COLLEGE OF NURSING

CARE OF OLDER PERSON

RELATED-LEARNING EXPERIENCE (RLE)
FLORES MEMORIAL MEDICAL CENTER

A CASE STUDY
ON
VOLVULUS (TWISTED BOWEL)

Submitted by:
BSN 4B-GROUP 3

Calonge, Rhealyne C. Mateo, Karen Mae

Capicio, Showbie P. Olay, Carlo Emmanuel
Lagman, Krishna Mae S. Ordanza, Jem Jerica C.
Lobo, Patrick Therrence Palma, Clarence M.
Marcos, Jaiah Jane B. Tomas, Jessa Mae

Presented to:
Level 4 Clinical Instructors

Submitted to:
Sir Darwin M. Viernes, RN, LPT, MAN

APRIL 2023

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OBJECTIVES

General objectives
This case study seeks to demonstrate students’ knowledge regarding
the general health and disease condition of a patient volvulus, its disease
process, possible complications, treatment plan, and nursing interventions.

Specific objectives
 To understand the pathophysiology and etiology of volvulus.
 To understand the role of drug therapy in managing the client
related to volvulus.
 To recognize the contributing factors associated in the
development of volvulus.
 To accurately present a thorough assessment of the patient
which includes physical assessment and medical history taking.
 To efficiently provide appropriate and proper nursing diagnosis
in volvulus and skillfully formulate nursing care plans for the
identified problems.
 To appropriately apply nursing interventions necessary for
patient’s condition.
 To exhibit mastery in answering relevant questions with positive
attitude towards criticisms and suggestions.
 To have more patience in applying every nursing intervention
necessary for patient’s condition.

OVERVIEW OF THE DISEASE

Definition
The term volvulus actually comes from the Latin word volvere, which
means “to roll”. So a volvulus is an obstruction caused by a loop of the
intestine that rolls or twists around itself and its surrounding mesentery, which
is the tissue that attaches the intestine to the back wall of the abdomen.

The three most common types of volvulus are a sigmoid volvulus,

which happens in the the last part of the large intestine, leading to the rectum;
a cecal volvulus, which happens in the beginning of the large intestine, and a
midgut volvulus, which happens in the small intestine.

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Signs and symptoms
The onset of symptoms may be insidious or sudden. It may include:
 abdominal distension
 pain
 vomiting
 constipation
 bloody stools

Diagnostics
A healthcare provider may suspect volvulus based on this history and begin
looking for a possible cause, which may include additional tests beyond a
physical exam such as:
 CT scan
 X-Rays
 Contrast Enema

Treatment
Volvulus treatment focuses on two goals: Fixing the currently twisted intestine
and preventing future episodes.
 The process of untwisting the intestines is called "reducing" the volvulus.
It first requires a flexible sigmoidoscopy procedure, which relies on a
flexible, tube-like instrument equipped with a light and camera.
 Surgery for a volvulus includes removing part of the bowel and then either
reconnecting it or creating a colostomy, a hole in the abdominal wall
through which fecal matter then passes.

Prevention

Volvulus can be prevented through following:

 Chew foods well.
 Eat in a relaxed setting and eat slowly.
 Eat smaller amounts of food more often throughout the day.
 Drink 2000 to 2500 mL (8 to 10 cups) of fluids every day.
 Limit fluids with caffeine (examples: coffee, tea, colas) and alcohol, as
they can irritate the bowel.
 Take a complete multi-vitamin with mineral supplements every day to
make sure you get enough nutrients.

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PATIENT’S PROFILE

Name: RQ
Age: 60 y.o
Sex: Male
Religion: INC
Marital status: Married
Address: P3, Namamparan, Diadi, Nueva Vizcaya
Birthday: October 15, 1962
Occupation: Messenger I
Weight: 57.6 kg
Height: 160 cm

Date of admission: March 30, 2023

Time of admission: 7:25 pm
Chief complaint: Abdominal Pain
Admitting Diagnosis: Gut Obstruction
Final Diagnosis: Volvulus
Procedure: Reduction of volvulus

Admitting Vital Signs:

Temperature: 36.9 C
BP: 110/70 mmHg
RR: 21 cpm
PR: 98 bpm
SPO2: 99%

PATIENT’S MEDICAL HISTORY

A. PAST MEDICAL HISTORY

According to the patient, during his high school years he was
hospitalized due to Ulcer. On year 2014, he was hospitalized because
he was experiencing headache and chest pain and later on was
diagnosed with Hypertension, he had been given the medication
Losartan as his maintenance. Then on the year 2018, he was rushed to
the Diadi Emergency Hospital due to an accident happened where
while he was working on their backyard of their house, a coconut fruit
suddenly fell over his head that lead him to the ER.

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B. PRESENT MEDICAL HISTORY
A week prior to admission, the patient was experiencing
intermittent abdominal pain, body weakness and diarrhea. There are
also times when he cannot pass stool. And on March 29, 2023 at 5pm,
he was brought to the Diadi Emergency Hospital because he was
experiencing severe abdominal pain with a pain scale of 10/10 that
prompted his admission. Then the same day at evening at 9pm, when
the pain subsided, he was discharged and was prescribed take home
medications, Omeprazole and Hyoscine Tablet for abdominal pain. But
after he was discharged, early in the morning, around 4am on March
30, he was still experiencing severe abdominal pain, that’s the time
when he decided to go to FMMC. However, the patient did not go to
the hospital right away, they waited an ambulance to arrive because
that’s their only transportation. Then at that night at exactly 7pm when
they arrived at FMMC, then the patient underwent some laboratories
and later on was diagnosed with a case of Gut Obstruction. Then on
march 31, the patient was scheduled for an operation, it was started at
5:30 pm and was finished at 7:30 pm.

C. FAMILY MEDICAL HISTORY

HEART
HPN DM ULCER CANCER
DISEASE
Father (-) (-) (-) (+) (-)
Mother (-) (-) (-) (-) (-)

The patient has history of Ulcer in his father’s side. Patient had no
known history of HPN, DM, heart disease, cancer on both sides of family.

D. SOCIAL HISTORY
The patient stated that she does not smoke and only drinks alcohol
occasionally.

PHYSICAL ASSESSMENT (HEAD-TO-TOE)

Date of Assessment: 04-01-2023 (3 days of Admission)

Time of Assessment: 8:30 – 9:30 pm

General Survey: The patient was awake, alert, and coherent, he was in a
supine position when we entered the room. The patient has a mesomorph
type of body build and weighs 57.6 kilograms and stands 160 cm. His BMI is
within range. The patient was certainly oriented to time, place, and persons.

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 He can speak clearly and can move well. The patient dresses appropriately in
the condition of his room (specifically the room temperature).

Vital signs were taken as follows:

Blood Pressure: 130/90 mmHg
Pulse rate: 90 bpm
Respiratory rate: 27 cpm
Temperature: 37.4*C
SpO2: 95%

Part to be Assessed Modality Findings Interpretation

Head  Inspection  Symmetrical; Rounded,  Normal
normocephalic, and
symmetrical.  Normal
 Palpation  Hard and smooth
 Absence of nodules or masses  Normal
Skin  Inspection  Dry and Wrinkled  Abnormal due to
heat and humidity
draw moisture
from the skin and
due to aging.
 No abnormal pigmentation,  Normal
bleeding, rash, or other
lesions.
 Poor skin turgor in extremities  Normal
due to aging but good skin
turgor in the sternum.
 Palpation Normal
 Skin is warm 

 Presence of incision in the  Abnormal due to

abdominal area. surgery done.
Hair and Scalp  Inspection  White hair, evenly distributed,  Normal
cover the whole scalp.
 No presence of dandruff  Normal
 There is no presence of lice,  Normal
nits, and lesions.
 Palpation  No tenderness upon palpation  Normal
Face  Inspection  Facial skin sagging.  Normal due to
 Palpation aging.
 No presence of nodules and  Normal
masses.
Ears  Inspection  Both ears were symmetrical;  Normal
 Auricle aligned with outer  Normal
canthus of the eye.
 Skin is smooth and warm;  Normal
without nodules;
 Normal
 Whisper test: both ears are
able to hear clearly.
 Normal
 Absence of tenderness,
nodules, and pain.
 Palpation  Mastoid process is easily  Normal
palpated
Eyes  Inspection  Wearing prescribed  Abnormal due to
eyeglasses with 150 eye grade overuse of the

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 in both eyes. eyes focusing
mechanism.
 Pupils are equal, round, and  Normal
reactive to light and
accommodation, and are
centrally located in the Iris.
 Sclera is light yellow in color.  Normal: It comes
gradually as a
person grows
older
 Conjunctiva on the eyeball is  Normal
equally pinkish in both eyes.
 Cornea is translucent, smooth,  Normal
and avascular.
 Iris is flat and color varies.  Normal
 Lens is transparent and  Normal
uniform in density.
 Eyelashes and Eyebrows are  Normal
black, equally distributed, and
symmetrical.  Normal
 Eyelids are monolid.  Normal
 Lacrimal gland is symmetrical
and has a tear-shaped gland.
Nose  Inspection  The nose was in the midline,  Normal
symmetric and straight.
 Has patent nares, clean nares,  Normal
and the mucosa was pink and
moist.
 Normal
 No discharges, no flaring with
respiration; no lesions.  Normal
 Sense of smell is good.  Normal
 Palpation  No tenderness and nodules
Mouth  Inspection  Lips are pinkish and have  Normal
brown pigment on edges.  Normal
 No swelling and no presence
of sores.  Normal
 The buccal mucosa is light
pink in color, moist and
smooth.  Normal due to
 Wearing dentures; 4 in upper aging.
teeth, 4 in lower teeth are
absent  Normal
 Mouth symmetry;  Normal
 The tongue is in the central
position, pink but with a whitish
coating which is normal, with
veins prominent in the floor of
the mouth.  Normal
 Uvula in the middle and tonsils
were not enlarged.
Nails  Inspection  Fingernails:
 Dirty nails.  Abnormal due to
poor hygiene.
 With a 2-second capillary refill  Normal
 Palpation time

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Neck  Inspection  Positioned at the mid-line  Normal
position; symmetrical;
landmarks identifiable
 The trachea and Thyroid are in  Normal
the midline, smooth and firm;
none tender
 Adam’s apple is in the center.  Normal
 Palpation  Cervical lymph nodes are not  Normal
palpable
Chest and lungs  Inspection  The chest contour is  Normal
symmetrical, and the spine is
straight.
 Uniform light to brown skin  Normal
color.
 Palpation  Absence of lesions, masses,  Normal
lumps, and tender areas.
 Inspection  Even and relaxed. Full and  Normal
symmetric 2 inches of chest
expansion.
 Auscultation  No Presence of crackles or  Normal
any abnormal sounds upon
auscultation in lungs.
Heart  Auscultation  Regular cardiac rhythm. S1  Normal
and S2 are present and
audible.  Normal
 No presence of murmurs is
heard.  Normal
 The apical pulse (PMI) is
heard.
Abdomen • Surgical incision at the • Abnormal due to
 Inspection hypogastric region. surgical procedure
Neurological status  Inspection  Oriented to person, place, and  Normal
time.
Level of  Inspection  Awake, alert, and coherent  Normal
consciousness
Upper Extremities  Inspection  Dry skin and wrinkled.  Abnormal due to
and Lower heat and humidity
Extremities draw moisture
from the skin and
due to aging.
 Normal
 Both extremities are equal in
size  Normal due to the
 Presence of scars natural process of
healed wounds
 Normal
 Abnormal due to
 White color of nails post surgery.
 Have a slightly limited range of
motion and slowed
movements; needs assistance
to stand and slightly able to
shrug shoulders against
resistance.
 Palpation
 No presence of edema  Normal

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 GORDON’S 11 FUNCTIONAL HEALTH PATTERN

BEFORE HOSPITALIZATION DURING HOSPITALIZATION

 According to the patient “Ang • The patient stated “dati naalagaan

kalusugan ay mahalaga at ko sarili ko pero di ko naman
mabuti”. He describes himself as a akalain na mayroon na pala
healthy individual and he was able akong iniindang sakit”. He
Health
to take care of himself not until he currently kept his health under
Perception/
found out about his disease. control by doing what the doctor
Health
According to him he managed instructed. And was open to
Management
himself by just taking whatever learning about and paying
medication is available and attention to health advices.
applicable for his condition.
Especially when he’s feeling pain.

• Patient QR usually eats 3 times a • The patient ate twice since

day, every meal he eats one cup hospitalization, then was ordered
of rice but sometimes two. He for NPO before his surgery. The
also stated that he limits his patient was advised for LSLF
meals sometimes due to his diet.
underlying condition, which is
Nutritional hypertension. Patient QR is not a
Metabolic picky eater, meat and vegetables
Pattern is his diet but mostly on
vegetables. He drinks 6-8 glasses
of water a day that contains
200ml. He is not allergic to any
foods or medications. Regarding
his religion, there are no dietary
restrictions.

 According to patient QR he voids • Patient QR stated that he

5-7 times a day with light yellow in defecated twice since his
color of urine. He also defecates hospitalization and voids 6 times
once or twice a day, specifically a day with small amounts.
Elimination
every morning when he wakes up.
Pattern
Stool is brown in color and formed.
Patient QR does not have painful
sensation during urination and
defecation.

 According to the patient QR, he  Patient QR need assistance from

was able to perform daily tasks
including housework, grooming,
Activity
taking bath, feeding himself, and
Exercise
exercising without assistance.
Pattern
healthcare professionals and
others since he finds it difficult to
perform basic daily tasks like
eating and grooming due to
physical weakness. He also tried
walking in the hallway but with
the assistance of SO.

 Patient QR sleeps at 10:30 pm  Patient QR sleeps 5 hours during

and wakes up at 5am in the
Sleep Rest
morning. According to him, he
Pattern
doesn't have trouble sleeping.
hospitalization. “Hindi ako
masyado makatulog kasi hindi
ako sanay sa hospital” as
verbalized by the patient.

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  QR was able to recall previous
events and can respond to
questions verbally. He doesn't
Cognitive have a hearing problem, but his
Conceptual vision is blurry and he wears
Pattern prescribed eye glasses with a
grade of 150.
Self-  Patient QR described himself as a
Perception/Self strong and caring individual.
Concept
Pattern
 Patient QR claims that he is
married, has two children, and
resides with her family but his
Role other daughter lives at Quirino
Relationship Province. His communication with
Pattern his family remains open.
 The patient QR said that he and
his wife were active in sexual
Sexual intercourse.
Reproductive
Pattern
 Patient cope with stress by
watching television. His children
and wife are always by his side,
Coping Stress
they manage the situation together
Tolerance
with each other's support.
 Patient QR is an INC; he regularly
attends mass with his family. The
Values Belief
patient rejects superstitious ideas
Pattern
and beliefs.
COURSE IN THE WARD
Date/Time Side Doctor’s Order
10
 Patient QR is a highschool
graduate, and he appropriately
answers the questions. He was
competent in responding to
detailed questions. The patient is
aware of time, place, and people.
None of his senses have
changed except for his blurry
vision.
 Despite his concerns, the patient
was still hopeful for a quick
recovery and that he was making
an effort to remain calm.
 During her hospital stay, he
continued to have the same
relationship with his family.
Through chats and video calls,
he stays in touch with his
children. Because telling his
family about the progress of his
condition makes her feel more
relieved.
 No sexual activity occurred due
to hospitalization.
 Patient QR relaxes and sleeps.
He makes an effort to maintain
his sense of optimism that his
medical condition will improve.
Also, he watches youtube videos
on his mobile phone to cope with
stress.
 According to patient QR, he was
always praying that he would get
better so he could go home. His
faith still remains. He believed
that God is always there to help.
Interpretation Nursing Responsibil
 Notes
March 31, 2023  Admit to ROC under  To provide quality care  Provide quality care a
60 / M service of Dr. F and monitoring for the monitor the patient.
patient
 Secure Consent  To obtain consent in  Act as a witness for th
rendering medical patient signing the
treatment to the patient. consent.
 DAT/SAP  To prevent risk for  Make sure the patien
aspiration. follows the diet exact
prescribed.
Diagnostics
 CBC, Stool exam, Na, K,  Routine medical analysis  Request for diagnosti
Crea, Bun, HGT, Rat, for patient’s condition. relay result to AP onc
ECG, X-ray available.

Treatments
 IVF PNSS 300ml FD then
for maintenance
 D5LR 1x to 8hours
 Omeprazole 40 mg IV now
then OD
 HNBB 1 amp TV 8hours
 For maintenance of  Monitor and regulate
fluids and electrolytes as ordered.
and replenishment
 For maintenance of fluid  Monitor and regulate
and electrolytes ordered.
especially to patient who
needs calories and
hydration.
 To clear the infection by  Advice patient that th
decreasing the amount medication must be ta
of stomach acid that the before meals.
stomach lining produces.
 To relieves painful  Assessed patient
stomach cramps. abdominal pain and g
the medication with s
push.

 Inform AP  

 To detect or medical  Monitor patients VS t

 Monitor VS q2 problem refer if there are any
abnormalities.

 Refer
March 31, 2023
- 60 male
8:25am - 3days progressive abdominal
pain
- PE: (+) tenderness
- voluntary guarding

8:34am  For abdominal UTZ;  For further evaluation. 

abdominal ratio

 NPO  Preparing the patient for  Make sure the patien

abdominal ultrasound follows the diet exact
and surgery. prescribed.
 Start

11
 1. Ceftriaxone 1g IV q12
2. Metronidazole 500ml IV q8
3. Omeprazole 20mg IV q12
4. HNBB 10 ml IV q4 PRN
5. Paracetamol 300mg IV q4
PRN
March 31, 2023  Abdominal X-ray upright;
dilated small bowel with air
fluid level
 Used as surgical
prophylaxis.  Ensure the patient is
negative ANST befor
 Used to prevent infection giving the medication
in the bowels before and  Assess for IV site the
after surgery. monitor adverse effec
such as headache or
 To improve gastric alterations in mental s
environment at the time  Monitor adverse effec
of anaesthesia. headache
 To treat abdominal pain
associated with cramps  Monitor signs of lack
bowel sounds or
movements,abdomin
 For relieving abdominal bloating and vomiting
pain.  Check for allergies,M
for adverse effect like
respiratory dysfunctio
insomnia and headac

 No rectal air

 Impression: intestinal
obstruction, mechanism
consideration.
- Abdominal aneurysm
- Bands
- Occult malignancy

 Refer to Dr. N  For further evaluation of

* Force no absolute patient’s condition.
contraindication to explore lap

Refer

March 31,2023  Acute abdominal problem

secondary to
Abdominal X-ray 1. Ruptured appendicitis
binds bench 2. Mass
appearance 3. TB?
4. Volvulus

* 60M  NPO
* 3days  To decreased the risk of
abdominal pain aspiration of gastric  Make sure the patien
* 2days(-) BM contents during follows the diet exact
* 1day (-) Flatus  VS q15 for 1hrs q4 anaesthesia. prescribed
* (-) Fever  To detect for medical
* ↑ Severity of problem.  Monitor patients VS t
pain promote  NPO clear water liquid
refer if there are any
consult. tom@10am To decreased the risk of
 abnormalities.
aspiration.  Make sure the patien
 IVF @ 40gtts/min
IVF D5LRS 1 x 8hours follows the diet exact

 For daily maintenance of
3bottles prescribed
body fluids and nutrition

12
 and for rehydration
 Paracetamol 600ml IV
q6hrs 6doses  For relieving
postoperative pain.
 Tramadol 50mg q6 doses
 To relieve moderate to
moderately severe pain
including pain after
surgery
April 1, 2023 Orders
4:41am  Remove IFC once with  To prevent infection and
urges complications
Urine output  Set up on bed  Help to reduce pressure
180ml bedsores.
7pm-1am  Early ambulation  To stimulate circulation
and stop development of
blood clots.
 Deep breathing exercise  Help calm your
nerves,reducing stress
and anxiety.
 IV D5LR 1L x 8  For daily maintenance of
body fluid and nutritions,
and rehydration
 Continue present meds  For continues
improvement of health
status.
 Apply abdominal binder  To provides support and
please. compression to the
upper and lower
abdomen weakened by
strain or the
postoperative phase of
surgery.
13
 Monitor and regulate
 Check for allergies,M
for adverse effect like
respiratory
dysfunction ,insomnia
headache.
 Assess for level of pa
monitor BP and respi
rate.
 Maintain aseptic
techniques.
 Observe and prevent
patient complications
 Assist patient during
ambulation.
 Observe the patient b
doing right deep brea
exercises.
 Monitor and regulate
per ordered.
 To ensuring right
medication right dose
dose,rite time and rig
route and right patien
 Ensure the patient ke
the dressing and ban
in place and speed up
wound and incision.
 LABORATORY AND DIAGNOSTICS

PATIENT: QR DIAGNOSIS: VOLVULUS

Request Date: March 30, 2023
Release Date: March 30, 2023 Time: 8:30 PM

HEMATOLOGY 1
REFERENCE
TEST RESULT INTERPRETATION
RANGE
Hgt 14.6 13.00-18.00 g/dL Normal
Hct 45.7 40.00-55.00 % Normal
RBC 5.23 4.00-6.00 x 106/uL Normal
WBC 9.6 5.00-10.00 Normal
Plt 357 150-400 x 103/uL Normal
MCV 87.4 82.50-98.00 fL Normal
MCH 27.9 26.10-32.80 pg Normal
MCHC 31.9 30.70-35.90 g/dL Normal
Segmenters 73.0 (H) 50.00-60.00% High neutrophils and low lymphocytes together
represent an elevated NLR ratio. The elevation can be
Lymphocyte 17.0 (L) 25.00-35.00% caused by the inflammatory disorder.
Monocyte 07.0 3.00-7.00% Normal
Eosinophils 03.0 1.00-3.00% Normal

PATIENT: QR DIAGNOSIS: VOLVULUS

Request Date: March 31, 2023
Release Date: March 31, 2023 Time: 10:40 PM

HEMATOLOGY 2
REFERENCE
TEST RESULT INTERPRETATION
RANGE
Protime:
Patient 11.7 seconds 11.1-14.3 seconds  Elevated INR means patient’s blood clots
Control 12.0 seconds - more slowly than desired
% activity 102.56% (H) 70-100%
INR 1.29 seconds (H) 0.9-1.2 seconds

PATIENT: QR DIAGNOSIS: VOLVULUS

Request Date: March 30, 2023
Release Date: March 30, 2023 Time: 8:31 PM

CLINICAL CHEMISTRY
REFERENCE
TEST RESULT INTERPRETATION
RANGE
BUN 21.6 (H) 7-20 mg/dL Due to dehydration since patient is having watery
stool prior to admission.
Creatinine 95.47 80-115 mmol/L Normal
Na 135.2 135-150 mmol/L Normal
K 4.49 3.50-5.50 mmol/L Normal

LABORATORY AND DIAGNOSTICS

14
PATIENT: QR DIAGNOSIS: VOLVULUS
Request Date: March 30, 2023
Release Date: March 30, 2023 Time: 8:26 PM

HEMOGLUCOSE TEST

REFERENCE
TEST RESULT INTERPRETATION
RANGE
HGT 126 (H) 70-100 mg/dL Abnormal due to elevated blood glucose
level.

PATIENT: QR DIAGNOSIS: VOLVULUS

Request Date: March 30, 2023
Release Date: March 30, 2023 Time: 8:30 PM

MISCELLANEOUS
TEST RESULT

COVID ANTIGEN TEST NEGATIVE

PATIENT: QR DIAGNOSIS: VOLVULUS

Request Date: March 30, 2023
Release Date: March 30, 2023 Time: 8:30 PM

URINALYSIS
ROUTINE RESULT ROUTINE RESULT
COLOR YELLOW NORMAL WBC 2-5 / HPF NORMAL

TRANSPARENCY TURBID NORMAL RBC 0-2 / HPF NORMAL

SPECIFIC EPITHELIAL
1.015 NORMAL RARE ---
GRAVITY CELLS

AMORPHOUS
pH 5.0 NORMAL FEW ---
URATES

MUCUS
PROTEIN NEGATIVE --- FEW ---
THREADS

GLUCOSE NEGATIVE --- BACTERIA FEW ---

LABORATORY AND DIAGNOSTICS

15
PATIENT: QR 60/M DIAGNOSIS: VOLVULUS
Collection Date: March 30, 2023
Referring Physician: Dr. F

EXAMINATION: ULTRASOUND OF THE WHOLE ABDOMEN

 Limited study due to gassy abdomen. There are dilated small loops in all
abdominal quadrants.
 Minimal fluid collection is also seen in the peritoneal cavity.
 The liver is normal in size exhibiting homogeneous parenchymal
echopattern. No focal mass noted. Portal vein and its tributaries are
unremarkable.
 The common bile duct measures about 0.3 cm which is within normal
size. Intrahepatic ducts are not dilated.
 The gallbladder is normal in size and configuration. Lumen is echofree.
The wall is not thickened. No pericholecystic fluid collection noted.
 The pancreas and abdominal aorta are obscured by overlying bowel gas
echoes precluding proper evaluation.
 The spleen is not enlarged with homogeneous parenchymal echopattern.
There are no masses noted. The slpeenic vessels are not dilated.
 The right kidney is normal in size measuring about 9.7 x 5.5 x 5.5 cm
(LxWxAP) exhibiting homogeneous parenchymal echopattern. No evident
lithiasis or focal masses noted. Its pelvocalyceal system is not dialted.
 The left kidney is normal in size measuring about 10.2 x 5.4 x 5.2 cm
(LxWxAP) exhibiting homogeneous parenchymal echopattern. No evident
lithiasis or focal masses noted. Its pelvocalyceal system is not dialted.
 The urinary bladder is physiologically distended showing smooth contour
outline. The wall is not thickened. No evident lithiasis seen.
 Transabdominal scanning shows a normal-size prostate gland with
concretions. It measures approximately 3.2 x 3.8 x 3.0 cm (LxWxAP) and
weighs about 19.6 grams.

Impression:
Ileus versus small intestinal obstruction. Upright and supine XRAYS of the
abdomen suggested for further evaluation.
Minimal ascites.
Unremarkable ultrasound of the liver, biliary tree, gallbladder, spleen, kidney,
and urinary bladder.
Normal-sized prostate gland with concretions.

16
 LABORATORY AND DIAGNOSTICS

PATIENT: QR 60/M DIAGNOSIS: VOLVULUS

Collection Date: March 30, 2023
Referring Physician: Dr. F

CHEST X-RAY PA OR AP (ADULT)

Examination: CHEST PA

Radiological Findings:
 There are no parenchymal infiltrates in both lung fields.
 The heart is not enlarged.
 Aorta is faintly calcified.
 Chst wall, hemidiaphragms, costophrenic sulci and visualize bones
are intact.

Impression:
Atheromatous aorta.

PATIENT: QR 60/M DIAGNOSIS: VOLVULUS

Collection Date: March 31, 2023
Referring Physician: Dr. F

EXAMINATION: ABDOMEN - AP (ADULT)

Radiological Findings:
 There is gaseous dilatation of the small loops with thickened
interserosal linings and exhibiting multiple air-fluid levels, both renal
outlines and psoas shadows are obscured.
 No organomegaly or calcifications noted.
 Flank stripes are uneffaced.
 Visualized osseous structures are intact.

Impression:
Consider small bowel obstruction. Follow-up study is suggested for
further evaluation.

17
ANATOMY AND PHYSIOLOGY

Small and Large Intestine Anatomy

Small Intestine
The small intestine extends from the pyloric sphincter to the ileocecal
valve, where it empties into the large intestine. The small intestine finishes the
process of digestion, absorbs the nutrients, and passes the residue on to the
large intestine. The liver, gallbladder, and pancreas are accessory organs of
the digestive system that are closely associated with the small intestine.

The small intestine is divided into the duodenum, jejunum, and ileum.
The small intestine follows the general structure of the digestive tract in that
the wall has a mucosa with simple columnar epithelium, submucosa, smooth
muscle with inner circular and outer longitudinal layers, and serosa. The
absorptive surface area of the small intestine is increased by plicae circulares,
villi, and microvilli.

Exocrine cells in the mucosa of the small intestine secrete mucus,

peptidase, sucrase, maltase, lactase, lipase, and enterokinase. Endocrine
cells secrete cholecystokinin and secretin.

The most important factor for regulating secretions in the small

intestine is the presence of chyme. This is largely a local reflex action in
response to chemical and mechanical irritation from the chyme and in
response to distention of the intestinal wall. This is a direct reflex action, thus
the greater the amount of chyme, the greater the secretion.

Large Intestine
The large intestine is larger in diameter than the small intestine. It
begins at the ileocecal junction, where the ileum enters the large intestine,
and ends at the anus. The large intestine consists of the colon, rectum, and
anal canal.

18
 The wall of the large intestine has the same types of tissue that are
found in other parts of the digestive tract but there are some distinguishing
characteristics. The mucosa has a large number of goblet cells but does not
have any villi. The longitudinal muscle layer, although present, is incomplete.
The longitudinal muscle is limited to three distinct bands, called teniae coli,
that run the entire length of the colon. Contraction of the teniae coli exerts
pressure on the wall and creates a series of pouches, called haustra, along
the colon. Epiploic appendages, pieces of fat-filled connective tissue, are
attached to the outer surface of the colon.

Unlike the small intestine, the large intestine produces no digestive

enzymes. Chemical digestion is completed in the small intestine before the
chyme reaches the large intestine. Functions of the large intestine include the
absorption of water and electrolytes and the elimination of feces.

Rectum and Anus

The rectum continues from the sigmoid colon to the anal canal and has
a thick muscular layer. It follows the curvature of the sacrum and is firmly
attached to it by connective tissue. The rectum ends about 5 cm below the tip
of the coccyx, at the beginning of the anal canal.

The last 2 to 3 cm of the digestive tract is the anal canal, which

continues from the rectum and opens to the outside at the anus. The mucosa
of the rectum is folded to form longitudinal anal columns. The smooth muscle
layer is thick and forms the internal anal sphincter at the superior end of the
anal canal. This sphincter is under involuntary control. There is an external
anal sphincter at the inferior end of the anal canal. This sphincter is composed
of skeletal muscle and is under voluntary control.

19

PRECIPITATING FACTORS
Chronic constipation
Frequent use of Laxatives
High-fiber diet
Post Abdominal surgery
Bacterial fermentation to accumulation of
↓ peristalsis, puhing the GI
contents against the obstruction
S/SX: Nausea/Vomiting
Severe abdominal pain
Rigidity
Hyperactive bowel sounds
PATHOPHYSIOLOGY
VOLVULUS ( TWISTED BOWEL)
PRE-OPERATION
PREDISPOSING FACTORS
Age: Between 50 to 60 years old
Gender: Male Adult
Stress
Genetics- Colon Cancer
- Abdominal Disorder
Sigmoid colon becomes dilated and
loaded with stools, making it
susceptible to torsion
Repeated attacks of torsion, leading
to shortening of mesentry
Development of adhesions that entraps
the sigmoid colon into a fixed twisted
position
Disruption of abdominal nerves
coordinating bowel peristalsis/ hernia/
adhesions
Blockage of bowel
(no peristalsis) / mechanical destruction
Inflammation of bowel
Irritation of autonomic
GI contents resulting to obstruction nerves in the peritoneum
Activation of solutes that draw H2O into S/SX: WATERY STOOL
the GI tract ABDOMINAL PAIN
CONSTIPATION
BODY WEAKNESS
↑ Bowel distention and pressure that is BLOATING
getting worse proximal to the twisted colon
Bowel ischemia tissue damage
Due to ↑ pressure, it squeezes the intestinal possible perforation
blood vessels, ↓ bowel perfusion (＋)/ (－) bacterial invasion
20
SURGERY
NURSING MANAGEMENT

Abdominal pain

Provide non pharmacologic measures to relive pain such as:

 Distraction - watching TV, playing video games, listening to music.
 Eliciting relaxation response - meditation and deep breathing exercises
 Provide comfort such as back rubbing.
 Positioning patient into comfortable position.

Body weakness

 Assist patient during activities.

 Emphasize importance of frequent rest periods.
 Teach energy conservation methods.
 Encourage an appropriate conditioning exercise.
MEDICAL MANAGEMENT

Pre-operative Medications
 Omeprazole 40 mg IV OD
 HNBB 1 amp IV Q8
 Ceftriaxone 1g IV Q12
 Metronidazole 500 mg IV Q8
 Paracetamol 300 mg IV Q4 PRN

Post-operative Medications
 Paracetamol 600 mg IV Q6 - 6 doses
 Tramadol 50 mg Q6 - 6 doses

SURGICAL MANAGEMENT

 Reduction of volvulus

21
NURSING CARE PLAN: PRIORITY 1

ASSESMENT NURSING PLANNNG INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Activity intolerance After 8 hours of  Assessed patient’s present  To evaluate where the After 8 hours of
“Hindi ako r/t presence of nursing level of activity and patient is beginning and nursing
masyadong  surgical wound as intervention, the tolerance to activity develop a patient specific intervention the
makagalaw kasi fresh evidence by patient will be activity plan goal set was met.
pa itong sugat ko.” inability to perform able to perform  .Reviewed medication list.  Some medications and the the patient has
Objective: basic activities of basic activities side effects may contribute been performed
 Slowed daily living. daily living with to decreased activity basic daily
movement minimal intolerance due to tiredness activities with
 Inability to assistance.  Monitored vital signs and fatigue. minimal
perform basic throughout activity. assistance
activities of daily  Encouraged patient to  This ensures patient is
living. continue gradual increases remaining in a stable state
in activity as they are able throughout activity.
to tolerate.  Patient can become
discouraged with decreased
 Educate patient on how to activity level that can further
safely increase activity level hinder their ability and
at home. desire to be active
 Allows patients
independence and the
ability to take control of their
own health and
improvement.

22
NURSING CARE PLAN: PRIORITY 2

ASSESMENT NURSING PLANNNG INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: ∅ Risk for infection Within 6 hours of  Monitored patient’s vital  To note any alterations or After 6 hours of
Objective: related to post- nursing signs. abnormalities in patient’s vital nursing
 Presence of wound operative intervention, the signs which may indicate an interventions t
dressing procedure. client shows no  Promoted good early sign of infection goal set was
 Presence of signs of infection. handwashing procedures for  To avoid bacterial cross met, The patient
incision due to staff and visitors. contamination. showed no
procedure  Instructed patient to  To prevent bacteria build up signs of
 Rubbing the emphasize personal and keep the patient’s body infection.
incision site hygiene. clean.
 Promoted adequate rest and  To limit fatigue and encourage
exercise periods. sufficient movement to
prevent stasis complications.
 Instructed the patient to
refrain from rubbing the  To avoid stressing the site
incision site. and further complications
 Educated the patient about  To educate patient about the
the signs and symptoms of signs and symptoms of
infection. infection.

 Instructed the patient to  To promote patient’s safety

verbalize needs or when with him/her knowing that you
signs and symptoms of are there to help
infection occur.

23
NURSING CARE PLAN: PRIORITY 3

ASSESMENT NURSING PLANNNG INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired skin integrity After 1 hour of  Monitored vital signs,  Fever may indicate After 1 hour of nursing
“May sugat ako sa related to post-surgical nursing intervention, specifically infection. intervention the set goal
tiyan ko, naoperahan procedure. the patient will be temperature. was met. The patient
kasi ako.” able to verbalized  Assessed status of  Systematic verbalized and
and demonstrate the the skin integrity inspection can demonstrated the right
Objective: right taking care of around wound color identify impending measures on taking
 Presence of his post-surgical skin changes, redness, problems early. care of his post-surgical
surgical incision to prevent infection. swelling, warmth, skin to prevent
on the pain and other signs infection.
abdomen. of infections.  It serves as a first
 Emphasized the line of defense
technique of against infection.
handwashing
technique.  Regular wound
 Maintained aseptic dressing promotes
technique when fast healing and
changing avoiding infection.
dressing/caring  Wet area can be
wound. lodge area of
 Kept area wound bacteria.
clean and dry.  Promote self-care
 Taught the patient in and self-
maintaining good management to
hygiene. prevent problem.

24
NURSING CARE PLAN: PRIORITY 4

ASSESMENT NURSING PLANNNG INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective:  Assessed patient level of  Facilitates planning of After 4 hours of
“ Ano ba pwede gawin Readiness for After 4 hours of understanding. post operative teaching nursing
para hindi na Enhanced nursing intervention, program, identifies intervention the
magdagdagan pa ang Knowledge related the patient will  Identified the steps content needs. set goal was met.
sakit ko.” to an adequate express his or her necessary to reach desired  Understanding the Patient had been
Objective: comprehension of awareness of the health goals. process enhance expressed
 Active asking the complications disease process and commitment of achieving understanding the
about the normal of post-surgery as treatment regimen  Worked with the patient to the goal. information gained
condition of his evidenced by and highlight explore suitable lifestyle  Changing familiar or of the disease,
health. patient’s questions potential possible modifications to lower typical behavioral habits treatment regimen
 Cooperative about preventive complications that modifiable risk factors. can be difficult and and possible
follows instruction measures against require medical stressful to patient. complication
bowel twisted. care.  Discussed the purpose of  Easily digested and
dietary regimen low fiber or absorbed and reduce
liquid diet. the risk of the bowel
becoming obstructed.
 Educate the patient and  Recognizing treatment
family members entails goals and the
discussing drugs their significance of promptly
purpose, and any side reporting side effects
effects. can help prevent the
onset of drug-related
problem.
 Teaches the patient and  Early detection of signs
family signs and symptoms and symptoms is the
of infection when they need ultimate way to manage
to notify their healthcare the condition
professional.

25
DRUG STUDY 1

DRUG NAME CLASSIFICATION MECHANISMS INDICATION AND ADVERSE NURSING

OF ACTION CONTRAINDICATION REACTION RESPONSIBILITIES
GENERIC THERAPEUTIC Inhibits proton INDICATION: CNS:  Monitor other CNS
NAME: CLASS: pump activity by - Asthenia side effects
Omeprazole Antiulcer Drugs binding to It works by decreasing - Dizziness (Drowsiness,
hydrogen – the amount of acid - Headache Fatigue,
potassium made in the stomach Weakness,
BRAND NAME: PHARMACOLOGIC adenosine and is used to treat Headache), and
Losec CLASS: triphosphatase, indigestion and acid GI: report severe or
PPIs located at reflux. - Abdominal pain prolonged effects.
secretory surface - Constipation
ACTUAL of gastric parietal - Diarrhea  Monitor any chest
DOSAGE: cells, to suppress CONTRAINDICATION: - Flatulence pain and attempt to
40 mg gastric acid - Nausea determine if pain is
secretion Contraindicated in - Vomiting drug induced or
patients with a history - Acid caused by
ROUTE: of hypersensitivity to regurgitation
IV/OD cardiovascular
the drug or any dysfunction
excipients from the
dosage form. MS:  Instruct patient to
- Back pain take drug at least
- Weakness 30 to 60 minutes
before meals
SKIN:
- Rash

26
DRUG STUDY 2

DRUG NAME CLASSIFICATION MECHANISMS INDICATION AND ADVERSE NURSING

OF ACTION CONTRAINDICATION REACTION RESPONSIBILITIES
GENERIC THERAPEUTIC Paracetamol INDICATION: CNS:  Routinely monitor
NAME: CLASS: relates to the - Nausea the effectiveness of
Paracetamol Analgesic and anti- inhibition of Paracetamol to ease - Drowsiness acetaminophen by
(PRN) pyretics prostaglandin mild to moderate - Headache assessing pain
synthetase. abdominal pain. levels and fever
reduction.
BRAND NAME: PHARMACOLOGIC CV:
Panadol CLASS: CONTRAINDICATION: - Chest pain  Assess for
Acetaminophen decrease in pain
Contraindicated in 30 minutes after IV
ACTUAL known hypersensitivity GI: administration
DOSAGE: to paracetamol in - Vomiting
300 mg hepatic and renal - Abdominal pain  Do not exceed the
failure. recommendation
dosage
ROUTE: RENAL:
IV q4 - Renal failure
 Give drug with food
if GI upset occurs.
SKIN:
- Rashes
- Cyanosis
- Jaundice

27
DRUG STUDY 3

DRUG NAME CLASSIFICATION MECHANISMS INDICATION AND ADVERSE NURSING

OF ACTION CONTRAINDICATION REACTION RESPONSIBILITIES
GENERIC THERAPEUTIC Diffuses into the INDICATION: CNS:  Monitor liver
NAME: CLASS: organism, inhibits - Headache function test results
Metronidazole Antiprotozoals and protein synthesis To prevent - Seizure carefully in elderly
antibiotics by interacting with postoperative infection - Dizziness patients.
DNA and causes in contaminated or
BRAND NAME: a loss of helical potentially contaminated  Advise the patient
Flagyl PHARMACOLOGIC DNA structure colorectal surgery. CV: to report sign and
CLASS: and strand - Flushing symptoms of
Nitroimidazoles breakage. - Edema candida
ACTUAL CONTRAINDICATION: overgrowth.
DOSAGE:
500mg Contraindicated in GI:  Instruct the patient
patients with a prior - Nausea to take drug with
history of - Vomiting food or milk to
ROUTE: hypersensitivity to - Abdominal pain decrease GI upset.
IV Q8 metronidazole or other - Diarrhea
nitroimidazole - Constipation  Inform the patient
derivatives. that drug may turn
urine brown, don’t
SKIN:
be alarmed.
- Rashes

28
DRUG STUDY 4

DRUG NAME CLASSIFICATION MECHANISMS INDICATION AND ADVERSE NURSING

OF ACTION CONTRAINDICATION REACTION RESPONSIBILITIES
GENERIC THERAPEUTIC Ceftriaxone is a INDICATION: CNS:  Advise the patient
NAME: CLASS: beta-lactam - Headache to report if the
Ceftriaxone cephalosporin antibiotic that is Used as surgical - Dizziness patient experienced
antibiotics bactericidal prophylaxis. - Lethargy severe diarrhea,
against both gram and pain at the
BRAND NAME: positive and injection site.
Rocephin PHARMACOLOGIC gram-negative CONTRAINDICATION: GI:
CLASS: organisms. Acts - Nausea  Discontinue if
Third- generation by inhibition of Ceftriaxone is - Vomiting hypersensitivity
ACTUAL cephalosporins bacterial cell wall contraindicated in - Diarrhea reaction occurs.
DOSAGE: synthesis. patients with known
1g allergies to the  Before giving the
cephalosporin group of GU: drugs ensure
antibiotics. - Nephrotoxicity patient isn’t allergic
ROUTE:
to cephalosporin.
IV q12
LOCAL:
- Pain and
inflammation of
the IV site.

SKIN:
- Rashes

29
DRUG STUDY 5

DRUG NAME CLASSIFICATION MECHANISMS INDICATION AND ADVERSE NURSING

OF ACTION CONTRAINDICATION REACTION RESPONSIBILITIES
GENERIC THERAPEUTIC Tramadol targets INDICATION: CNS:  Reassess patient
NAME: CLASS: pain receptors in - Headache level of pain at least
Tramadol Analgesic the central It has specific - Dizziness 30 minutes after
nervous system. It indications for moderate - Sleep disorder administration.
acts by blocking to severe pain after - Seizures
BRAND NAME: PHARMACOLOGIC the nerve signals surgery. - Nervousness
Conzip CLASS: responsible for  For better analgesic
Synthetic centrally pain. effect, give drugs
active analgesic CONTRAINDICATION: GI: before onset of
ACTUAL - Constipation intense pain.
DOSAGE: Tramadol is - Nausea
50mg contraindicated in - Vomiting
patients who have had - Abdominal pain  Monitor patients at
a hypersensitivity - Dry mouth any adverse
ROUTE: reaction to any opioid. - Diarrhea reaction of drugs.
IV q6 x 6doses

SKIN:  Monitor patient for

- Rashes sign and symptoms
of adrenal
insufficiency.

30
DRUG STUDY 6

DRUG NAME CLASSIFICATION MECHANISMS INDICATION AND ADVERSE NURSING

OF ACTION CONTRAINDICATION REACTION RESPONSIBILITIES
GENERIC THERAPEUTIC Angiotensin II INDICATION: CNS:  Monitor patient's
NAME: CLASS: receptor - Blurred vision blood pressure.
Losartan Antihypertensive, blockers help Losartan is used to treat - Headache  Stop medication if
diuretics high blood pressure - Dizziness adverse reaction
relax your veins occurs, notify
(hypertension). It is also - Insomnia
BRAND NAME: and arteries to used to lower the risk of prescriber
Cozaar PHARMACOLOGIC lower your blood stroke. GI: immediately.
CLASS: pressure and  Take drug without
- Diarrhea
make it easier regard to meals.
Angiotensin receptor - Dyspepsia
ACTUAL CONTRAINDICATION:  Tell patient to
blockers (ARBs) for your heart to take drug at
DOSAGE: pump blood. MS: morning to
50mg Hypersensitivity to - Muscle cramps prevent insomnia
losartan is used at night.
cautiously with hepatic
ROUTE: or renal dysfunction,
tablet/OD hypovolemia.

31
DRUG STUDY 7

DRUG NAME CLASSIFICATION MECHANISMS INDICATION AND ADVERSE NURSING

OF ACTION CONTRAINDICATION REACTION RESPONSIBILITIES
GENERIC THERAPEUTIC Buscopan is that it INDICATION: CNS:  Educate patients
NAME: CLASS: blocks the - Dizziness regarding desired
Hyoscine Antispasmodic muscarinic receptor The relief of smooth - Anaphylactic and adverse
butylbromide found on the muscle spasm/cramping reaction effects.
PHARMACOLOGIC stomach muscle of gastrointestinal system - Headache  Encourage
(HNBB)
CLASS: walls which means and its associated pain - Drowsiness patient to void.
Anticholinergic its blocks the action and discomfort. - Irritability  Monitor BP for
BRAND NAME: of acetylcholine on - Restlessness possible
Buscopan the receptor found hypertension.
within the smooth GI:  Monitor urine
muscle of the CONTRAINDICATION: - Xerostomia output.
ACTUAL gastrointestinal and - Constipation  Be alert for
DOSAGE: urinary tract and Contraindicated in - Nausea adverse reactions
1 AMP thus reduces the patients who have and drug
spasms and demonstrated prior SKIN: interaction.
contraction. This hypersensitivity to - Flushing
ROUTE: relaxes the muscle
Hyoscine-N- - Dyshidrosis
IV q8 and thus reduces
the pain from the butylbromide or any
cramps and other component of the
spasms. product; myasthenia
gravis, mechanical
stenosis in the
gastrointestinal tract,
paralytical or
obstructive ileus,
megacolon.

32
DISCHARGE PLANNING

METHODS RATIONALE
 Patient must be advised on the  To make sure that the patient has an effective amount of drug in her
proper time and dosage of taking body at all times, to prevent overdose.
her medicine.
Medication
 Educated patient to take  Medication that not prescribed by physician can affect to patient
medications that are only Health.
prescribed by the physician
 Encouraged patient to exercise  Exercise can improve brain health, help manage weight, reduce the
as doctor recommend risk of disease, strengthen bones and muscles and improve your
Exercise/ ability to do everyday activities.
Environment Encouraged patient to find ways
  It promotes relaxation and avoid stress
to make life less stressful and
meditate
 Continue home medication as  To manage the health condition and improve one’s wellness.
Treatment doctor prescribed.

 Teach the patient the proper way  To avoid infection and improve skin integrity.
of cleaning the wound.

 Encourage patient to take bath  To promote personal hygiene.

Hygiene
daily.
 Instructed patient to get plenty of  To have better mental health, increased concentration and memory,
rest. a healthier immune system, improved mood and even a better
metabolism.
Out Patient  Encouraged the patient to obey  To identify if there’s improvement to patient’s health.

33
 the exact date for their follow up
check-up.
 To avoid complication and worsening of patient illness.
 Remind the patient if there’s
problems, go to doctor
immediately for check up.
 Encouraged the patient to eat  To promote health and help to heal the wound faster.
healthy foods that high in protein
Diet and Vitamin C

 Encouraged the patient to drink  To avoid dehydration.

enough fluid.
 Advised the patient minimize  To avoid bleeding and open the wound
sexual activity and be in
missionary position (3-6 months)
Sex Activity
and  Encouraged the patient to pray  To get closer to God
Spirituality every time.
 To promote socialization and spiritualization.
 Encouraged the patient to
practice religious activity.

34