HYDOM LUTHERAN HOSPITAL

GROUP 2

CASE PRESENTATION

DEMOGRAFIC DATA OF THE PATIENT

Name :MHG

Age :86 Years

Sex :M

Address :MULUBADA

Religion :ROMAN CATHOLIC

Trible :IRAQ

Ward :GENERAL WARD GW-1 inpatient

Occupation :ANIMAL CULTIVATION

Marital status :MARRIED

Date of admission :17/09/2022

CHIEF COMPLAIN

The patient was complaing

• Abdominal pain,Distended abdomen,Loss of consciousness

HISTORY OF PRESENTING ILLINESS

• The patient present with Nausea and Vomiting which is nonbillious that contain undigested
food particles.The patient also present with gastric retention,including bloating or epigastric
fullness,indigestion ,anorexia ,epigastric pain and weight loss

PAST MEDICAL HISTORY

Previously was suspected to have ulcers and was taking pantaprazole tabs

PAST SURGICAL HISTORY

In 2003 abdominal operation was done but the fully history is not clear
PRIOR HOSPITALIZATION

The patient has already being admitted at Hydom Lutheran Hospital on 22 June 2016 with eczema
unspecified and on 18 August 2016 with seborrhoeic eczema

ALLERGIES TO MEDICATION

No known allergies

PERSONAL HISTORY

Its a peasent and was not attended any class

FAMILY HISTORY

One wife with 12 children

PHYISICAL EXAMINATION

VITAL SIGNS

Temperature 36.9C (auxiliary),Pulse rate 75b/min,Respiratory rate 19bpm,Blood pressure 111/65mmHg

(right arm while lying down)

HEALTH PERCEPTION-HEALTH MANAGEMENT PARTTERN

Mental –oriented, Sensorium –Alert, Memory –Remote , Vision –Good , Pupil size—
Normal ,Hearing—Able

Taste :sweet—Normal, Sour—Normal, Toungue movement –Normal, Toungue appearance –normal

Touch :Blunt –normal, Sharp—Normal , Light touch sensation –Normal

No any numbness noted,No any tingling noted,Able to smell ,Cranial nerve –normal ,Reflexes –normal,
No lymph nodes enlargement in the neck

General appearance

Hair –Good, Skin –intact , Nails—Good, No body odor , The health status is Good, Tobacco use –Yes,
Alcohol use –Yes

No history of chronic disease, No immunization received

NUTRITIONAL –METABOLIC PATTERN

Skin examination
 Skin—Warm , No lesions , No rash , Skin turgor is firm, Skin color pale

Mucous Membranes

Mouth :moist , NO lesions, pale in color, Teeth normal, Gums normal

No Edema , Thyroid is normal , No jugular vein distention

Patient can not move easily because of body weakness

Fair appetite, No any diet restriction , 4 meals with no snack a day taken, 1L fluid intake

Ugali mostly liked food by the patient , Nausea and vomiting noted

ELIMINATION PATTERN

Bowel sound heard and is decreased , No any tenderness of the abdomen, The abdomen is soft , No any
masses palpated in the abdomen, Rectal exam , Sphincter is good , No hemorrhoids noted

Characteristics of stool

The stool is soft ,brown in color and no bleeding noted during bowel movement

ELIMINATION PATTERN

Usually voiding pattern, Frequency 4 times a day ,yellow urine in color,catheter is inserted

ACTIVITY-EXERCISE

1.Cadiovascular

No cyanosis ,normal heart sound

2.Respiration

No any SOB noted,normal pulse rate

3.Musculoskeletal

Range of motion is limited, Muscle strength is normal , Use mobile aids , No tremors , No paralysis
present

4.Sleep and rest

Pt Sleeping too much , No insomia

COGNITIVE-PERCEPTUAL PATTERN

1.Pain
Pain noted in the area of incission

2.Decision making

Difficulty decision making

SELF-PERCEPTION AND SELF-CONCEPT PATTERN

During assessment the pt. appear anxious , Body language was observed but some difficulty due to pt.
condition

ROLE-RELATIONSHIP PATTERN

• The patient sometime can not speak clearly due to disease conditions and language barrier,
Family interactions is very nice, The patient do not live alone , The patient is married

SEXUAL REPRODUCTIVE PATTERN

• No history of prostate gland problems, No history of penile discharge , No history of STIs

LABARATORY FINDINGS

C/S no growth., Cell and diff N-8% L-92% Wbc: increased lymphoctes,no malignant cells seen .Hep C
negative., Albumin 15.90g/l., AST 59.7u/l., ALT 31.5u/l.,Hep B negative., Blood group o Rh +ve ,
X matching compatible ( WBC=4.7 x10^3/mm^3, RBC=3.58x10^6/uL, HGB=10.1g/d,
HCT=28.8% ,MCV=80.4u/m^3, MCH=28.2pg/cell ,MCHC=35g/dL, PLT 313plts/mL of blood.), FBP
(LYM=0.9%,GRA=73.6gm/dL,), Urea 4.2mmol/l, Creatinine 88.85umol/l, Electrolytes Na 131.0mmol/l , K
3.64mmol/l, Cl 97.0mmol/l, ESR 5mm/hr.

THE NORMAL RANGE OF LABARATORY TEST

• ALT( Alanine aminotransferase) 4-36u/L, AST(Aspartate aminotransferase)8-33u/L

The high level of ALT and AST enzeyme in blood means liver disorders

• WBC (4.5-11.0x10^3/mm^3), RBC(3.9-5.2x10^6/uL), MCH(Mean corpuscular hemoglobin) 25.0-

35.0pg/cell, MCV(Mean corpuscular volume)76-100u/m^3, ESR(Sedimentation rate)0.15mm/h,
HGB(haemoglobin test) 13.6-16.6g/d, HCT(Hematocrit) 41-50%, MCHC(Mean corpuscular
hemoglobin concentration) 33-36g/dL , Platelets (150,000-450,00plts /mL of blood),
LYM(lymphocytes ) 20-40%, GRA (Granuloocytes) 14-17.5gm/dL,
UREA-2.9-8.9mmol/liter ,Creatinine 0.7-1.3mg/dL

MEDICAL DIAGNOSIS

• Alcoholic liver cirrhosis,Gastric outlet obstruction,Peritonitis

PLAN AND MANAGEMENT

Continue with iv fluids , antibiotics , ant pain , continue with catheter, encourage oral sips and
ambulation

OPERATION

Operation date 19/09/2022

Procedure: Explorative laparotomy

Indication :Gastric outlet obstruction and peritonitis

Special notes:

Under GA ,patient in supine position, prepped and draped aseptically, through upper midline
incisionn,abdomen opened in layers

--findings: 2l ascites noted and sucked , bowel inspected, no perforation noted, liver
shrunked,afungating tumor on pylorus obstructing the lumen originating from the pancreases

POST OPERATION

--diclofenac 75mg tds for 1day , paracetamol 1g iv bd for 1day , ceftriaxone 1g iv bd for
3days ,metronidazole 500mg iv tds for 3days ,DNS/RL 3L in 24hrs , monitor vitals closely , keep npo for
48 hrs

POST OPERATIVE MANAGEMENT

-Catheter

-lasix 40mg iv bd

-Spironolactone

-Ciprofloxacin 400mg iv bd

-Iv fluids 2L NS/RS

-Lactulose 30mls tds

-Dressing

-Monitor u/o

NURSING MANAGEMENT

To administer medication as prescribed

To monitor vital signs

Feeding

Morning care

-patient bathed, linen changed ,dressing cleam and dry ,patient is fully awake, proper suction

NURSING DIAGNOSIS

DAY (7/10/2022)

Acute pain related to surgical incision as evidencied by patient verbal report on pain

Interventions

- Position the patient in a cormfortable position

- Reduce noises

- Give anti pain

Imbalance nutrition less than body requirements related to decreased oral intake as evidenced
by decreased muscle mass

Intervantions

-encourage the patient to eat small meals and frequency

-encourage the patient to eat nutritionally food
-give anti emetics

Activity intolerance related to generalized weakness as evidenced by report of body weakness

Interventions

-encourage the patient to rest

-assist the patient with daily activity

Urinary incontinence related to incomplete bladder emptying as evidenced by reported dribbling

Interventions

-insert the urinary catheter

 -asses the urine charateristics before emptying the urine bag

DAY (8/10/2022)

Self care deficit related to tiredness and weakness as evidenced by inability to perfom daily activities like
dressing and bathing

Interventions

-assit the patient to perform daily activities like toileting and bathing

-encourage rest period

Anxiety related to change in health status as evidenced by restless

Interventions

-provide adequate information to the patient about his health and treatment

-reassure the patient

-listen carefully to the patient needs and respond immediately

Knowledge deficit related to lack of information concerning disease process as evidenced by request for
information

Interventions

-responds to the questions politely

-give adequate information regarding the patient health and treatment

DAY( 9/10/2022)

Disturbed thought process related to aging as evidenced by inability to make decisions

Interventions

-assist the patient in making proper decisions for his health

-advocates for the patient

 -attends to the patient needs

Risk for fluids volume deficit related to loss of fluid through indwelling tubes

Interventions

-administer iv fluids as ordered

-encourage increased oral fluids