CASE

PRESENTATION
 LYCEUM OF THE PHILIPPINES UNIVERSITY- BATANGAS
Capitol Site, Batangas City

PANCREATIC PSEUDOCYST
Prepared By:

Florendo, Rachael Ann G.

BSN III-5
Group C

Submitted to:
Dra. Annabelle Iturralde
INTRODUCTION
 Pseudocyts is applied to a collection of fluid that arises from loculation of
inflammatory processes, necroses or hemorrhages. This type represents the
overwhelming majority of clinically important cyst and is almost always
associated with pancreatitis. Pseudocyts may also follow traumatic injury to
the abdomen with direct damage and hemorrhage in the pancreas. Acute
pancreatitis or trauma precedes the clinical discovery of a pseudocyst in nine
of ten cases.
These cyst are usually solitary and most measure 5-10 cm in diameter.
They may be situated with in the pancreatic substance, but more often they
are found adjacent to the pancreas, particularly in the region of the tail of the
pancreas. The cyst walls may be thin or thick and fibrous. Characteristically,
they do not have an epithelial lining and have no connection of
communication with surrounding ductal systems. There may have a marked
inflammatory reaction in the fibrous capsule and often organizing blood clot,
old blood pigment, precipitates of calcium and cholesterol crystals. The cyst
fluid is usually serons and turbid .
 Pseudocyst produce abdominal pair and intraperitoneal
hemorrhage and if infected, may cause generalized peritonitis.
However, their clinical significance lies in their being discovered as
an abdominal mass in a location that strongly suggest a primary intra
abdominal malignancy. The diagnosis is made by ultrasonography or
CT sacnning with the ultrasound, pseudocysts are evident as
sonolucent areas with re;atively smooth, well outlines. They are
usually unilocular, multi-loculation suggests a neoplastic cyst. CT
scanning adds specificity by ultrasound in this settting.

Pancreatitis in children is uncommon and represents a

diagnostic challenge for clinicians. Although most adult cases of
pancreatitis are caused by alcohol abuse or gallstone disease, the
etiology for pancreatitis in children is diverse. The predominant
causes include abdominal trauma (23%), anomalies of the
pancreaticobiliary system (15%), multisystem disease (14%), drugs
and toxins (12%), viral infections (10%), hereditary disorders (2%),
and metabolic disorders (2%). In the United States, trauma is
responsible for 15-37% of cases.1
 In general, the prognosis of children with acute pancreatitis is
excellent, although pseudocysts have been reported to complicate
10-23% of acute episodes. In addition, when associated with
abdominal trauma, the frequency rate of pseudocyst identification is
higher than 50%. Approximately 60% of pancreatic pseudocysts that
are caused by blunt trauma require surgical intervention.

In children, however, the presenting signs and symptoms can be

quite varied. So I choose this case for further understanding these
disease and to know the prevention and management.

In this case study, I want to learn, know and understand better

the disease. It has been chosen, since it is now fastly increasing in
our morbidity rates among diseases. It is better for us to be educated
with its causative factors as well as the prevention and management
whenever Pancraetic Pseudocyst occurs.
OBJECTIVE
GENERAL OBJECTIVES:

At the end of the case presentation I will be enhanced with the

knowledge ,equipped with the skills and acquire positive attitude
about pancreatic pseudocyst its effect to the individual as well as to
their significant others, its manifestation and prevention, necessary
treatment and appropriate nursing action.
SPECIFIC OBJECTIVES:

1)The patient condition. State the patient profile, past medical history,
personal, social, and family as well as history of present illness.
2) Asses the physical appearance of the patient and the recognizes
the clinical manifestations of the disease.
3) Identify, interpret and understand laboratory examination and
diagnostic tests indicated and its significant finding.
4) Understand the anatomical parts and explain the nature and
identify the cause, disease process and manifestation of the disease.
5)Utilize the nursing process in the delivery of cared based in the
clients needs and concerns.
6) Enumerate and analyze the drugs that have been administered to
the patient.
7) Provide information on the prognosis and discharged planning
intended to the patient condition.
PATIENT’S
PROFILE
• NAME: Child X
• AGE: 16 years old
• SEX: Female
• DATE OF BIRTH: January 19, 1992
• CIVIL STATUS: Teen
• ADDRESS: Brgy. Look Balete Batangas
• NATIONALITY: Filipino
• RELIGION: Roman Catholic
• DATE OF ADMISSION: December 5, 2008
• PHYSICIAN: Dr. Arellano,Dr. Gonzales and Dr. Reyes
• CHIEF COMPLAINT: Abdominal pain
• ADMITTING DIAGNOSIS. Pancreatic Pseudocyst s/s explore by acute
hemorrhologic pancreatitis.
• FINAL DIAGNOSIS: Pancreatic Pseudocyst
 CLINICAL
APPRAISAL
A. Past Health History

Ms. X have completed the childhood immunization. She was operated

for acute hemorrhologic pancreatitis on October 1, 2008. She stayed in the
hospital for 10 days and was discharged improved. However she came
back about a week later with symptoms of obstruction. An ultrasound was
taken which showed a pancreatic pseudocyst. Alimentation was advised. A
few days ago, a request ultrasound showed an increase of the size of the
mass. She is coherent to undergo a CT scan of the abdomen often with
note surgery to drain the pseudocyst is contemplated.

B. Family History

Her father is a security guard and her mother is a plain housewife. She
has 2 brothers and 3 sisters. They have a history of disease hypertension,
hypotension and cancer of the bone in mother side.
C. Personal History

Ms. X is a 16 year old who finished a high school degree only.

Before her hospitalization, she has been working in a small store as a
cashier.
According to her she’s fun of eating sour and salty foods, she
added that she even drink the vinegar after eating the snacks. She
also loves drinking soft drinks.
When Ms. X was high school, she was a honor student. Therefore
she sleep for 4-5 hours only because she studied her lesson well.

D. Social History

Their house are made of cement and woods. They have only four
neighbors. They welcomed all persons on their house especially their
relatives. They believe in “anting-anting” for them to have a healthy
life.
E. Psychological History

Her major stressor is the duration of her hospitalization. She felt

bored in the hospital. She wants someone to talk.
For her to cope up her stressor, she talks to every person that she
met. Like the other patient in the hospital and also a student nurse like
me.

F. History of Present Illness

Three months PTA Ms. X developed abdominal pain vomiting, fever,

anorexia, persistent of abdominal pain is prompted consults.
Second months PTA , she had an operation at BRH, after one week of
discharged from the hospital she had dehydration and was returned to
the hospital.
GENERAL
SURVEY
 As the assessement revealed for the general appearance
the findings was she has a poor body coordination and it is
abnormal that affects body movement and posture. Her body
becomes either very floppy or very stiff because of her
condition. The body and breath odors I found out that she is
having a foul mouth odor that can result from poor oral hygiene,
or suffer from different tooth problem. About the psychological
presence, she was clean and neat and dress properly. When I
talked to her she’s so cooperative that she’s the one who wants
to talked everything about her life. But she’s distress when we
talked about her operation.

The vital sign was taken, temperature 36.1, 36.6, 36.1, blood
pressure 90/70, 100/70, 100/60, pulse rate 74, 76, 69, respiratory
rate 25, 27, 25 and her height is 153 and weight is 24.8 kg.
 PHYSICAL
ASSESSMENT
 BODY PARTS METHOD FINDINGS ANALYSIS

Skin >Inspection >Skin tones >Normal

>Poor skin turgor >Abnormal. It

indicates
dehydration,
malnutrition
Or lack of fluid in the
>Absence of edema tissue.

>Palpation >Not tender >Normal

Hair >Inspection >Short and black >Normal

with normal
distribution >Normal
>Scalp >Inspection
>Clean and dry >Normal
 BODY PARTS METHOD FINDINGS ANALYSIS

>Inspection >No abrasion >Normal

Nails >Pink tones >Normal

>Long and dirty >Abnormal. Dirty,

nails broken or jagged
fingernails may be
seen poor hygiene.
They may also result
from clients hobby
>Inspection or occupation.
Head
>Palpation >Symmetrical >Normal

>Absence of masses >Normal

or nodules
 BODY PARTS METHOD FINDINGS ANALYSIS

Face >Inspection >Facial features & >Normal

facial movements
are symmetrical

Neck >Inspection & >No enlargements of >Normal

Palpation lymph nodes

Shoulders >Inspection >Does not use >Normal

muscles when
breathing

Thyroid Gland >Inspection & >No enlargement of >Normal

Palpation the thyroid gland
 BODY PARTS METHOD FINDINGS ANALYSIS

Eyes

>Eyebrow >Inspection >Symmetrically >Normal

aligned

>Equal movements >Normal

>Hair evenly >Normal

>Eyelashes >Inspection distributed

>Normal distribution >Normal

>Conjunctiva >Inspection >Bulbar conjunctiva >Normal

 BODY PARTS METHOD FINDINGS ANALYSIS

>Pupillary reaction >Inspection >Constricting & >Normal

dilating

Ear >Inspection >Auricles are >Normal

mobile, firm & not
tender
>Normal
>Symmetrically
aligned

>Color of the >Normal

auricles is same as
the face
 BODY PARTS METHOD FINDINGS ANALYSIS
>With yellow >Abnormal. Foul
discharge smelling, sticky,
yellow discharge_
otitis, external or
impacted foreign
body. Due to poor
hygiene practices.

>Palpation >Pinna recoils after >Normal

pinna is being folded

Nose >Inspection >No discharge >Normal

>Palpation >Not tender >Normal

 BODY PARTS METHOD FINDINGS ANALYSIS

Sinuses >Palpation >Frontal & maxillary >Normal

sinuses are not
Mouth tender

>Lips >Inspection >Dry with cracks >Abnormal. Dry lips

indicates
dehydration.

>Teeth >Inspection >With yellow >Abnormal. Due to

cavities oral hygiene
practices.

>Tongue >Inspection >Dry >Abnormal. It

indicates
dehydration.

>Moves freely >Normal

 BODY PARTS METHOD FINDINGS ANALYSIS

>Palpation >Tongue at midline >Normal

>Not tender >Normal

>Uvula >Inspection >presence of uvula >Normal

Chest & Lungs >Inspection & >Does not use >Normal

Auscultation accessory muscles
when breathing

>Palpation >No tenderness or >Normal

pain

>Thorax >Inspection >Normal chest >Normal

configuration
 BODY PARTS METHOD FINDINGS ANALYSIS

>Depth >Auscultation >Regular rhythm >Normal

Heart >Inspection >76 beats per >Normal

minute
(Normal 50-90)

Abdomen >Inspection & >Asymmetrically >Abnormal. Due to

Palpation abdominal mass

>With reddish scar >Abnormal.

Redness indicates
inflammation
BODY PARTS METHOD FINDINGS ANALYSIS

>With 8 inches >Abnormal. Results

keloid from surgery.

>Severe tenderness >Abnormal. Related

or pain @ Right to abdominal mass.
lower quadrant

>Percussion >Mass detected >Abnormal. Related

to abdominal mass.

>Dull sound heard >Abnormal.

Dullness may be
caused by a mass,
tumor, pregnancy,
ascites or a full
intestine.
 BODY PARTS METHOD FINDINGS ANALYSIS

Umbilicus >Inspection >Dirty >Abnormal. Due to

poor hygiene
Upper Extrimities practices.

>Hands >Inspection & >Strong grip >Normal

Palpation
>Presence of IV >Abnormal. Fluids
D5Lr regulated at are regulated to
KVO replace losses and
aid immobilization of
secretions.

>Pulse >Palpation >Distal pulses are >Normal

palpable
 BODY PARTS METHOD FINDINGS ANALYSIS

>Nail beds >Inspection >Pink tones >Normal

>Capillary refill >Normal

every 2-3 seconds
(Normal 2-3
seconds)

Lower Extremities >Inspection & >No edema >Normal

Palpation
 SUMMARY
OF
PHYSICAL
ASSESSMENT
 Child X, the subject of the study is diagnosed with Pancreatic
Pseudocyst. Physical Appearance of the patient was assessed
through inspection, palpation, percussion and auscultation. This will
serve as a baseline guide to recognize the signs and symptoms of the
disease.
She has a poor skin turgor that indicates dehydration or
malnutrition. She has a long and dirty nails that indicates poor
hygiene may be result from her hobby.
Upon inspecting the ear she has a yellow discharge. Foul
smelling, sticky, yellow discharge or otitis, external or impacted
foreign body. Due to her poor hygiene practices. Her lips and tongue
was dry indicates dehydration. She also have a yellow cavities due to
her oral hygiene practices.
 Upon inspecting and palpating the abdomen she has abdominal
mass, with reddish scar that
redness indicates inflammation. She also have a 8 inches keloid
from her last operation.
she suffer from severe tenderness or pain at right lower quadrant
related to abdominal mass. When I percussed her abdomen I heard a
dull sound that may be caused by her mass. Her umbilicus was also
dirty due to poor hygiene practices.
Presence of D5ILR regulated at KVO was also noted to replace
losses and aid to immobilization of secretions.
LABORATOTY
RESULTS
 Ultrasound Nov. 26 2008
Examination Requested
Whole abdomen UTS

Report

Follow whole abdominal ultrasound since Oct. 19, 2008.

Liver is normal in size. Parenchymal echo pattern is homogenous. No

facial mass is seen. Intrahepatic ducts is
not dilated.
Gall bladder is normal in size and wall thickness. No intraluminal
echoes seen. Proximal common ducts is not
dilated and measures 0.3 cm.
There are two wall defined a necrosis structures seen at the mid upper
abdomen which are intimate to the
anterior surface of the pancreas measuring approximately 4.4 x 4.9 x 4.8
cm.
 Medium level echoes and some septations, are seen with in the
cystic structures.
Spleen is normal in size and echopattern with no focal solid or cystic
nodule seen.

Both kidneys are normal in size and echopattern. The right kidney
measures 7.1x2.3 cm
withcortical thickness of 0.78 cm, while the left kidney measures 10.6x4.5
cm with cortical
thickness of 1.7 cm. No stone mass or hydronephrosis seen.
Uterus is anteverted normal in size measuring 4.7 x 2.2 cm.
Myocardial echopattern is
homogenous. No focal mass is seen. Endometrial lining is not thickened
and measures 0.7 cm.
 The abdominal aorta is not dilated and measures 0.76 cm in its
widest diameter.
Urinary bladder is well distended it’s wall is not thickened. There is no
stone or mass seen.
There is a well defined cystic structure at the left adnexa which
measures 3.8x3.0x3.o cm. Leveling fluid and hyperechoic structure is
seen with in the cyst probably fat fluid density.

IMPRESSION
Two anechoic structures detected at upper mid abdomen intimate to
the anterioir surface of the pancreas. This may relate to pseudocyst
of the pancreas, differential diagnosis is marked distended stomach
and duodenum bulb. Correlation with abdominal CT scan with oral
contrast is suggested.
 SURGICAL PATHOLOGY REPORT

Attending Physician: Dr. Apalisok

Specimen: Appendix and Omentum
Dtae received:10/03/08
Date completed:10/07/08

Final Pathologic Diagnosis

A. Fta Necrosis with congestion, omentum
B. B. Congestion, appendix
Gross microscopic descriptions

Gross description:
Received two specimen
A. The labeled “omentum” consists of a yellow fragment of
fibroadipose tissue measuring 4.5x3x1 cm. There is a few cream
while nodules at the surface cut sections show yellow doughy
surface.

Block 5(2)

B. The specimen consists of an appendix measuring 4x0.5x0.5 cm

with brown smooth
serosa. Cut sections show 0.4 cm walt thickness with 0.2 cm luminal
diameter. Block 3(1).
Microscopic Description
A. Histological sections reveal mature adipocytes with dilated
vessels. Focal fat necrosis is
noted.
B. Histological sections reveal appendix with dilated vessels at the
serosal surfsce.
Dec. 9, 2008 HEMATOLOGY

TEST RESULTS NORMAL ANALYSIS

Erythrocytes 4.08 10 ^12L Female: 4.2-5.4 Normal

Hemoglobin 120.5 g/L Female: 120-140 Normal

Hematocrit 0.364 % Female: 0.38-0.47 Normal

Leukocyte 5.78 10 ^9/L 4.5-11 Normal

Neutropil 0.339 % 50-70 % Decrease. Folic acid

deficiency

Eosinophils 0.087 % 0-O.7x10 9/L Eosinophilia

Basophils 0.003 % 0.5-1.0 % Decrease. Anemia

plastic

Lymphocytes 0.492 % 25-35 % Lymphopenia

 TEST RESULTS NORMAL ANALYSIS

Monocyte 0.79 % 4-6 % Increase.

Anemias:sickle cell/
hemolytic

Thrombocyte 285 10 ^9/L 150-400 Normal

MCH 29.57 27-31 Normal

MCV 89.25 80-96 Normal

MCHC 0.33 0.32-0.36 Normal

RDW 11 % 11.5-14.5 % Normal

MPV 7 7.4-10.4 % Decraesed. Wiskott

Aldrich syndrome
 CLINICAL CHEMISTRY REPORT

TEST RESULT REFERENCE ANALYSIS

RANGES

Chemistry

Creatinine 26.20 Umol/L 53.1-115.0 Decreased.

Females have a
slightly lower
values because
of their lesser
muscle mass.

Remarks
Troponon I: Hba/C (N.V. 4.5-6.3 %) Typhidot H. Pylori
 SUMMARY
OF THE
LABORATORY
RESULT
 As the laboratory exam has been released I found some
abnormalities in the blood. The neutrophil was decreased that may
caused a folic deficiency. The eosinophil indicates eosinophilia and
the basophil is decreased indicates anemia plastic. The lymphocytes
indicates lymphopenia.

The monocytes is increased indicates anemias= sickle cell or

hemolytic. The MPV is decraesed indicates Wiskott Aldrich syndrome.

The creatinine is decreased because females have a slightly lower

values because of their lesser muscle mass.
 ANATOMY
AND
PHYSIOLOGY
 The digestive tract (also known as the alimentary canal) is the system
of organs within multicellular animals that takes in food, digests it to
extract energy and nutrients, and expels the remaining waste. The major
functions of the GI tract are ingestion, digestion, absorption, and
defecation. The picture to the right doesn't show the Jejunum. The GI tract
differs substantially from animal to animal. Some animals have multi-
chambered stomachs, while some animals' stomachs contain a single
chamber. In a normal human adult male, the GI tract is approximately 6.5
meters (20 feet) long and consists of the upper and lower GI tracts. The
tract may also be divided into foregut, midgut, and hindgut, reflecting the
embryological origin of each segment of the tract.

The first step in the digestive system can actually begin before the
food is even in your mouth. When you smell or see something that you just
have to eat, you start to salivate in anticipation of eating, thus beginning
the digestive process. Food is the body's source of fuel. Nutrients in food
give the body's cells the energy they need to operate. Before food can be
used it has to be broken down into tiny little pieces so it can be absorbed
and used by the body. In humans, proteins need to be broken down into
amino acids, starches into sugars, and fats into fatty acids
and glycerol.
 Pancreas
The pancreas is located posterior to the stomach and in close
association with the duodenum. The pancreas is a 6-10 inch elongated
organ in the abdomen located retro peritoneal. It is often described as
having three regions: a head, body and tail. The pancreatic head abuts the
second part of the duodenum while the tail extends towards the spleen.
The pancreatic duct runs the length of the pancreas and empties into the
second part of the duodenum at the ampulla of Vater. The common bile
duct commonly joins the pancreatic duct at or near the point.

The pancreas is supplied arterially by the pancreaticoduodenal arteries,

themselves branches of the superior mesenteric artery of the hepatic
artery (branch of celiac trunk from the abdominal aorta). The superior
mesenteric artery provides the inferior pancreaticoduodenal arteries
while the gastroduodenal artery (one of the terminal branches of the
hepatic artery) provides the superior pancreaticoduodenal artery. Venous
drainage is via the pancreatic duodenal veins which end up in the portal
vein. The splenic vein passed posterior to the pancreas but is said to not
drain the pancreas itself.
 The portal vein is formed by the union of the superior mesenteric
vein and splenic vein posterior to the body of the pancreas. In some
people (as many as 40%) the inferior mesenteric vein also joins with the
splenic vein behind the pancreas in others it simply joins with the
superior mesenteric veininstead.

The function of the pancreas is to produce enzymes that break down

all categories of digestible foods (exocrine pancreas) and secrete
hormones that affect carbohydrates metabolism(endocrine pancreas).

The pancreas is near the liver, and is the main source of enzymes for
digesting fats (lipids) and proteins - the intestinal walls have enzymes
that will digest polysaccharides. Pancreatic secretions from ductal cells
contain bicarbonate ions and are alkaline in order to neutralize the acidic
chyme that the stomach churns out. Control of the exocrine function of
the pancreas are via the hormone gastrin, cholecystokinin and secretin,
which are hormones secreted by cells in the stomach and duodenum, in
response to distension and/or food and which causes secretion of
pancreatic juice.
DIGESTIVE SYSTEM
Variations in Embryology of pancreas Arterial supply to the pancreas
portal And duct variation.
Venous antomy.
Venous drainage Lymphatic supply to the Innervation of the pancreas
From the pancreas pancreas
PATHOPHYSIOLOGY
 PANCREATIC PSEUDOCYST

Non modifiable Acinar cell injury

Modifiable factor
factor

Viral infection, drugs, ischemia, Socio economic status

Hereditary lifestyle
Gender direct trauma
Lipase leakage

Inflammation of edema
Fat necrosis

Increased pressure Tissue necrosis

Rupture of duct
Trypsin leakage Erosion of
Hemorrhage pseudocyst
into
vascular
structure
Acute renal failure MODS
DEATH Hypovolemic shock ARDS
Acute liver failure acute renal tubular
Necrosis
 SUMMARY
OF
PATOPHYSIOLOGY
 The specific inciting factors causing pancreatitis remain to be
elucidated. Pancreatitis may be induced by primary acinar cell injury
as a result of viral infections, drugs, ischemia, and direct trauma.
Pancreatitis may originate from a disruption of the ductal system
and subsequent excretion of digestive enzymes from the acinar cells
of the pancreas. Normally these cells release inactive enzymes into
collecting ducts, which then drain into the main or accessory
pancreatic ducts emptying directly into the duodenal lumen. If
obstruction or disruption of these ducts occurs, the pancreatic
secretions are activated within the parenchyma of the pancreas and
initiate autodigestion of the pancreatic tissue.
 Interstitial edema is an early finding. Exacerbation of pancreatitis
may result in pancreatic necrosis, blood vessel occlusion or
disruption inciting hemorrhage, and systemic inflammatory response
syndrome with multiorgan failure. Collections of pancreatic
secretions often become walled off by granulation tissue to form a
pseudocyst either within or adjacent to the pancreas. Predominantly,
the pseudocyst is localized in the lesser sac behind the stomach. The
stomach, duodenum, colon, small bowel, or omentum may abut or
form part of the pseudocyst capsule.
NURSING CARE
PLAN
ASSESSMENT NURSING DIAGNOSIS

Subjective: >Acute pain related to mass in the abdomen

“Kaninang umaga
masakit lang, mas Medical-Surgical Nursing Brunner and Suddarath’s
sumasakit pag 6th edition
tumatagal,
Pero kaya ko pa naman”

Objective:
>facial grimace connotes pain
P-lying & sitting position
Q-stabbing pain
R-left hypochondriac region
S-6 scale
T-constant
SCIENTIFIC EXPLANATION PLANNING

>Due to mass in the abdomen, the patient may experience, >After 1hr of nursing intervention,
severe pain and discomfort even with minimal the clients level of pain will be
movement. minimized.
Pseudocyst and abscesses in & around the pancreas
may occur as a result of localized necrosis, & may exert
pressure on the stomach or colon.
Medical-Surgical Nursing Brunner and Suddarath’s 6th
edition
INTERVENTION
>Obtained pain history from
patient/ family and patient’s
ability to handle pain.
>Assessed patient for pain
level.
>Instructed patient to report
pain as it develops rather
than visualization level is
severe.
>Encouraged verbalization of
feeling.
>Determined the location,
frequency , duration and
intensity of pain.
>Encouraged to use of
relaxation techniques like
deep breathing exercise.
>Performed palliative
measures (e.g.
repositioning)
RATIONALE EVALUATION
>Pain is specific to each individual and >The client’s level
each person has their own coping of pain is
strategies to deal with their comfort. minimized as
>Helps to establish plan of care and evidenced by
shows concern for the patient. pain scale
>Efficiency of comfort measures and decreases 2/6.
medication is improved with timely
intervention.
>Can reduce anxiety and for there by
reduce perception of intensity of pain.
>Information provides baseline data and
evaluate needed for effectiveness of
intervention.
>Enables client to participate actively in
non-drug treatment of pain and
enhances sense of control.
>May relieve pain and enhance
circulation.
INTERVENTION
>Provided accurate, concrete
information about what is being
done. E.g. sensation the expect,
usual procedures under taken.
>Provided calm, quite environment.
>Helps reduce fears of going through a >Helps go to deal with own anxiety that can be
frightening experience alone.
Provide opportunity for so to
express feelings/concerns.
RATIONALE
>Involves in a patient plan of care and decreases
unnecessary anxiety about unknown.
>Removing patient from outside stressors promotes
relaxation may enhance coping skills.
>Encourage significant other patient as able.
>respond to call signal promptly, use touch and eye
contact as appropriates.
transmitted to patient. Promotes a supportive
attitude that can facilitate recovery.
Nursing Care Plan Guidelines for Individualizing Client
Care Across Lifespan
ASSESSMENT NURSING DIAGNOSIS

Subjective: Boredom related to long hospital stay

“Gusto ko ng umuwi nakakainip”

Ojective:
>restless
>irritable
>unsuccessful social interaction behavior
SCIENTIFIC EXPLANATION PLANNING

It is always a factor that trigger the mood of a person. After 2 hours of nursing intervention the
patient will be able to cope with her
present condition.
INTERVENTION RATIONALE EVALUATION

>Provide structured >Provides continuity of care The patient was able

environment with daily to cope her present
routines. condition as
>Encouraged verbalization of >Establishes a therapeutic relationship. verbalized by
concerns. Assist patient in Assist patient in dealing with feelings, successful social
experiencing feelings by and provides opportunity to clarify interaction.
Active Listening. misconception. Acknowledge that this
is a fearful situation and that others
have expressed similar fears.
>Provided frequent rest >Fatigue and sensory overload increases
periods and decreases confusion.
sensory stimuli.
>Determined coping >To note how these behaviors affect
mechanism used. current situation.
>Observed interactions with >To note difficulties or ability to establish
others. satisfactory relationship.
INTERVENTION
>Conveyed attitude of acceptance and
respect.
>Encouraged control in all situation
possible, include client in decision
and planning.
>Instructed family to assist with
reorientation as needed.
>Encouraged client to learn relaxation
techniques, use guided imagery an
positive affirmation of self.
RATIONALE
>To avoid threatening client’s self-concept, preserve
existing self-esteem.
>To preserve autonomy.
>Involves family in care. Patient may be more trusting
of family members.
>In order to incorporate and practice new behavior.
NANDA
Nursing Care Plan Guidelines for Individualizing Client
Care Across Lifespan
ASSESSMENT NURSING DIAGNOSIS

Subjective: Readiness for enhanced self-concept related to

“Sa 18 na ang opera ko, dito na ako the acceptance of the condition
magpapasko”

Objective:
>happy
>calm
>relax
>sitting comfortably
SCIENTIFIC EXPLANATION PLANNING

Acceptance of the condition may help for fast After 2 hours of nursing intervention the
recovery patient will verbalized the understanding
of own sense of self-concept.
INTERVENTION RATIONALE EVALUATION

>Determined current status of >Self-concept consists of the physical The patient

individual’s belief about self, personal identity and self-esteem, verbalized sense of
self. and information about client’s current self-concept, as
thinking about self provides as verbalized by “handa
beginning for making changes to naman ako sa
improve self. operasyon”
>Determined availability or >Presence of supportive people who
quality of family support. reflect positive attitudes regarding the
individual promotes a positive sense of
self.
>Noted willingness to seek >Individuals who have a sense of their
assistance, motivation for self-image and are willing to look at
change. themselves realistically will be able to
progress in the desire to improve.
>Developed therapeutic >Promotes trusting situation in which
relationship. client is free to be open and honest
with self and others.
INTERVENTION RATIONALE

>Accepted client’s perception or >Avoids threatening existing self-esteem and provides

view of current status. opportunity for client to develop realistic plan for
improving self-concept.
>Discussed what behavior does >Encouraged thinking about what inner motivations are and
foe client. what actions can be taken to enhance self-esteem.
>Given reinforcement for progress >Positive words of encouragement support development of
note. effective coping behaviors.
>Allowed client to progress at own >Adaptation to a change in self-concept depends on it’s
rate. significance to the individual and disruption to lifestyle.
>Emphasized importance of >Looking your best improves sense of self-esteem and
grooming and personal presenting a positive appearance enhances how others
hygiene. see you.
>Prepared patient and family >Operation are required and family must be prepared.
members for the operation.
NANDA

Nursing Care Plan Guidelines for Individualizing Client Care

Across Lifespan
DRUG STUDY
 MECHANISM OF
NAME OF DRUG INDICATION CONTRAINDICATION
ACTION
GENERIC NAME: >proton pump inhibitor >Patologic >Contraindicated in
Omeprazole >inhibits activity of acid hypersecretory patients
BRAND NAME: (proton) pump and condition hypersensitive to
Omeprazole binds to hydrogen- >Duodenal ulcer drug or its
Magnesium potassium denosine >Short term treatment components.
Route: triphosphatase at of active benign
Oral secretory surface of gastric ulcer
Dosage: gatric parietal cells to
40mg block formation of
Frequency: gastric acid.
OD
 ADVERSE REACTION NURSING RESPONSIBILITY MONITORING PARAMETERS
> CNS: dizziness, headache >Drug increases its own >None reported.
> GI: vomiting, nausea bioavailability with repeated
>Skin: rash doses.
>Respiratory: >Don’t confuse Prilosec with
cough Prozac, Prilocaine or Prinivil.
 MECHANISM OF
NAME OF DRUG INDICATION CONTRAINDICATION
ACTION
GENERIC NAME: >Diphenylmethane >Chronic >Contraindicated in
Bisacodyl derivative constipation; patients hypersensitive
BRAND NAME: >Stimulant laxative preparation for to drug or it’s
Dulcolax that increases childbirth, surgery, components and in
Route: peristalsis, or rectal or bowel those with rectal
Oral probably by direct examination bleeding,
Dosage: effect on smooth gastroenteritis,
2 tabs muscle or intestinal, abdominal
Frequency: stimulating the pain, nausea, vomiting,
OD colonic intramural or other symptoms of
plexus. Drug also appendicitis or acute
promotes fluid surgical abdomen.
accumulation in
colon and small
intestine.
 ADVERSE REACTION NURSING RESPONSIBILITY
> CNS: dizziness, faintness >Give drug at times that don’t
> GI: vomiting, nausea interfere with scheduled
>Metabolic: alkalosis, activities or sleep. Soft, formed
hypokalemia stools are usually produced 15
to 60 minutes after rectal use.
>Before giving for constipation,
determine whether patient has
adequate fluid intake, exercise
and diet.
MONITORING PARAMETERS
>May be increase phosphate
and sodium levels. May
decreased calcium,
magnesium and potassium
level.
 MECHANISM OF
NAME OF DRUG INDICATION CONTRAINDICATION
ACTION
GENERIC NAME: >Adrenocorticoid >Severe >Contraindicated in
Prednisone >Decreases inflammation, patients hypersensitive
BRAND NAME: inflammation, immuno to drug or it’s
Apo- mainly by suppression components and in
prednisoneRout stabilizing; those with systemic
e: suppresses fungal infection, and in
Oral immune reponse, those with receiving
Dosage: stimulates bone immunosupressive
2 tabs marrow; and doses together with live-
Frequency: influences protein, virus vaccines.
OD fat, and
carbohydrate
metabolism.
 ADVERSE REACTION NURSING RESPONSIBILITY MONITORING PARAMETERS
>CNS: headache, vertigo >Determine whether the patient is >May increase glucose and
>CV: heart failure sensitive to corticosteroids. cholesterol levels. May
> GI: peptic ulcer and >Drug maybe use d for alternate-day decreases T3 T4 potassuim
pancreatitis therapy. and calcium level.
>Metabolic: hypokalemi >Always adjust to lowest effective
>Skin: various skin dose.
eruption
PROGNOSIS
 The prognosis is good because the surgery was successful and
the patient was able to do some of her activities in daily living.

Because of the continuous care that is given to the client, Child

X’s condition has improved.
DISCHARGE
PLANNING
M
Instructed the significant others to give home medications
that the physician will prescribe upon discharge.
>Omeprazole 40 mg OD
>Dulcolax 2 tabs OD
>Prednisone 2 tabs OD
E
Avoid strenuous activities due to surgery. Emphasized the
importance of quiet and healthy environment.
T
Encouraged the patient to take the medicine on time and
take the medicine after meal.
H
>Advised the patient and the mother to provide good
hygiene like cleaning the nails and ears.
>Advised the significant others to provide good personal
hygiene of the client.

O
Encouraged to have a follow-up check-up after one week to
Dr. Arellano, Dr. Gonzales and Dr. Reyes.
D
Advised the patient to eat foods rich in protein ,
carbohydrates and calcium. Avoid eating sour and salty
foods. Avoid also too much soft drinks and increase fluid
intake.

S
Advised whole family to keep their faith in GOD and never
forget to ask guidance and support from our Lord.
ACKNOWLEDGEMENT
 I would like to extend my heartfelt thanks to the following people
that with their presence, the accomplishment of this case study and
presentation will not be possible.
To the Almighty One for giving me the strength, knowledge and
power.
To my parents and friend for continuously supporting me
financially and emotionally.

To my clinical instructor Mrs. Iturralde for professionally guiding

us throughout the accomplishment study and for spending time and
ideas with us.
To the staff of the IMC for letting me, lend books and assisting
me in all I needs without hesitations.
To my classmate for their cooperation and for giving extra
information even in the smallest thing that they know.
 THANK YOU
VERY MUCH
AND GOD BLESS
BIBLIOGRAPHY
Applying Nursing Process, Alfaro- Le Fevre Rosalinda, pg. 207
Current Diagnosis and treatment,Marcus A.Krupp and Milton J. Chatton
Delmar’s Pediatric Nursing Care Plans, 3rd edition,Luxner
Health Assesment & Physical Examination, Estes
Health Assesment in Nursing 3rd edition, Janet Weber & Jane Kelley
Human Anatomy and Physiology, Hole,Jr,et.al, 6th edition.
Ignatius, et.al.
Laboratory and diagnostic tests with nursing implications Seventh Edition,Joyce
Medical-surgical nursing, Smeltzer,et al.
Medical- Surgical Nursing Critical Thinking for collaborative care, vol.1,5th edition,
Medical-Surgical, 6th edition, Burner et al, pg 468-469
MIMS 107th edition 2006
Medical-Surgical Nursing, Brunner and Suddharts, Smeltzer,vol.1 & 2
Nursing Care Plan,7th edition, Doenges, et.al
Nurses’ Pocket Guide 11th edition, by Donges et. Al.
Nursing Care Plans; 6th edition, Donenges et. Al, pg. 130.
Nursing Care Plan, Meg Gulanck,et. Al, pg. 3
Pediatric Nursing Care Plan, Axton, et. Al, pg. 296-300
NURSING
PROCESS
 The nursing process is an organized, systematic approach used
by medical-surgical nurses to meet the individualized health care
needs of their clients, families and communities. The term nursing
process emerged in the mid-1960s. As nursing became more
recognized and respected as a profession, there was a growing need
to define more clearly what nurses do.
 OBJECTIVE

Identify the steps of the nursing process

Nurses apply the Nursing Process as a competency when
delivering care
This is a DYNAMIC, CONTINUOUS process which allows for a
nurse to modify care as needed
 PURPOSE

Purpose: A nurse follows the nursing process to organize and

deliver nursing care
Use of the process allows the nurse to integrate elements of
critical thinking to make judgments and take actions based on reason
The nursing process is a variation of scientific reasoning that
allows nurses to organize and systematize nursing practice
 STEPS
OF THE
NURSING PROCESS
 STEPS

I. Assessment
II. Nursing diagnosis
III. Planning
IV. Implementation
V. Evaluation
ASSESSMENT
 ASSESSMENT

This is the first step of the nursing process. It involves the

systematic and continuous collection, validation (evaluation) and
selection of data. Data is collected from a variety of sources (clients,
families, health records, physicians, nurses, and other healthcare
professionals). Data collection guidelines reflect the CSUB
Department of Nursing Conceptual Model. Activities
include: (1) establishing the database (nursing history, physical
assessment, review of the patient/client’s record and nursing
literature, and consultation with patient/client’s support persons and
healthcare professionals); (2) continuously updating the database;
(3) validating data; and (4) communicating data.
 TWO STEPS OF NURSING ASSESSMENT

1. Collection and verification of data from a primary source (client)

and secondary sources (family, health professionals, medical record)
2. Analysis of all data as a basis for developing nursing diagnoses
and an individualized plan of care for the client
Assessment
• When beginning an assessment, it is helpful for the nurse to organize
the assessment process and determine which data must be collected
• Assessment data must be descriptive, concise, and complete
Types of data:
• – Subjective-client’s perceptions
• – Objective-observations or measurements made by the data
collector
 SOURCE OF DATA

• Subjective: from the client, family, significant others, health care

team members, and health records
• Objective: physical examination, diagnostic and laboratory test
results, pertinent nursing and medical literature
• Usually the client is the best source of information

Subjective-Client Interview
• Interview the client
• An interview is an organized conversation with the clients to obtain
the client’s health history and information about the current illness
 Phases of the interview-orientation, working, and termination
• Schedule interviews around interruptions if possible, and in a
conducive atmosphere
• Use open-ended questions, back channeling, problem seeking
interview techniques, and close ended questions for symptom
clarification
Nursing Health History

• The nursing health history is data collected about the client’s

current level of wellness, including a review of body systems, family
and health history, socio-cultural history, spiritual health, and mental
and emotional reactions to illness
• Obtained during an interview
 NURSING HEALTH HISTORY-COMPONENTS

• Biographical Information
• Reason for Seeking Health Care
• Client Expectations
• Present Illness or Health Concerns
• Health History

• Family History
• Environmental History
• Psychosocial History
• Spiritual Health
• Review of Systems
 PHYSICAL EXAM
• Vital signs are taken
• Other objective measurements are taken
• (ht, wt, VS, general survey)

• All body systems are examined in a systematic manner

• head to toe physical examination of all body systems
• Assessment –Formulating Nursing Judgments
• The successful interpretation of assessment data requires critical
thinking
• After gathering data, the nurse validates the collected information to
ensure its accuracy
• After validating and interpreting assessment data, the nurse
organizes the information into meaningful clusters, keeping in mind
the client’s response to illness (a cluster is a set of signs or
symptoms that are grouped together in a logical order)
 NURSING
DIAGNOSIS
 NURSING DIAGNOSIS

From the assessment of functional health patterns human

response patterns are identified and classified according to
statements of actual, high risk and possible problems, and wellness
diagnoses (Carpenito, 1993). It requires data analysis to identify the
patient/client’s strengths and health problems that independent
nursing interventions can resolve. Activities include: (1) interpreting
and analyzing patient/client data; (2) identifying patient/client
strengths and health problems; (3) formulating and validating nursing
diagnoses; and (4) developing a prioritized list of nursing diagnoses.
 PURPOSE OF NURSING DIAGNOSIS
• Nursing diagnoses offer a language to promote understanding
between nurses about clients’ health problems to facilitate
communication and care planning
• Nursing diagnoses distinguish the nurse’s role from that of the
physician
• Nursing diagnoses help nurses to focus on the role of nursing in
client care
• Diagnostic Process
_ Includes decision-making steps
– Gathering the assessment database
– Validating data
– Analyzing and interpreting data
– Identifying client needs
– Formulating the nursing diagnoses
 FORMULATION OF THE NURSING DIAGNOSIS

• Actual nursing diagnosis: describes human responses to health

conditions/life processes that exists in an individual, family, or
community
• Risk nursing diagnosis: describes human responses to health
conditions/life processes that may develop in a vulnerable individual,
family, or community
• Wellness nursing diagnosis: describes human responses to levels
of wellness in an individual, family, or community that have a
readiness for enhancement
 NURSING DIAGNOSIS-COMPONENTS
• Diagnostic label-name of the nursing diagnosis as approved by
NANDA, often includes descriptors (nursing assessment data must
support the diagnostic label)
• Related factors-causative or other contributing factors that have
influenced the client’s actual or potential response to the health
problem, and can be changed by nursing interventions (related
factors must support the etiology)

• Definition-approved NANDA definition for each diagnosis following

clinical use and testing; the definition describes the characteristics of
the human response identified
• Risk Factors-environmental, physiological, psychological, genetic,
or chemical elements that increase the vulnerability of an individual,
family, or community to an unhealthful event
 SOURCE OF DIAGNOSTIC ERRORS
• Errors in data collection
• Errors in interpretation and analysis of data
• Errors in data clustering
• Errors in the diagnostic statement

Avoiding and Correcting Errors

• Identify the client’s response, not the medical diagnosis
• Identify a NANDA Int. diagnostic statement rather than the symptom
• Identify a treatable etiology rather than a clinical sign or chronic
problem
• Identify the problem caused by the treatment or diagnostic study
rather than the treatment or study itself
 MORE AVOIDING & CORRECTING ERRORS

• Identify the client response to the equipment rather then the

equipment itself
• Identify the client’s problems rather than the nurse’s problems
• Identify the client problems rather than the nursing intervention
• Identify the client problem rather than the goal
• Make professional rather then prejudicial judgments

More Avoiding and Correcting Errors

• Avoid legally inadvisable statements
• Identify the problem and etiology
• Identify only one client problem in the diagnostic statement
PLANNING
 PLANNING

Specification of client goals to promote health and/or prevent,

reduce, or resolve the problems that are identified in the nursing
diagnoses, and related nursing interventions. Implementation
strategies address the patient/client’s health state and aim to facilitate
attaining the desired outcomes. Implementation encompasses four
levels of care: preventive, supportive, restorative and
rehabilitative. Activities include: (1) establishing priorities; (2) writing
goals and developing an evaluative strategy; (3) selecting nursing
measures; (4) communicating the plan of nursing care.
 PLANNING
• Priorities are classified as high, intermediate, or low
• Goals: should be realistic and based on client needs and resources;
client participation in goal setting is ideal
• A client-centered goal is a specific and measurable behavior or
response that reflects a client’s highest possible level of wellness and
independence in function

Planning
• Short term goal: an objective that is expected to be achieved within
a short time frame, usually less than a week
• Long term goal: an objective that is expected to be achieved over a
longer time frame, usually over weeks or months
• Expected outcome: specific measurable change in a client’s status
that is expected to occur in response to nursing care
 GUIDELINES FOR WRITING GOALS

• Client centered
• Singular goal or outcome
• Observable
• Measurable
• Time-limited
• Mutual factors
• Realistic
 NURSING
INTERVENTION
 INTERVENTION

Implementing the plan of care. Activities include: (1) carrying out

the plan of care; (2) continuing data collection and modifying the plan
of care as needed; (3) documenting the care given.
 TYPES OF INTERVENTION

Nursing interventions are any treatment or action, based upon clinical

judgment and knowledge, that nurses perform to enhance clients’
outcomes
Three categories of nursing interventions:
• – Nurse-initiated interventions
• – Physician-initiated interventions
• – Collaborative interventions
 TYPES OF INTERVENTION
• Nurse-initiated interventions are the independent response of the
nurse to the client’s health care needs and nursing diagnoses.
• Physician-initiated interventions are based on a physician’s
response to treat or manage a medical diagnosis.
• Collaborative interventions are therapies that require the
knowledge, skill, and expertise of multiple health care professionals.
Choosing interventions
• The nurse does not select interventions haphazardly. The nurse
deliberates about six important factors:
1. characteristics of the nursing diagnosis
2. expected outcomes
3. research base, or nursing knowledge for interventions
4. feasibility of the intervention
5. acceptability to the client, and
6. competencies of the nurse
EVALUATION
 EVALUATION

Measures the extent to which the patient/client has achieved the

goals specified in the plan of care, and identifies the factors that
positively or negatively influenced goal achievement. The plan of
care is revised as necessary. Activities include: (1) measuring how
well the client has achieved the desired goals; (2) identifying factors
that contributed to the client’s success or failure; (3) modifying the
plan of care (if indicated).
NURSING CARE
PLAN
 NURSING CARE PLAN

• A nursing care plan is a guide for clinical care

• A written care plan is designed to direct clinical care and to
decrease the risk of incomplete, incorrect, or inaccurate care
• It is organized so that any nurse can quickly identify the client’s
nursing diagnoses, goals, and outcomes, and nursing interventions
to be delivered
• It can help identify and coordinate resources used to deliver
nursing care
 STUDENT CARE PLAN

• Nursing students learn to write and use a nursing care plan as part
of their education
• By using a nursing care plan, students can apply the knowledge
gained from nursing and medical literature and the classroom to a
practice situation
• The nurse enters a scientific rationale for a specific intervention
• Scientific rationale: the reason that, based on supporting literature,
a specific nursing action was chosen
THANK YOU MAM
GOD BLESS