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Case study on intestinal obstruction
Medical Surgical Nursing (blaw213)
Nursing School Iveria
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ESIC SCHOOL OF NURSING
AHMEDABAD
SUB: MEDICAL-SURGICAL NURSING
(CASE STUDY ON)
TOPIC: INTESTINE OBSTRUCTION
SUBMITTED TO:
MR PAREKH SUBMITED BY:
MSN FACULTY
ESIC SON SY
Batch: 2019-
BIO-DATA OF THE PATIENT
Name of the patient : Ms. Geetaben Ramanbhai Dabhi
Registration No. : Ward : E-
Indoor No. 622062 OPD No.: 1722167 E-
Age/ Sex :
Marital status :
Religion :
Occupation :
Education :
Family Income /Capita.
35 year / Female
Married
Hindu.
Nil
10 th standard
3500/ month.
Dr unit : .Dr.C.J., patient transferred from SSICU ,under Dr. C.J. Unit.
Date of admission : 20/07/
Date of Discharge.
Address : Sant Ashramnagar Thakkar Nagar Ahmedabad.
Diet : Vegetarian.
Diagnosis : Intestine Obstruction
Final Diagnosis: Intestine Obstruction
C/O Fever since 2 month. Abdominal pain since 2 days Abdominal distension since 2 days.
Proper ventilation in the house.
NUTRITIONAL HISTORY:
Diet pattern: Vegetarian
Patient Nutritional Status Is Very Poor Because Of disease condition. Patient Hb- 7 Gm%. Patient Look’s Like Weak. Bowel Habit : 1 Times In A Day Patient Weight- 45kg Patient Height- 5 Inch Head circumference:22 Inch Chest circumference :32 Inch Mid arm circumference: 16 cm.
PERSONAL HISTORY:
My patient is Ms. Geetaben Ramanbhai Dabhi is 35 year old she is house wife, she is dependent on
his husband and father. She is married she have no any children. she is very weak, she has less stamina, and she is from Hindu family. Due to diseases condition she is stay with her father.
Personal Hygiene :
Oral Hygiene : poor - Bath : she is taking bath daily. Sleep And Rest : Adequate
Elimination :
Bowel Per Day : Regular 1 Times Per Day Urine Frequency : 1000ml/ Day
Mobility And Exercise :
Moderate : Not Applicable
Socio Economic History:
My patient is Ms. Geetaben Ramanbhai Dabhi is 35 year old she is from middle class family
socially she is very in mix nature
PAST MEICAL HISTORY:
Patient is taking Anti Kocks Treatment, last 4 month. Patient has Intestinal Kocks detected before 4 month.
PAST SURGICAL HISTORY: There is no any history of previous operation, Blood transfusion, Accident.
Present History of the patient : Patients were relatively, Asymptomatic before 2 days. She develop high grad Fever since 2 days abdominal distention, which was sudden, Ms. Geetaben Ramanbhai Dabhi is 35 year old he is a house wife. Patient was a relatively a symptomatic before 12 hours she develop abdominal distention ,which was sudden ,the abdominal pain since 6 hours which was dull achy and non radiating in nature H/O constipation since 2 days. H/O No flatus pass since 2 days. Then patient developed abdominal pain since 6 hours. Which was dull, Achy and none radiating in nature. H/O: He was stopped food since 15 days. Constipation since two days.
No pass stool or flatus since two days. FAMILY HISTORY: No any significant in family history. In family there is no H/O DM, HT, TB, Heart Diseases, Jaundice,
PHYSICAL ASSESSMENT :
Height and weight : Ht centimeter /Wet : 45 Kg. Vital Signs : Temperature : 96 F hit Pulse :72 / minute Respiration Rate: 18/minute thru the ventilation. B. + + Blood pressure: 110/70 mm of Hg. Anemia : + + Skin color :
Normal (But Slide Black over Healed lesion) Posture :
Normal Gait :
Normal Hair :
Normal (Black Smooth) Eye
: Subcojuctivan Bleeding ENT :
Normal :
Normal Gum :
Healthy Teeth
:Normal ,But Slide Black :Normal :Normal, by asking relative patient is bed ridden Normal (white , dirty Smooth) Normal swelling surrounding eye present, sclera yellow in color. No any discharge from ear, nose. Throat : Normal , yellow , tobacco chewing, color brown Healthy , Normal No bleeding ,pyorrhea,
Front teeth decay, other teeth normal, No dental carries.
Respiratory System :
Bilateral Air Entry Positive
Bilateral Air Entry Positive
Cardiovascular System : Present
: S1S2 Present, heart rate normal, HR: maintain 72 / minute.
Per Abdomen : Upper Quadrant : Soft
Lower Quadrant : Soft
Right Upper Quadrant : Soft Right Lower Quadrant : Soft Left Upper Quadrant : Soft Left Lower Quadrant : Soft
X3A : Karatimalea not present XS : Cornea scar not present XF : Xeropthalic funds not present
BLOOD INVESTIGATION
Sr. No.
Biochemical test Patient’s Report Normal Value
- HB 7 gm% M-13-18 gm% F-12-14 gm%
- TC 10,000 cm/m
- Differential Count Polymophs Lymphocytes Eeosinophil Monocytes Basophil
76%
21%
02%
01%
00%
- ESR 1 hr 18 mm M-12mm F – 3-12mm
- PS for mp Not done
- Blood Urea 23 mg / dl 13-40 mg / dl
- Sr. Creatinine 1 mg / dl 0.08-1 mg / dl
- Sr. Na+ 126 mEq/L 135-149 m Eq/L
- Sr. K+ 3 mEq/L 3 – 5 m Eq/L
- Sr. Bil. Total : Direct Indirect
+ 0.
+
0.0-1 mg% 0.0-0 mg% 0.0-0 mg% 11. SGPT --- 0-40 U/L 12. RBS 106 mg/dl. 13. HIV Test Non reactive Non reactive 14. HbsAg Non reactive Non reactive 15. Platelet count 1. lake 1 to 4 lake Normal 17. PPBS 126 mg. 120-160mg/dl 18. Urine Exam Albumin - NIL Sugar – NIL
19 S. Alk,PO4 --- 2-5mEq/L 20 S. Protein T0tal -2. D-1. G-2.
6 8 g/dl.
X-RAY CHEST.
Both rotate lung field sander vision normal Right CP angle is clear Cardiac size is within present limit Boney thorax under vision appears normal. Air fluid level noted normal Ryle’s tube noted.
U.S. Abdomen Liver appear normal Portal vein appears normal. CBD appear normal Spleen appears normal in size and echo texture Pancreas and Para aortic region. normal. Both kidneys appears in normal size Urinary bladder full normal. Moderate free fluid seen in peritoneal cavity There is ells inflamed terminal ileum ascending colon transverse and Descending colon.
OPERATION PROCEDURE.
Surgery done by Dr.R.A Operation procedure Emergency Exploratory laprotomy + Resection of jajuno, Ilial anastomosis Jejunal loop perforater with distal part. Loop constist distal stricture +jejuno iliac anastomosis Primary sloughed present clinic flushed + Peritonial wash ↓ Spinal Anesthesia +General Anesthesia. ↓SA+GA Supine position Painting and draping done Mid line skin incision kept Over abdomen. Abdomen open in layer. Midline incision 400 cc residual clienced omentun found adherent to small bowel ,loop separate 0*0 cm notuation found approximately 1 feet distal to D-J. Junction with skin. Jajunal loop proximal to stricture thicken and occlude two stricture present resection of jejunal segment with contain and stricture 8m done with jajuno anastomosis with silk 2-0 in 4 layer. Drainage of niplerred located wall of abdominal 3-4 serosal tear in jejunal loops closer with Silk 2- Primary closure of sloughed out. Splinic flexema in 2 layer with silk 2-0 after freshing of its margin. Through peritoneal wash given with saline + Betadine + Drained. Ileal and brought out an left lumbers and diverting ileostng and transverse colon brought out through same size as fistula + Metrlize done. 4 tensin stitched taken Skin close with Stepples
Nursing Diagnoses:
- Harnia- protrusion of intestine through a weakened area in the abdominal muscle or wall. 5- A tumor that exists within the wall of the intestine extendeds in to the intestinal lumen.
Neurogenic cause:- An dynamic obstruction. Sometimes called “paralytic ileus” it caused by a lake of peristaltic activitity Vascular cause:- Blood supply to the bowel by the way of celiec & mesentric arteries. 1. Complete Occlusion (Mesenteric Infarction) -Any occlusion of arterial blood supply to the bowel, as in mesenteric thrombosis, effectively stops bowel function. Partial Occlusion (Abdominal Angina). This condition usually results from atherosclerosis of the mesenteric arteries. Because there is an increase need for oxygenation during the digestive process.
Clinical manifestation
- In intestine obstruction increase pressure leads to reverse peristalsis Producing vomiting Loss of fluids & electrolyte balance Peritonities
- Pain because of intestinal distention It is in coliky & wave like pain
- If the obstruction lies below the ileu Vomiting fails to empty the bowel completely
Muscle become atonic, loop of small bowel dialate Severe distention may raised the diaphragm ,there by inhibiting respiration Hypoxia 4. Perforation develop distention 5. If the obstruction in ileum fecal vomiting may take place. 6. Dehydration 7. Hypovolemic shock 8. Loss of plasma volume This all sign and symptoms are present in my patient. Diagnostic test
X-Ray study Show abnormal quantities of gas & fluid in the bowel.
Laboratory studies: Reveal a picture of dehydration & loss of plasma volume & possibly infection.
U.S.G It gives clear idea regarding blockage, gas , fluids in the bowel
Pathophysiology:
Because of any cause
Accumulation of intestinal contents,fluids,&gas develop
Develop abdominal distention & retention of fluid It reduce the absorption of
Reflux vomiting Fluid & stimulate more gastric secretion Increase distention pressure of lumen increase
Loss of hydrogen ions increase distention pressure of lumen increase and potassium from the Stomach
Reduction of cl- and pressure decrease the venouse&arteriolar pressure K+ in blood & to metabolic alkalosis
Metabolic alkalosis congesion necrosis
decrease the venous and arteriolar pressure Eventual rapture
Planning: Expected Outcome. The client will maintain fluid balance, as evidenced by balanced intake and output, no signs of dehydration, and blood pressure within the client's normal range Implementation. The nurse must maintain good fluid balance in the client with an obstruction by carefully replacing fluids and electrolytes. The nurse administers parenteral fluids with sodium chloride, bicarbonate, and potassium added as ordered. Maintain an intestinal tube attached to suction to relieve the vomiting and distention (see the section on care of a client with intestinal tubes). Antibiotics are often given before surgery. The nurse must be careful about administering narcotics, because these medications may mask symptoms of increasing obstruction or impaired blood flow. The client with a bowel obstruction with impaired tissue perfusion requires an emergency bowel resection. (See the section on care of a client after a bowel resection with or without a colostomy Evaluation : The nurse must evaluate client outcomes based on the established plan of care. If these goals were not achieved, the plan and interventions must be revised to meet the client's needs. Discharge training o The learning needs of the client depend on the resolution of the obstruction. o If the obstruction was relived without surgery, the client needs to learn ways prevent recurrence and maintain bowel elimination. Client needs to maintain an adequate nutritional intake so lost weight can be regained. o If the client had surgery, the learning need based on the surgical procedure performed. The client, with a temporary colostomy needs to learn to care for the colostomy. Without a colostomy, the client' learning needs are the same as for any client after a bowel resection. Follow up care: o The client needs to be seen at intervals after obstruction is relieved to ensure that it has not recurred. o The client's nutritional status also should be monitored to ensure that adequate nutrition is maintained
Nursing diagnosis
o Measure are taken to prevent skin break down
o Measure s are taken to promote adequate nutritional intake
o Intravenous lines are infusing properly, are clearly labeled and recorded correctly
o Measures are taken to prevent pain
o Clinical sign and symptoms associated with wound complication are assessed
o Clinical signs and symptoms associated with thrombophlebiti-s are assessed
o Signs and symptoms related to the underlying disease process are assessed
o Assess the skin of the abdomen for the following factors, which might make appliance fitting difficult o Contact the enterostomal
o therapy nurse and communicate
o Allow the patient and/or significant other to verbalize their feelings concerning changes in body
image, affect on sexuality, the possible/actual diagnosis of maintenance of the iloostomy and colostomy postoperatively, and other life style changes related to the surgery. o Assess the ileostomy drainage
o Assess the skin of the abdomen for the following factors, which might make appliance fitting
difficult o Measures are taken to preserve peristomal skin integrity
NURSING CARE PLAN
ASSESS
MENT
NURSING
DIAGNOSIS
PLAN AND
GOAL
INTERVENTION EVALUATION
Assess the skin integrity (break down ) By observa- tion
Measure are taken to prevent skin break down
To prevent bed sore
To prevent skin break down by performing the following nursing intervention 1. assist the patient with range of motion exercises. 2. Turn every two hours. 3. Apply heal protectors and anti-decubity mattress while on bed rest. 4. provide skin care twice in a day, While on the bed rest including massage on a boney prominences. 5. Inspect all pressure point twice a day for breakdown.
Patient observation and chart review
Assess adequate nutritional intake. By measuring output and input and patient condition.
Measure s are taken to promote adequate nutritional intake
No expectation
Monitor and promote adequate nutritional intake by performing the following nursing intervention
- Assess the patient’s nutritional status. By.
- weaning weekly or as per prescribed
- Monitor intake ,Fluid and electrolyte as per day
- Assist dietitian in identified patient performance.
- Provide diet as per prescribed.
- Administered I/V Fluid as
Degree of redness and swelling. C.. Presence of drainage and odor. D. Condition and temperature of Surrounding skin. F. Patency and character of drainage from wound ,drains Tubes. G. Systematic temperature elevations 72 hours or more Postoperatively. H. Presence of localized pain and /or tenderness.
ASSESS-
MENT
NURSING
DIAGNOSIS
PLAN AND
GOAL
INTERVENTION EVALUATION
Assessed thrombo - phlebitis By observatio n of blood reports and C/o
Clinical signs and symptoms associated with thrombophlebiti -s are assessed.
No expectation
Assess the sign and symptoms of thrombophlebitis associated with are assessed by evaluating and documenting the following information Predisposing factors:
- Venous stasis Surgery. Obesity. Immobility. Varicosities. CHF 2 Wall injury. Dislocation Chemical injury Vascular diseases.
- hypercoagulability :
Blood dyscrasias
Neoplasm
- Atrial fibrillation
- pain and tenderness
- Skin infection Cardiovasculars : Venous distentation Tenderness over affected vein Absence of distal pulses.
Review nursing progress notes for documentation The nurse is only responsible for reviewing tests which have been prescribed.
Assess sign and symptoms related to diseases
Signs and symptoms related to the underlying disease process
No exceptions 1. Assess signs and symptoms related to the underlying disease process including the following information: A. Bowel functioning factors
24 hours after admission. Indicators: Nursing documen- tation describing.
condition. are assessed. 1. Bleeding. 2. Constipation or diarrhea. 3. Odor of stool. 4. Color, consistency, and composition (mucus , pus) of stool. B. Assessment of pain: 1. Onset. 2. Predisposing factors. 3 Characteristics. a. Quality. b. Location and radiation. c. Intensity and severity.
Special Instructions: Review the nursing data base and progress notes.
ASSESS
ME-NT
NURSING
DIAGNOSIS
PLAN AND
GOAL
INTERVENTION EVALUATION
d. Duration. e. Aggravating and relieving factors. f. Associated symptoms Factors affecting nutritional status such as 1. weight loss 2. Dehydration. 3. Fluid retention (edema) Food tolerance/intolerances. 4. Loss of appetite. 5. Diet alterations. 6. Emaciation. 7. Anemia. 8. Decreased serum protein 9. Electrolyte imbalances.
Assess the skin of the abdomen. By observatio n
Assess the skin of the abdomen for the following factors, which might make appliance fitting difficult
Emergency surgery.
Assess the skin of the abdomen for the following factors, which might make appliance fitting difficult:
Scars. Masses. Break in integrity. Bony prominences. Skin folds.
Special notes: Site should be checked while patient is sitting, lying, and standing since marking of the stoma site preoperatively is preferable- Notify the physician Of potential problems.
Chart review. When: 8 hours preoperatively. Indicatory: Nursing documen- tation of the presence or absence of. Special Instructions: Review the nursing progress notes and data base.
The ileostomy drainage is assessed
Assess the ileostomy drainage
No exceptions Assess the ileostomy drainage as follows: Monitor the amount of output from the ileostomy as drainage should not exceed 500cc in 24 hours during the initial postoperative period. Thereafter, it should fall within the parameters of 500cc -I500cc /
In my patient it was 750/24 hours.
Nursing documentation describing the assessment the stoma including at least once every 8 hours.
ASSESS
M-ENT
NURSING
DIAGNOSIS
PLAN AND
GOAL
INTERVENTION EVALUATION
Per 24 hours. Monitor the color and consistency of the drainage
Special Note: Notify the physician for any drainage that is grossly bloody or positive for occult blood. The initial postoperative drainage will be serous in nature. The patient will return from the operating room with a pouch placed over the stoma.
Nursing care Review the nursing Progress notes and flow sheets.
. Assess the stoma status
Assess the stoma status and include the following information:
Short term goal
Assess the stoma status and include the following information: A Circulatory status: The stoma should be red with no evidence of cyanosis which is indicated by a dusky skin. B. Moistness. C. Amount of protrusion, the usual being 1" to 1 1/2". D. Any increase in swelling. The stoma should gradually decrease in size, not increase. E. Pouch adhesion and opening size. Note if too small and restrictive of circulation or too large and exposing skin. Special Note: If any changes from baseline stoma assessment are apparent, notify the physician. If pouch size is in appropriate, change pouch to correct size
Review the nursing Progress notes and flow sheets. Write note Patients stoma is pink in color No protrusion Indicators: Nursing documen- tation describing the amount, color, and consistency of rectal drainage at least once every 8 hours for 48 hours, then once every 24 hours
. Assess the rectal area drain- age
Assess the rectal area drainage including the amount color and consistency.
Short term goal.
Assess the rectal area drainage including the following: A. Amount, color, and consistency of drainage, B. The presence of excessive amounts of drainage, C. The presence of bloody drainage Special note In a patient who has not had, their rectum removed: A. Small amounts of mucus and/ or stool may drain from the rectal area
Maintain flow chart for specified input / output and peristalsis of the rectum.
ASSESS
M-ENT
NURSING
DIAGNOSIS
PLAN AND
GOAL
INTERVENTION EVALUATION
Return of bowel functionin g is assessed by auscultatio n
Signs and symptoms related to obstruction are assessed
Short term goal
Assess for the return of bowel functioning as follows: A. Auscultate for bowel sounds to determine if peristalsis is has returned. B. Monitor for the passing of flatus through the stoma as an indication that peristalsis is present Special Note: Paralytic ileus is a functional disorder which usually is symptomatic 48-72 hours postgastro-intestinal surgery.
Nursing documentation describing bowel functioning status at once every 24 hours. Special instruction : nursing progress notes flow sheets.
Assess for fluid and electrolyte imbalance s that are specific to ileostomy patients by monitorin g for:
To maintain the fluid and electrolyte balance
Short term goal
Assess for fluid and electrolyte imbalances that are specific to ileostomy patients by monitoring for: A. Large amounts of drainage from the ostomy or diarrhea. Special Note: Dehydration, hyponatremia, hypokalemia, and metabolic alkalosis may occur when excessive amounts of intestinal juices are lost.
B. Imbalances in daily intake and output record. C. Abnormal lab values for:
- K+.
- Na+.
- HC03-.
Instructions:
Review the nursing progress notes, flow sheets, and intake and output sheets.
Case study on intestinal obstruction
Course: Medical Surgical Nursing (blaw213)
University: Nursing School Iveria
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