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In Partial Fulfillment
Of The Requirements In
RELATED LEARNING EXPERIENCE
Case Study:
Inguinal Hernia
Submitted to:
Ms. Rose Elan Bundac, R.N.
Clinical Instructor
By:
Kristine Claire S. Quicho-SalvadorBSN-4Ma. Adelene Lagrada
BSN-3
July 27, 2005
Department of Nursing
HOLY TRINITY COLLEGE
Puerto Princesa City
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TABLE OF CONTENTS
Title Page . . . . . . . . . .1
Table of Contents . . . . . . . . .2
Introduction . . . . . . . . . .3
Approval Sheet . . . . . . . . .5
Significance of the Study . . . . . . . .6
Statement of the Problem . . . . . . . .7
Personal Information . . . . . . . . .8
Family History . . . . . . . . .8
Past Medical History . . . . . . . . .8
Present Condition . . . . . . . . .9
Physical Assessment . . . . . . . . .10
Laboratory Examinations . . . . . . . .11
Review of Anatomy & Physiology . . . . . . .13
Pathophysiology . . . . . . . . .14
Treatments . . . . . . . . . .15
Pharmacological Studies . . . . . . . .16
Summary of Findings . . . . . . . . .21
Nursing Care Plans . . . . . . . . .22
Conclusions . . . . . . . . . .28
Discharge Plans . . . . . . . . .29
References . . . . . . . . . .30
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INTRODUCTION
A hernia is the abnormal protrusion of an organ, tissue, or part of an organ
through the structure that normally contains it. Hernias frequently occur in the abdominal
cavity as a result of a congenital or acquired weakness of abdominal musculature.Hernias can occur at any age and in either sex. Indirect Inguinal hernias are the
most common type and typically occur in men. Direct hernias are found more commonly
in older adults. Incisional or ventral hernias occur most often in clients who had poorwound healing after surgery. Obese or pregnant clients are more likely to develop
umbilical hernias.
Two factors must be present for hernia to occur: (1) a defect in the integrity of the
muscular wall and (2) increased intra-abdominal pressure.Congenital muscle weakness is one risk factor combined with the factors that
increase intra-abdominal pressure. The muscle weakness cannot be prevented, but
exercise can strengthen the weak muscles. Because obesity is one cause of increased
intra-abdominal pressure, it can be prevented by weight control. Avoiding heavy liftingand straining also reduces intra-abdominal pressure. Early diagnosis is important to
prevent incarceration and strangulation.Defects in the muscular wall may be congenital owing to weakened tissue or a
wide space at the inguinal ligament, or may be caused by trauma. Intra-abdominal
pressure most commonly increases as a result of pregnancy or obesity. Heavy lifting also
causes increased intra-abdominal pressure, as do coughing and traumatic injuries fromblunt pressure. When two of these factors coexist, with some tissue weakness, the person
may develop hernia. Increased pressure without a weakness is not likely to cause hernia.
Weakness, in addition to being present from birth, is acquired as part of the agingprocess. As clients age, muscular tissues become infiltrated and are replaced by adipose
and connective tissues.
When the contents of the hernia sac can be replaced into the abdominal cavity bymanipulation, the hernia is said to be reducible. Irreducible and incarcerated are terms
that refer to a hernia that cannot be reduced or replaced by manipulation. When pressure
from the hernia ring (in the case of Rolando, the inguinal ring) cuts off the blood supplyto the herniated segment of the bowel, the bowel becomes strangulated. Incarcerated
hernias often become strangulated. This situation is an emergency procedure because
unless the bowel is released, it soon becomes gangrenous owing to a lack of blood
supply.
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APPROVAL SHEET
Kristine Claire Q. Salvador and Ma. Adelene LAgrada, a 4 th year and third year
BSN students respectively, assigned in the Surgical Ward of Ospital ng Palawan has
prepared this case study entitled, Inguinal Hernia. This serves as a partial fulfillment
of the Requirements in Related Learning Experience (RLE). It was examined and
approved with the grade of ________%.
Ms. Rose Elan Bundac, R.N.
Clinical Instructress
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SIGNIFICANCE OF THE STUDY
This case study, entitled Inguinal Hernia is aimed not only to finish a
requirement in Related Learning Experience with clinical exposure at the Surgical Ward
of Ospital ng Palawan, it serves:
a. The client and his family, because the making of nursing care plans
considers his immediate needs;
b. The medical staff of Ospital ng Palawan and other members of the health
team, because they would have a reference in the course of their
assessment and health care of clients with hernia;
c. The ordinary people, because they would have a guide to aid them should
such symptoms of illness occur to them; and,
d. The student-nurses/researchers, to broaden their understanding, knowledge
and experience to render effective, accurate and prompt nursing care to
such clients.
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STATEMENT OF THE PROBLEM
This case study aims to answer the following questions:
a. What is the nature and dynamics of Inguinal hernia?
b. What are the diagnostic and laboratory tests needed to diagnose inguinal
hernia?
c. What nursing problems are identified and corresponding nursing care
plans are appropriate for patients with Inguinal hernia?
d. What possible discharge plan and home care is indicated for patients with
inguinal hernia?
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PERSONAL INFORMATION
Name: ROLDAN JESOROAge: 23 years old
Sex: Male
Address: Bgy. Inagawan, Puerto Princesa City, PalawanCivil Status: Live-in
Religion: Roman Catholic
Educational Attainment: High school levelOccupation: Farming
Date and Time Admitted: July 24, 2005 at 3:01pm
Chief Complaint/s: Abdominal pain
Informant: Rolando Baldo, sonPhysician: Dra. Nufuar
FAMILY HISTORY
Name of Father: Leonardo Flores (Deceased)Name of Mother: Ignacia Flores (Deceased)
Name of Spouse: Rodolfo Baldo (Deceased)
Number of children in the family: 10
Position in the family: 2ndNumber of offsprings: 4
Presence of Hereditary diseases:
a. Diabetes (-)b. Cardiovascular diseases (-)
c. Bronchial Asthma (-)
d. Others No history of hereditary diseasesDeaths in the family: Husband/Spouse
Cause/s: Undiagnosed and untreated illness, said to have
been caused by supernatural forces such as nuno sapunso and others.
PAST MEDICAL HISTORY
a. Type of delivery Normal
b. Childhood diseases Unknownc. Immunization status Unknown
d. Previous sickness/hospitalization Bicycle accident where she reportedly sustained a
head trauma that caused her hearing impairmentwhen she was 10 years old. She, however, was not
brought to the hospital and received only home
remedy.
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PRESENT CONDITION
a. Perceptions and Expectations of Illness/HospitalizationThe patient does not answer regarding this because her attention is focused on her
abdominal pain. Her children, however, verbalized that they expect her to get well
enough soon but are uncertain due to their financial status.b. Specific Basic Needs
1. Comfort/Rest Needs
The patient shows physical signs of abdominal pain that interfereswith her normal sleeping pattern. Her naps are usually short (often only
lasting about 3-5 minutes) and interrupted by sudden pain episodes. She
also is not able to do her usual daily activities such as bathing, brushing
her teeth, etc. as well as leisure activities which include listening to radioand reading short stories due to her attention being focused on her
discomfort and pain.
2. Safety Needs
Nanay Elena has hearing impairment that interferes with her abilityto express her needs and desires. This impairment also predisposes her to
hazards such as traffic and household accidents as well. Her old age alsopredisposes her to a lot of other illness such as colds and flu. Added to
this, the family is insecure about medical bills and costs of drugs because
they are not financially capable of supporting a sick member of the family.
3. Fluids and NutritionShe has not been able to retain any food or fluid for at least a week
prior to admission because she vomits every time she eats or drinks even a
tablespoon of rice or a few sips of water. She is however, placed on DATduring admission and IV fluids has been administered to replace lost
fluids, counteract any fluid and electrolyte imbalance, and as a route for
administration of medications.1. Elimination
The client has not moved her bowel for approximately 1 week.
Although she does not have any difficulty urinating, she has less frequentvoiding and U/A shows a slightly hazy urine transparency of urine.
2. Oxygen
RR=33/minute. When she was brought to the ward, she became
apneic and was given O2 inhalation via nasal cannula @ 3-4LPM. Prior toher illness, she is a kaingin farmer who is always exposed to a lot of
smoke.
3. Others:a. Sexuality She is feminine and has had 4 sons with her husband who
is now deceased.
b. Allergies No known allergies to food and drugs.c. Communication She cannot hear very well and cannot express her
feelings verbally. She only gestures and her pain is evident only
through her facial expressions and movements such as grimacing,
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crying or softly groaning in pain episodes and waving to her sons if
she needs to do anything..
PHYSICAL ASSESSMENT
a. EENTEyes Pale conjunctiva, white sclera, gray pupils, tearful.
Ears Ears are long and symmetrical.
Nose Nose is small, centrally-located.Throat Unremarkable.
b. Chest and Lungs
Clear breath sounds on both lung fields, bones prominent on chest.Symmetrical lung expansion observed.
c. Abdomen
Flat abdomen with minimal stretch marks seen. Hyperactive bowel soundson the hypogastric region heard upon auscultation. Epigastric, hypogastric and
RLQ pain upon palpation. Unable to palpate for mass or systolic bruit due to theintense pain she expresses with facial expression during palpation.
d. Genito-Urinary
With gray pubic hair, no BM and less frequent urination as reported bypatients sons.
e. Skin/ExtremitiesHand and foot digits are complete (20 in all), nails are short but with dirt
underneath and pale in color, poor skin turgor noted. White spots seen which the
sons claim is an-an.
f. General Conditions
The patient is conscious, alert but in severe abdominal pain. Her attentionis focused on this pain. She does not respond when asked if she comprehends
orientation to 4 spheres such as asking the date, time, place or her identity due to
her attention being focused in her pain.
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LABORATORY EXAMINATIONS
Diagnostic
Procedure:
Results: Normal
Values
Interpretation: Rationale:
June 27, 2005
CBC Hemoglobin
DIFFERENTIAL
COUNT
Neutrophils
Eosinophils
Lymphocytes
WBC Count
Platelet Count
BSMP
120 g/L
84
3
13
18.10 x
109/L
250 x 10 9/L
Negative
120-160 g/L
60-70%
1-4%
20-30
4-9 x 109/L
150-450 x109/L
Negative
Not yetindicative of
anemia;
borderline.
Indicatespresence of
bacterial or
parasiticinfectious
process.
No allergicreaction or
anemia
Indicative of
trauma
Coagulationmechanism
intact
Malaria is ruled
out.
CBC with
differential,WBC, plateletcount and
BSMP is
ordered for
Nanay Elena torule out
presence of
any infectionsdue to the
inconclusive
nature ofinterview and
assessment.
June 28, 2005Urinalysis
Color
Transparency
Albumin pH
Glucose sg
Microscopic Exam
Pus cells
RBC
Epithelial cells Squamous
Bacteria
Amorphous
urates
Pale yellow
Sl. Hazy
++ - 6++++ - 1.00
1-4/hpf
8-12/hpf
Few
Moderate
Moderate
Pale yellow
Clear
++ - 4.6-8++++ - 1.01-
1.025
No reference
No reference
No reference
No reference
No reference
(-)
Sediments
presentAverage of pH
range
(-)
(-)
(-)
(-)
(-)
Urinalysis isimportant to
determine
whether there
is infection inthe body.
June 28, 2005Ultrasound Abdominal
Aortic
Normal
pattern
Abdominal
Aortic Aneurism
Ultrasonography
was ordered due
to the
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Aneurism images of
structuresbeing
studied
(abdominal
aorta)
seen that
thereforechanges the
medical
impressions to a
definite medicaldiagnosis.
inconclusive
nature of
interview and
assessment. This
study creates
sound waves that
allowvisualization of
organs inside the
abdomen.
June 28, 2005Hemoglobin (Hgb) 52 g/L 120-160 g/L Indicative of
anemia
Ordered to assess
for hypovolemia
or shock.
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REVIEW OF ANATOMY & PHYSIOLOGY
OF
CARDIOVASCULAR SYSTEM: BLOOD VESSELS
Except for the microscopic capillaries, the walls of blood vessels have three coats
or tunics: Tunica Intima, which lines the lumen or interior of the vessels, is a thin layerof endothelium resting on a scanty layer of loose connective tissue, Its cells fit closely
together and form a slick surface that decreases friction as blood flows through the
lumen.
The Tunica Media is the bulky middle coat. It is mostly smooth muscle and
elastic tissue. The smooth muscle, which is controlled by the sympathetic nervous
system, is active in changing the diameter of the blood vessels. As the vessels constrict ordilate, blood pressure increases or decreases, respectively.
The Tunica Externa, is the outermost tunic, it is composed largely of fibrous
connective tissue. Its function is basically to support and protect the blood vessels.
The aorta is the largest artery of the body. In adults, the aorta is about the size of agarden hose where it issues from the left ventricle of the heart. It decreases in size as it
runs to its terminus. Different parts of the aorta are named for their location or shape. The
aorta curves upward from the left ventricle of the heart as the ascending aorta, arches to
the left as the aortic arch and then plunges downward through the thorax following thespine (Thoracic aorta) to finally pass through the diaphragm into the abominopelvic
cavity where it becomes the abdominal aorta.
Blood circulates inside the blood vessels, which form a closed transport system,
the so-called vascular system. Like a system of roads, the vascular system has its
freeways, secondary roads, and alleys. As the heart beats, blood is propelled into the largearteries leaving the heart. It then moves into successively smaller and smaller arteries,
then into the arterioles, which feed the capillary beds in the tissues. Capillary beds are
drained by venules, which in turn empty into the veins that finally empty into the greatveins entering the heart.
Thus arteries, which carry blood away from the heart, and veins, which drain the
tissues and return blood to the heart, are simply conducting vessels the freeway sandsecondary roads.
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PATHOPHYSIOLOGY OF
ABDOMINAL AORTIC ANEURISM (AAA)
PREDISPOSING PRECIPITATING FACTORS: CONTRIBUTING FACTORS:FACTORS: Focal weakness in the muscular - Trauma
Age: 50-80 y/o Layer of the aorta
Genetic
Inner layer (Tunica intima) & outer layer (tunica adventitia) stretches outward
Aneurism Palpable mass in the periumbilical
area
Tenderness Systolic bruit over
the aorta
Blood pressure in the aorta
weakens the vessel walls
Aneurism is enlarged
Pressure on lumbar nerve
Lumbar pain Aneurism ruptures
Peritoneal cavity Retroperitoneal space
Severe, persistent abdominal Tamponade
and back pain
Subtle weakness, sweating, tachycardia, hypotension
Shock
Death
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TREATMENTS
Treatment/Special Procedures/Surgery Rationale
Pharmacotherapy
IV therapy
O2 therapy
Pharmacotherapy is done to the
patient which is aimed at managinggastric acid secretions and pain, as
well as constipation. IV therapy is given to the patient to
replace lost fluids and manage fluid
and electrolyte imbalance as well as
a route for administration of
medication.
O2 therapy is given the patient to aid
in her oxygenation. She isexperiencing apnea in the ward
which may be due to her pathologic
condition.
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DRUG STUDY
Generic/
Brand Name
Dosage/Freq/
Route
Action Indication Nursing
Responsibilities
Ranitidine/Zantac
1 amp, ANSTthen q8, IV
Inhibits histamineat H2-receptor site
in parietal cells,which inhibitsgastric acid
secretion.
Duodenal ulcer,
Zollinger-Ellison
Syndrome, gastriculcers,
hypersecretory
conditions,
gastroesophageal
reflux disease,
stress ulcers,
erosive esophagitis
(maintenance),
active duodenal
ulcers with
Helicobacter pylori
in combination
with
clarithromycin.
Ranitidine is
indicated to Elena
Baldo to alleviate
pain episodes due
to gastritis where
there is too much
gastric acid
secretions and to
protect the mucosa
of the stomach.
Since there has yet
to be a conclusive
diagnostic/lab
exam, in the
incidence that she
may have gastric
ulcerations,
coating and
protecting the
mucosa of her
stomach will also
aid in the healing
of the ulcers.
Assessgastric pH
AssessI&O ratio
Assess GI
complaints
: nausea,vomiting,
diarrhea,
cramps
Providestorage at
room
temperature
Evaluate
therapeutic
response:
decreasedabdominal
pain
Teach
pt/family
to avoidblack
pepper,caffeine,
alcohol,
harshspices,
extremes
intemperatur
e of food
and thatdrug mustbe
continued
forprescribed
time to be
effective.
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Nalbuphine/
Nubain
1 amp q8 IV
prn for severeabdominal pain
Depresses pain
impulsetransmission at
the spinal cord
level by
interacting opioidreceptors.
Moderate to severe
pain. In ElenaBaldos case, she isexperiencing
severe epigastric,hypogastric and
RLQ pain and thisdrug was given to
her to help managethat pain.
AssessI&O ratio.
Assess for
allergic
reactions.
Check forrespiratory
dysfunction.
Administe
r IV routeundiluted
over 3-5
minutes.
Provide
storage in
light-resistant
area at
room
temperature.
Provide
assistancewith
ambulatio
n.
Evaluatetherapeuti
cresponse:
decrease
in pain.
Teach thatphysical
dependenc
y mayresult
from long-term use.
Ephedrine/Ep
hedrine
sulfate
1 amp x 2 doses
IV
Causes increased
contractility and
heart rate byacting on -
receptors in the
heart; also acts on
Shock; increased
perfusion,;
hypotension,
bronchodilation. Inthis case ephedrinewas given to
Assess
I&O ratio.
Assess forparesthesi
as and
coldness
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-receptors,
causingvasoconstriction
in blood vessels.
counteract the possibility of animpendinghypovolemic shock.
of
extremities.
Administe
r IV direct
routethrough
Y-tube or3-way
stop-cock;
give 10-25mg
slowly,
mayrepeat in
5-10
minutes. Storage of
reconstitut
ed
solutionrefrigerate
d no
longer
than 24hours.
Do not use
discoloredsolution.
Evaluate
therapeutic
response:
increasedBP with
stabilizatio
n.
Metronidazol
e/Flagyl
500 mg q8 IV
ANST (-)
Direct acting
amebicide/trichomonacidebinds, degrades
DNA in
organism.
Intestinal
amebiasis, amebicabscess,
trichomoniasis,
refractorytrichomoniasis,
bacterial anaerobic
infections,
giardiasis,septicemia,
Assess for
infections. Assess
stools
during
entiretreatment.
Assess
vision by
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endocarditis, bone,
joint infections,
lower respiratory
tract infections. In
Nanay Elenascase, she was
prescribedmetronidazole at
the ER becausethere was yet to bea conclusiveevaluation of her
disease due to thefact that she cannotverbalize her feelings at the time.
ophthalmi
c exam.
Assess
I&O ratio.
Assess for
allergicreactions.
Administer IV route
prediluted.
Providestorage in
light-
resistant
container;do not
refrigerate.
Evaluate
therapeuti
cresponse:
decreased
symptomsof
infection.
Teach
patient/family that
urine may
turn dark-reddish
brown,
drug maycause
metallic
taste.
Teach
properhygieneafter BM
Bisacodyl/Du
lcolax
1 Suppository
stat
Acts directly on
intestine byincreasing motor
activity; thought
to irritate colonic
Short-term
treatment of
constipation, bowel
or rectal preparation for
Assess
blood,urine
electrolyte
s if drug is
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intramural plexus. surgery,examination. InMrs. Baldos case,her sons reported
that she has notmoved her bowel
for more than aweek before
seeking medicalattention. Dulcolaxwould help her beable to move her
bowel due to thedirect increase in peristalsis that isits action.
used often
by patient.
Assess
I&O ratio.
Assess
cause forconstipatio
n.
Assess for
cramping.
Evaluatetherapeuti
c
response:
decreasein
constipation.
Teach not
to use for
long-termuse.
Teach that
normalBM do not
always
occur
daily.
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SUMMARY OF FINDINGS THAT ARE RELEVANT TO NURSING CARE
After assessment of physical, past medical history, family history, perceptions,specific and basic needs, I conclude that the following should be the focus of nursing
care:
ER assessment:
1. Severe pain r/t disease process2. Constipation r/t inability to retain ingested food 2 to disease process
3. Impaired verbal communication r/t childhood accident/trauma
Ward Assessment:
4. Fluid volume deficit r/t disease process
5. Ineffective breathing pattern r/t disease process
In prioritizing these problems, I have the following list of nursing problems:
1. Severe pain r/t disease process
2. Ineffective breathing pattern r/t disease process
3. Fluid volume deficit r/t disease process
4. Constipation r/t inability to retain ingested food 2 to disease process5. Impaired verbal communication r/t childhood accident/trauma
Due to the fact that assessment in ER is most essential for this case study becausethis is the area of assignment and owing to time constriction, the 1 st three problems
assessed in ER are given priority although some of the last three are more important in
nature.
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NURSING CARE PLANS
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ASSESSMENT STATEMENT OF
THE PROBLEM
PLANNING NURSING ACTION OUTCOME
Subjective/Objective
Cues
Nursing Diagnosis Long Term Goal/
Short Term Goal
Nursing Interventions with Rationale
Independent, Dependent, & Interdependent
Evaluation/
Revision
Subjective Cue:
None
Objective Cues:
Pale conjunctiva
Teary eyes noted
Sweaty forehead
Grimaced facenoted
Groaning
Guarding
behavior noted
Assuming fetalposition
Seeking SOoften
RR=30/minute
BP=90/70mmHg
Pain scale =10/10
Severe pain r/t disease
processBACKGROUND
KNOWLEDGE:Pain is defined in
NANDA as a state in
which an individualexperiences and
reports the presence ofsevere discomfort or
an uncomfortablesensation. In Elena
Baldos case, the painis severe enough for
her to try and getmedical treatment as
she can possibly be
able to do so.
Pharmacotherapy. IVtherapy, medical andnursing management
is focused on
alleviating thiscondition.
LTG: At the end
of 3 days nursingintervention, the
client will be ableto demonstrate
relaxed body
posture and ableto sleep/rest
appropriately.
STG: At the endof 1 days
nursing
intervention, theclient should be
able to expressthrough written
communication
reduction of painfrom a scale of
10/10 to 8/10.
Independent:
1. Monitor and record V/S.R: For baseline data and because V/S are usuallyaltered during pain episodes.
2. Instruct patient to relax and breatherhythmically.R: Anxiety and too much pain cause clients to
breathe rapidly and has more difficulty managingthe pain.3. Encourage client to do deep breathingexercises.R: Helps promote comfort and relaxation.4. Do and instruct SO about comfort measuressuch as backrubbing, soft massage of extremities,etc.R: Promotes patients comfort and deviatesattention from pain experience.5. Establish a form of communication such aswriting or nodding in agreement or shaking head
in disagreement.R: Gives the client a way to communicate desiresand needs.Dependent:
1. Administer IV fluid therapy.
R: To replace lost fluids and as a route forparenteral medications.
2. Administer medications, Ranitidine(Zantac).R: Inhibits histamine at H2-receptor site in parietal
cells, which inhibits gastric acid secretion.
Evaluation of
effectivity ofcare plan is
through theclients
communicati
on of painreduction/
and appearrelaxed and
well-rested.
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ASSESSMENT STATEMENT OF
THE PROBLEM
PLANNING NURSING ACTION OUTCOME
Subjective/Objective
Cues
Nursing Diagnosis Long Term Goal/
Short Term Goal
Nursing Interventions with Rationale
Independent, Dependent, & Interdependent
Evaluation/
Revision
Subjective Cue:
None
Objective Cues:
Pale conjunctiva
Seeking SO
often
Episodes of apnea (ward)
Hooked to O2tank via nasal
cannula @ 3-4LPM
Ineffective breathing
pattern r/t diseaseprocess
BACKGROUNDKNOWLEDGE:
Ineffective breathing
pattern is a NANDA-accepted nursing
diagnosis of aninhalation or
exhalation pattern thatdoes not enable
adequate pulmonary
inflation or emptying.Such is Nanay Elenascase who experienced
apneic episodes in the
Medical ward.
LTG: At the end
of 3 days nursingintervention, the
client will be ableto establish
effective
breathing pattern.
STG: At the endof 1 days
nursingintervention, the
client should be
able toexperience no
signs of respiratory
compromise/
complications.
Independent:
1. Monitor and record V/S to pay particularattention to respiratory rate, rhythm and depth.R: For baseline data and because shallow
breathing, splinting with respirations, holdingbreath may result to hypoventilation or atelectasis.2Auscultate breath sounds.R: To assess for any signs of respiratory
problems.3. Assist patient to turn, cough and breath deeply
periodically.R: Promotes ventilation of all lung segments.Dependent:
1. Administer O2 therapy.
R: Assists in oxygenation by regulating O2volume.
Evaluation of
effectivity ofcare plan is
through theclients
establishment
of effectivebreathing
pattern andshow no
signs ofrespiratory
compromise
orcomplication
s.
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ASSESSMENT STATEMENT OF
THE PROBLEM
PLANNING NURSING ACTION OUTCOME
Subjective/Objective
Cues
Nursing Diagnosis Long Term Goal/
Short Term Goal
Nursing Interventions with Rationale
Independent, Dependent, & Interdependent
Evaluation/
Revision
Subjective Cue:
None
Objective Cues: Pale conjunctiva
Poor skin turgor
Anorexia
Hgb=52g/L
Fluid volume deficitr/t disease process
BACKGROUND
KNOWLEDGE:
NANDA defines thisas the state in which
an individualexperiences vascular,
cellular, or intracellular
dehydration. In Nanay Elenas case, this is
evident in her dry skinand poor skin turgor
as well as her
generalized weakness.
LTG: At the endof 3 days nursing
intervention, theclient will be able
to maintain
adequate fluidvolume as
evidenced bymoist mucus
membranes andgood skin turgor.
STG: At the endof 1 days
nursingintervention, the
client should be
able todemonstrate
behaviors tomonitor and
correct deficit.
Independent:
1. Monitor and record V/S I&O.R: Provides information about overall fluid
balance.2. Assess V/S: BP, PR, and T.R: Hypotension, tachycardia, fever can indicate
response to fluid loss.3. Observe for excessively dry skin and mucus
membranes, decreased skin turgor, slowedcapillary refill.
R: Indicates excessive fluid loss.4. Monitor lab studies (electrolytes, and ABGs).R: Determines replacement needs andeffectiveness of therapy.Dependent:
1. Administer parenteral fluids as indicated.
R: To help in rehydration of client.
Evaluation ofeffectivity of
care plan isthrough the
clients
maintenanceof adequate
fluid volumeas evidenced
by moistmucus
membranes
and goodskin turgor.
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ASSESSMENT STATEMENT OF
THE PROBLEM
PLANNING NURSING ACTION OUTCOME
Subjective/Objective
Cues
Nursing Diagnosis Long Term Goal/
Short Term Goal
Nursing Interventions with Rationale
Independent, Dependent, &
Interdependent
Evaluation/Revision
Subjective Cue:
NoneObjective Cues:
Guardingbehavior
noted
Irritability
Assuming
fetal position
Seeking SOoften
Decreasedactivity level
noted
Vomiting
ingested foodor fluid.
RR=30/minute
Constipation r/tinability to retain
ingested food 2 to
disease processBACKGROUND
KNOWLEDGE:
Constipation,
according to Billings
and Stokes for MedicalSurgical Nursing, is
the retention of fecalmaterial, delay in
excretion or delayfrom usual elimination
habits. In ElenaBaldos case, although
not yet conclusive, itmay have been
brought about by her
inability to retain foodand fluid intake due to
her pathologiccondition.
LTG: At the end of 3days nursing
intervention, the client
will be able toestablish/return to
normal patterns ofbowel functioning.
STG: At the end of 1hours nursing
intervention, the clientshould be able to
cooperate in procedures that will
enhance bowel
pattern.
Independent:
1. Review dietary regimen.
R: To assess direct cause of constipation.2. Record fluid intake.
R: Dehydration aggravates constipation.
3. Auscultate bowel sounds.
R: Bowel sounds are decreased in
constipation.
4. Encourage fluid intake if not
contraindicated.
R: Assists in improving stool consistence.
Interdependent:
1. Consult with dietician to provide well-
balanced diet high in fiber and bulk.
R: Fiber resists enzymatic digestion and
absorbs liquids in its passage along the
intestinal tract and thereby produces bulk,
which acts as a stimulant to defacation.
Dependent:
1. Administer IV fluid therapy.R: To facilitate rehydration and as a route
for parenteral medications.
2. Administer medications, Bisacodyl
(Dulcolax)
R: Acts directly on intestine by increasing
motor activity; thought to irritate colonic
intramural plexus.
Evaluation ofeffectivity of care
plan is through the
clients ability toreturn to normal
bowel patterns.
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ASSESSMENT STATEMENT OF
THE PROBLEM
PLANNING NURSING ACTION OUTCOME
Subjective/Objective
Cues
Nursing Diagnosis Long Term Goal/ Short
Term Goal
Nursing Interventions with Rationale
Independent, Dependent, &
Interdependent
Evaluation/Revision
Subjective Cue:
NoneObjective Cues:
Silent crying
Guardingbehavior noted
Soft groaningnoted
Irritability
Assuming fetalposition
Signaling SOwith handwaves
No oral/
writtencommunica-
tion expressed
No verbalresponses toquestions andenquiries
SOs verbalizationof a childhoodhead trauma
Impaired verbalcommunication r/tchildhood
accident/traumaBACKGROUND
KNOWLEDGE:
Nursing Care Plans byMarilyn Doenges statesthat impaired verbalcommunication may berelated to impairedcerebral circulation,neuromuscularimpairment, and loss oforal/facial/muscle tone /control or generalizedweakness. In Elena
Baldos case, her
childhood head traumacould be the cause ofthis impairment due butdue to the fact that shedid not have and seekmedical attention at thattime and she does notexpress this in her ownwords, this summary is
not yet conclusive.
LTG: At the end of 1
days nursingintervention, the client
will be able to
establish a method ofcommunication which
needs can beexpressed.
STG: At the end of 1hours nursing
intervention, the clientshould be able to
indicate anunderstanding of the
communication
problems.
Independent:
1. Assess type/degree of dysfunction.R: Helps determine difficulty that patient
has with any or all steps ofcommunication process.2. Provide alternative methods ofcommunication.R: Provides for communication ofneeds/desires based on individualsituation.3. Anticipate and provide for patientsneed.R: Helps in decreasing frustration whendependent on others and unable tocommunicate desires.4. Encourage SO/visitors to persist inefforts to communicate with patient.R: To reduce patients isolation and
promotes establishment of effectivecommunication pattern.Interdependent:
1. Consult with or refer to speechtherapist.
R: Assesses individual verbalcapabilities and sensory, motor, and
cognitive functioning to identifydeficits/therapy needs.
Evaluation of
effectivity of careplan is through the
clients
establishment of ameans to
communicate needsand desires.
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CONCLUSION
The study of Abdominal Aortic Aneurism (AAA) was a real challenge to me forseveral reasons:
1. It is the first time I have ever encountered this disease in the ER or in any
ward for that matter;2. It was a very time-constricted research for me;
3. I was alone in my research;
4. The interaction with the client was very fast-paced; and,5. My client died.
But through all these challenges, I have learned and experienced so much. In
dealing with AAA, I conclude the following:1. To render effective nursing care to an AAA patient must be done promptly
and with compassion.
2. That we should not only think of nursing as a job to do, especially in AAA
clients whose needs and concerns are immediate.3. That AAA is a very serious illness that comes rarely but gravely.
4. It is essential that we do not wait for an AAA to rupture because thiswould have very austere repercussions, most of the time such as in the
case of my client, death is a real possibility.
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DISCHARGE PLAN
M Instruct patient on medication the proper medicine, route, dosage, and duration.
E Instruct about proper financial and social assistance for economic needs.
T Treatments should be continued for prescribed time for continued effectivity.
H Health teachings should focus on maintaining optimum lood pressure to avoidcontinues enlargement and subsequent rupture of aneurism.
O Out-patient or home care should be continued for check-ups and diagnosticprocedures (ultrasound every 6 months)
D Diet should restrict salty and cholesterol-rich food.
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REFERENCES
Anderson, Kenneth N. et. al., 1990, Mosbys Pocket Dictionary, 3rd ed., St. Louis,
Missouri, The CV Mosby Company, pp. 52, 66, and 135.
Black, Joyce M. et. al., 1993, Luckmann and Sorensens Medical-Surgical Nursing
4th ed. Vol. 2, United States of America, W.B. Saunders Company, pp. 1295-1297.
Charnogursky, Gerald A. et.al., 1999, Handbook of Diseases 2nd ed.,Pennsylvania,
Springhouse Corporation, pp. 44-46.
Doenges, Marilynn E. et. al., 1993 Nurses Pocket Guide, 4th ed., Philadelphia, F.A.
Davis Company, pp. 105-108, 109-115, 126-134, 193-196, and 306-309.
Doenges, Marilynn E. et. al., 2002, Nursing Care Plans 6
th
ed.,Thailand, F.A. davisCompany, pp. 65-67, 234-236, 506-507, 595-596, and 654-655.
Lemone, Priscilla et. al., 2004, Medical-Surgical Nursing 3rd ed. Vol. 2, New Jersey,
Pearson Education, Ltd., pp. 994-996.
Marieb, Elaine N., 2002, Essentials of Human Anatomy & Physiology 6th ed.,Singapore, Addison Wesley Longman, pp. 313-330.
McFarland, Mary B. et. al., 1991, Nursing Implications of Laboratory Test 6th ed,New York, Delmar Publishers, pp. 19-38 and 166-177.
Roth, Linda S. et. al., 2004, Mosbys Nursing Drug Refernce, 2004 ed., Missouri,Mosby Inc., pp. 174-175, 400-403, 665-667, 702-704, and 871-873.
Smeltzer, Suzanne C. et. al., 1996, Medical-Surgical Nursing 8thed. Vol 1,Philadephia, Lippincott, pp. 738-741.
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