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
He is 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)
 PHYISICAL EXAMINATION
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
 PHYISICAL EXAMINATION
HEALTH PERCEPTION-HEALTH MANAGEMENT PARTTERN
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
 PHYISICAL EXAMINATION
HEALTH PERCEPTION-HEALTH MANAGEMENT PARTTERN
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
 PHYISICAL EXAMINATION
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
 PHYISICAL EXAMINATION
NUTRITIONAL –METABOLIC PATTERN
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
 PHYISICAL EXAMINATION
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
 PHYISICAL EXAMINATION
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
 PHYISICAL EXAMINATION
ACTIVITY-EXERCISE
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
 PHYISICAL EXAMINATION
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
 PHYISICAL EXAMINATION
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
 PHYISICAL EXAMINATION
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
 LABARATORY FINDINGS
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
THE NORMAL RANGE OF LABARATORY TEST

• 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
 NURSING DIAGNOSIS ..
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
 NURSING DIAGNOSIS …
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
 NURSING DIAGNOSIS ..
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
 NURSING DIAGNOSIS ..
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
 NURSING DIAGNOSIS ..
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
 NURSING DIAGNOSIS …
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
 NURSING DIAGNOSIS …
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
 NURSING DIAGNOSIS …
Risk for fluids volume deficit related to loss of
fluid through indwelling tubes
Interventions
-administer iv fluids as ordered
-encourage increased oral fluids