Columban College

College of Nursing
Barretto, Olongapo City

In Partial Fulfillment of the Requirement

for the

CASE PRESENTATION

ACHALASIA
Submitted by: A1, A2

ALMONTE, ROSE ANN G. BATOON, DESIREE MAE P.

ANGOB, FREILYN M. BUENO, DEAN MIGUEL D.

AÑONUEVO, MARY RUTH T. CADAHING, REEDEN W.

ARBOLENTE, CHRISTINE JOYCE V. CANONIZADO, CRISLIE M.

AREVALO, JEFFERSON P. CONCHA, KRISTINA MAE G.

Submitted to:

Ms. Gelynne Perea, RN

 Columban College
College of Nursing
Barretto, Olongapo City

I. INTRODUCTION
 Columban College
College of Nursing
Barretto, Olongapo City

II. CLIENT’S PROFILE/ HISTORY/ DATA:

Name: Mr. M
Age: 22 y/o
Birth Day: August 8, 1987
Nationality: Filipino
Status: Married
Date of Admission: Dec. 1, 2009

History of Present Illness:

 1 year prior to admission – patient had difficulty in swallowing solid and

liquid foods, associated with loss of appetite and weight loss.
 1 month prior to admission – patient had still difficulty in swallowing.
Consult done with private endoscopy done and revealed achalasia. Patient
was referred to surgery for evaluation and management.
 2 weeks prior to admission – consult done at Out Patient Department
surgery where he was advised surgical intervention, and laboratory was
up due. Due to patient condition patient opted to have the operation
hence, the admission.

History of Past Illness:

Patient has frequent tonsillitis almost every month when he was 5 until he
reach 18 years old.

Past Medical History:

 No previous operation.
 No known allergy to any food and drugs.
 Columban College
College of Nursing
Barretto, Olongapo City

Family History:

 Denies any heredofamilial diseases

Personal/ Social History:

Tricycle driver
Smoker (20 sticks/day)
Alcohol beverage drinker

Chief Complaint:

The patient’s chief complaint is difficulty in swallowing.

 Columban College
College of Nursing
Barretto, Olongapo City

III. HEAD TO TOE - SYSTEM ASSESSMENT

PRE-SURGERY assessment:

Dec. 7, 2009

*no duty

Dec. 8, 2009

VITAL SIGNS

BP:110/ 80 PR: 74
RR: 16 T: 36.3

SKIN:

- deep brown complexion - good skin turgor

- no tenderness and masses - warm to touch

HEAD
a) Hair and Scalp

- well distributed - no tenderness

- ( + ) dandruff - no masses
- short and dry hair - no infestations

b) Skull

- face is proportional to head

- no tenderness and depression felt upon palpation

c) Eyes

- symmetrical in size and shape

- black eyes
 Columban College
College of Nursing
Barretto, Olongapo City

d) Eyebrow

- well distributed

e) Conjunctiva

- shiny, smooth, pink to red

f) Teeth

- yellowish
- presence of decayed upper and lower

NECK

- able to move freely with ease

- centrally aligned
- lymph nodes not palpable

THORAX

- chest symmetric
- skin intact and uniform in color
- no lesion

HEART

- s1 heard at all site

- s2 heard at all site

- CR= 89bpm

NOSE

-uniform in color
 Columban College
College of Nursing
Barretto, Olongapo City

- patent nares
- no discharge
- presence of NGT
- able to smell and differentiate different aromas

MOUTH
a) Lips

-uniform pink in color

- dry lips
- symmetry of contour

- able to purse lips

b) Buccal Mucosa and Gums

- pinkish mucosa and gums

- ( - ) ulceration

ABDOMEN

- symmetric contour
- normal bowel sounds
- no tenderness and no masses

UPPER EXTREMITIES

- arms symmetric in size and shape

- able to flex and extend both arm
- ( + ) scars
-no tenderness, no masses
- normal capillary refill (less than 2 sec)
- able of both hands to grasp object effectively

LOWER EXTREMITIES

- legs symmetric in size and shape

 Columban College
College of Nursing
Barretto, Olongapo City

- uniform in color
- ( + ) scars
- able to flex and extend both lower extremities

- no tenderness, no masses

Dec. 9, 2009

*no change except for:

VITAL SIGNS

BP: 110/80 PR: 79 bpm

RR: 21 T: 36.5ºC

POST-SURGERY assessment:

Dec. 14, 2009

GENERAL SURVEY

- conscious, coherent
- ambulatory
( - ) NGT

VITAL SIGNS
BP: 120/80 PR: 81 bmp
RR: 21 bmp T: 36.5ºC

EYES
Palpebral Conjunctiva: (+) pinkish
Sclera: (+) anisteric

THORAX
( + ) CTT
( + ) tenderness Left upper quadrant; pain: 5/10
 Columban College
College of Nursing
Barretto, Olongapo City

Dec. 15, 2009

*no duty

Dec. 16, 2009

*no change

GENERAL SURVEY

- conscious, coherent
- ambulatory

VITAL SIGNS

BP: 120/80 PR: 87

RR: 19 T: 36.7

THORAX
( + ) tenderness Left upper quadrant; pain: 3/10
 Columban College
College of Nursing
Barretto, Olongapo City

IV. ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY

 Columban College
College of Nursing
Barretto, Olongapo City

PATHOPHYSIOLOGY
PREDISPOSING FACTOR
CONTRIBUTING FACTOR
 VIRAL/BACTERIAL INFECTIONS
 AGE
 SMOKING and ALCOHOLISM
 GENDER

UNKNOWN CAUSE

LOSS OF GANGLIONIC CELLS IN AUERBACH’S (MYENTERIC) PLEXUSES

NARROWING OF THE DISTAL PORTION OF ESOPHAGUS (Bird’s Beak Sign)

IMPAIRED RELAXATION OF THE LOWER ESOPHAGEAL SPHINCTER

(LES) / CARDIOESOPHAGEAL SPHINCTER
and
LOSS OF PERISTALTIC MOVEMENT OF THE LOWER TWO-THIRDS OF
THE ESOPHAGUS

REGURGITATION DYSPHAGIA FERMENTATION of INTRA-

ESOPHAGEAL CONTENT

VOMITING/CHOKING MALNUTRITION

HEART BURN HALITOSIS

ASPIRATION
WEIGHT LOSS
PNEUMONIA

ACHALASIA
 Columban College
College of Nursing
Barretto, Olongapo City

VIII. RELATED JOURNALS

IX. BIBLIOGRAPHY
 Columban College
College of Nursing
Barretto, Olongapo City

Marieb, Elaine N. “Digestive System”. Essentials of Human Anatomy &

Physiology. Pearson Education, Inc., Philippines, @ 2006, 8th ed., pp. 454-
478.

Pillitteri, Adelle. “Achalasia”. Maternal & Child Health Nursing: Care of the
Childbearing & Childrearing Family. Lippincott Williams & Wilkins,
Inc., Los Angeles: California, @ 2007, 5th ed., vol. 2, pp. 1825.

Spratto, George R. and Adrienne Woods. “Drug Study”. Nurse’s Drug

Handbook. Thomson Delmar Learning Inc., U.S.A., @ 2008, 2008th ed., pp.
273-275, 1261-1263, 1356-1359, 1590-1592.
 Columban College
College of Nursing
Barretto, Olongapo City

X. CURRICULUM VITAE

Name: ROSE ANN ALMONTE

Nickname: Shaine

Birthday: September 6, 1990

Cellphone #: 09109565877

Address: Calapacuan Subic, Zambales

Status: Single

Interest: Texting and eating

Motto: What's said can't be unsaid.

EDUCATIONAL BACKGROUND

Elementary: Calapacuan Elementary School

High School: St. James High School

 Columban College
College of Nursing
Barretto, Olongapo City

Name: FREILYN ANGOB

Nickname: Frei

Birthday: July 03, 1991

Cellphone #: 09293949103

Address: Baltao Calapandayan Subic Zambales

Status: Single

Interest: Playing basketball, playing guitar reading horror books, soundtrip,

eating, singing and sleeping

Motto: If you trust before you try, you may repent before you die.

EDUCATIONAL BACKGROUND

Elementary: Subic Central School

High School: Subic National High School

 Columban College
College of Nursing
Barretto, Olongapo City

Name: MARY RUTH AÑONUEVO

Nickname: Ruth

Birthday: October 16, 1990

Cellphone #: 09162703150

Address: #83 18th St. East Bajac Bajac Olongapo City

Status: Single

Interest: Watching Movies, Playing Cp and PC games, thinking/imagining

Motto: Obstacles are those frightful things you see when you take your eyes off
your goal.

EDUCATIONAL BACKGROUND

Elementary: St. Joseph College Elementary

High School: St. Joseph College High School

 Columban College
College of Nursing
Barretto, Olongapo City

Name: JEFFERSON AREVALO

Nickname: Jeff

Birthday: May 1, 1991

Cellphone #: 09089568828

Address: #2003 Hi-way Old Cabalan Olongapo City

Status: Single

Interest: Sleeping, Anatomy and Physiology

Motto: Better to be silent than speak ill of another.

EDUCATIONAL BACKGROUND

Elementary: Old Cabalan Elementary School

High School: St. Joseph High School

 Columban College
College of Nursing
Barretto, Olongapo City

Name: CHRISTINE JOYCE ARBOLENTE

Nickname: Tin

Birthday: December 24, 1990

Cellphone #: 09086557319

Address: # 0123 Santo Tomas Subic Zambales

Status: Single

Interest: Watching TV, playing pc games, eating and sleeping

Motto: Water far away cannot put out a fire nearby.

EDUCATIONAL BACKGROUND

Elementary: Subic Central School

High School: St. James High School

 Columban College
College of Nursing
Barretto, Olongapo City

Name: DESIREE MAE BATOON

Nickname: Treng

Birthday: January 01, 1991

Cellphone #: 09083316509

Address: Tala St. Matain Subic Zambales

Status: Single

Interest: Playing badminton, eating

Motto: A wise man makes his own decisions; an ignorant man follows the public
opinion.

EDUCATIONAL BACKGROUND

Elementary: Matain Elementary School

 Columban College
College of Nursing
Barretto, Olongapo City

High school: St. Anthony School of Matain

Name: DEAN MIGUEL BUENO

Nickname: Dinoboy

Birthday: September 11, 1990

Cellphone #: 09193639018

Address: Subic Zambales

Status: Single

Interest: Nursing Care Plan

Motto: A fool... is a man who never tried an experiment in his life.

EDUCATIONAL BACKGROUND

Elementary: Love of Jesus Learning Center

High School: St. Joseph College

 Columban College
College of Nursing
Barretto, Olongapo City

Name: REEDEN CADAHING

Nickname: Dhen

Birthday: June 07, 1990

Cellphone #: 0908799946

Address: Caron St. West Bajac Bajac Olongapo City

Status: Single

Interest: Playing computer games, cooking, biking

Motto: The customer is always right.

EDUCATIONAL BACKGROUND

Elementary: Nellie E. Brown Elementary School

High School: St. Joseph College

 Columban College
College of Nursing
Barretto, Olongapo City

Name: CRISLIE CANONIZADO

Nickname: Crislie

Birthday: November 23, 1989

Cellphone #: 09204193989

Address: Brgy. Candelaria, San Narciso Zambales

Status: Single

Interest: Soundtrip, texting, watching, playing volleyball,

collecting Mickey mouse and Pooh stuff, sleeping and eating

Motto: Contentment is wanting what you have, not having everything you want.

EDUCATIONAL BACKGROUND

Elementary: Dose Martinez Elementary School

 Columban College
College of Nursing
Barretto, Olongapo City

High School: Magsaysay Memorial College

Name: KRISTINA MAE CONCHA

Nickname: Mae

Birthday: March 23, 1991

Cellphone #: 09086533793

Address: 7th St. New Kababae Olongapo City

Status: Single

Interest: Playing basketball, dancing and eating

Motto: Live fast, die young, and have a good-looking corpse.

EDUCATIONAL BACKGROUND

Elementary: Columban College Olongapo Main

 Columban College
College of Nursing
Barretto, Olongapo City

High School: Columban College Olongapo Main

Name: LORSELL RIGUINDIN

Nickname: Lors

Birthday: April 25, 1990

Cellphone #: 09216331263

Address: #47 National Road Baranggay Farañal San Felipe Zambales

Status: Single

Interest: Nothing that interest me.

Motto: No one knows what you can do till you try.

EDUCATIONAL BACKGROUND

Elementary: Sto. Tomas Elementary School

 Columban College
College of Nursing
Barretto, Olongapo City

High School: St. Columban’s Montessori High School

VI. LABORATORY and DIAGNOSTIC EXAM

Columban College
College of Nursing
Barretto, Olongapo City
 Columban College
College of Nursing
Barretto, Olongapo City

VII. N VII. NURSING CARE PLAN

NURSING
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:  Risk for Short term: INDEPENDENT INDEPENDENT Short term:

“Kakaoper After 8 hours of Short Term: Short Term: After 8 hours of
a ko lang,” infection r/t nursing intervention WOUND CARE: nursing
as surgical the patient will display 1. Irrigate wound with 1.Cleans wound intervention the
verbalized incision signs of healing w/ room temperature w/out harming patient will
by the wound edges sterile NS TID delicate tissues displayed signs of
patient. clean/pink. 2. Assess wound w/each 2.Provides healing w/ wound
dressing change. information about edges clean/pink.
Objective: Long term: Obtain wound tracing effectiveness of
 (+) Redness on After 72 hours of on admission and at therapy, and Long term:
the site nursing intervention discharge identifies After 72 hours of
 Improper the patient will be
3. Apply wet to dry additional needs nursing
wound dressing free to risk of intervention the
sterile dressing. Use 3.Keep wound
 V/S taken: infection and achieve
paper tape clean/ minimizes patient was free
BP= timely wound healing to risk of infection
cross
120/90 contamination, and has achieve
Long Term:
PR= 89 adhesive tape may timely wound
INFECTION COTROL:
RR= 21 be abrasive to healing.
4. Follow wound
T= precautions. fragile tissues
36.7
5. Obtain sterile
specimen of wound
drainage on admission.