Name: Mr. X
Address: Bagong Tuklas, Brgy. San Agustin, Novaliches Quezon City Civil Status: Married
Chief Complaint: Abdominal Pain & Constipation
Admitting Diagnosis: Small Intestinal Obstruction
Final Diagnosis: Hiatal Hernia
Family Health Illness History
It was revealed in the diagram that on father side, Mr. T’s grandfather is hypertensive and has Diabetes mellitus, and his grandmother died because of old age. On the other hand, on his mother side, Mr. P’s grandparents are both alive, his grandmother has heart disease while his grandfather is living healthy. His father was also hypertensive and his mom has heart disease. In addition his eldest sister is hypertensive and she was diagnosed of Diabetes mellitus Type II.
Lastly, our client was currently diagnosed of Partial Intestinal Obstruction secondary to ileocecal tumor. Patient claimed that aside from those, there are no significant hereditary familial disease like asthma, bone disease and etc.
Intestinal Obstruction is a blockage of your small intestine or colon that prevents food and fluid from passing through. Can be caused by many conditions, including fibrous bands of tissue in the abdomen (adhesions), hernias and tumors. Alternative names: Paralytic ileus; Intestinal volvulus; Bowel obstruction; Ileus; Pseudo-obstruction - intestinal; Colonic ileus. Etiology of bowel obstruction is pathological prevention of passage of gastrointestinal luminal content from passing distally. The signs and symptoms of intestinal obstruction are Abdominal swelling, Constipation, Severe abdominal cramps, Intermittent abdominal cramps, nausea and Vomiting, Green vomit, Fecal vomiting (vomit that looks like feces) Blood-stained mucus passed, Passing jelly-like mucus Diseases and conditions that can increase your risk of intestinal obstruction include: Abdominal or pelvic surgery, which often causes adhesions — a common cause of intestinal obstruction. Crohn's disease — an inflammatory condition that can cause the intestine's walls to thicken, narrowing its passageway. Cancer within your abdomen, especially if you've had surgery to remove an abdominal tumor or radiation therapy.
Upon completion of this case study, the student nurse should be able to: >Recognize and understand the disease condition.
>Identify predisposing and precipitating factors that could possibly contribute to the occurrence of the disease. >Understand the normal anatomy and physiology of the organs that are affected by the underlying disease condition. >Review literature and background of the signs and symptoms manifested by the client. >Identify specific theoretical and/or research-based causes and clinical manifestations of the disease, and trace the pathophysiology of the disease condition. >Assess the following such as:
Personal history such as demographic data
Pertinent family health and history by making use of a diagram
History of past and present illness
>Formulate nursing diagnosis that address the needs of the patient and plan nursing interventions to meet those needs. >Conduct physical assessment (cephalo-caudal approach, review of systems) >Review and monitor diagnostic and laboratory results
>Construct individualized nursing care plans.
>Able to formulate discharge planning
Anatomy and Physiology
The GI System
The gastro-intestinal system is essentially a long tube running right through the body, with specialised sections that are capable of digesting material put in at the top end and extracting any useful components from it, then expelling the waste products at the bottom end. The whole system is under hormonal control, with the presence of food in the mouth triggering off a cascade of hormonal actions; when there is food in the stomach, different hormones activate acid secretion, increased gut motility, enzyme release etc. etc....