative occult blood Respirations 24 breaths per minute and unlabored with head of bed elevated 45 degrees Alert, lucid, vital signs stable, abdomen firm, not rigid Appears relaxed and reports feeling better

Concept map: 

Concept map

Slide 66: 

Mr. William Lippincott 77 years old, Male Abdominal Pain Acute Abdominal Problem 2° to Volvulus; Gangrenous Ileum 35 cm from Ileus Cecal Valve with Ileo-ileal Anastomoses INEFFECTIVE BREATHING PATTERN r/t Restricted Lung Expansion 2° to Moderate Ascites DECREASED CARDIAC OUTPUT r/t Impaired Heart Contractility 2° to Cardiomegaly FLUID VOLUME DEFICIT (Isotonic) r/t Active Fluid Loss 2° to Ascites Fluid and Fluid Drainage ACUTE PAIN r/t Abdominal Incision 2° to Surgical Procedure IMPAIRED SKIN INTEGRITY r/t Abdominal Incision 2° to Surgical Procedure RISK FOR SECONDARY INFECTION r/t Traumatized Tissue 2° to Surgical Procedure ACTIVITY INTOLERANCE r/t Generalized Weakness 2° to Surgical Procedure INEFFECTIVE AIRWAY CLEARANCE r/t Ineffective Cough Reflex 2° Pain in Incision Site and Generalized Weakness 1 2 3 4 6 5 7 8 RISK FOR INJURY r/t Generalized Weakness and Activity Intolerance 10 HYPERTHERMIA r/t Increased Metabolic Demands 2° to Disease Process 9

Discharge plan: 

Discharge plan

Slide 68: 

Date of Discharge: October 7, 2011 Condition upon Discharge: Improved Medication Review the proper use of prescribed medications, focusing on their correct administration, desired effects, and possible adverse reactions. Instruct client not to abruptly stop the medication without any order from the physician. Discuss side effects of the drugs Exercise Allow physical exercises as tolerated. Ensure adequate physical activity. Encourage patient to have adequate rest periods to prevent fatigue.

Slide 69: 

Diet Advice patient to progress diet slowly as tolerated once home. Encourage high-calorie, high vitamins foods. Teach patient about the food pyramid and recommended daily servings for age. Advice patient and SO to have adequate intake of nutritious foods like vegetables, fruits and other foods rich in vitamins. Encourage patient to have adequate intake of fluids to help in elimination and prevent dehydration 2-3 L of fluids per day. Health Teaching Teach the patient about his disorder, focusing on his type of intestinal obstruction, its cause, and signs and symptoms. Listen to his questions and took time to answer them. Demonstrate techniques for coughing and deep breathing. Teach wound care. Schedule for Next Visit Encourage patient to follow-up as directed. Instruct patient to call surgeon or health care provider if increasing abdominal pain, abdominal distention, nausea, vomiting, or fever occur prior to follow-up.

Slide 70: 

Spiritual Encourage client to always pray and never give up hope in any cases or conditions they may pass through. Also encourage client to have faith and seek for strength in God Respect beliefs of clients but be ready to explain and correct misconceptions. Lifestyle Advise plenty of rest and slow progression of activity as directed by surgeon or other health care provider. Encourage a healthy lifestyle by eating a well-balanced diet and maintaining proper body exercise. Encourage active lifestyle and participation in activities appropriate for age and socialization. Referral Refer to the barangay health center/station for follow up check-up and evaluation. Refer also to health center for minor problems. Refer to nearest hospital for any complications.

Slide 71: 

Thank You!