Professional Documents
Culture Documents
College of Nursing
PRESENTED BY:
Katrene Lequigan
PRESENTED TO:
Ma. Liwayway Salcedo, RN
CLINCAL INSTRUCTOR
AUGUST 2010
Table of Contents
Introduction……………………………………………………………………………..
Client’s Profile………………………………………………………………………….
Socio-demographic data……………………………………………………..
Vital Signs……………………………………………………………………..
Physical Assessment………………………………………………………...
Pathophysiology………………………………………………………………………
Drug Studies…………………………………………………………………………
Discharge Planning…………………………………………………………………
Learning Experiences………………………………………………………………
References.......................................................................................................
Introduction
In choosing an individual case study was very easy to find and choose but
in making it was very hard. But in making ICS is not about only to pass
something or to do it for a requirement but the essential thing there is what you
learn and being contented and successful of what you have studied. For me in
choosing Rectal Prolapsed secondary to rectal new growth was very challenging.
I was very curious about the disease condition that’s why I choose it.
………………………………………………………..
This case study has come to realization with the primordial aim of
nursing interventions that would help bring back the patient to the normal health
status in a gradual stage. Nursing care has been rendered to patient for one-duty
Socio-demographic Data
Patient X’s age is 56 years old; her mobility status is limited due to her age
and condition. She requires special nutritional needs appropriate for her age –
low fat especially low saturated fats, and sugar. She also needs to eat
vegetables and fruits.
Vital Signs
Physical Assessment
This portion of the case study will present the deviation from the abnormal
findings of the physical assessment presented in a cephalo-caudal approach.
These data are then considered in the making of the nursing care plan.
Head
Eyes
Aspect of Consideration Findings
Conjunctiva Pale
Wears eyeglasses
Mouth
Skin
Texture Rough
Moisture Dry
Abdomen
Elimination Pattern
Pain
at the anal area during and after defecation and occasional abdominal
pain during bedtime
Sexuality-Reproductive Pattern
Pathophysiology
Predisposing
Precipitating Factors:
Factors: refer to
refer to figure B
figure A
Pathologic Report:
Rectal new growth
positive for
(neoplasm or Polyps)
malignancy
Invading of
Formation of muscularis mucosa, Invading of Fatty
bowel mass of regional lymph distant site liver
tissue arises nodes at the especially liver grade II
from bowel wall rectum, vascular
structure
Attack
immune
Anemia of
Protrudes into the system
intestinal track
lumen and grow lesion
slowly (large)
Partial
Constrict the obstruction
intestinal lumen
Electrol
yte
imbalan
ce Weig
ht
loss
Rectal
prolapsed
Gender: Recent studies Patient X’s gender Women are more prone to
found out that the female is female with 9 develop cancer than men.
is most commonly children
affected to it, with
multiple pregnancies
Laboratory Result
Hematology Report
8/3/10 8/8/10 8/9/10 8/12/10 8/13/10 8/17/10
5.0-10.0
10^3/uL
4.2-5.4
10^6/uL
17.4-48.2 %
Neutrophil 78.2
43.4-76.2 %
Monocyte 11.6
4.5-10.5 %
RDW-CV The RDW may also be useful in monitoring the results of hematinic
therapy for iron-deficiency or megaloblastic anemias.
Examination Results
8/3/10 8/12/10 8/17/10
APTT A prolonged PTT means that clotting is taking longer to occur than
expected and may be caused by a variety of factors (see the list below). Often,
this suggests that there may be a coagulation factor deficiency or a specific or
nonspecific inhibitor affecting the body’s clotting ability. Coagulation factor
deficiencies may be acquired or inherited. Several factors are Vitamin K
dependent. If a person has liver disease, for instance, or more rarely a Vitamin K
deficiency, he may have one or more factor deficiencies. Inherited factor
deficiencies may affect the quantity and/or function of the factor produced.
PROTIME The prothrombin time (PT) test measures how long it takes for a clot
to form in a sample of blood. In the body, the clotting process involves a series of
sequential chemical reactions called the coagulation cascade, in which
coagulation or “clotting” factors are activated one after another and result in the
formation of a clot. Prothrombin is one of the coagulation factors produced by the
liver. One of the final steps of the cascade is the conversion of prothrombin
(factor II) to thrombin. The PT test evaluates the integrated function of the
coagulation factors that comprise the extrinsic and common pathways of the
coagulation cascade, including factors I (fibrinogen), II (Prothrombin), V, VII and
X. It evaluates the body’s ability to produce a clot in a reasonable amount of time
and, if any of these factors are deficient, the PT will be prolonged.
Clinical Data: Circumferential mass 5cm from the anal verge per
proctosigmoidoscopy findings: Scout film shows minimal gas filled bowel loops
within the abdomen without air fluid levels. The flank stripes and psoas shadows
are distinct. No definite mass, organomegaly and intra-abdominal calcification is
seen. Minimal spurs are seen along the lumbar spine margins. The rest of the
visualised osseuos structures are intact.
Subsequent fillins following introduction of barium mixture into the ano via
F24 catheter show ascert of barium from the rectum up to the cecum with
minimal passage into the terminal ileum (as visualised in the decubitus study).
There is a large mucosal irregularity with shouldering pattern with approximate
widest diameter of 8cm noted in the rectum. No other mucosal irregularity, mass
lesion effect is seen.
Impression:
3. Lumbar spondylosis
• chronic diarrhea.
• blood in stools.
• constipation.
• irritable bowel syndrome.
• unexplained weight loss.
• a change in bowel habits.
• suspected blood loss.
• abdominal pain.
Images of the small bowel and colon are also used to diagnose inflammatory
bowel disease, a group of disorders that includes Crohn's disease and ulcerative
colitis.
Findings:
Pancrease is unremarkable.
Diagnosis:
• kidneys
• liver
• gallbladder
• pancreas
• spleen
• abdominal aorta and other blood vessels of the abdomen
Doppler ultrasound images can help the physician to see and evaluate:
Discharge Planning
Medication
> Emphasis to take home medication consistently following the right drugs,
dosage, timing & frequency, and route.
Exercise
> It is best to start the exercise program slowly until you get stronger, also find a
suitable exercise program to suit your condition.
> Exercise is important this makes your heart stronger, lowers blood pressure,
and help keep your body healthy.
> Maintaining a regular exercise will help facilitate adequate blood flow for
nourishing different parts of the body and can help to increase peristaltic
movement.
> Exercise can reduce joint pain and fatigue. It can also increase ROM and
strength.
Treatment
> Have a regular check-up with your physician regarding with your condition for
any continuing treatment and medications.
Health Teachings
> Do regular exercises, eat right food, and take medications to enhance recovery
and healing as indicated by the physician.
Out Patient
> Regular check-up for monitoring of development and if there are presence of
complication.
Diet
Tips:
> Eat nutritious and healthy food, to avoid constipation. Eat foods such as
oatmeal, whole-grain breads and cereals, fruits (banana for decrease potassium
level) and vegetables.
> Drink at least 8-10 glasses of water a day; limit the amount of soda, tea and
coffee.
> Diets high in vegetables and high-fiber foods such as whole-grain breads and
cereals may rid the bowel of these carcinogens and help reduce the risk of
cancer.
Spirituality
>Tell the patient/client to pray for God, for him nothing is impossible. Ask for
inner strength to carry his trials
Learning Experience
In doing this case study, the essence of patience and hard working were
always there. Everything I have done entails patience, knowledge and skills in
doing research studies about the case. I have learned a lot about proper nursing
interventions, rendering care to my patients, regarding the disease conditions,
manifestations and a lot more. One should also need to analyze all the significant
data to know the relationship of other data.
While in the other hand, my experience in NMMC-Surgical Ward was
honestly a big and challenging experienced in my life. It was fortunate to have a
good relationship to my group mates, hospital staffs and to my beloved clinical
instructor as well. What happened in this rotation was a lot of new ideas, new
learning and new applications for my field. In the ward, I also learned a lot of new
procedures and I was totally amazed and proud to myself because I am confident
in doing some procedures in the ward. I admit that I have committed a couple of
mistakes, but what is more important is what I’ve learned from my mistakes.
I would like to thank, our ever grateful, God Almighty, thank you so much
for giving me strength to handle each situation confidently. To my dear CI,
Ma. Liwayway Salcedo, RN, thank you for being effective in the field. As a clinical
instructor, she emphasized the values of professionalism, respect and patience.
To my PCI that was patience and understanding, thank you Sir. To my beloved
parents who have shown support and understanding in all activities. And to the
Hospital Staffs who helped and guided me for this rotation.
References
http://www.google.com
http://www.yahoo.com
http://www.scrib.com
http://www.nursingcrib.com
http://www.wikipedia.com
http://www.webmd.com
http://www.emedicinehealth.com
http://www.medicinenet.com
http://web2.airmail.net/uthman/lab_test.html
http://www.radiologyinfo.org/en/info.cfm?pg=abdominus
http://medical-dictionary.thefreedictionary.com/Rectal+neoplasm
http://www.homehealth-uk.com/medical/polyps.htm
http://www.merck.com/mmpe/sec02/ch021/ch021g.html
http://www.procto-med.com/polyps-of-the-colon-and-rectum/
http://www.bestsyndication.com/?q=20080305_colorectal_polyps.htm
http://www.fascrs.org/patients/conditions/polyps_of_the_colon_and_rectum/
http://digestive.niddk.nih.gov/ddiseases/pubs/colonpolyps_ez/
http://www.healthline.com/galecontent/rectal-polyps/2
http://www.wrongdiagnosis.com/symptoms/rectal_prolapse/book-causes-20a.htm
http://emedicine.medscape.com/article/931455-overview
http://www.acg.gi.org/patients/women/rectal.asp
http://www.patient.co.uk/doctor/Rectal-Prolapse.htm
http://hcd2.bupa.co.uk/fact_sheets/html/rectal_prolapse.html
http://www.hemorrhoid.net/prolapse.php
http://www.embarrassingproblems.com/docspots/DocSpot-rectal-prolapse
http://www.umm.edu/ency/article/001132prv.htm
http://www.nlm.nih.gov/medlineplus/ency/article/001132.htm