FUMC Case Presentation

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CASECASEPRESENTATIONPRESENTATION



P A T I E N T · S P

R O F I L

E

P A T I E N T · S P

R O F I L

EName: Mrs. D

Age: 39 years old

Gender: Female

Address :Bonifacio, Makati City

Date of Birth: July 3, 1972

Civil Status: Married

Religion: Baptist

Nationality: Filipino

Occupation: Accountant

Spouse: Mr. D



Date of Admission: January 16, 2012 (9:12pm)

Mode of Admission: Wheelchair from ER(Accompanied by Husband)

Chief Complaint:

Abdominal Pain

Admitting Diagnosis:

Fatty Liver, Gallbladder Polyp

Patient D has no history of Hypertension, DM,

Asthma, or any allergic reaction to medications. She

has also no history of any discussed diseases on herfamily. The patient was neither a smoker nor a drinker.

She consumes four meals a day, with some foods high

on fats.

P A T I E N T · s H

I S T O

R Y



ANATOMY and PHYSIOLOGYANATOMY and PHYSIOLOGY



Gastrointestinal SystemGastrointestinal System

LIVER largest organ in the body

Mainly located RUQ of the abdomen

Divided into two regions:

Right lobe (larger)

Left lobe (smaller)

LOBULES: functional unit

Blood Supply: (1,500 ml of blood flow/minute)

Hepatic Portal Vein

Hepatic Artery

Phagocytic KUPFFER CELLS



GALLBLADDER A pear-shaped bulbous sac , located

inferior surface of the liver

Three portions:

Neck ² continuos with

cystic duct Body ² main portion

Fundus ² lower bulbous

section

Drained by the Cystic duct, joining

the Hepatic Duct from the liverforming the COMMON BILE

DUCT



y LIVER:

Produces BILES Regulates blood glucose ( Glycogenesis/ Glycogenolysis)

Synthesizes proteins and other AA

Converts Ammonia to Urea for kidney elimination

Stores Vitamins (ADEK) and Minerals

Brakes down certain toxic substances and hormones

(Kupffer cells)

GALLBLADDER:

Collects, concentrates, and stores BILE

Releases the bile into duodenum via common bile duct

when fat is present.



UNKNOWN

(Lifestyle, Excessive intake of fatty foods)

STEATOSIS

(Abnormal accumulation of lipid)

Fat deposits in the liver

Inflammation of the Liver

Swelling of surrounding tissues

Vasoconstriction of blood vessels on theaffected part

Decreased blood supply

Decreased tissue perfussion

Tissue Ischemia

ActivationofNociceptors

Somatic Pain

Damaged hepatocytes

Inc. AST & ALT / SGPT & SGOT

Bile Duct obsttruction

LRUQ Pain

Gallbladder Polyps



LABORATORYLABORATORY

EXAMINATIONSEXAMINATIONS



Blood Components Result Normal Range Interpretation

ALKALINE

PHOSPHATASE

156 F: 42-98 µ/L INCREASED

in liver diseases (cholestasis, fatty liver, cholecystitis,

cirrhosis, hepatitis, liver tumor), drug intoxication; drugs

(verapamil, carbamazepine, phenytoin, erythromycin,

allopurinol, ranitidine)

BLOOD UREA

NITROGEN (BUN)

1.4 2.2-7.1 mmol/L DECREASED

in hepatic failure, nephrotic syndrome, cachexia (low

protein and high carbohydrate diets)CREATININE 62 F: 53-97 µmol/L NORMAL

FASTING BLOOD SUGAR 5.0 3.9-5.8 mmol/L NORMAL

SERUM GLUTAMIC

PYRUVIC

TRANSAMINASE (SGPT)

301 F: 3-31µ/L INCREASED

in acute viral hepatitis, diabetes, CHF, liver damage, bile

duct obstructions, infectious mononucleosis, myopathy;

hepatotoxic drug

AMYLASE 69 27-102 µ/L NORMAL

SERUM GLUTAMIC

OXALOACETIC

TRANSMINASE (SGOT)

249 F: 2-31 µ/L INCREASED

in acute viral hepatitis, biliary tract obstraction,

mononucleoisis, alcoholic hepatitis and cirrhosis, liver

abscess, ischemic injury to liver, myopathy



Lipid Profile Result Normal Range Interpretation

HIGH DENSITY

LIPOPROTEIN

CHOLESTEROL

(HDL)

1.36 Low <1.03

Medium 1.03-1.56

High >1.56

MEDIUM / NORMAL

TOTAL

CHOLESTEROL

6.50 Desirable <5.16

Borderline High

5.16-6.17

High >6.18

HIGH

Associated with atherosclerosis, biliary

cirrhosis, high-cholesterol diet,

hypothyroidism, myocardial infarction,

nephritic syndrome, uncontrolled diabetes

LOW DENSITY

LIPOPROTEIN

CHOLESTEROL

(LDL)

4.36 Optimal <2.58

Near/Low Optimal

2.58-3.34

Borderline High

3.35-4.12

High 4.13-4.89

Very High >4.90

HIGH

Connected with heart diseases including

atherosclerosis, heart attack, stroke, and

coronary heart disease

TRIGLYCERIDES 1.72 Normal <1.70

Borderline High

1.70-2.25

High 2.26-5.63

Very High >5.65

BORDERLINE HIGH

Slightly above normal; associated with

cirrhosis, hypothyroidism, low protein in diet

and high carbohydrates, pancreatitis, poorly

controlled diabetes, nephrotic syndrome



Serum

ElectrolytesResult Normal Range Interpretation

SODIUM 141 138-146 mmol/L NORMAL

POTASSIUM 3.9 3.6-5.0 mmol/L NORMAL

CHLORIDE 101 96-110 mmol/L NORMAL

CALCIUM 1.24 1.15-1.29 mmol/L NORMAL

Complete Blood Count Result Normal Range Interpretation

WBC 9.3 5.0-10.0x10 g/L NORMAL

Differential Count Result Normal Range Interpretation

NEUTROPHILS 0.62 0.40-0.60 INCREASED

in infection (bacterial or early viral), acute stress,

acute and chronic inflammation, tumor, drugs, DKA

LYMPHOCYTES 0.26 0.20-0.40 NORMAL

MONOCYTES 0.08 0.02-0.08 NORMAL

EOSINOPHILS 0.02 0.01-0.03 NORMAL

BASOPHILS 0.02 0-0.02 NORMAL



Blood Compounds Result Normal Range Interpretation

HEMOGLOBIN 142 F: 123-152 g/L NORMAL

HEMATOCRIT 0.42 F: 0.37-0.42 NORMAL

RBC 4.88 F: 4.5-5.5x1012

/L NORMALMEAN CORPUSCULAR

VOLUME (MCV)

87 88-96 NORMAL

MEAN CORPUSCULAR

HEMOGLOBIN (MCH)

29.1 27-33 pg NORMAL

MEAN CORPUSCULAR

HEMOGLOBIN

CONCENTRATION

(MCHC)

336 300-360 g/L NORMAL

RANDOM DISTRIBUTION

WIDTH (RDW)

12.5 12.7-22.7% DECREASED

in iron deficiency anemia (blood loss, parasites,poor iron absorption), vitamin B6 anemia, rheumatoid

arthritis

PLATELET 327 150-450x20 g/L NORMAL

MEAN PLATELET

VOLUME (MPV)

4.38 4.5-7.5 fL DECREASED

platelet production problems; thrombocytopenia,

leukemia



Macroscopic Result Interpretation

COLOR Dark yellow May indicate dehydration

TRANSPARENCY turbid May be a symptom of bacterial infection;

can be caused by crystallization of salts

(calcium phosphate)

Chemical Result Range Interpretation

SPECIFIC GRAVITY 1.010 1.003-1.030 NORMAL

pH 8.5 4.5-8 INCREASED

Alkalinic; kidney failure, UTI, vomiting;

in diet high in citrus, vegetables, dairy;

drugs (acetazolamide, potassium citrate,

sodium bicarbonate)

UROBILINOGEN +2 0.2-1 mg/dL INCREASED

Associated with liver diseases (hepatitis,

cirrhosis), increased RBC destruction

(haemolytic anemia)



Chemical Result Chemical Result

NITRITE Negative BILIRUBIN Negative

PROTEIN Negative LEUKOCYTES Negative

GLUCOSE Negative BLOOD Negative

KETONE Negative PREGNANCY Negative

Microscopic Results

RBC 0-2 / HPF

PUS CELLS 0-2 / HPF

BACTERIA Few

EPITHELIAL CELLS +1

MUCUS THREADS Few

Crystal Result Interpretation

AMORPHOUS

PHOSPHATES

+1 Present in an alkaline urine; can be caused

by diet (vegetarian, phosphate-rich foods),

or by pathological conditions (UTI, kidney

failure)



Drug Name &

Classification

Classifi

cationAction Indication

Adverse

Effects

Contra

indications

Nursing

Considerations

Generic Name:

Pantoprazole

Brand Name:

Pantoloc

Antacid and

antiulcer

Symptomatic

treatment of

mild reflux

esophagitis;

long term

management

and

prevention

of relapse of

reflux

esophagitis;

duodenal

and gastric

ulcers, reflux

esophagitis;

eradication

of H. pylori.

Inhibits proton

pump activity

by binding to

hydrogen-

potassium

adenosine

triphosphatas

e, located at

secretory

surface of

gastric parietal

cells, to

suppress

gastric acid

secretion.

Frequently:

headache,

diarrhea

Rarely:

nausea,

upper

abdominal

pain,

flatulence,

skin rash,

pruritus or

dizziness.

Patients with

a history of

hypersensitivi

ty to

pantoprazole

or to any

constituents

of the

medication. It

is also

contraindicat

ed in patients

with cirrhosis

of the liver

and in cases

of severe liver

disease.

>alert: dont confuse

with protonix tablet

>drug can be given

without regard to

meals

>drug shouldnt be

used for

maintenance

therapy beyond 16

weeks.

>symptomatic

response to therapy

doesnt preclude the

presence of gastric

malignancy.



Drug Name &

Classification

Classifi


Adverse

Effects

Contra

indications

Nursing

Considerations

Generic Name:

Metocloprami

de

Brand Name:

Plasil

Antiemetic Prevention

of nausea

and

vomiting

associated

with

emetogenic

cancer

chemothera

py; relief

symptoms of

acue and

recurrent

diabetic

gastroparesi

s;

prophylaxis

of

postoperativ

enausea and

vomiting

when

nasogastric

suctioning isundesirable.

Stimulates

motility of

upper GI tract

without

stimulating

gastric biliary,

or pancreatic

secretions

Restlessness,

drowsiness,

insomnia,

extrapyramid

al reactions,

akathisia,

myoclonus

Contraindicat

ed with

allergy to

metocloprami

de; GI

hemorrhage,

mechanical

obstruction

or

perforation,

epilepsy

>Monitor BP

carefully during IV

administration

>monitor

extrapyramidal

reactions, and

consult physician if

they occur.

>Keep

diphenhydramine

injection readily

available incase of

extrapyramidal

reactions occur.

> Do not use

alcohol, sleep

remedies or

sedative; serious

sedation may occur.



Drug Name &

Classification

Classifi


Adverse

Effects

Contra

indications

Nursing

Considerations

Generic Name:

Ursodeoxycolic

Acid

Brand Name:

Ursofalk

Antichole-

lithic

Indicated in the

treatment of

primary biliary

cirrhosis (PBC) and

for the dissolution

of radiolucent

gallstones in

patients with a

functioning gall

bladder

Gallstone

formation(prophylaxis). trea

tment of some

chronic liver

diseases, including

primary biliary

cirrhosis, primary

sclerosing

cholangitis, cystic

fibrosisassociated

liver disease,

biliary atresia,

chronic hepatitis,

and alcoholic

cirrhosis

Anticholelithic

Although the

exact

mechanism of

ursodiol's

anticholelithic

action is not

completely

understood, it

is known that

when

administeredorally ursodiol

is concentrated

in bile and

decreases

biliary

cholesterol

saturation by

suppressing

hepatic

synthesis and

secretion of

cholesterol, and

by inhibiting its

intestinal

absorption.

Back pain,

diarrhea,

alopecia,

constipation

, dyspepsia,

dizziness,

nausea,

psoriasis,

vomiting

Acute

inflammation of

the gallbladder

and bile ducts;

obstruction of the

biliary tract

(common bile

duct or cystic

duct),

inflammation

disorders of the

large and smallintestine,

pregnancy.

Ursofalk should

not be taken

when the

gallbladder

cannot be

visualized at x-ray,

in patients with

calcified

gallstones,

disturbed

contractility of

the gallbladder or

frequent biliary

colic.

> Regular visits to

physician to check

progress;

laboratory tests

may be required

during therapy

>Avoiding

aluminum-

containing

antacids; may

interfere with

absorption of ursodiol

>Notifying

physician

immediately if

symptoms of acute

cholecystitis

develop

>Should be taken

with food



Drug Name &

Classification

Classifi

cationAction Indication Adverse Effects

Contra

indicationsNursing Considerations

Generic Name:

Paracetamol

Brand Name:

Biogesic

Antipyretic

and

analgesic

Symptomati

c relief of

pain an

fever

Reducing

fever by

acting

directly onthe

hypothalami

c heat-

regulating

center to

cause

vasodilation

and

sweating,

which helps

dissipate

heat.

hemolytic

anemia,

neutropenia,

leucopenia,pancytopenia,

Jaundice,

hypoglycemia,

rash

Contraindicat

ed in patients

hypersensitiv

ity to drug.Use

cautiously in

patients with

long

term alcohol

use because

therapeutic

doses cause

hepatotoxicit

y in these

patient.

>Use liquid form for children

and

patients who have difficulty

swallowing.> In children, dont exceed

five doses

in 24 hours.

>Advise patient that drug is

only for

short term use and to

consult the

physician if giving to children

for

longer than 5 days or adults

for

longer than 10 days.

>Advise patient or caregiver

that

many over the counter

products

contain acetaminophen; be

aware

of this when calculating total

daily

dose.



Classification cationAction Indication

Effects indicationsNursing Considerations

Generic Name:

Atorvastatin

Brand Name:

Lipitor

Anti

hyperlipid

emic

Adjunct to diet in

treatment of

elevated total

cholesterol,

serum

triglycerides,

and LDL

cholesterol in

patients with

primary

hypercholesterolemia and mixed

dyslipidemia,

primary

dysbetalipoprotei

nemia, and

homozygous

familialhypercholesterole

mia whose

response to

dietary restriction

of saturated fat

and cholesterol

Inhibits enzyme

that catalyzes

the first step in

the cholesterol

synthesis

pathway,

resulting in a

decrease in

serum

cholesterol,

serum LDLs(associated

with increased

risk of CAD),

and increases

serum HDLs

(associated

with decreasedrisk of CAD);

increases

hepatic LDL

recapture sites,

enhances

reuptake and

catabolism of LDL;

Headache

, asthenia,

Flatulence

,

abdominal

pain,

cramps,

constipati

on,

nausea,

dyspepsia,heartburn,

liver

failure,

Sinusitis,

pharyngiti

s,

arthralgia,myalgia

Contraindicat

ed with

allergy to

atorvastatin,

fungal

byproducts,

active liver

disease or

unexplained

and

persistentelevations of

transaminase

levels,

pregnancy,

lactation. Use

cautiously

withimpaired

endocrine

function.

> Withhold atorvastatin in

any acute, serious

condition (severe infection,

hypotension, major

surgery, trauma, severe

metabolic or endocrine

disorder, seizures) that may

suggest myopathy or serve

as risk factor for

development of renal

failure.> Ensure that patient has

tried cholesterol-lowering

diet regimen for 36 mo

before beginning therapy.

> Administer drug without

regard to food, but at same

time each day.> Consult dietitian about

low-cholesterol diets.

> Take this drug once a day,

at about the same time

each day, preferably in the

evening; may be taken with

food. Do not drinkgrapefruit juice.



ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

-Masakit ang

aking tagiliran, a s

verbalized by the

patient.

Objective:

-Vital signs

BP: 130/90

Temp: 36.9

PR: 90

RR: 25

-feeling of

bloatedness

-Pain scale of 7/10

-with facial

grimace

-with guarding

behavior on the

affected site.

-verbal report of

acute pain.

Acute pain

related to

abdominal

distention as

manifested by

facial grimace,

guarding

behavior and

verbal report of

acute pain.

After 2 hours

of nursing

interventions,

the client

should

manifest a

decrease in the

pain scale of

7/10 to a

manageable

level of 0 to 4.

Independent:

- Assess the clients pain

scale and perception

- Encourage verbal report

during and after the nursing

interventions

- Monitor vital signs and pain

scale.

- Provide a quiet, non

disturbing environment

with comfortable

temperature

- Teach client divertional

activities

- Elicit behaviours that are

conditioned to produce

relaxation, such as deep

breathing or abdominal

breathing.

- Bed rest in low fowlers

position.

Dependent:

- Administer analgesic as

ordered by the physician.

Collaborative:

- Carry out doctors order for

blood test

Educative:

- Suggest patient limit gum

chewing, hard candy.

Independent:

- To identify the intensity,

onset, and duration

- To identify the

effectiveness of the

interventions

- Vital signs changes

during onset of pain, for

future comparison after

interventions.

- Comfort and a quiet

atmosphere promote a

relaxed feeling

- To divert clients

attention from pain

- Relaxations techniques

help reduce skeletal

muscle tension which

will reduce the intensity

of the pain.

- Reduces intraabdominal

pressure

Dependent:

- To relieve clients pain

using pharmacologic

intervention.

Collaborative:

- Blood test reveals an

increase in WBC count.

Educative:

- Promotes gas formation,

which can increase

gastric

distention/discomfort.

After 2 hours of

nursing

intervention the

goals are met

and the clients

pain is

decreased from

7/10 to 3/10.



Be sure the patient understands any medication

prescribed, including names of the drugs, dosage, route,action and side effects.

Advocate the patient to adhere to therapeutic regimens.

Encourage to follow up with his nutritionist regarding his

diet.

Encourage to use of stress management techniques, e.g.,

progressive relaxation, deep-breathing exercises to

promote muscle relaxation and manage any discomfort.

Encourage the patient to routinely exercise digits/joints

distal to injury to enhance circulation.Advocate the patient to report any unusual/sudden pain

or deep, progressive, and poorly localized pain to prevent

further infection/complication.



Encourage family members to inform the patient

to attend follow up appointments with his physician.

Advise the patient to have adequate rest and sleep

and to eat a healthy & balanced diet.

Encourage patient to eat high calorie, moderate

protein meal and to have supplementary feedings.Suggest small, frequent feedings and attractive

meals in an aesthetically pleasing setting at meal

time.

Encourage and assist with gradually increasing

periods of exercise.

Provide emotional support to enhance coping

abilities in the management of the stress of injury

and pain.

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