SRepublic of the Philippines

GOLDEN GATE COLLEGES

P.Prieto St. Batangas City
COLLEGE OF NURSING, CAREGIVING AND MIDWIFERY

CASE STUDY

COLONIC MASS PROBABLY MALIGNANT

RLE- GROUP 3A2

BUHAT, Fatima Mae R.

BULASAG, Kimberly

BUISAN, Aniway F.

CABATAY, Sharnelle Nicolle A.

CATEDRILLA, Kristine Joy M.

CLARIN, John Michael F.

CRUZ, L-jay

DAGOS, Kaila Antonette D.

DE CASTRO, Camila Jean

DE CASTRO, Maria Aliza Gwen D.

DEL ROSARIO, Joricel P.

GALDIANO, Paula Angela

GALLARDO, Kimberly Anne

Clinical Intructor

LENY ABAYA VERAÑA, R.N., MAN

 TABLE OF CONTENTS
I. Introduction 2
II. Clinical History 2
A. Patient's Profile
B. Present Illness History
C. Past Medical History
D. Family History

III. Physical Assessment 4

IV. Anatomy and Physiology 5

V. Pathophysiology 6

VI. Laboratory Diagnostic Examination with Analysis 7

VII. Drug Study 10

VIII. Nursing Care Plan 15

IX. Prognosis 16

X. Discharge Plan 16

XI. Proposed Actions & Recommendations 17

1
INTRODUCTION DE CASTRO, CAMILA JEAN

A colonic mass, also known as a colonic tumor or colonic lesion, refers to an abnormal growth of
tissue in the colon, which is part of the large intestine. It can be benign (non-cancerous) or malignant
(cancerous). When a colonic mass is suspected to be malignant, it means that there is a concern that the
growth could be cancerous. Most cases of colon cancer begin as small, noncancerous (benign) clumps of cells
called adenomatous polyps. Over time some of these polyps become colon cancers.Polyps may be small and
produce few, if any, symptoms. For this reason, doctors recommend regular screening tests to help prevent
colon cancer by identifying and removing polyps before they become colon cancer.

Colorectal cancer is one of the most common types of cancer, and early detection and diagnosis of
malignant colonic masses are crucial for effective treatment and improved outcomes. This often involves a
combination of medical imaging, such as colonoscopy and biopsy, to determine the nature of the mass and
guide treatment decisions. Malignant colonic masses may require surgery, chemotherapy, radiation therapy, or
a combination of these treatments, depending on the stage and type of cancer. Regular screening and
awareness of potential symptoms are essential in the early detection and management of colonic masses to
increase the chances of successful treatment.

CLINICAL HISTORY BULASAG, KIMBERLY

A. Patient's Profile

a. Biographic Data

Name: Patient X

Age: 61 years old

Sex: Male

Address: Sitio Sahingan, Balete, Batangas, City

Religion: Roman Catholic

Nationality: Filipino

Civil status: Married

Weight: 60.5 kilograms

Height: 173.5 cm

b. Admission Data

Name of hospital: Golden Gate Batangas Hospital Inc.

Case number: 23-1932

Date of admission: September 19, 2023

Time of Admission: 12:55 pm

2
 c. Vital sign upon admission

Temperature- 36.4°C

Heart rate- 110 beats per minute

Respiratory rate- 22 breaths per minute

Blood pressure- 110/80 mmHg

02 Stat: 98%

d. Chief complaint
Abdominal Pain

e. Source of information
The main or primary source of information is the patient.

f. Final Diagnosis
Colonic mass probably malignant

B. Present Illness History

One day ago prior to admission, the Patient X experiences a abdominal pain, cough, nausea , he also
positive of having a diabetes before the admission. Despite most of the time he was also having hypertension
and experiencing body weakness and his abdominal pain started at night. An hour prior to admission, a 61
years old male patient presented on September 19, 2023 with expressing pain on his face . This sought the
patient to seek medical advice at Golden Gate Batangas Hospital Inc. His wife accompanied him and made
the answers for him in the nurse's assessment.

Upon physical examinations, he was showing extremely abdominal pain. He had a blood pressure of
110/80 mmHg. His temperature is 36.4. His pulse rate is 110 and respiratory rate of 22 breaths/min. His
oxygen saturation on room air was 98%.

C. Past Medical History

Patient X has no reported accidents and injuries during his childhood days. He does not have any
allergies in food or certain medications. He was admitted twenty three years ago in a hospital and was
diagnosed with appendicitis and having appendectomy surgery. He was known to be a smoker until he
stopped smoking after being admitted twenty three years ago. He constantly drank alcohol. He does not have
any diet preference while he is working. And Patient X was known a hypertensive and diabetic person.

3
D. Family History

Patient X was a male and 61 year- old. They are currently living in Sitio Sahingan, Balete, Batangas
City. His wife was 58 years old and she is a housewife. Patient X's family reveals had a history of appendicitis
Other than that, there’s no report of having a colonic mass probably malignant in his family. His children have
a normal state and are considered healthy.

PHYSICAL ASSESSMENT DE CASTRO, MARIA ALIZA GWEN D.

GENERAL SURVEY: Awake, Alert, Responsive and no respiratory distress.

BP: 130/90 mmHg SPO2: 97%

TEMP: 36.5 WEIGHT: 60.5 kilograms

RR: 21 bpm HEIGHT: 173.5 cm

PR: 73 bpm

CATEGORY NORMAL OR ABNORMAL DESCRIBE BELOW

HEAD AND SCALP normal No dandruff, no lesions, no scars

noted

EYES normal Evenly placed and inline with

each other

EARS normal No lesions, no discharges

NOSE normal Is in the middle line, no

discharges

MOUTH/LIPS/TONGUE normal Pinkish, no edema

NECK normal Supple, straight, no visible mass

SKIN normal No skin lesions, no rash

CHEST/BREAST normal Equal chest expansion, clear

breath sounds

ARMS/HAND/NAILS normal No edema, no discolorations,

pink nail beds, no white spots

ABDOMEN abnormal Tenderness noted, distended

abdomen

LEGS/FEET normal No edema, no lesions

EXTREMITIES normal No edema, no tenderness, no

strong pulses

4
ANATOMY AND PHYSIOLOGY CABATAY, SHARNELLE NICOLLE A.

The colon makes up most of the large intestine, beginning with where it connects to the small intestine, called
the cecum. The five other sections of the colon body part then continue, including:

● Ascending colon (up from the cecum, in the lower right of the abdomen)- Absorbs the remaining
water and other key nutrients from the indigestible material, solidifying it to form stool.
● Transverse colon (across the abdomen)- absorbs water and salts from indigestible food matter.
● Descending colon (down toward the final colon portion)- stores feces that will eventually be emptied
into the rectum.
● Sigmoid colon (final part of the colon)- transports fecal matter from the descending colon to the
rectum and anus.
● Rectum (final part of digestive tract before the anus)- collects and hold poop until it is time to release
it.

The colon is a tubular organ that is part of the digestive system. It works alongside organs
such as the stomach and small intestine to remove stool and maintain your fluid and electrolyte
balance. Also known as the large intestine, the colon is made up of different sections. They connect
at one end to the ileum, the final part of the small intestine, and at the other end to the anus (where
stool leaves the body).

The rectum is the end part of the large intestine that connects the colon to the anus. It is the area
where a person holds stool before excreting it from the body. The sigmoid colon is part of the hindgut. It is the
last part of the colon before the rectum.

5
PATHOPHYSIOLOGY CATEDRILLA, KRISTINE JOY M.

6
LABORATORY DIAGNOSTIC EXAMINATION GALLARDO, KIMBERLY ANNE E.

CLINICAL CHEMISTRY

09-19-23 7:023pm

TESTS NORMAL RANGE RESULT

CBG 3.80 - 6.90 mmol/L 197 mg/dL = 10.84 mmol/L

The first capillary blood glucose test has a 197 mg/dL which is equivalent to 10.84 mmol/L that is
above the normal range.

09-20-23 10:20am

TESTS NORMAL RANGE RESULT

Creatinine 58 - 110 umol/L 144 umol/L

On 10;20am of September 20, another clinical chemistry was done to determine the patient’s
creatinine level. The test resulted a 144 umol/L which is above the normal range.

09-21-23 12:00pm

TESTS NORMAL RANGE RESULT

CBG 3.80 - 6.90 mmol/L 166 mg/dL = 9.13 mmol/L

Another CBG test was done on September 21 at exactly 12:00 in the afternoon. The CBG test has an
above normal range result which is 166 mg/dL that is equivalent to 9.13 mmol/L.

09-21-23 2:05pm

TESTS NORMAL RANGE RESULT

Creatinine 58 - 110 umol/L 92 umol/L

Na+ Sodium 135 - 148 mmol/L 141 mmol/L

K+ Potassium 3.50 - 5.30 mmol/L 4.20 mmol/L

On the same day, another three chemistry test were done to measure the level of Creatinine, Sodium,
and Potassium on the Patient’s body. The three tests were all normal.

09-21-23 4:00pm

TESTS NORMAL RANGE RESULT

CBG 3.80 - 6.90 mmol/L 120 mg/dL = 6.60 mmol/L

On 4:00 o’clock in the afternoon, another CBG test were done and has a result of 6.60 mmol/L which
in the normal range.

7
09-21-23 5:16pm

TESTS NORMAL RANGE RESULT

Total Protein 63 - 82 g/L 63 g/L

Albumin 35 - 50 g/L 34 g/L

Globulin 28 - 32 g/L 29 g/L

A/G Ratio 1.3 - 1.6 1.2

Another tests to measure the level of the proteins on the Patient’s body was conducted on the same
day. The Globulin and A/G Ratio were both normal while the Albumin was below the normal range. But over
all, the total protein were in a normal range which is 63g/L.

09-21-23 8:00pm

TESTS NORMAL RANGE RESULT

CBG 3.80 - 6.90 mmol/L 156 mg/dL = 8.58 mmol/L

At exactly 8:00 in the evening, another CBG test were conducted and has a normal result of 156
mg/dL which is equivalent to 8.58 mmol/L.

HEMATOLOGY

TEST REFERENCE RESULT TEST REFERENCE RESULT

Red Blood Cell 4-6x10^12/L 5.04 Differential

Count

WBC 5-10x10^9/L 3.85 Segmenters 38.3 - 73.7% 62

Hematocrit 0.37 - 0.45 0.37 Lymphocytes 18.0 - 48.3% 27

Hemoglobin 140 - 170g/dL 115 Bands/Stabs 0.80 - 7.30%

1
MCV 86 - 110 fL 73.0 Eosinophils 0.80 - 7.30%

MCH 26 - 38 pg 22.8 Monocytes 4.40 - 12.7% 10

MCHC 310 - 370 g/L 313 Basophils 0.00 - 1.70%

204
Red Cell Dist. 737 - 54 fL Platelet Count 150 - 450 x
Width 10^9/L

A hemotology were conducted on the same day with a normal results on Red Blood Cells,
Hematocrit, MCH, Segmenters, Lymphocytes, Bands/Stabs, Eosinophils, Monocytes, Basophils, amd Platelet
Count. On the other hand, the WBC has a 3.85 result, Hemoglobin of 115, and 73.0 for MCV which were all
below in the normal range.

8
PROTIME / APTT

TEST REFERENCE RANGE RESULTS

APTT 25.4 - 38.4 seconds 32.5 seconds

Control 23.8 - 32.8 seconds 32.1 seconds

Ratio 1.41

A protime / APTT test were conducted on the same day with a normal result.

X-RAY REPORT

Findings:

There are gas distended small bowel loops noted in the abdomen with air fluid levels in the upright projection.

There are no abnormal masses nor calcifications noted. The psoas lines and renal shadows are intact. The
flank stripes are not effaced. The interserosal stripes are not thickened. There is no evident organomegaly
noted.

There is minimal spur formation noted in the margins of the lumbar vertebral bodies.

Impression:

ILEUS

CANNOT TOTALLY RULE OUT SMALL BOWEL OBSTRUCTION.

MINIMAL DEGENERATIVE CHANGES OF THE LUMBAR SPINE

9
 DRUG STUDY DEL ROSARIO, JORICEL P.
Drug Mechanism of Action Indications Contraindications Adverse Effects Nursing Responsibilities

Generic Name: Metronidazole diffuses It is used to treat Metronidazole is Dizziness, headache, stomach Assessment
Metronidazole into the organism, intestinal amebiases, contraindicated in patients upset, nausea, vomiting, loss Genitourinary symptoms: unusual
inhibits protein liver amebiasis, with documented of appetite, diarrhea, vaginal discharge, burning with
Brand Name: synthesis by bacterial septicemia, hypersensitivity to the drug constipation, or metallic taste urination, vaginal pain, irritation or
Flagyl interacting with DNA, bone and joint or its components, and it in your mouth may occur. If itching, and fish-like odor
and causes a loss of infections, meningitis, should be avoided in any of these effects last or get Laboratory test results: CBC, renal
Therapeutic Class: helical DNA structure brain abscess, first-trimester pregnancy. worse, tell your doctor or and hepatic function, culture and
Nitroimidazole and strand breakage. endocarditis, Patients should also avoid pharmacist promptly. This sensitivity, gram stain, vaginal pH
Antimicrobials Therefore, it causes endometritis, bacterial consuming alcohol or medication may cause your and wet mount results; confirm
cell death in vaginosis, products containing urine to turn darker in color. pregnancy status
Pharmacologic Class: susceptible organisms. intra-abdominal propylene glycol while
Antibacterial infections, lower taking metronidazole and Monitoring
respiratory tract within three days of therapy Side effects
Order: infections, skin completion. Therapeutic effect: resolution of
500g IV q8 ANST structure infections, infection
and surgical
prophylaxis colorectal
surgeries

10
 Drug Mechanism of Action Indications Contraindications Adverse Effects Nursing Responsibilities

Generic Name: Cefoxitin inhibits Cefoxitin sodium MEFOXIN is Swelling, redness, pain, or ● Determine previous
Cefoxitin sodium bacterial cell wall (Monowel) is indicated contraindicated in patients soreness at the injection site hypersensitivity to
synthesis and is for adjunctive therapy who have shown may occur. This medication cephalosporins,
Brand Name: bactericidal. The in the surgical hypersensitivity to cefoxitin may also rarely cause loss of penicillins, and other drug
Monowel unique molecular treatment of infections, and the cephalosporin group appetite, nausea, vomiting, allergies before therapy is
structure of cefoxitin including abscesses, of antibiotics. diarrhea, or headache. If any initiated.
Therapeutic Class: gives a particularly infection complicating of these effects last or get ● Lab tests: Perform culture
Beta-lactam antibiotics high degree of hollow viscous worse, tell your doctor or and sensitivity testing
resistance to perforations, cutaneous pharmacist promptly. prior to and periodically
Pharmacologic Class: beta-lactamases, a infections and during therapy. Periodic
Cephalosporin antibiotics major mechanism of infections of serous renal function tests.
bacterial resistance to surfaces, whether ● Inspect injection sites
Order: penicillins and caused by aerobes, regularly. Report evidence
1 gram IV q8 ANST cephalosporins. mixed aerobes and of inflammation and
anaerobes, or patient's complaint of pain.
anaerobes. ● Monitor I&O rates and
pattern

11
 Drug Mechanism of Action Indications Contraindications Adverse Effects Nursing Responsibilities

Generic Name: Omeprazole is a proton Omeprazole is a Omeprazole is Omeprazole is considered a Monitor improvements in GI
Omeprazole pump inhibitor that proton-pump inhibitor contraindicated in patients benign drug; however, the symptoms (gastritis, heartburn,
inhibits secretion of used to manage and with a history of primary adverse effects and so forth) to help determine if
Brand Name: gastric acid by treat several hypersensitivity to the drug reported in drug labeling drug therapy is successful.
Prilosec irreversibly blocking conditions, including or any excipients from the include headache (6.9%),
the enzyme system of uncomplicated dosage form. abdominal pain (5.2%), Assess dizziness that might affect
Therapeutic Class: hydrogen/potassium heartburn, peptic ulcer Hypersensitivity reactions diarrhea (3.7%), nausea gait, balance, and other functional
Antiulcer drugs adenosine disease, like anaphylactic shock, (4.0%), vomiting (3.2%), activities (See Appendix C).
triphosphatase, the gastrointestinal reflux angioedema, interstitial and flatulence (2.7%) in Report balance problems and
Pharmacologic Class: “proton pump” of the disease, nephritis, anaphylaxis, adults. Other than these functional limitations to the
ProtonPump Inhibitors gastric parietal cell. Zollinger-Ellison urticaria, and bronchospasm adverse effects, cough, rash, physician, and caution the patient
syndrome, multiple may occur. asthenia, back pain, and family/caregivers to guard
Order: endocrine adenomas, regurgitation, upper against falls and trauma.
40 mg IV OD systemic mastocytosis, respiratory infection,
erosive esophagitis, constipation, and dizziness Monitor other CNS side effects
gastric ulcers, and are also reported in 1 to 2 % (drowsiness, fatigue, weakness,
helicobacter pylori of patients. headache), and report severe or
infection prolonged effects.

Monitor any chest pain and

attempt to determine if pain is drug
induced or caused by
cardiovascular dysfunction (e.g.,
angina that occurs during
exercise).

12
 Drug Mechanism of Action Indications Contraindications Adverse Effects Nursing Responsibilities

Generic Name: Simethicone is a Simethicone is Simethicone is Simethicone does not have ●Assess patient for abdominal
Simethicone surfactant that indicated for the contraindicated in patients any serious side effects. pain, distention, and bowel sounds
decreases the surface treatment of bloating, with a simethicone allergy There have been reports of prior to and periodically
Brand Name: tension of gas bubbles pressure, and cramps mild diarrhea and nausea throughout course of therapy.
Infacol in the gastrointestinal caused by gas. Frequency of belching and passage
tract, more easily Simethicone is also of flatus should also be assessed.
Therapeutic Class: allowing gas to exit the used as part of bowel ●Explain to patient the importance
Gastrointestinal agents body preparation for of diet and exercise in the
colonoscopies. prevention of gas. Also explain
Order: that this medication does not
1 tab TID prevent the formation of gas.
●Advise patient to notify health
care professional if symptoms are
persistent.

13
 Drug Mechanism of Action Indications Contraindications Adverse Effects Nursing Responsibilities

Generic Name: The mechanism of Tramadol is approved Tramadol is contraindicated Assess for level of pain relief Assess for level of pain relief and
Tramadol action for Tramadol is for the management of in patients who have had a and administer prn dose as administer prn dose as needed but
not exactly known. But moderate to severe hypersensitivity reaction to needed but not to exceed the not to exceed the recommended
Brand Name: it is known to act on pain in adults. any opioid. Patients under recommended total daily total daily dose. Monitor vital
Losec the mu opioid the age of twelve should not dose. Monitor vital signs and signs and assess for orthostatic
receptors to produce Tramadol is also used use the medication. Patients assess for orthostatic hypotension or signs of CNS
Therapeutic Class: pain relief. Opioid off-label in the under the age of eighteen hypotension or signs of CNS depression. Discontinue drug and
Antiulcer drugs receptors are located in treatment of premature should not be given the depression. Discontinue drug notify physician if S&S of
the brain and there are ejaculation medication if they have had and notify physician if S&S hypersensitivity occur.
Pharmacologic Class: three types, of which a history of tonsillectomy or of hypersensitivity occur.
ProtonPump Inhibitors the mu opioid receptor adenoidectomy.
is one. Normally, when
Order: a painful stimulus
50 mg IV q8 PRN for occurs, a neuron
Pain communicates to the
brain and the person
feels pain. When a
person takes Tramadol,
it acts on the mu opioid
receptor, blocking the
neuron from
communicating pain to
the brain.

14
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING
Subjective: Acute pain related to colonic Long term:
mass After 8 hour of nursing
“Sumasakit ang aking tiyan interventions, the client
ko” as verbalized by the will be able to participate
patient in therapeutic regimen.
Expected outcomes:
> Maintain position of
function as evidenced
by absence contractures
and decubitus.
Objective: > Display improvement
in physical mobility like
> Connotes facial grimace turning in bed.
> Restless > Increase strength and
> (+) Guarding behavior function of affected
body parts.
Short term:
After 8 hours of
intervention the patient
will be at ease and will no
longer feel pain.
Expected outcomes:
> Verbalize understanding
of the situation
and individual treat-
ment regimen and
safety measures.
> Verbalization of will to
participate in prescribed
therapy.
> Able to participate in
the interventions
rendered by the
nurses.
INTERVENTION
> Established rapport with
the patient
> Provided safety measures
by putting up side rails.
> Supported affected body
part using pillows
> Encouraged participation
in self-care.
> Provide nasogastric tube
feeding.
> Provided passive range of
motion.
> Encouraged patient to do
as much as they can.
> Educated the patient and
relative about the
importance of changing the
lifestyle.
> Due medications given as
ordered by the physician
CLARIN, JOHN MICHAEL
RATIONALE
> To have therapeutic
relationship with patient.
>To avoid fall.
> To maintain position
function and reduce risk of
pressure ulcers.
> To enhance self-concept
and sense of independence.
> To avoid aspiration while
maintaining proper
nutrition.
> To avoid muscle
weakness and contractures
and decubitus.
> To avoid dependency.
> For relatives to have an
idea on how to best support
their loved ones, how to
keep them safe, and how to
use equipment.
EVALUATION
After series of nursing
interventions the patient
was able to:
- Display
improvement in
physical mobility
like turning in bed.
- Increase strength of
affected parts of
body as evidenced
by sensation and
ability to move the
right foot.
- Be free from
pressure ulcers.
- Verbalized the will
to participate in
prescribed therapy.
15
PROGNOSIS BUHAT, FATIMA MAE R.

In the United States, excluding skin cancer, colorectal cancer is the third most common cancer
diagnosed in both men and women each year. In 2023, an estimated 153,020 adults in the United
States will be diagnosed with colorectal cancer. These numbers include 106,970 new cases of colon
cancer (54,420 men and 52,550 women) and 46,050 new cases of rectal cancer (27,440 men and
18,610 women). Worldwide, colorectal cancer is the third most diagnosed cancer. An estimated
1,880,725 people were diagnosed with colorectal cancer in 2020. These figures include 732,210
instances of rectal cancer and 1,148,515 cases of colon cancer.

Since the middle of the 1980s, there have been fewer incidences of colorectal cancer in the
US. Incidence rates decreased 3% to 4% year during the 2000s. This resulted from more screening of
persons 50 and older. The annual incidence rates decreased by 1% from 2011 to 2019. But from the
middle of the 1990s, incidence among younger people has been increasing by 1% to 2% a year.
According to estimates, men and women between the ages of 30 and 39 who have colorectal cancer
are four times more likely than those who do not.

Several variables affect colorectal cancer survival rates. These factors include the cancer's
stage, a person's age and general health, and the effectiveness of the treatment strategy. For colon
cancer, the overall 5-year relative survival rate for people is 63%. If the cancer is diagnosed at a
localized stage, the survival rate is 91%. If the cancer has spread to surrounding tissues or organs
and/or the regional lymph nodes, the 5-year relative survival rate is 72%. If colon cancer has spread to
distant parts of the body, the 5-year relative survival rate is 13%.

DISCHARGE PLANNING BUISAN, ANIWAY F.

Patient Name: Patient X

Date of Birth: June 15 1962
Admission Date: September 19, 2023
Discharge Date:
Final Diagnosis: Colonic Mass Probably Malignant

DISCHARGE PLAN

I. ASSESSMENT AND GOALS

Medical condition: Patient x underwent a successful colonoscopy procedure due to abdominal

pain. His admitting diagnosis is GI Bleeding and his final diagnosis is Colonic Mass Probably
Malignant.
Functional Abilities: Patient X can perform basic self-care tasks with assistance but has limited
mobility.
Support System: Patient lives with his wife, who is willing and able to provide assistance with
daily activities.
GOALS: Patient X’s goals are to to regain mobility and vitality, manage pain, and return to his
previous level of independence.

16
 II. DISCHARGE DESTINATION AND ENVIRONMENTAL CONCERNS

> Patient X will be discharged to his home, where he will continue his recovery and rehabilitation.
> Instruct Patient X and his family members to provide a peaceful, relaxing, comfortable, and well
ventilated room.
> Advise them to provide stress free environment
> Instruct to provide a clean environment to prevent lodging of infectious microorganisms.

III. MEDICATION MANAGEMENT

Prescribed Pain Medication:

> Patient X will be prescribed an appropriate pain medication, with instructions on dosage, time,
and frequency of the medication. And Instruction of potential side effects.
> Advise the client not to miss the intake of medications given by the physician upon discharge.
> Review drug and food interaction with the patient.
> Patient X And his wife will be educated on proper medication management and storage.

IV. MEDICAL EQUIPMENTS AND SUPPLIES

Patient X and his relatives will be instructed to ensure that equipment and supplies are clean and
used properly.

V. HEALTH TEACHING

> Patient X will be instructed to avoid alcohol, cigarettes and caffeine because it can irritate the
lining of the digestive tract. And foods that are high in fats and cholesterol. And to follow any diet
instructions given by the healthcare provider and increase oral fluid intake.
> Instruct Patient X and his relatives to monitor the vital signs and his blood sugar level.
> Patient X will be instructed to eat on time to take medication in the right time.
> Teach Patient X how to plan the progression of activities.
> Patient X advised to ambulate but limit heavy activities during recovery.
> Instruct Patient X to report bowel elimination problems to family members and physicians.
Emphasise that, in the case of recurrent abdominal pain, fever and vomiting, the patient should go
to the emergency department for evaluation.
> Instruct Patient X the importance of daily hygiene.
> Instruct Patient X to have enough rest
> Patient X’s relatives advice to be patient’s support system and assist Patient X in his everyday
activities when needed for his fast recovery.
> Patient X and his relatives advice to ensure safety measures in their home.

VI. FOLLOW UP CHECK UP

Patient X will be advised to go back to the hospital on a specific date to have follow-up check up
after discharge. And talk with his provider about any questions or concerns he has.

PROPOSED ACTIONS AND RECOMMENDATION DAGOS & GALDIANO

The following are the proposed actions and recommendations suitable for the patient which
may help to improve his health condition and for home healthcare.

FOR TREATMENT
Surgery:
● Proper incision site care regularly is highly encouraged.

17
 ● Soft diet for the first week after surgery.
● Maintain adequate fluid intake.
● Fiber: Avoid raw vegetables and raw fruits for 1-2 weeks.
● Activity: Avoid activity which causes pain. Walking and climbing stairs OK. No
lifting more than 20 lbs and no vigorous sports for 4-6 weeks or as directed.
● Resume home medications as prescribed.
● Call and go back to clinic for follow up.
● Consult the doctor if there are presence of the following:
○ Large amounts of bloody leakage from the wound.
○ Blood in the stool.
○ Fever and chills.
○ Pain that is not relieved by prescribed pain killers.
○ Tender, swollen abdomen.
○ Swelling, tenderness, redness at or around the incision
● Participation on adjuvant therapy is recommended.
Colostomy/ileostomy:
● Proper colostomy care regularly, highly recommended.
● Avoid gas-forming food.
● Pouch covers are proposed.
● Moral and emotional support from the family is highly encouraged.
● Refer to physician if there is irritation or complication arise.

FOR PREVENTION

● Choose healthy foods and drinks

● Keep a healthy weight
● Get regular physical activity
● Don’t smoke
● Limit alcohol
● Limit red meat, especially processed meat
● Control diabetes
● Take your medicine

18