Case Of Amoebiasis

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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 Brigusamhita, 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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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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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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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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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 help

Consultation of a physician gastroentrologist; stool specimen - Three fresh stool specimens 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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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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2.

3.

4.

5. 6.

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. 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. 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. 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. Absorption: movement of nutrients from the digestive system to the circulatory and lymphatic capillaries through osmosis, active transport, and diffusion 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. Partiallydigested 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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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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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 semiliquid 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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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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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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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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#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, .510% 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. 16

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

PATHOPHYSIOLOGY OF AMOEBIASIS

Predisposing Factors Developing countries Tropical and subtropical countries Urban areas

Precipitating Factors Unsanitary food handling Ingestion of contaminated food and drinks 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

Decrease integrity of thee intestinal wall

Release of enterotoxins

Increase secretion of water and electrolytes (Chloride and Bicarbonate)

Stimulation of the symphatetic/parasymphatetic responses

Inhibits sodium reabsorption Stimulation of the emetic center Large amount of CHON rich fluids Nausea/ Vomiting

Decrease absorption

Increase Gastrocolic reflex

Increase peristalsis

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 intestinal tissues

Increase vascular permeability

Swelling

Chemotaxis occurs

Mobilization of leukocytes and macrophages

Burrows deeper invading the sub mucosa

Activation of prostaglandin

Stimulates the goblets cells in the colon

Edema

Compression of nerve endings

Abdominal pain

Migration of RBC and WBC

Increase mucus production

Formation of lesions

Flask shaped ulceration

Squeezed out / contraction

Carried to lower portion of the colon

Blood and pus formation

Progressive ulceration

Irritation of the intestine Hematochezia

Blood streaked feces

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Ulcerative Colitis

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 Age Address Birthday Birthplace Gender Nationality Religion Marital Status Educational Attainment Occupation Informant Reliability

: : : : : : : : : : : : :

Ms. L.G. 33 years old Lim Compound, San Dionisio, Paranaque City January 21, 1975 Bohol Female Filipino Roman Catholic Single 2 yrs. Vocational Graduate (Sewer) Businesswoman Patient and patient’s mother Total 95%

HOSPITAL DATA Admission No. : Ward Room/Bed : Admitting Diagnosis : Chief Complaint : Final Diagnosis : AMD : Date of Admission : Discharge Date :

78256 Station Annex Room 105C Amoebiasis Loose bowel movement and abdominal pain Amoebiasis T/C Amoebic Colitis Dr. William Hoping Gan August 16, 2008 August 28, 2008

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METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

FAMILY BACKGROUND

Family Members

Position

Date of Birth

Age

Sex

Civil Status

Place of Residence

Educational Attainment

Occupation

Salary

Mr. R.G

Father

01/05/42

66 y/o

Male

Married

Davao City

High School Graduate

Unemployed

N/A

Mrs. D.G

Mother

02/02/47

61 y/o

Female

Married

High School Graduate

House helper

3,500/ month

Ms. L.G (patient)

Eldest sibling

01/21/75

33 y/o

Female

Single

San Dionosio, Paranaque City

2-yr. Vocational Course

Store vendor

15,000/ month

Mrs. C.G

Middle sibling

09/04/78

30 y/o

Female

Married

Davao City

High School Graduate

Unemployed

N/A

Mr. J.G

Youngest sibling

07/24/81

27 y/o

Male

Single

Qatar

College Undergraduate

Factory Worker

Binondo, Sta. Cruz, Manila

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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20,000/ month

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 23 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.

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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.

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METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

LEVEL

OF

COMPETENCIES PHYSICAL COMPETENCY BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AND SYMPTOMS

DURING HOSPITALIZATION

DURING HOSPITALIZATION ( APRIL 2008AUGUST 2008) DATE OF CONFINEMENT: AUGUST 16-28, 2008 The client is of During the onset of healthy condition. signs and symptoms She was able to and the time he was perform activities diagnosed of having a of daily living disease and confined in with no limitation the hospital, the client and with no experience body alterations on weakness and decrease energy levels. She energy levels. There was able to was a gradual decrease managed her on activities that were ‘sari-sario’ store. previously performed The client by the client. The client verbalized, “ verbalized, “ Sobra Masigla at yung panghihina na malakas ako bago naramdaman ko noong ako magkasakit. nagkasakit ako, Wala akong nanghihina at wala nararamdaman na talaga akong ganang kakaiba sa magkikilos, kahit nga katawan ko.” maglakad, hirap ako.”

PRIOR DISCHARGE DATE DISCHARGE: AUGUST 28, 2008 After hospitalization, the client regained some energy and was able to tolerate activities such as walking, preparing her meals, managed her ‘sari-‘sari’ store. However, there are still limitations on her activities such as those that are strenuous in nature (e.g. lifting, pushing etc.) The client verbalized, “Mas ok na ako ngayon. Mas nagagawa ko yung mga Gawain sa bahay at nakakapagbantay uli ako ngb tindahan. Pero medyo nanghihina pa din ako lalo na kapag nagbubuhat.”

30

ANALYSIS

Client’s physical competency was altered during her illness state; there was a gradual decrease on her physical competency that includes activity intolerance in some degree and decrease energy levels. Previous activities that were done prior illness were not tolerated by the client. However, after illness state, the client was able to regain energy levels and tolerate activities previously performed but still with little limitations on task that induce force or stress to client’s physical attributes.

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

MENTAL COMPETENCY BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AND SYMPTOMS

DURING HOSPITALIZATION

DURING HOSPITALIZATION ( APRIL 2008AUGUST 2008) DATE OF CONFINEMENT: AUGUST 16-28, 2008 Client finished a During her two year confinement, the vocational primary decision maker graduate. She is as with regards to capable of client’s condition was making her own her mother, the client decisions and was irritable, loses her expressing her focus and decrease own opinions. attention span during She is quite her confinement. She independent with allows her mother to her decision take decisions for the makings since she plan of care lives alone. There appropriate to her were no condition. The client significant others verbalized, “ Nung na that influences ospital ako, si nanay her decisions. The talaga ang client verbalized, nagdedesisyon para sa “ Wala naman akin. Syempre, hindi akong problema talaga maganda yung pagdating sa pakiramdam ko.” pagdedesisyun, madalas ako talaga ang nagdedesisyun kasi hindi ko din kasam ang pamilya ko simula ng nagtrabaho ako hanggang sa pagbalik ko.”

PRIOR DISCHARGE DATE OF DISCHARGE: AUGUST 28, 2008 After hospitalization, the client presently lives with her mother, she was able to make decisions again on her own but her mother’s opinion is of great influence in making decisions. The client verbalized, “ Sa ngayon, sinasanguni ko na din kay mama yung mga desisyon ko, pinaguusapan na namin.” Decisions of the client where first informed

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ANALYSIS

As regards to client’s mental competency, the client is independent with regards to decision making prior to illness state. This is primarily affected since client lives alone for almost a long time making responsible with all her decisions made. But through the course of her illness up to her discharge, the mother of the client plays a significant role on the client’s decisions which heightens during her hospitalization. to her mother and together they make a decision.

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

EMOTIONAL COMPETENCY BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AND SYMPTOMS

DURING ILLNESS

DURING HOSPITALIZATION ( APRIL 2008AUGUST 2008) DATE OF CONFINEMENT: AUGUST 16-28, 2008 The client is quite The client was unhappy and is emotionally distress burden on how to during her support his family hospitalization; this and significant was manifested by the relative. Since client by becoming their clan has irritable, frowns all the problems with time and refrain from their finances, this talking to others. The serves as major patient verbalized, “ problem to the Sobrang nahirapan din client which talaga ako nung naaffects her ospital ako. Ang dame emotionally. The kong iniisip lalo na client verbalized, yung gastos tapos “ Mahirap talaga sabayan pa ng ang buhay masamang ngayon. Hindi din pakiramdam.” naman kami mayaman, maraming panahon na medyo nagigipit talagga kami. Tapos ako din kasi yung tunutulong sa mga kamag-anak ko.”

PRIOR DISCHARGE DATE OF DISCHARGE: AUGUST 28, 2008 After hospitalization, the client was still quite emotionally distressed but is relief from being discharge to the hospital. The client verbalized, “ Syempre masaya ako na nakalabas na ako sa ospital at wala na ako nararamdaman na masama sa katawan ko.”

32

ANALYSIS

Due financial problems within the client’s family, the client was unhappy and feels burden on how she could manage to support the basic needs of her family and significant relatives. She is emotionally affected with this situation and was aggravated when she was confined to the hospital. Her peak of emotional disturbances reaches it’s height when she had a disease. But felt relief when she was healed and discharged from the hospital. Still, existing problems within the client’s family affects the client emotionally.

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

SOCIAL COMPETENCY BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AND SYMPTOMS The client is of good interpersonal relationship with her friends and neighbors. This is evident with client having conversation with neighbors during mid-afternoon in front of her ‘sarisari’ store. She had good relationships with her previous coworkers at Africa and Brunei. The client verbalized, “ Wala naman akong problema sa mga kaibigan ko at sa mga katrabaho ko dati, marunong naman kasi ako makisama.”

DURING ILLNESS DURING HOSPITALIZATION ( APRIL 2008AUGUST 2008) DATE OF CONFINEMENT: AUGUST 16-28, 2008 During her confinement, the client interpersonal relationship was interrupted. This is manifested during nurse-patient interaction. The client was irritable and refrains from speaking to others. The client verbalized, “ Ayoko talaga makipagusap sa kahit kanino nung nasa ospital ako. Hindi kasi talaga maganda yung pakiramdam ko at irritable pa talaga ako.”

PRIOR DISCHARGE DATE OF DISCHARGE: AUGUST 28, 2008 The client was able to return her good interpersonal relationship with others immediately after her discharge to the hospital. She was visited by her neighbors and friends after hospitalization. The client verbalized, “Naging ok naman na yung pakikitungo ko sa mga kaibigan at kapit bahay ko simula nung na-discharge ako, wala naman nagbago.”

SEXUAL COMPETENCY

33

ANALYSIS

The patient experienced an interrupted interpersonal relationship during her illness state; this is possibly related with client experiencing an alteration in comfort that results to client’s becoming irritable and refrain interacting with others.

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AND SYMPTOMS The client’s civil status is single and has no recent sexual affairs. The patient verbalized, “ Wala akong asawa, medyo pihikan ako sa lalake eh. Pero dati may mga nanliligaw sa akin.”

DURING ILLNESS DURING PRIOR HOSPITALIZATION DISCHARGE ( APRIL 2008DATE OF AUGUST 2008) DISCHARGE: DATE OF AUGUST 28, 2008 CONFINEMENT: AUGUST 16-28, 2008 There was no There was still no significant change on significant changes to the client’s sexual client’s sexual competency during her competency as illness state since the compared before her client is single and illness state. does not have any affairs to anyone.

SPIRITUAL COMPETENCY

34

ANALYSIS

The client has no significant changes with regards to her sexual competency. The client was single and no recent sexual affairs.

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AND SYMPTOMS

DURING ILLNESS DURING PRIOR HOSPITALIZATION DISCHARGE ( APRIL 2008DATE OF AUGUST 2008) DISCHARGE: DATE OF AUGUST 28, 2008 CONFINEMENT: AUGUST 16-28, 2008 The client is a During her After hospitalization, Roman Catholic confinement, the client the client resumed her and attends was unable to attend regular attendance Sunday mass on a Sunday mass but was during Sunday mass regular basis and able to pray anytime and prays regularly practices religious she wants. The client anytime she wants. The beliefs. The client verbalized, “ Syempre client verbalized, “ verbalized, “ nung nasa hospital ako, Nung makalabas na Palage ako hindi ako ako ng ospital at nagsisimba nakakapagsimba. Pero medyo ok na yung tuwing lingo. kahit papaano pakiramdam ko, Pinapraktis nagdadasal ap din ako nagsisimba na uli ako.” naming yung mga lalo pa at may sakit prusisyon, ako.” penitensya kapag mahal na araw.’

ANALYSIS

The client was unable to attend with her religious activity such as attending church mass every Sunday when she was hospitalized. However, was able to resume again after hospitalization. The clients have an aptitude on 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, (Daily Basis) August 2008 ) 2008) Onset of recurrent signs and symptoms BREAKFAST (7 am- BREAKFAST (7 am-varies) DIET UPON ADMISSION: varies) Usually consumes 1-2 pcs. Of Low fat diet Usually consume 3-4 medium size pandesal, at least pcs. of medium size 2 thin slices of dairy cream, ½ pandesal, 3-4 thin cup coffee with creamer Succeeding Diet: slices of dairy cream BRAT diet and Bland Diet and 1 cup of coffee LUNCH without dairy products with creamer (12:00 NN – time varies ) • Usual meal of the Usually consumes a cup of client during LUNCH rice, approximately ¼ portion hospitalization varies (12:00 NN – time of meat or fish, and 1-2 to the hospital food varies ) glasses of water being given. This Usually consumes a includes 1 cup of 1- 1 1/2 cup of rice, SNACK rice, a portion of fish a portion of meat or (4:00 pm) or meat without fish,1 cup of soup Usually 3-4 pcs. Of crackers spices, side and 2 glasses of or biscuits and a glass of vegetables, banana water or sometimes water. and apple. However 12oz. of soft drinks. the client only DINNER consumes 3-6 tbsp. of SNACK (8:00 – 8:30 pm) rice, ¼ portion of the (4:00 pm) Usually consumes a ¾ to 1 viand, 2 tbsp. of the Usually just a glass cup of rice, a portion of meat side vegetables, ¼ to of water or juice and or fish, and a glass of water. half servings of either bread or banana cue. banana or apple, 1-2 glasses of water per DINNER meal (7:30 – 8:00 pm) Usually consumes a Patient verbalized, “Wala cup of rice, a portion akong ganang kumain nung of meat or fish, and a nasa ospital ako. Sobrang glass of water. nanghihina din talaga ako.”

DRINKING PATTERN DURING ILLNESS Prior to Hospitalization During Hospitalization 36

Analysis

There is a decreased in food intake of the patient prior to hospitalization. During the onset of signs and symptoms, the client has a gradual decrease on servings of her previous meals eaten. This could be related to client’s altered comfort primarily by her recurrent loose bowel movements and abdominal pain. Once the client was hospitalized, there is a sudden change on client’s food preferences as ordered by her physician. Previously eaten food such as dairy products, coffee and soft drinks are prohibited for her. There is a remarkable loss of appetite by the client during hospitalization that leads her to some degree of weakness and decrease energy levels.

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

Before Illness (Daily Basis)

 Consumes 4-5 glasses of water per day (approximately 840-1050 ml per day).  1 cup of coffee ( approximately 110 ml per day)  12 oz. soft drinks ( 360 ml.) but is seldom

Analysis (Early April 2008-Early (August 16 2008-August 28, August 2008 ) 2008) Onset of recurrent signs and symptoms  Consumes 4 glasses of  Consumes 3-4 glasses of water per day water per day (approximately 840 ml (approximately 630- 840 per day) ml per day).  ½ cup of coffee ( 50-60 ml of per day)

ELIMINATION PATTERN URINATION DURING ILLNESS 37

The client drinks insufficient amount of oral fluids required per day even before illness state. Prior to hospitalization, a gradual decrease on fluid intake was noted. This decrease on the client’s fluid intake persisted until 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.

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

Before Illness (Daily Basis)

Urinary frequency – 3x/day – 4x/day Color – amber yellow Amount- moderate Odor – aromatic

Prior to Hospitalization (Early April 2008-Early August 2008 ) Onset of recurrent signs and symptoms Urinary frequency 3x/day – 4x/day Color – amber yellow Amount – scanty to moderate Odor – aromatic APPROXIMATE TOTAL = 650- 700 ml/day

During Hospitalization (August 16 2008-August 28, 2008) Urinary frequency – 2x/day – 3x/day Color – amber yellow Amount- moderate Odor – aromatic APPROXIMATE TOTAL = 700-750 ml/day

APPROXIMATE TOTAL = 850- 900 ml/ day

BOWEL MOVEMENT DURING ILLNESS Prior to Hospitalization During Hospitalization 38

Analysis

The patient’s urine output before illness state is within the normal range. However, during the onset of signs and symptoms, the client had a decrease in urine output approximately 100200 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.

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

Before Illness (Daily Basis)

Bowel Frequency – once a day early in the morning Color – yellowish to light brown Consistency – semi-formed; soft bowel Amount- 1- 1 ½ cup per bout

Analysis (Early April 2008-Early August 2008 ) Onset of recurrent signs and symptoms Bowel Frequency – 3-6x/day recurrent in nature Color – brownish yellow with blood streak Consistency - loose and mucoid Amount- 1- 1 ½ cup per bout

(August 16 2008-August 28, 2008) Bowel Frequency2-3x/ day Color- brownish yellow with blood streak Consistency – loose and mucoid Amount- 1 cup per bout

BATHING PATTERN DURING ILLNESS Prior to Hospitalization During Hospitalization 39

Before illness, client had a usual bowel movement with normal characteristic and amount of feces. As soon as signs and symptoms occur prior to her hospitalization, the 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.

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

Before Illness (Daily Basis)

Complete bath twice a day in the morning and afternoon.

Analysis (Early April 2008-Early (August 16 2008-August 28, August 2008 ) 2008) Onset of recurrent signs and symptoms Complete bath once a day in Sponge or bed bath once a The patient’s the morning day in the morning c/o bathing pattern has 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

Before Illness (Daily Basis) Duration : 7-8 hrs/day = Time of sleep is usually 11:00 in the evening and awakens by 7:00 in the morning. = Does not take naps during midafternoon since the client watches her ‘sari-sari’ store.

DURING ILLNESS Prior to Hospitalization During Hospitalization (Early April 2008-Early (August 16 2008-August 28, August 2008 ) 2008) Onset of recurrent signs and symptoms Duration : 5-6 hrs/day Duration : Irregular = Time of sleep is usually but reaches 5-6 hours a day. 11:00 in the evening and awakens by 7:00 in the morning. Interruption of sleep is experienced whenever the client experienced defecating due to episodes loose bowel movement. = Does not take naps during mid-afternoon since the client watches her ‘sari-sari’ store.

40

Analysis

The client has enough sleeping hours before her illness. But prior to her hospitalization, she experienced a decrease on the duration of her sleep and was interrupted whenever she felt the urge to defecate due 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.

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

• • • • • • • • • • •

1500H-2300H

• • • • •

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

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.

41

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

DATE/TIME

NURSES OBSERVATION •

08/17/08 2300H- 0700H

• • • • • • •

Client was awake in supine position with on going IVF of D5LR 1l + 20meqs KCl at 31gtts/min 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

• • • • • •

DATE/TIME

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

NURSES OBSERVATION

42

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

08/19/08 1500H-2300H • • • • • 2300H-0700H

• • •

• 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 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

43

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

Normal Findings

Assessment Findings

Analysis

Inspection

Whitish pink or brown in color; dark skin tone depending on patients race; no evidence of discoloration

Pale and dull skin; no evidence of discoloration

b. Bleeding, Ecchymosis and Vascularity

Inspection

c. Lesions

Inspection & Palpation

No bleeding, ecchymosis and increased vascularity was noted No evident skin lesions noted

d. Moisture

Palpation

e. Tenderness

Palpation

f. Texture

Palpation

No areas of increased vascularity, ecchymosis and bleeding No skin lesions present except freckles, birthmarks or nevi which may be flat or raised Dry with minimum perspiration. Moisture varies with changes in environment, stress, activity and body temperature Skin surface should be nontender Feel smooth, even and firm with rough

Abnormal Pale and dull skin can be related to a decrease in fluid volume in the body and decrease levels of oxygen carrying capacity of the blood Normal

Skin a. Color

Technique

44

Normal

Skin feels dry; with minimal perspiration

Normal

Non tender with no evident inflammation Smooth and firm, minimal roughness on

Normal Normal

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

g.Turgor/Edema Palpation

Hair

Inspection & Palpation

Nails

Inspection & Palpation

Head

Inspection & Palpation

Face

Inspection & Palpation

Mandible

Palpation

surfaces Skin should return to it’s original contour rapidly when released; no edema present Color varies from dark black to pale blonde; evenly distributed; pale white to light brown scalp with no lesions; thin, straight, coarse, thick or curly; shiny and resilient Pink to brown cast; 2-3 seconds capillary refill; smooth, flat and slightly rounded; 160ͦ angle

elbows and knees No edema present; with fair skin turgor

Normocephalic and symmetrical; smooth, nontender without masses and depression Facial features should be symmetrical; shape can be oval, round or slightly square; no involuntary movements; no edema and disproportion No discomfort with movement; no clicking or crepitus heard

Normocephalic and symmetrical; nontender; no masses and depression noted

45

Thin, dry, straight dark black; evenly distributed with moderate hair fall noted, pale white scalp with no lesions noted

Pale nail beds; with normal capillary refill; smooth, flat and round; 160ͦ angle

Normal

Abnormal Dryness and hair fall can be acquired both genetic and nutritional imbalances due to lack of collagen, a protein than nourishes the hair for growth Abnormal This is due to decrease oxygen supply in the body. An early sign of oxygen desaturation Normal

Symmetrical facial features; oval in shape; no involuntary movements, edema and disproportion noted

Normal

No pain or discomfort experienced upon movement of the

Normal

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

tempomandibular joint; articulates smoothly Neck/Thyroid gland/ Lymph Nodes

Inspection & Palpation

Symmetrical neck muscles; able to move head in full ROM without discomfort; no palpable masses or enlargement of thyroid glands and lymph nodes

Symmetrical neck muscles with head in a central position; able to move head in full ROM without discomfort; no thyroid gland enlargement noted; with palpable anterior cervical lymph nodes

Eyes a. Visual Acuity

Inspection

20/20 vision; able to read within a near distance of 14 inches

Unable to read within a distance of 14 inches;

b. Eye Alignment

Cover/Uncover Test

c. Eye Movement

Inspection

Eyelids

Inspection

Eyes are aligned if no movements of either eyes Both eyes move smoothly and symmetrically in each of the six field of gaze Symmetrical; no drooping(ptosis), infections or tumors

No movements noted; eyes are aligned Able to move both eyes in six field of gaze smoothly and symmetrical Asymmetrical; right eyelid with mild ptosis noted

Lacrimal Apparatus

Inspection & Palpation

No enlargement, swelling,

No enlargement or swelling

46

Abnormal Palpable lymph nodes are attributed to infectious process in which the lymph drains and filters such foreign bodies and accumulates on the lymph nodes Abnormal Decrease visual acuity is related to degenerative or hereditary factors with some risk factors on nutritional intake Normal Normal

Abnormal Ptosis is related to cranial nerve damages that affects the neuromuscular attributes of the eye. Normal

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

redness, exudates; no excessive tearing or discharge from the punctum Pink and moist; no swelling, lesions or foreign bodies

noted; with minimal discharges

Conjunctiva

Inspection

Pupil

Inspection

Deep black, round, equal in diameter ( 26mm), constrict briskly to direct light

Deep black; equal in diameter; equally reactive to direct light; 2-3mm; brisk in reaction

Ears a. Hearing Acuity

Voice-Whisper Test

The patient should be able to repeat words whispered from a distance of 2 feet Match the flesh color of the entire skin; proportional; no pain or tenderness during palpation No redness, swelling, lesions, drainage, foreign bodies or scaly surface No evidence of swelling around nose and eyes; no discomfort during palpation

Able to repeat words whispered from a distance of 2 feet

Normal

Flesh in color; proportional to head; non tender auricles; no pain experienced upon palpation

Normal

No redness, swelling, lesions and drainage noted; with minimal non-dry cerumen noted No swelling and discomfort upon palpation noted

Normal

Symmetrically in the midline of the face; no

Located midline to the face; no lesion, swelling,

Normal

b. External Ear

Inspection & Palpation

c. Ear Canal

Inspection

Sinuses

Inspection & Palpation

Nose a. External

Inspection

47

Pale palpebral conjunctiva noted

Abnormal Pale palpebral conjunctiva is a sign of decrease fluid volume and oxygen in the blood Normal

Normal

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

lesion, swelling, bleeding and masses; no occlusion to air passage Nasal mucosa should be pink or dull red without swelling or polyps; no deviation in septum; with small amount of clear watery discharge

masses or bleeding noted; patent nostril Pale nasal mucosa without swelling or polyps; septum is at midline; with minimal thick, whitish discharge noted

Abnormal Pale nasal mucosa is related to decrease oxygen supply in the blood

Abnormal Pale and dry lips is related to fluid volume deficit or dehydration Normal

b. Internal

Inspection

Mouth a. Lips

Inspection

Pink and moist with no evidence of lesion or inflammation

Pale and dry lips; no swelling and inflammation noted

b. Tongue

Inspection

Midline in the mouth; pink, moist and rough; can move freely and stick out tongue

c. Buccal Mucosa

Inspection

Midline in the mouth; pink, moist and rough ( from taste buds), no lesions and swelling; moves freely Pinkish in color; moist, smooth and absence of inflammation and lesions

d. Gums

Inspection

e. Teeth

Inspection

Pale-red stippled surface; well defined gum margins; no swelling or bleeding 32 set of teeth, white with smooth edges, properly aligned and without caries

Pale-red stippled surface; well defined gum margins; mildly retracted from the teeth Incomplete set of teeth with areas of tooth extraction; improperly aligned; with black patches

48

Mildly pale; smooth and moist; no lesions or inflammation noted

Abnormal Related to fluid volume deficit or decrease oxygen in the blood Abnormal Related to fluid volume deficit or decrease oxygen in the blood Abnormal Dental carries can be acquired if oral hygiene is inadequate and with decrease in

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

and erosion on the surface of certain teeth f. Palate

Inspection

Throat

Inspection

Breast

Inspection

Thorax and Lungs a. Shape and Symmetry

b. Muscles of

calcium and fluoride intake that makes teeth strong and free from carries Normal

Hard and soft palate are concave and pink; hard palate with many ridges; soft palate is smooth; no lesion and malformations Pink, vascular and without swelling, exudates or lesions; Uvula is midline; tonsillar size is 1+ to 2+; (+) gag reflex Flesh colored; areolar area and nipples with darker pigmentation; No thickening or edema; symmetrical; convex; no lesions or masses

Concave and pinkish; hard palate with ridges and soft palate is smooth. No lesion or malformations noted Pink, vascular with no swelling or exudates noted; Uvula is at midline: Tonsillar size is 2+ with (+) gag reflex Flesh in color; darker pigmentation on areolar areas and nipples; convex and symmetrical with breast on the side of the dominant arm being larger ( right side); no thickening, lesions or dimpling noted.

Normal

Inspection

Elliptical in shape; shoulders should be at the same height; scapula should be the same height bilaterally with no masses

Abnormal Related to misalignment of the spinal cord.

Inspection

No accessory

Thorax is elliptical in shape; left shoulder is lower in height compared to right shoulder; right scapula higher in height bilaterally Eupnea; no

49

Normal

Normal

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

Respiration

c. Tactile Fremitus

Palpation

c. Breath Sounds

Auscultation

Heart a. Precordium

muscles are used accessory in normal muscles being breathing used; no exaggerated respiratory effort upon breathing noted Normal Fremitus Buzzing is felt 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 Blowing or Fine crackles hollow sound, (rales) heard high in pitch upon ( Bronchial); auscultation gentle rustling or breezy, low in pitch ( Vesicular); no adventitious breath sounds should be heard

Inspection & Palpation

Symmetrical; no vibrations, thrills and expansions noted

b. Heart Sounds

Auscultation

Rhythm is regular; distinguishable S1 and S2; no murmurs heard

Peripheral Vasculature

Inspection

No pallor, cyanosis or ulceration noted; no complaints of pain or discomfort

Inspection

Flat or rounded;

Abdomen a. Contour,

50

Normal

Abnormal Heard when there is fluid accumulation on the alveoli of the lungs

Adynamic precordium; PMI at 5th Intercostal space, left midclavicular line Regular heart sounds; S1 and S2 are distinguishable upon auscultation No discoloration and complains of pain or discomfort noted

Normal

Flat abdomen;

Normal

Normal

Normal

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

Symmetry and Pigmentation

symmetrical bilaterally; no discoloration

non tender; symmetrical; uniform in color and pigmentation; no scars, striae or lesions noted Umbilicus at lower midline of the abdomen; depressed and beneath abdominal surface Normoactive to hyperactive bowel sounds prominent at right lower quadrant

b. Umbilicus

Inspection

Should be depressed and beneath abdominal surface

c. Bowel Sounds

Auscultation

Intermittent gurgling sounds throughout abdominal quadrants; high pitched and occurs 5 to 30 times per minute

Inspection

Muscle shape may be accentuated in certain body areas but should be symmetrical; no involuntary movement

Reduced muscle size; thin and flabby muscles; contour is less distinct; no involuntary movement noted

b. Muscle Strength

Inspection

Complete voluntary range of joint motion against gravity and moderate to full resistance; strength is equally bilateral; no involuntary muscle movements

Decrease muscle strength was observed on upper extremities; complete range of joint motion against both gravity and moderate manual resistance; good muscle strength

c. Upper Extremities

Inspection & Palpation

Able to perform full ROM; no

Can perform full range of motion

Musculoskeletal System a. Muscle size and shape

51

Normal

Abnormal

Abnormal Decrease in muscle size and shape is due to nutritional imbalances and lack of movements leading to atrophy Normal

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

swelling or inflammation noted; symmetrical; with five fingers on each hand; aligned; no numbness or paralysis noted d. Lower Extremities

Inspection & Palpation

Able to perform full range of motion; no swelling or inflammation noted; symmetrical; with five toes on each foot; aligned; no numbness or paralysis noted

e. Spinal cord

Inspection

Cervical concavity; thoracic convexity; lumbar concavity; with full ROM

but with slowed movements; no Normal digital clubbing observed; with five fingers on each hand; symmetrical; equally aligned; no inflammation and swelling noted Can perform full Abnormal range of motion; Slowed body with slowed gait movements observed; no may be swelling or attributed to inflammation pain or noted; alteration in symmetrical; discomfort. with five toes on Numbness is each foot; no due to slowed complains of calf or blockage of 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 Cervical is Abnormal concave; thoracic Related to has increased curvature of the convexity ( slight spinal cord such hump); lumbar is as scoliosis, concave; with lordosis etc. 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

52

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.” ( no positive findings)

Female Reproductive

53

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” ( no positive findings)

Endocrine 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: Date received:

Dr. William Hoping Gan 08/16/08 10; 09 AM 54

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

Date released: Hemoglobin Hct RBC WBC Platelet

08/16/08

10:54 AM

Result 100 0.31 3.72

Normal Values 112-157 g/L 0.34-0.3510^12/L 3.93-5.22 x 10 ^ 12/L 4.7810^9/L 150-400

6.2 Adequate

Differential Count Results Segmenters 0.58 Lymphocytes 0.29 Monocytes 0.08 Eosinophils 0.04 Basophils 0.01

Normal Values 0.55- 0.70 0.25- 0.40 0.02- 0.08 0.01- 0.06 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 55

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 Hemoglobin Hematocrit

Results 105 0.32

Normal Values 120-160 g/L 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

56

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 lifethreatening 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 APTT Control

Results 39.0 27.4

Normal Values 25-27 seconds 27-35 seconds

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

sec % 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 57

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 TEST BUN L Creatinine SGPT (ALT) Sodium Potassium

Results 5.25 mg/dL 0.61 mg/dL 8 u/L 139 meq/L 3.4 meq/L

Reference 7.79- 21.40 0.50- 1.20 0-41 135- 145.0 3.80- 5.50

SI Unit Results 1.97 mmol/.L 55.02 umol/L 8 u/L 139 mmol.L 3.4 mmol/L

Reference 2.78- 7.64 44.0- 106.0 0- 41 135.0- 145.0 3.80- 5.50

L 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

58

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

TEST Potassium

L

Conventional Unit Results Reference 3.6 meq/L 3.80- 5.50

SI Unit Results 3.6 mmol/L

Reference 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

59

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

MACROSCOPIC Physical/Macroscopic

Result

Color

Amber

Transparency

Slightly hazy

Specific Gravity

1.010

Ph

7.5

Protein

Negative

Glucose

Negative

Alkaline

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

60

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

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 Color Red Consistency WATERY/MUCOID

MICROSCOPIC RBC 70- 80/ HPF Pus cells 12-20/ HPF

Others SPECIAL TEST Occult blood: NOT REQUESTED Entamoeba histolytica Cyst Trophozoite Parasites Ascariasis ova:

1-3L/LPF 1-2/LPF NONE SEEN

61

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

Hookworm ova: Trichiuris ova:

NONE SEEN 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

62

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

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: Anus Rectum

Seen / /

Finding / /

63

Biopsy / /

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

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

64

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

Succeeding Intravenous Fluid: Date Ordered 8/19/08 8/20/08

Time 2:20 pm 6 am

8/20/08 8/22/08

1:30 pm 7:30 am

8/23/08 8/23/08 8/26/08 8/26/08

7am 12 MN 6:35 am 7:37 am

Name of IVF D5NM 1L X 8 hours D5NM 1L + 20 meqs Kcl x 12 hours D5NM 1L X 12 hours D5 NSS 1L X 10 hours TF: D5LR 1L X 10 hours D5LR 1L X 10 hours D5NM 1L X 14 hours D5NM 1L X 16 hours 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

8/16/08 8/17/08

6:00 pm 9:25 am

8/17/08

11:35 am

8/18/08

5:45 am

8/19/08 8/28/08

6:00 am 1:15 am

BRAT diet ,no dairy products Banana per meal TID BRAT, free of dairy products Clear liquids after dinner up to 5 am Tuesday then NPO thereafter. Bland diet, no dairy products BRAT diet 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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#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila

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 fatfree 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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METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

•

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. 70

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

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

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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METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

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

TEN IDENTIFIED PROBLEMS 1. 2. 3. 4. 5.

Diarrhea Fluid Volume Deficit Acute Pain Altered Sensory Perception Imbalance Nutrition less than Body Requirements

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METROPOLITAN HOSPITAL COLLEGE OF NURSING

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NURSING CARE PLAN CUES SUBJECTIVE: “Madalas ako nadudume na may kasamang dugo at medyo basa. Nakaramdam din ako ng pagsusuka kung minsan at pananakit ng tiyan”

NURSING DIAGNOSIS Diarrhea related to invasion of the lining of the colon secondary to infectious processes as manifested by:

ACF of stool • 2-3X/ day • brownish OBJECTIVE: yellow with ACF of stool blood streak, • 2-3X/ day loose and • brownish mucoid yellow with • 1 cup per bout blood streak, • Hyperactive bowel loose and sounds mucoid • 1 cup per bout • Abdominal cramps •

Hyperactive bowel sounds With patient verbalization, “Madalas ako nadudume • Abdominal cramps na may kasamang dugo at medyo basa. Nakaramdam Inferences: din ako ng pagsusuka Fecalysis (08/16/08) kung minsan at pananakit Presence of Entamoeba ng tiyan” histolytica

SCIENTIFIC OBJECTIVES NURSING RATIONALE RATIONALE INTERVENTION Release of enterotoxins SHORT INDEPENDENT: by invading TERM GOAL microorganism - Observe and -To note for After 30-45 record amount, degree of fluid minutes of characteristics and losses Increase nursing frequency of bowel secretion of intervention the movement. water and client will be electrolytes able to - Increase oral -To replace promptly fluid intake fluid losses replace fluids due to frequent and vowel Inhibits the electrolyte movement sodium losses through - Monitor intake reabsorption hydration and and output - To assess for electrolyte decrease in supplement as fluid volume evident by resulting to Large amount increasing oral dehydration of CHON rich fluid intake and fluids electrolyte - Assess for signs -To determine balances of dehydration client’s hydration Diarrhea LONG TERM status and GOAL determine dehydration After 3-4 hours Reference: nursing DEPENDENT:

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EVALUATION SHORT TERM GOAL After implementation of appropriate nursing intervention, the client was able to promptly replaced fluids and electrolyte losses through hydration and electrolyte supplement as evidenced by increased in oral intake and maintained electrolyte balance - Goal fully met

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

Result: Cyst = 1-3L/LPF Trophozoite= 1-2/LPF

Medical Surgical Nursing by Black and Hokanson Pg 1078-1079

intervention the client will be able to reestablish hydration status as to prevent dehydration through physical assessment and careful monitoring of intake and output.

-Administer IV fluids as indicated with electrolyte supplements (KCl)

-To replenish and establish hydration and maintain electrolyte balance

-Administer antiprotozoal medication (Flagyl)

-Inhibits nucleic acid of the bacteria there by eliminating spread of infection

LONG TERM GOAL After implementation of appropriate nursing intervention, the client was able partially reestablished hydration status as to prevent dehydration through absence of signs of dehydration minimum intake and output - Goal is partially met

CUES

NURSING

SCIENTIFIC

OBJECTIVES

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NURSING

RATIONALE EVALUATION

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

SUBJECTIVE: “Nararamdaman ko din na nanghihina ako at para bang palage akong walang lakas.” OBJECTIVES: ACF of Bowel movement • Frequency2-3x/ day • Color- brownish yellow with blood streak • Consistency – loose and mucoid • Amount- 1 cup per bout • • • • • •

Decrease in urine output ( 700-750ml) Decrease oral fluid intake ( 630-840 ml) Fair skin turgor Pale nail beds Pale palpebral

DIAGNOSIS Fluid Volume Deficit related to active fluid volume loss ( diarrhea) secondary to infectious process as manifested by ACF of Bowel movement • Frequency2-3x/ day • Colorbrownish yellow with blood streak • Consistency – loose and mucoid • Amount- 1 cup per bout • • • • • •

Decrease in urine output Decrease oral fluid intake Fair skin turgor Pale nail beds Pale palpebral conjunctiva Slightly pale

RATIONALE Infectious process Invades the lining of the intestines Stimulation of the SNS/PNS and decrease water reabsorption Increase gastrocolic reflex Diarrhea results ( Active fluid volume loss)

Fluid Volume Deficiency

INTERVENTION SHORT TERM GOAL After 1-2 hours of nursing intervention, the client will maintain adequate fluid volume versus active fluid volume loss through fluid hydration and monitoring of intake and output as evidence by moist mucous membranes, good skin turgor, and increase in oral fluid intake from 840 ml to at least 1000ml and urine output of at least 850cc

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INDEPENDENT > Encourage client to increase oral fluid intake

> Provide meticulous oral care (toothbrush and mouthwash)

> Check voiding and record amount

> Promote a quiet environment and bed rest

> Regularly assess client for changes

SHORT TERM > To replenish GOAL patient with fluid volume After 1-2 hours losses of implementing appropriate nursing intervention, the > To moisten client maintained the mucous adequate fluid membrane and volume versus prevent injury active fluid from dryness volume loss as evidenced by an increase in oral > To check for fluid intake from an increase or 840ml to at least decrease fluid 1000ml with losses moistened mucous > To decrease membrane, good oxygen skin turgor and demand increase urine thereby output of 800 cc resulting from weakness - Goal partially met > To assess for signs of

LONG TERM

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

• • •

conjunctiva Slightly pale nasal and buccal mucosa Dry and cracked lips Thready/weak pulse

INFERENCES • • •

Slight increase in urine specific gravity- 1.030 Fecalysis (08/16/08) Presence of Entamoeba histolytica

nasal and buccal mucosa INFERENCES •

Slight increase in urine specific gravity- 1.030

Reference: Medical Surgical Nursing by Black and Hokanson Pg. 1078-1079

With client’s verbalization, “Nararamdaman ko din na nanghihina ako at para bang palage akong walang lakas.”

LONG TERM GOAL After 4-6 hours of nursing intervention, the client will have an increase in energy levels and prevent further complication as evident by client’s verbalization of an increase in energy levels

in conditions (e.g. mental status, fatigability, restlessness etc.) > Strictly monitor I/O

DEPENDENT > Administer IV fluids as indicated

> Monitor client’s urine specific gravity

CUES SUBJECTIVE:

NURSING DIAGNOSIS

SCIENTIFIC RATIONALE

OBJECTIVES

Acute pain related to inflammatory

Damage to the intestinal

SHORT TERM GOAL

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NURSING INTERVENTION INDEPENDENT: >Encourage adequate

dehydration and monitor progress of client.

GOAL

After 4-6 hours of implementing appropriate nursing >To measures intervention, the if client had client reported a enough fluid slight increase in intake and energy level and output absence of complications as verbalized by the client, “ > For Medyo ok na replacement of ang pakiramdam fluids and ko, hindi na ako electrolytes gaano nanghihina.” > To assess for hydration - Goal partially status of the met. client

RATIONALE

EVALUATION

>To promote

SHORT TERM GOAL

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

“Pabalik balik yung response sakit ng tiyan ko. secondary to Humihilab at para compression of bang umiikot yung nerve endings sikmura ko” • Recurrent abdominal pain • Pain scale of 7-8 out of 10 • Guarding behavior OBJECTIVES: during episodes of • Recurrent pain abdominal pain • Slight facial • Guarding grimace behavior during • Irritable and episodes of less pleasant pain • Narrowed focus ( less • Slight facial interested grimace with conversing to others) • Normal to • Irritable and hyperactive less pleasant bowel sounds • Narrowed focus ( less With verbalization interested of patient, “Pabalik with balik yung sakit ng conversing to tiyan ko. Humihilab others) at para bang umiikot

tissue Increase vascular permeability Vasodilation Swelling Edema Compression of nerve endings Pain Perception Reference: Medical Surgical Nursing By: Brunner and Suddarths Pg. 810-812

relaxation as to prevent fatigue After 15-30 rest periods minutes of After 15-30 implementing minutes of > To decrease appropriate nursing pain through nursing intervention the >Provide comfort stimulation of intervention the patient will be measures (e.g. back release of patient was able report a rub, proper endorphins reported a decrease in pain positioning etc.) decrease in pain perception scale from 7-8 to through 6 out of 10 providing > To assist in methods to muscle and Goal fully met alleviate pains generalized as evident by a > Encourage deep relaxation LONG TERM decrease in pain breathing exercise GOAL scale from 7-8 >To lessen to at least 6 preoccupation After 1-2 hours of implementing > Provide diversional to pain and lessen it appropriate LONG TERM activities such as nursing GOAL listening to music and >To reduce intervention the watching television stimulation patient After 1-2 hours that may demonstrated of nursing >Provide quiet and behavioral intervention the calm environment and trigger pain perception modifications patient will be cluster nursing care that has lessened able pain perception demonstrate > To release through appropriate endorphins and relaxation skills behavioral > Encourage right enhance well and other modifications to sided brain being comfort lessen pain stimulation such as

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METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

•

Normal to yung sikmura ko” hyperactive bowel sounds • Pain scale of 7-8 out of 10

CUES SUBJECTIVE:

NURSING DIAGNOSIS Altered Sensory Perception; Tactile

perceived through relaxation skills and comfort measures as evident by decrease irritability and preoccupation to pain

love, laughter and music Dependent: >Administer anti inflammatory drugs ( Prednisone)

SCIENTIFIC OBJECTIVES NURSING RATIONALE INTERVENTION Prolonged used SHORT TERM INDEPENDENT of GOAL

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> To decrease inflammation that may cause pain

measures as evidenced by decrease irritability and decrease preoccupation to pain -Goal fully met

RATIONALE

EVALUATION SHORT TERM GOAL

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

“Nagmamanhid nga yung mga daliri ko sa paa, hindi ako nakakaramdam.” OBJECTIVES: •

•

•

Positive (+) numbness of toes both in right and left feet Change in usual response to tactile stimuli Unable to feel touch or object applied to both toes

related to prolonged use of medication (Flagyl) secondary to chronic bacterial infection of the colon as manifested by •

Positive (+) numbness of toes both in right and left feet • Change in usual response to tactile stimuli • Unable to feel touch or object applied to both toes With client’s verbalization, ““Nagmamanhid nga yung mga daliri ko sa paa, hindi ako nakakaramdam.”

Metronidazole

After 30-45 minutes of nursing Damage nerve intervention, the endings client will be safe from any cause of dangers Altereation on that may the axonal precipitate injury regions of the due to altered neurons tactile perception through Decrease measures that amplitude on will promote nerve safety to the conduction client to as velocity evident by absence of Altered nerve injury or trauma transmission to caused by periphery sensory deficit

Altered sensory perception ( Tactile) Reference:

>Provide client with shoe wear or slippers when ambulating

> Remove sharp or unnecessary objects ( needles, clutters etc.) within client’s area > Monitor use of heating pads as well as cold packs and temperature of water use for sponge bath

> Assist during ambulation

LONG TERM GOAL After 1-2 days of >Place call bell nursing within client’s reach intervention, the client will

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>To prevent injury ( e.g. punctured wound) while ambulating > To prevent falls, slipping or wound to get unnoticed > To protect from thermal/cold damage or burns

> To aid in maintaining balance and avoid unwanted injury > To allow easy access to when client needs help and when emergency

After 30-45 minutes of implementing appropriate nursing care, the client had been safe from any cause of dangers that may precipitate injury due to altered tactile perception as evidenced by absence of injury, trauma or hazards caused by sensory deficit. -Goal fully met

LONG TERM GOAL After 1-2 days of implementing appropriate nursing care, the client had

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

cases happen Neurologyindia recognize website alteration on tactile perception through health teaching and be able to compensate to it by providing measures or ways of dealing with perceptual deficit as evident by client able to make independent compensatory techniques that will aid in making necessary activities

>Provide diversional activities for the client (e.g. watching TV, listen to music, read etc.)

> Provide tactile stimulation (cotton ball, pin, feather , pinching etc.)

> Instruct client to check her path during ambulation

recognized alteration in > To promote tactile perception stimulation of and learned other sense independent unaffected and skills as a avoid client’s compensatory preoccupation technique which to sensory aided her in deficit making necessary activities. > It communicate -Goal fully met connection to other people and provide stimulation to sense of touch > To presume path to be taken is free from harm

> To assist client when ambulating if decrease tactile > Use assistive device deficit is severe as necessary (e.g. wheelchair, cane etc.) > To recognize

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METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

> Discuss with the client the cause of the alteration in tactile perception and measures to deal with it

and understand the reason of sensory deficit and allow client to make appropriate ways to deal with it

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

CUES

NURSING DIAGNOSIS

SUBJECTIVE: “Wala talaga akong

Imbalance nutrition less than body

SCIENTIFIC RATIONALE Chronic damaged of intestinal tissue

OBJECTIVES SHORT TERM GOAL

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NURSING INTERVENTION INDEPENDENT

RATIONALE EVALUATION

> Give a health

>To determine

SHORT TERM GOAL After 45-60

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

ganang kumain. Mga 3-4 na subo lang ayoko na agad. Sumasakit kasi ang tiyan ko at masama talaga ang pakiramdam ko” •

Reports of abdominal pain

OBJECTIVES: •

94 lbs ( ABW) • Stands 5’0 feet • IBW vs. ABW 104lbs =94 lbs • BMI = 18.6 ( Underweight) • Appears thin and frail • Decrease subcutaneou s and muscle mass • Pale conjunctiva • Moderate

requirements related to loss of appetite due chronic illness state secondary to abdominal pain as manifested by •

94 lbs ( ABW) • Stands 5’0 feet • IBW vs. ABW 104lbs = 94 lbs • BMI = 18.6 ( Underweight) • Appears thin and frail • Decrease subcutaneou s and muscle mass • Pale conjunctiva • Moderate hair loss was observed • Weak and decrease energy level

Inflammatory response Compression of nerve endings Pain perception Narrowed focus Preoccupation to pain perceived Loss of appetite ( Anorexia)

Imbalanced Nutrition less than body requirements

After 45-60 minutes of nursing intervention, the client will be able to understand the need to eat a well balanced diet both in quality and quantity as to improved nutritional status through health teaching and demonstration as evidence with client’s desire to make appropriate diet modifications of improving general health status LONG TERM GOAL

teaching on the importance of a balanced diet and adequate hydration that it helps in building strong immune system. > Prepare food samples that are nutritious and demonstrations of food preparations that is within client’s income >Assess client’s condition such as energy levels and feeling of body weakness

>Encourage to eat a well balanced meal After 1-2 days and proper hydration of nursing by citing some health intervention the benefits that could

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health knowledge of client that needs to be modified or to enhance regarding food management.

minutes of implementing appropriate nursing intervention, the client understood the need to eat a well balance diet both in quality >Stimulates and quantity by the client’s means of health desire to teaching as initiate ways in evidenced by how to achieve client’s desire to an optimum make health. appropriate diet modification with > To verbalization of, determine “ Gusto ko client’s talaga maging physiologic masustansya ang response to kinakian ko para food intake as makaiwas sa with regards to sakit. At least quality and ngayon alam ko quantity na ang mga dapat kong >Balanced diet piliing pagkain.” and adequate hydration are -Goal fully met known to

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

•

hair loss was observed Weak and decrease energy level

With verbalization of the client, “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”

Reference: Pathophysiology by Carol Mattson Porth

patient will be able to increase food intake both in quality and quantity appropriate to her illness status through proper preparation of food to serve with client reports on an increase in energy levels and decrease body weakness

build strong line of defense. > Encourage bed rest during acute phase of illness

>Provide foods that are high in calories, proteins and carbohydrates

> Provide the client with adequate time to eat and prepare food aesthetically

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contribute to a good nutrition.

LONG TERM GOAL

After 1-2 days of implementing > Decrease appropriate metabolic nursing needs aids in intervention, the preventing client had a caloric gradual increase depletion and in food intake conserves both in quantity energy and quality appropriate to >To provide her illness state client nutrients through proper that will boost preparation of 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 > To facilitate madame na din adequate food ako nakakain intake and ngayon.” make food attractive -Goal fully met

METROPOLITAN HOSPITAL COLLEGE OF NURSING

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

> Prepare foods that are easy to chew and palatable

DEPENDENT >Administer vitamins and supplements as per doctors order

> To enhance mechanical digestion of food and promote client’s appetite

> To build strong immune system and body resistance to COLLABORATIVE diseases > Refer to dietician > To for diet regimen 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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