CP Intestinal Obstruction Chap7

7/31/2019 CP Intestinal Obstruction Chap7

1/57

Chapter VII

MEDICAL AND NURSING MANAGEMENT

A. Ideal Diagnostic Tests

i. Abdominal CT scan - combines special x-ray equipment with

sophisticated computers to produce multiple images or pictures of

the inside of the body. These cross-sectional images of the area

being studied can then be examined on a computer monitor,

printed or transferred to a CD.

ii. Abdominal X-Ray - An abdominal X-ray is a picture of structures

and organs in the belly (abdomen). This includes the stomach,

liver, spleen, large and small intestines, and the diaphragm, which

is the muscle that separates the chest and belly areas. Often two X-

rays will be taken from different positions. An abdominal X-ray may

be one of the first tests done to find a cause of belly pain, swelling,

nausea, or vomiting.

iii. Abdominal Ultrasonography - An ideal clinical tool for determining

the source of abdominal pain. It can simplify the differential

diagnosis of abdominal pain, especially when pain and tenderness

are present over the site of disease.
http://www.webmd.com/hw-popup/x-rayhttp://www.webmd.com/hw-popup/abdominal-organshttp://www.webmd.com/hw-popup/x-rayhttp://www.webmd.com/hw-popup/abdominal-organs


2/57

iv. Barium Enema - X-ray examination of the large intestine (colon

and rectum). The test is used to help diagnose diseases and other

problems that affect the large intestine. To make the intestine

visible on an X-ray picture, the colon is filled with a contrast

material containing barium. This is done by pouring the contrast

material through a tube inserted into the anus.

v. Laboratory studies (e.g., electrolyte studies and a complete blood

cell count) reveal a picture of dehydration, loss of plasma volume,

and possible infection.

B. Ideal Medical Management

Decompression of the bowel through a nasogastric or small bowel

tube is successful in most cases. When the bowel is completely

obstructed, the possibility of strangulation warrants surgical intervention.

Before surgery, intravenous therapy is necessary to replace the

depleted water, sodium, chloride, and potassium.

The surgical treatment of intestinal obstruction depends largely on

the cause of the obstruction. In the most common causes of obstruction,

such as hernia and adhesions, the surgical procedure involves repairing

the hernia or dividing the adhesion to which the intestine is attached. In

52
http://www.webmd.com/hw-popup/x-rayhttp://www.webmd.com/hw-popup/large-intestinehttp://www.webmd.com/hw-popup/contrast-materialhttp://www.webmd.com/hw-popup/contrast-materialhttp://www.webmd.com/hw-popup/x-rayhttp://www.webmd.com/hw-popup/large-intestinehttp://www.webmd.com/hw-popup/contrast-materialhttp://www.webmd.com/hw-popup/contrast-material


3/57

some instances, the portion of affected bowel may be removed and an

anastomosis performed. The complexity of the surgical procedure for

intestinal obstruction depends on the duration of the obstruction and the

condition of the intestine.

A colonoscopy may be performed to untwist and decompress the

bowel. A cecostomy, in which a surgical opening is made into the cecum,

may be performed for patients who are poor surgical risks and urgently

need relief from the obstruction. The procedure provides an outlet for

releasing gas and a small amount of drainage.

A rectal tube may be used to decompress an area that is lower in

the bowel. The usual treatment, however, is surgical resection to remove

the obstructing lesion.

A temporary or permanent colostomy may be necessary. An

ileoanal anastomosis may be performed if it is necessary to remove the

entire large colon.

C. Ideal Nursing Management

Nursing management of the nonsurgical patient with a small bowel

obstruction includes maintaining the function of the nasogastric tube,

assessing and measuring the nasogastric output, assessing for fluid and

electrolyte imbalance, monitoring nutritional status, and assessing

improvement (eg, return of normal bowel sounds, decreased abdominal

53


4/57

distention, subjective improvement in abdominal pain and tenderness,

passage of flatus or stool). The nurse reports discrepancies in intake and

output, worsening of pain or abdominal distention, and increased

nasogastric output. If the patients condition does not improve, the nurse

prepares him or her for surgery. The exact nature of the surgery depends

on the cause of the obstruction. Nursing care of the patient after surgical

repair of a small bowel obstruction is similar to that for other abdominal

surgeries

D. Actual Diagnostic Tests

Fluid Serum

December 8, 2010

Electrolytes exist in the blood as acids, bases, and salts (such

as sodium, calcium,potassium, chloride, magnesium, and bicarbonate).

They control such things as cardiac function and muscle contraction and

are routinely measured by laboratory studies of the serum.

Fluid Serum is the cell-free fluid of the bloodstream. It appears in a

test tube after the blood clots and is often used in expressions relating to

the levels of certain compounds in the blood stream.

54
http://www.digitalnaturopath.com/treat/T134865.html#G750http://www.digitalnaturopath.com/treat/T134865.html#G539http://www.digitalnaturopath.com/treat/T134865.html#G539http://www.digitalnaturopath.com/treat/T134865.html#G722http://www.digitalnaturopath.com/treat/T134865.html#G650http://www.digitalnaturopath.com/treat/T134865.html#G118http://www.digitalnaturopath.com/treat/T134865.html#G745http://www.digitalnaturopath.com/treat/T134865.html#G750http://www.digitalnaturopath.com/treat/T134865.html#G539http://www.digitalnaturopath.com/treat/T134865.html#G722http://www.digitalnaturopath.com/treat/T134865.html#G650http://www.digitalnaturopath.com/treat/T134865.html#G118http://www.digitalnaturopath.com/treat/T134865.html#G745


5/57

A Blood chemistry test is a procedure to examine the general

health of a patient especially to assess the functioning of certain organs.

Test Result Reference value Interpretation

Creatinine 0.8 mg/dl 0.7-1.2 Normal

Sodium 137 mmol/L 137-145 Normal

Potassium 3.4 mmol/L 3.5-5.0 Low

Amylase 37 u/L 30-110 Normal

Interpretation:

The table shows that Potassium is slightly decreased. This

decrease in potassium may be due to patients vomiting, deficient

potassium intake, or dehydration.

Nursing Responsibilities:

define and explain the test

state the specific purpose of the test

explain the procedure

discuss test preparation, procedure, and posttest care

some blood chemistry tests will have specific requirements such as

dietary restrictions or medication restrictions.

55


6/57

Complete Blood Count

December 8, 2010

The complete blood count (CBC) is one of the most commonly

ordered blood tests. The complete blood count is the calculation of the

cellular (formed elements) of blood. These calculations are generally

determined by special machines that analyze the different components of

blood in less than a minute.

This test may be a part of a routine check-up or screening, or as a

follow-up test to monitor certain treatments. It can also be done as a part

of an evaluation based on a patient's symptoms.

Test Results ReferenceValue

Interpretation

WBC 12.1 5-10 x 10^9/L High

Segmenters 0.76 0.55-0.65 High

Lymphocyte 0.15 0.25-0.35 Low

Monocyte 0.08 0.03-0.06 High

Eosinophil 0.01 0.02-0.04 Low

Hemoglobin 96 140-170 9/L Low

Hematocrit 0.29 0.40-0.50

volume

Low

Platelet 291 150-350x10^9/L Normal

56


7/57

Interpretation:

CBC is a combination report of a series of test of the peripheral

blood. White blood cells (leukocytes) are bodys defense against

infective organisms and foreign substances. The table shows that there is

elevated number of WBC which indicates that there is possible infection or

immunosuppression happening inside.

Segmenters are above the normal range which indicates infection.

Low lymphocyte, Eosinophil and Monocyte count indicates that

the body's resistance to fight infection has been substantially lost and one

may become more susceptible to certain types of infection, namely cancer

and tumor. As lymphocyte cells make up fifteen to forty percent of the total

white blood cells that circulate in the bloodstream, a low count can cause

damage to organs.

Hemoglobin is the oxygen carrying protein within the RBCs. The

table shows that there is decreased hemoglobin concentration in the

blood, which indicates that there is less oxygen being transported

throughout the body, because of the less oxygen being transported. With

this, the patient is likely experiencing difficulty of breathing that leads

patient to have impaired gas exchange.

Hematocrit is the percentage of RBC mass to original blood

volume. The table shows that hematocrit volume is decreased which

57
http://www.buzzle.com/articles/cancer/http://www.buzzle.com/articles/cancer/


8/57

indicates that there is over expansion of extra cellular fluid volume, since

the patient has a decreased RBC she also have a decreased hematocrit

level.


Explain that the tests are done to detect any hematologic disorders

as well as infection and inflammation.

Tell the patient that a blood sample will be taken and that she may

feel slight discomfort from the tourniquet and needle puncture.

Use gloves when collecting and handling all specimens.

Transport the specimen to the laboratory as soon as possible after

the collection.

Do not allow the blood sample to clot, of the results will be invalid.

Place the specimen in a biohazard bag.

Abdomen Supine and upright

December 8, 2010

Abdominal x-rays may be performed to diagnose causes of

abdominal pain, such as masses, perforations, or obstruction. Abdominal

x-rays may be performed prior to other procedures that evaluate the

58


9/57

gastrointestinal (GI) tract or urinary tract, such as an abdominal CT scan

and renal procedures.

Result:

Lung bases are clear. Free subphrenic air is noted. There are gas

containing loops of small and large bowel in all quadrants with no definite

pattern. An ovoid soft tissue density is seen in the right lower quadrant

area overlying pattern of the right superior iliac crest. This is seen in the

supine view only and may be in the soft tissues. Reacted gas is present.

There are advance degenerative changes in lumbar spine characterized

by osteophytes/ spurs formation. Asymmetrical narrowing of L4-L5

intervertebral joint space, left is seen with linear lucencies within. Mild

levoseoliosis is noted.

Impression:

Essentially (-) study of the abdomen save for degenerative changed

of the lumbar spine.

Abdomen Supine and upright

December 9, 2010

Re-examination no longer shows the ovoid soft tissue density in the

right lower quadrant area or seen in the abdominal supine view. Gas

containing loops of predominantly small bowel segments are still seen in

59


10/57

all quadrants with no definite pattern. Rectal gas is present. Pro-

peritoneal flank stripes are intact, abdomen are not displaced laterally.

Nursing Management:

Remove any clothing, jewelry, or other objects that might interfere

with the procedure.

Given a gown to wear.

Position in a manner that carefully places the part of the abdomen

that is to be observed. The patient may be asked to stand erect, to

lie flat on a table, or to lie on the side on a table, depending on the

x-ray view the physician has requested.

Body parts not being imaged may be covered with a lead apron

(shield) to avoid exposure to the x-rays.

Once positioned, ask the patient to hold still for a few moments

while the x-ray exposure is made. Also, ask the patient to hold

his/her breath at various times during the procedure.

It is extremely important to remain completely still while the

exposure is made, as any movement may distort the image and

even require another x-ray to be done to obtain a clear image of the

body part in question.

The x-ray beam is then focused on the area to be photographed.

60


11/57

Urinalysis

December 9, 2010

Routine urinalysis is performed for general health screening to

detect renal and metabolic diseases; to diagnose diseases or disorders of

the kidneys or urinary tract. In addition, it is performed to help diagnose

specific disorders such as endocrine diseases.

Physical properties:

Color Reaction Transparency Specific gravity

Light yellow 6.0 Clear 1.003

Chemical reaction:

Sugar Albumin

Negative Negative

Microscopic examination:

Pus cell RBC

0.1/ HPF 0.1/ HPF

Interpretation:

The physical and chemical properties of the patients urine show

normal results. Normally, blood must be absent in the urine. Presence of

blood may indicate acute kidney infections, chronic infections, and stone

formation in the kidneys.61


12/57


Explain how to collect a clean catch specimen of at least 15 mL.

Explain that there is no food or fluids restriction.

Obtain a first voided morning specimen if possible.

Medications may be restricted for it may affect laboratory results.

Fecalysis

December 9, 2010

It refers to a series of laboratory tests done on fecal samples to

analyze the condition of a person's digestive tract in general. Among other

things, a fecalysis is performed to check for the presence of any reducing

substances such as white blood cells (WBCs), sugars, or bile and signs of

poor absorption as well as screen for colon cancer.

Color Chemical and occult

blood

Result

Black Positive No intestinal parasite

62


13/57

seen

Interpretation:

Black stool may be a result of possible internal bleeding,

particularly somewhere in the digestive tract.


Discourage patient from taking aspirin, alcohol, vitamin C,

ibuprofen, and certain types of food if fecal sample will be checked

for any sign of blood.

The patient must urinate first to prevent any urine from mixing with

feces.

The patient must wear gloves when it's time to handle stool and

transfer it to a safer container. This will prevent any possibilities of

being contaminated or infected by bacteria found within the stool.

Solid and liquid fecal samples are both acceptable as long as they

do not have urine or other foreign substances like soap, water, and

toilet paper mixed in them.

If the patient is suffering from diarrhea, placing a plastic wrap and

securing it under the toilet seat could facilitate the collection

process.

63


14/57

Collected samples must be brought to the doctor's office or

laboratory as soon as possible. Delays could compromise the

quality of the sample.

Volume or amount is also important so the patient must be sure he

has collected an adequate amount of stool.

Potassium Test

December 10, 2010

This test measures the amount of potassium in the blood.

Potassium (K+) helps nerves and muscles communicate. It also helps

move nutrients into cells and waste products out of cells.

Test Result Reference value Interpretation

Potassium 4.1 3.6-5.0 mmol/L Normal

Interpretation:

The potassium level of the patient is normal.

Ultrasound in the Whole Abdomen

December 10, 2010

64


15/57

It is an ideal clinical tool for determining the source of abdominal

pain. It can simplify the differential diagnosis of abdominal pain, especially

when pain and tenderness are present over the site of disease.

Result:

Liver is normal in size and contour. It shows normal homogenous

echo pattern. No mass lesion is noted. Intrahepatic bile ducts and CBD

are not dilated. Hepatic vessels are unremarkable. Gallbladder is

physiologically distended. It shows normal wall thickness. No internal

echoes are noted. No pevicholecystic fluid collection is seen.

Pancreas and spleen are normal. Right kidney measures 9.6 x 4.2

cm with cortical thickness of 1.2 cm. Left kidney measures 9.5 x 4.0 cm

with cortical thickness of 1.5 cm. Both are normal in size showing

homogenous corticomedullary parenchymal echogenecity. No echogenic

focus or mass lesion is noted. There is no separation of the central echo

complexes. Proximal uterus is not dilated. Uterus is atrophic and is

compatible with the age of the patient. No abnormal masses are seen in

both advexac.

Moderately dilated, fecal-filled segment of large bowel are noted in

both paracolic gutters, iliac regions and pelvis. No evident mass lesion is

appreciated.

65


16/57

Impression:

Considers ileus; Partial obstruction

Fecal stasis


Before procedure, instruct patient to be on NPO 8-12 hrs since air

or gas can reduce quality of image

Assess abdominal distention because it may affect quality ofimage

During procedure, keep the patient in a supine position

E. Actual Medical Management

Date Ordered Doctors order Rationale66


17/57

December 8,

2010 (8:39 PM)

c/c: abdominal

pain

T-370C

PR-92bpm

RR-24cpm

BP-

122/76mmHg

O2-95

HG-145

Please admit room of

choice under the service

of Dr. Albano

NPO

CBC, serum Amylase

blood type

U/A

Na, K, Creatinine

Req. X-ray of abdomen

flat

For admission and to

provide quality care.

In preparation for

diagnostic tests.

To diagnose a

disease and evaluatethe stages of the

particular disease.

General health

screening to detect

renal and metabolic

disease.

To examine the

general health of a

patient especially to

assess the

functioning of certain

organs.

To view the

obstruction in the

67


18/57

PLR 1 L x 12o

TPR monitor and record

Decrease IVF to 60cc/hr

Fecalysis and stool for

occult

Prosec IV now

intestine.

To replenish fluid loss

and electrolyte

imbalance.

For baseline data.

To check for the

presence of blood.

For antacids and

antiulcer function.

December 8,

2010 (10:40

PM)

Incorporate 30 mEq KCl

to present IVF

To provide a direct

replacement of

potassium in the

body.

December 9,

2010

Soft abdomen

(-) flatus

Soft diet

kalium durule TID x 6

doses

D5NM x 16o

To prevent further

obstruction.

To provide a direct

replacement of

potassium in the

body.

To replenish fluid loss

and electrolyte

68


19/57

Nexium p.o OD

Motilium tab TID

imbalance.

To reduce gastric

acid secretion.

To increase the

movements or

contractions of the

stomach and bowel.

It is also used to treat

nausea and vomiting.

December 10,

2010

Senokot Forte 2 tabs now

For Serum test (1:45)

Ultrasound of whole

abdomen

Cleansing enema

To stimulate

peristalsis and

increase intestinal

motility.

To examine the

general health of a

patient especially to

assess the

functioning of certain

organs.

For determining the

source of abdominal

pain.

To alleviate

symptoms of poor

69


20/57

Colonoscopy tomorrow

12 noon

Dulcolax 2 tabs tonight

digestive health.

To examine colon

internally.

It stimulates bowel

movements.

December 11,

2010

Tympanic

abdomen

Senokot Forte 2 tabs BID

x 3 doses

Soft diet

D5LR 1 L x 16o

D5LR 1 L x 16o (10:35)

To stimulate

peristalsis and

increase intestinal

motility.

To prevent further

obstruction.

For maintenance of

nutritional balance.

December 12,

2010

Partial

obstruction

Discussed with

patient/ relative

(+) BM

Lactulose 30 cc To increase water

content in colon and

enhances peristalsis

and for the

breakdown of

products in colon that

lead to acidification of

colonic contents,

softening of feces,

and decreased

ammonia absorption

from colon to

70


21/57

D5NM 1 L x 16o

Continue soft diet

systemic circulation.

December 13,

2010

(-) BM

11:25 AM

NPO

Vomit (3x)

(-) BM

(-) flatus x 2

days

(+) vomiting

NPO

Refer to Dr. Mercado for

co- management

D5NM 1 L x 12o

Give Metoclopramide 1

amp IVTT now

Assessment: For surgical

management - Bowel

obstruction

For emergency exlap

5PM today once cleared

AP Homez for anesthesia

For Na+ K+- refer to Dr. A

Rosete for CP clearance

No absolute

contraindication for

To reduce nausea

and vomiting.

To treat large bowel

obstruction.

To know the real

cause of obstruction.

To assist during

surgery.

In preparation for

surgery.

71


22/57

(-) HPN, (-) DM

11:20 PM

surgery (ex-lap)

Re: acute abdomen-

intestinal obstruction

Nebulize with combivent

1 ampule before transport

to OR

Transderm 5mg patch to

Left Anterior Chest now

OD

Secure 2 u of FWB/

packed RBC for OR use

Transderm patch- defer if

BP 90 systolic

Post-op orders

To RR x 2o then back to

room if stable

O2 at 2-3 LPM

Flat on bed until fully

awake

VS q 15, q 10

NPO- NGT tip (opened)

attached to BTB

IVF right- KVO rate

BT #1 of packed RBC at

To assist respiration.

To replace blood

loss.

For respiration.

To promote

circulation.

For monitoring.

To replace blood

loss.

72


23/57

11:20 PM

11:55 PM

20-25 gtts/min. To follow

BT as packed RBC BT #2

IVF left- LR at 30

gtts/min.

TF D5LR 1 L x 8o

Sidedrip- NSS 500 cc +

voltaren 2 ampules at 20

cc/hr

post-op meds

1. cefuroxime 750 mg q8o

IVTT

2. metronidazole left IVF

500 mg q8o at AM

3. Omepron 8 AM OD 40

mg IVTT OD

4. Voltaren 20 cc/hr

5. Nebulize with

Combivent now then q8o

with volume/ volume

6. nalbuphine 5 mg q6o x

12 doses IVTT (6AM-12-

6-12AM)

Replace NGT loss q4o

(volume/ volume

replacement) To assist the patient

73


24/57

SPO2 95-96%

11:57 PM

December 14,

2010

10:45 AM

Patient

comfortable

Clear breath

sounds

O2 via face mask at 2-3

LPM RTC

Attach to pulse oximeter

at bedside

Specimen for pathologic

exam

Continue nebulization

every 8o

D/c O2 supplement

for enhanced airway.

For monitoring.

To assist her

respiration

Surgery

An exploratory laparotomy is done especially when a person

complains of abdominal pain. The operation allowed the surgeon to

examine the internal organs. Disease or damage can be uncovered. In

some cases, the problem can be corrected during the surgery.

A colostomy is when the colon is cut in half and the end leading to

the stomach is brought through the wall of the abdomen and attached

to the skin. The end of the colon that leads to the rectum is closed off

74


25/57

and becomes dormant. Usually a colostomy is performed for infection,

blockage, or in rare instances, severe trauma of the colon. This is not

an operation to be taken lightly. It is truly quite serious and demands

the close attention of both patient and doctor. A colostomy is often

performed so that an infection can be stopped and/or the affected colon

tissues can heal.

F. Actual Nursing Management

Assess and measure the nasogastric output

Assess fluid and electrolyte balance and administer IV as

prescribed

Monitor nutritional status

Assess improvement such as return of normal bowel sounds,

decreased abdominal distention, abdominal pain and

tenderness, passage of flatus or stool

Prepare patient for surgery which includes preoperative

teaching

After surgery, provide wound care and post-operative nursing

care

75


26/57

Place ice chips on the same day of surgery to ease the

patients thirst. By the next day, the patient may be allowed to

drink clear liquids.

Slowly add thicker fluids and then soft foods as the bowels

begin to work again.

Patient may eat normally within 2 days after the surgery.

The colostomy drains stool (feces) from the colon into the

colostomy bag. Most colostomy stool is softer and more liquid

than stool that is passed normally. The texture of stool

depends on the location of the segment of intestine used to

form the colostomy.

G.Actual Pharmacologic Management (Drug Study)

Drug # 1

Date Ordered: Dec. 09, 2010

Generic Name: esomeprazole magnesium

Brand Name: Nexium

Classification:Antiulcer drugs

Dosage: 40 mg 1 tab OD P.O

76


27/57

Mechanism of Action: Proton pump inhibitor that reduces gastric acid

secretion and decreases gastric acidity.

Indications:

Indicated to Gastroesophageal reflux disease (GERD)

Healing erosive esophagitis

Reduce the risk of gastric ulcers in patients receiving continuous

NSAID therapy.

Contraindications:

Contraindicated to patients hypersensitive to drug or components of

esoprazole or omeprazole.

Patients receiving continuous NSAID therapy who are at increased

risk for gastric ulcers include those age 60 and older or those with a

history of gastric ulcers.

Adverse Reactions:

CNS: headache

GI: dry mouth, diarrhea, abdominal pain, nausea, flatulence,

vomiting, constipation


Give drug at least 1 hour before meals.

Antacids can be used while taking drug, unless otherwise directed

by prescriber.

77


28/57

Monitor patient for rash or signs and symptoms of hypersensitivity

or worsening.

Monitor GI symptoms for improvement or worsening.

Instruct patient to take drug exactly as prescribed.

Health Teachings:

Tell patient to take drug at least 1 hour before a meal.

Advise patient that antacids can be used while taking drug unless

otherwise directed by prescriber.

Warn patient not to chew or crush drug pellets because this makes

the drug ineffective.

Tell patient to inform prescriber of worsening signs and symptoms

or pain.

Rationale: To reduce gastric acid secretion.

Drug # 2


Generic Name: potassium chloride

Brand Name: Kalium Durule

Classification: Electrolytes and minerals

Dosage: 1 tab tid x 6 doses

78


29/57

Mechanism of Action: Supplemental potassium in the form of high

potassium food or potassium chloride may be able to restore normal

potassium levels.

Indications:

For hypokalemia

As prophylaxis during treatment with diuretics

Indicated when potassium is depleted by severe vomiting, and

prolonged diuresis

Contraindications:

Severe renal impairment

Severe hemolytic reactions

Acute dehydration

Heat cramps

Hyperkalemia

Cautious use in: cardiac or renal disease; systematic acidosis

Adverse Reactions:

Renal insufficiency

Hyperkalemia

Nausea and Vomiting

Irritability and Muscle Weakness

Difficulty in swallowing

79


30/57


Some patients find it difficult to swallow the large sized KCl tablet.

Administer while patient is sitting up or standing (never in

recumbent position) to prevent drug- induced esophagus.

Dont crush sustained-release potassium products.

Monitor ECG and electrolyte levels during therapy.

Monitor for adverse effect that may reflect by perkalemia.

Health Teachings:

Tell patient to take with or after meals with full glass of water or fruit

juice to lessen GI distress.

Teach patient signs and symptoms of hyperkalemia, and tell patient

to notify prescriber if they occur.

Warn patient not to use salt substitutes concurrently, except with

prescribers permission.

Rationale: To provide a direct replacement of potassium in the body.

Drug # 3


Generic Name: domperidone

Brand Name: Motilium

Classification:Antidiarrheal and Antiemetic

Dosage: 10 mg 1 tab tid

80


31/57

Mechanism of Action: Gastrointestinal emptying (delayed) adjunct;

peristaltic stimulant: The gastroprokinetic properties of domperidone are

related to its peripheral dopamine receptor blocking properties. Motilium

facilitates gastric emptying and decreases small bowel transit time by

increasing esophageal and gastric peristalsis and by lowering esophageal

sphincter pressure. Antiemetic: The antiemetic properties of domperidone

are related to its dopamine receptor blocking activity at both the

chemoreceptor trigger zone and at the gastric level.

Indication: For management of dyspepsia, heartburn, epigastric pain,

nausea, and vomiting

Contraindications:

Known hypersensitivity to domperidone or any of the excipients

Prolactin-releasing pituitary tumour (prolactinoma).

Motilium should not be used when stimulation of the gastric motility

could be harmful:

Gastro-intestinal haemorrhage, mechanical obstruction or

perforation.

Adverse Reactions:

Immune System Disorder: Very rare; Allergic reaction

Endocrine disorder: Rare; increased prolactin levels

81


32/57

Nervous system disorders: Very rare; extrapyramidal side effects

Gastrointestinal disorders: Rare; gastro-intestinal disorders,

including very rare transient intestinal cramps

Skin and subcutaneous tissue disorders:Very rare; urticaria

Reproductive system and breast disorders: Rare; galactorrhoea,

gynaecomastia, amenorrhoea


If clinical symptoms dont 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.

Know the patients sensitivity to domperidonebefore giving it.

Health Teachings:

Advise patient not to exceed recommended dosage.

Tell patient with acute diarrhea to stop drug and seek medical

attention if no improvement occurs within 48 hours. In chronic

diarrhea, tell patient to notify prescriber and to stop drug if no

improvement occurs after taking 16 mg daily for at least 10 days.

Advise patient with acute colitis to stop drug immediately and notify

prescriber about abdominal distention.

82


33/57

Warn patient to avoid activities that require mental alertness until

CNS effects of drug are known.

Rationale: To increase the movements or contractions of the stomach

and bowel. It is also used to treat nausea and vomiting.

Drug # 4


Generic Name: senna

83


34/57

Brand Name: Senokot Forte

Classification: Laxatives

Dosage: 2 tabs bid x3 doses

Mechanism of action: Unknown. Stimulant laxative that increases

peristalsis, probably by direct effect on smooth muscle of the intestine. Its

thought to either irritate the musculature or stimulate the colonic intramural

plexus. Drug also promotes fluid accumulation in colon and small

intestine.

Indication:Acute constipation, preparation for bowel examination.

Contraindications: Contraindicated in patients with ulcerative bowel

lesions, fecal impaction, intestinal obstruction, intestinal perforation, or

signs and symptoms of acute surgical abdomen, such as nausea,

vomiting, and abdominal pain.

Adverse reactions:

GI: nausea, vomiting, diarrhea, loss of normal bowel function with

excessive use, abdominal cramps, especially in severe

constipation, malabsorption of nutrients, yellow or yellow-green cast

to feces, darkened pigmentation of rectal mucosa with long-term

use, protein losing enteropathy.

GU: red-pink discoloration in alkaline urine, yellow-brown

discoloration in acidic urine.

Metabolic: electrolyte imbalance such as hypokalemia.

Other: laxative dependence with long-term or excessive use.

84


35/57


Before giving drug for constipation, determine whether patient has

adequate fluid intake, exercise and diet.

Limit diet to clear liquids after X-prep liquid is taken.

Avoid exposing product to excessive heat or light.

Drug is for short-term use.

Health Teachings:

Teach patient about dietary sources of bulk, including bran and

other cereals, fresh fruit, and vegetables.

Tell patient to report persistent or severe reactions.

Rationale: To stimulate peristalsis and increase intestinal motility.

Drug # 5


Generic Name: lactulose

85


36/57

Brand Name: Duphalac

Classification: Laxatives

Dosage: 30 cc now

Mechanism of Action: Produces an osmotic effect in colon; resulting

distention promotes peristalsis. Also decreases ammonia, probably as a

result of bacterial degradation, which lowers the pH of colon contents.

Indication: Constipation

Contraindications: Contraindicated in patients on a low galactose diet

and in those with diabetes mellitus.

Adverse Reactions:

GI: abdominal cramps, belching, diarrhea, gaseous distention,

flatulence, nausea, vomiting.


To minimize sweet taste, dilute with water or fruit juice or give with

food.

Prepare enema by adding 200 g (300 ml) to 700 ml of water or

normal saline solution. The diluted solution is given as retention

enema for 30 to 60 minutes. Use a rectal balloon.

If enema isnt retained for at least 30 minutes, be prepared to

repeat dose.

Monitor sodium level for hypernatremia, especially when giving to

patients with hepatic encephalopathy.

86


37/57

Monitor mental status and potassium level when giving to patients

with hepatic encephalopathy.

Be prepared to replace fluid loss.

Health Teachings:

Show home care patient how to mix and use drug.

Inform patient about adverse reactions and tell him to notify

prescriber if reactions become bothersome or if diarrhea occurs.

Instruct patient not to take other laxatives during lactulose therapy.

Rationale: To increase water content in colon and enhances peristalsis

and for the breakdown of products in colon that lead to acidification of

colonic contents, softening of feces, and decreased ammonia absorption

from colon to systemic circulation.

Drug # 6


Generic Name: cefuroxime

87


38/57

Brand Name: Zegen

Classification: Antibiotic

Cephalosporin ( 2nd generation)

Dosage: 750 mg q8 IVTT

Mechanism of Action: Cefuroxime is a bactericidal antibiotic, which

exerts antibacterial activity by inhibition of bacterial cell wall synthesis in

susceptible species. Cefuroxime has good stability to several bacterial

beta-lactamase enzymes and, consequently, is active against many

penicillin-resistant and amoxicillin-resistant strains of susceptible species.

Indications:

Lower respiratory tract infections caused by S. pneumoniae, S.

aureus, E. coli, Klebsiella, H. influenzae, S. pyogenes

Dermatologic infections caused by S. aureus, S. pyogenes, E. coli,

Klebsiella, Enterobacter

UTIs caused by E. coli, Klebsiella

Uncomplicated and disseminated gonorrhea caused by N.

gonorrhoea

Septicemia caused by S. pneumoniae, S. aureus, E. coli, Klebsiella,

H. influenzae

Meningitis caused by S. pneumoniae, H. influenzae, S. aureus, N.

meningitidis

Bone and joint infections caused by S. aureus

Perioperative prophylaxis

88


39/57

Contraindications:

Allergy to cephalosporins or penicillins

Renal failure

Adverse Reactions:

CNS: Headache, dizziness, lethargy, paresthesias

GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain,

flatulence, pseudomembranous colitis, liver toxicity

Hematologic: Bone marrow depression: decreased WBC,

decreased platelets, decreased Hct

GU: Nephrotoxicity

Hypersensitivity: Ranging from rash to fever to anaphylaxis, serum

sickness reaction

Local: Pain, abscess at injection site; phlebitis, inflammation at IV

site

Other: Superinfections, disulfiram-like reaction with alcohol


Assess for history of hepatic and renal impairment

Observe the 12 rights when administering the drug

Have vitamin K available in case hypoprothrombinemia occurs

89


40/57

Discontinue if hypersensitivity occurs

Observe for adverse reactions

Do not mix with aminoglycosides

Inject slowly over 3-5min

Health Teachings:

Avoid alcohol while taking this drug and 3 days after because

severe reactions often occurs

May experience side effects

Report diarrhea, difficulty in breathing, unusual tiredness or fatigue,

pain at injection site

Rationale: To treat the existing acute infection.

Drug # 7


Generic Name: metronidazole

90


41/57

Brand Name: Rosex

Classification: Amebicide; Antibacterial; Antibiotic; Antiprotozoal

Dosage: 500mg q8 IVF @ am

Mechanism of Action: Metronidazole exerts rapid bactericidal effects

against anaerobic bacteria. It inhibits DNA synthesis, causing cell death.

Indications:

Acute infection with susceptible anaerobic bacteria

Acute intestinal amebiasis

Amebic liver abscess

Trichomonias ( acute and partners of patients with acute infection)

Bacterial vaginosis

Preoperative, intraoperative, postoperative prophylaxis for patients

undergoing colorectal surgery

Prophylaxis for patients undergoing abdominal surgery

Contraindications:

Hypersensitivity to metronidazole

Used cautiously with CNS, hepatic diseases, candidiasis, blood

dyscrasias

Adverse Reactions:

91


42/57

CNS: Headache, dizziness, ataxia, vertigo, incoordination,

insomnia, seizures, peripheral neuropathy, fatigue

GI : unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea,

GI upset, cramps

GU:dysuria, incontinence, darkening of the urine

Local: thrombophlebitis

Other: Superinfections , disulfiram-like reaction with alcohol


Assess for history of CNS or hepatic disease, candidiasis, blood

dyscrasias

Reduce dosage with hepatic disease




Do not refrigerate neutralized solution

Do not administer solution that has not been neutralized

Infuse over 1hr

Discontinue other solutions while running metronidazole

Protect medication from sunlight

Health Teachings:

Take full course of drug therapy

92


43/57

Avoid alcohol while taking this drug and 3 days after because

severe reactions often occurs


Expect dark colored urine

Report severe GI upset, dizziness, unusual fatigue or weakness,

fever, chills

Rationale: To treat the existing acute infection.

Drug # 8


Generic Name: diclofenac sodium

Brand Name: Voltaren

93


44/57

Classification: Analgesic (non-opioid); Anti-inflammatory (NSAID);

Antipyretic

Dosage: 20cc/hr IV

Mechanism of Action: Inhibits prostaglandin synthetase to cause

antipyretic and anti-inflammatory effects; the exact mechanism of action is

not known.

Indications:

Acute or long-term treatment of mild to moderate pain

Rheumatoid arthritis

Osteoarthritis

Ankylating spondylitis

Contraindications:

Contraindicated in the presence of significant renal impairment, and

allergies to NSAIDs

Use caution in the presence of impaired hearing, allergies, hepatic,

cardiovascular, and GI conditions and in elderly patients

Adverse Reactions:

CNS: Headache, dizziness, somnolence, insomnia, fatigue,

tiredness, dizziness, tinnitus, ophthamologic effects

94


45/57

GI: Nausea, dyspepsia, GI pain, vomiting, constipation, flatulence,

diarrhea, GI bleed

Hematologic: Bleeding, platelet inhibition with higher doses

GU: Dysuria, renal impairment

Dermatologic: Rash, pruritus, sweating, dry mucous membranes,

stomatitis

Other: Peripheral edema, anaphylactoid reactions to fatal

anaphylactic shock


Assess for history of hepatic and renal impairment, CV and GI

conditions, impaired hearing


Administer drug with food

Institute emergency procedures if overdose occurs


Monitor with use of anticoagulants ( increased risk of bleeding)

Health Teachings:

Take drug with food

95


46/57

Take only the prescribed dosage


Report sore throat, fever, rash, itching, weight gain, swelling in

ankles or fingers, changes in vision, black, tarry stools

Rationale: This drug is given to alleviate the pain perceived and

experienced.

96


47/57

Drug # 9


Generic Name: omeprazole

Brand Name: Omepron

Classification: Antisecretory drug; Proton pump

inhibitor

Dosage: 40mg IVTT OD

Mechanism of Action: Gastric acid pump inhibitor: Suppresses gastric

acid secretion by specific inhibition of the hydrogen-potassium ATPase

enzyme system at the secretory surface of the gastric parietal cells; blocks

the spinal step of acid production

Indications:

Short-term treatment of active duodenal ulcer

Treatment of heartburn or symptoms of GERD

Short-term treatment of active benign gastric ulcer

GERD

Eradication of H. Pylori

Reduction of risk of upper GI bleeding in critically ill patients

Contraindications:

Hypersensitivity to omeprazole or its components

97


48/57

Adverse Reactions:

CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy,

anxiety, paresthesia, dream abnormalities

GI: Nausea, vomiting, constipation, diarrhea, abdominal pain, dry

mouth, tongue atrophy

Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry

skin

Respiratory : cough, epistaxis

Other: back pain, fever


Assess for hypersensitivity to omeprazole or its components


Administer with antacids if needed administer before meals


Health Teachings:

Take drug before meals and take only the prescribed dosage

May experience side effects and report severe headache,

worsening of symptoms, fever, chills

Rationale: This is given to suppress the gastric secretion and thus,

reduce the pain perceived.

98


49/57

Drug # 10


Generic name: nalbuphine

Brand name: Nubain

Classification: Opioid agonist-antagonist

analgesic

Dosage: 5mg q6 x 12 doses IVTT

Mechanism of Action: Nalbuphine acts as an agonist at specific opioid

receptors in the CNS to produce analgesia and sedation. It inhibits the

ascending pain pathways, altering the perception of and response to pain

by binding to opiate receptors in the CNS but also acts to cause

hallucinations and is an antagonist at mu receptors.

Indications:

Relief to moderate to severe pain

Preoperative analgesia, as a supplement to surgical anesthesia

Prevention and treatment of intrathecal morphine-induced pruritus after

CS

Contraindications:

Hypersensitivity to nalbuphine, sulfites

99


50/57

Use cautiously with emotionally unstable patients or those with

history of opioid abuse, bronchial asthma, COPD, respiratory

depression, anoxia, increased ICP,acute MI

Adverse Reactions:

CNS: sedation, clamminess, sweating, headache, nervousness,

restlessness, depression, crying, confusion, faintness, unusual

dreams, hallucinations, dizziness, vertigo, floating feeling, feeling of

heaviness, numbness, tingling, flushing, warmth, blurred vision

GI: Nausea, vomiting, cramps, dyspepsia, bitter taste dry mouth

GU: urinary urgency

Respiratory : respiratory depression, dyspnea, asthma


Assess for hypersensitivity to nalbuphine, sulfites, emotional

instability or history of opioid abuse, bronchial asthma, COPD,

respiratory depression, anoxia, increased ICP, and MI


Taper dosage when discontinuing after prolonged use to avoid

withdrawal symptoms

Reassure patient about addiction liability



100


51/57

Health Teachings:


Avoid performing tasks that require alertness

For loss of appetite, lying quietly and eating small frequent meals

may help

Report severe nausea, vomiting, palpitations, shortness of breath,

or difficulty in breathing

Rationale: It is given to alleviate the pain experienced by the patient.

H. Prognosis

101


52/57

Scoring:

102

Poor

(1)

Fair

(2)

Good

(3)Justification

Duration of

Illness

She has already a 1 year background of

intermittent pain on her abdomen and lately,

she is having difficulty and inability to defecate.The physician believes that symptoms develop

gradually in time.

Onset

She was not diagnosed immediately since she

doesnt have regular check-ups. It is not clear

when was obstruction started and how she

acquired the tumor causing obstruction and

such manifestations.

PrecipitatingFactors

It is fair since she practices healthy lifestyle by

eating fruits and vegetables. She doesnt have

any vices like smoking and drinking alcohol.However, the real factors arent clear of what

aids in developing obstruction caused by the

tumor.

Willingness

to

Compliance

of

Treatment

When she found out what her condition is, all

she desires is for her cure and recovery. She

gives her trust to the health care providers and

is willing to cooperate with every procedure

and follows what the physician is saying. She

is also complying with the medications

prescribed for her.

Age

She is at higher risk because age is a

predisposing factor that may lead in having

intestinal obstruction.

Environment

She wants a clean environment especially at

their house. With that, she does household

chores to maintain neat and organized

surroundings.

Family

Support

She is well loved and supported by her

husband, children, and grandchildren. She has

a close relationship among them.

Good Fair Poor

3- 2.7 2.5- 1.6 1- 1.5


53/57

The patients score is 2.14 which is a fair prognosis. The patient

wasnt diagnosed immediately since she already had a one year

background of abdominal pain. She only then decided to have her check-

up after having difficulty in defecating. She was admitted and the

physician advised her o undergo surgery.

I. Discharge Planning

When client is to be discharged from the hospital, nursing care is

still continued. With sufficient support at home, most client recover

gradually. During home visits, the clients physical status and progress

103


54/57

towards recovery is assessed. The clients understanding of therapeutic

regimen is also assessed, and previous teaching is reinforced.

Method

Instruct the significant others to take the following home medication

as ordered by the physician.

Explain to the significant others the drug names as well as the right

route and dosage.

Inform the significant others about the side effects that may occur

brought by the medication.

Encourage the significant others to comply and follow religiously the

right timing in taking the medication.

Confer with the patients family the need take precautions regarding

medication therapy, activity, and dietary restriction.

Discuss with the patients family ways to cope with stressful

situations in positive manner.

Instruct patients family to report for immediate occurrence of signs

and symptoms to a health care professional.

Reinforce and supplement patients family knowledge about

diagnosis, prognosis, and expected level of function.

Provide patients family with specific directions about when to call the

physician and what complications require prompt attention.

104


55/57

Peer support and psychological counseling may be helpful for some

families.

Exercise/ Environment

Once at home, patient may resume much of the normal activity short

of aggressive physical exercise.

Walk short distances everyday and gradually increase activity.

No lifting of a weight greater than 20 lbs (9kg) for 6 weeks. Exercise

should be started cautiously.

Encouraged to practice deep breathing exercise and range of motion

exercises up to the level of capability.

Explain the need for rest periods both before and after certain

activities.

Teach client the importance of stress management through

relaxation technique, and regular appropriate exercise.

Help improve patients self-concept by providing positive feedback,

emphasizing strengths and encouraging social interaction and

pursuit of interests.

Treatment

105


56/57

Explain to the significant others the need to continue drug therapy

Provide patients family with a list of medications, with information on

action, purpose and possible side effects.

Advise significant others to always comply with the medications. Call

the physician if there is a problem taking them.

If the result of biopsy showed malignancy of the tumor,

chemotherapy must be followed up.

Hygiene

Keep proper hygiene. Teach clients family the importance of hygiene

like daily oral care, bathing and changing clothes.

Proper Wound care must be observed.

Outpatient

Advise to visit or have her follow up check-up with her attending

physician.

Advise to call and notify the attending physician for any unusualities

that may occur

106


57/57

Routinely, follow up check up with patients within two weeks. If

there are staples that require removal, postoperative problems, or

wound issues, a follow-up appointment will be scheduled sooner.

Diet

Emphasize to the clients family the importance of proper nutrition, its

need for early recovery. This can aid in restoring body functioning.

Provide dietary instructions to help patients family identify and

eliminate foods that is needed by the patient.

Soft or low residue diet upon discharge; this should be continued at

home for approximately 2 weeks (this includes breads, cereals,

chicken, fish, and soup).

Avoid large quantities of raw fruits and vegetables.

After 2 weeks, gradually reintroduce regular diet.

Encourage to drink plenty of fluids.

Take nutrition supplements

CP Intestinal Obstruction Chap7

Documents