Philippine Christian UniversityMary Johnston College of Nursing

415 Morga St., Tondo Manila

HEMORRHOIDECTOMY(CASE STUDY)

INTRODUCTION

Hemorrhoids are vascular structure that helps in controlling stool in the anal canal. They became pathological when there’s inflammation also known as piles which are often painful, swelling and irritating. “Almoranas” is another word for hemorrhoids that comes from the tagalong dialect spoken by many people here in the Philippines.

It was first attested in English 1398, the word hemmorrhoid derives from the old French "emorroides", from Latin "hæmorrhoida -ae", in turn from the Greek (haimorrhois), which means "liable to discharge blood", from (haima) "blood”, (rhoos) "stream, flow, current", and from (rheo) "to flow, to stream". Hemorrhoids are the varicosities of the veins of the hemorhoidal plexus. Hemorrhoids are classified into internal and external. Our patient had external hemorrhoid. External hemorrhoid can be seen easily under the skin at the opening of anal cavity. This type of hemorrhoid is extremely painful. If the vein ruptures it will became thrombosed hemorrhoid. While internal hemorrhoid are not usually painful until they bleed when they became swollen. Hemorrhoids are caused by many factors which include poor diet, pregnancies, genetic and poor lifestyle. Other factors that can increase the rectal vein pressure resulting in hemorrhoids include obesity.

Hemorrhoids can occur at any age, but tend to become more common as people age. Symptomatic hemorrhoids affect at least 50% of the American population at some time during their lives, with around 5% of the population suffering at any given time, and both sexes experiencing the same incidence of the condition. They are more common in Caucasian. Hemorrhoids are usually benign. Prevalence of this condition here in the Philippines is about Philippines 3,297,476. A peak in prevalence was noted from age 40-65 yr. “About 50% of people have hemorrhoids (NIH,2005)

In famous notable cases, Hall-of-Fame baseball player George Brett was famously removed from a game in the 1980 World Series due to hemorrhoid pain. After undergoing minor surgery, Brett returned to play in the next game, quipping "...my problems are all behind me. Brett underwent further hemorrhoid surgery the following spring.

Hemorrhoids are not life-threatening. “Hemorrhoids alone are not dangerous, though they can be annoying. The risk is that you may assume bleeding is from hemorrhoids when it could be caused by cancer of the rectum or colon, especially if you are over 40. That is why you have to consult your physician at the first sign of bleeding.”quoted by Dr. Gary S. Sy.

Hemorrhoidectomy is a surgical procedure that is performed to remove hemorrhoids. As the surgical site is very sensitive area, hemorrhoid surgery causes a lot of pain. It is a simple operation. Surgery is completely effective in about 95% of cases. However, additional surgery may be required if the hemorrhoids recur.

DEMOGRAPHIC DATA:

Name: CREAge: 44 y/oDOB: Nov. 1, 1996Gender: FemaleMarital status: MarriedReligion: Born Again ChristianAddress: 895 Int M Noval St. NavotasNationality: FilipinoEducational attainment: College graduate

NURSING HISTORY:

CRE is 44 y/o, female born in residing in Navotas admitted for the 1st time in Mary Johnston Hospital on August 08, 2011 due to severe rectal pain and inflammation hemorrhoids for several days. Admitted to surgery ward @ room 333 bed 3.

Interviewee: Patient

Chief Complaint: Rectal pain

History of present Illness:Present illness started 20 years before admission to hospital. Exacerbation of illness

started 3 days prior to admission, patient is afebrile and still with good appetite/

Patterns of health:Date of Admission: August 8, 2011Attending Physician: Dr. Michael PescanteAdmitting Physician: Dr. Michael PescanteAnesthesiologist: Dr. Vivar

Obstetrics history:G3P3 Had delivered 2 full term babies via NSD and 1CSNo complications

Family Health History:(+) Asthma/ Urticaria -Skin asthma(+) Allergy to Foods and drugs- seafood(+) Unknown cause of allergy- Dust

(+) DM

Social History:He lives with family in a well-lit, well ventilated house. She is a teacher of 3rd year high

school students teaching Filipino subject. A middle adulthood, who has a feeling of concern for others (on her students and co-

teachers), beyond family; moves away from oneself to become involved with the community

Growth and Personality Development: Psychosexual:- Genital

-Sexuality is channeled into relationships with opposite sex-Development of sexual identity; ability to love and work-more suitable love objects, or person of opposite sex

Psychosocial: -Generativity vs. Stagnation/ Self-absorption-Learns to look beyond self, and pays attention to community (co-

teachers and students)- This is the most productive and creative years of the life cycle inTerms of child-bearing, personal career and social goal reaching

fruition Cognitive: -Formal operational

-Abstract thinking-Separation of fantasy and fact-Reality oriented-Able to think a problem-Logical, deductive reasoning-Minds the cause of her illness and what to do about it

Moral stage: -Post-conventional-feeling of obligated to obey the law because one has made a social contract to make and abide by laws for common good-Developed inner control of behavior because of understanding the equality of human rights and respecting the dignity of human

beings as individuals Developmental tasks:

-assists teenage children to become responsible and happy adults-achieving adult civic and social responsibility-relates oneself to spouse-reaching and maintaining satisfactory performance as a Filipino teacher-adjusts to physiological changes especially to her illness (hemorrhoids)

DATE: August 08, 2011 9:15 am

GORDON’S FUNCTIONAL HEALTH PATTERN

(Pre-operative)

Health Perception:-“ Eto okay pa naman,medyo nabawasan na yung sakit na nararamdaman ko sa bandang puwet siguro dahil sa gamot na pinainom sa akin kaya medyo nabawasan yung sakit”-“Medyo kinakabahan din ng konti kasi sabi ng nanay ko nung naoperahan din siya katulad sakin,medyo masakit daw pagakatapos ng operasyon.”-“Nung dalaga pa ako siguro mga 18 y/0, may nakakapa akong nakalawit sa puwet ko pero maliit pa nun"-“Tapos nung nanganak ako sa panganay ko,dun lumaki pati dun sa pangalawa, tapos hanggang sa tumagal ganito na siya kalaki”-“Dapat nga dati ko pa to napacheck-up at nai-schedule na mapaoperahan eh kaya lang ang dami kasing proseso nung nasa Chinese ako kaya tinamad ako,nagpabalikbalik pa ako”-“oo low blood ako, anemic nga rin ako eh”

Nutrition-Metabolic Pattern:-“Hindi ako palainom ng tubig eh”-“Puros kami juice at nestea sa bahay”-“Hindi rin ako mahilig sa mga gulay pati yung mga anak ko”-“Hindi kasi masarap kapag walang lasa yung tubig at ulam”-“Ayoko rin ng kalabasa at mga dahon-dahon,yung pinakgusto ko lang na gulay

ay yung bitswelas”-“Minsan isang beses lang ako nakakakain ng heavy meal sa isang araw”-“Kumakain din ako sa mga turo-turo paminsan-minsan”-“Mahilig din ako sa mga maaalat tulad ng patis”-“Dalawang coffee na may kasamang tasty bread ang inaalmusal ko sa umaga,kung minsan pa nga wala ng tinapay,kape na lang”

Sleep-Rest Pattern:-“Natutulog ako sa gabi mga 12 na tapos ang gising ko mga 9 na ng umaga”-“12 ng tanghali yung pasok ko tapos mga 7pm ako umuuwi”-“Pag may pasok, di ako nakakatulog sa hapon, ganundin pag walang pasok kasi pag nakatulog naman ako ng mahaba di na ako nakakatulog sa hapon,nakahiga lang ako o di kaya nagpapahinga”

Elimination:-“Last month sobrang nag constipate ako, nahihirapan ako makadumi”-“Naranasan ko na rin yung hindi makadumi ng halos mga isang linggo”-“Matigas talaga yung dumi ko,tapos sumasakit din yung puwet ko paminsan-minsan, yung sa bandang ilabas ng puwet”-“Wala naman akong napapansin na dugong lumalabas pag dumudumi ako pero nung nagpacheck-up ako sabi may konting pula pula daw na nakita sa panty ko”-“Normal naman yung pag-ihi ko talagang sa pagdu I lang ako may problema”-“Kulay yellow yung ihi ko tapos kulay brown naman yung dumi ko”-“Nilabatiba ako ng 6 ng umaga tapos mamayang 10 na naman”

Activity-Exercise:-“Pag weekdays pumapasok ako sa school,teacher ako sa 3rd year high school”-“ Filipino subject yung itinuturo ko”-“Nag-absent nga ako ngayon eh,hindi ako nagpa-sick leave”-“Sumasama din ako sa mga school activities lalo na pag filipino”

Cognitive-Perceptual:-“Malabo na rin yung mata ko kaya nagsasalamin na rin ako”-“500/500 yung grado ng mata ko.2nd year high school pa lnag ako nung nagkasalamin ako ako sa mata”-“Nung sobrang sumakit yung almuranas ko ng sobra sobra lumilipat yung sakit sa ulo”-“sobrang namimilipit talaga ko sa sakit nun parang sinisilaban na mainit at mahapdi-hapdi”-“may varicose veins na rin ako”

Sexual-Reproductive:-“Dalawang beses ako nanganak ng normal tapos isang beses na CS.”-“ nag CS ako sa bunso ko kasi baka lumaki yung hemorrhoids ko.”

Role-Relationship:-“Medyo may tampo pa rin yung pamilya ko sakin lalo na sina mama kasi nagpaconvert ako ng religion.”-Tatlo yung anak ko,alam na rin nilang andito ko sa ospital. Tapos yung asawa ko ang nagababantay sakin dito sa ospital at nag-aasikaso sa akin”

Coping-stress:-“Napapiyak ako sa sakit kapag inaalmuranas ako”-“Nagha-hot sitz bath ako pag humahapdi yung pakiramdam ko”

Self-Perception:- “Nabawasan naman ng konti yung kaba ko nung nalaman ko na magaling pala yung doctor na mag-oopera sa akin. May nakapagsabi kasi sa akin na magaling talaga si Dr. Pescante at marami ng naoperahan kaya kampante ako.”-“Tingin ko hindi ko naman namana yung almuranas ko sa nanay ko kasi sabi nila hindi naman daw to namamana,talagang sa lifestyle daw tong sakit na to”

Value-Belief:-“Dati katoliko ako,tapos nagpaconvert ako ng religion.”-“Ngayon Born again na ko mga 2 years na.”-“Nahikayat ako ng co-teacher ko.”-“Sa bahay namin ung bata ako maraming mga santo santo kasi mahilig si mama

ko dun eh pero hindi ko sinasamba yung mga yun hindi naman yun ang makakapag save sayo eh,kahoy lang yun”

DATE: August 10, 2011

GORDON’S FUNCTIONAL HEALTH PATTERN

(Postoperative)

Health Perception:-“Ito may sakit na nararamdaman banda sa inoperahan sa akin, wala na rin kasi yung anesthesia kaya nararamdaman ko na.”-“Nakakayanan ko pa naan kahit na masakit,sabi nga ni doctor kaya ko na kasi nakakangiti na raw ako”-“Totoo pala yung sinsabi sa akin na hindi ka makakramdam ng sakit habang inooperahan.mararamdaman mo lang pagkatapos mong oprahan.”-“Pain scale rate of 8 out of 10 last night as verbalized by the patient-“Pain scale rate or 6 out of 10 today as verbalized by the patient”-“Pag umuupo ako medyo nababawasan yung sakit tska pagnagsisitzbath”-“Bukas pwede na akong umuwi ng hapon sabi ni doctor”

Nutritional-Metabolic:-“ Pwede na kong kumain kaya lang ang inadvice sakin ay yung mga malalmbot

muna para hindi ako mag constipate.”

Activity- Exercise:-“Ineexercise ko yung paa ko baka kasi mamanhid”-“Medyo umuupo ako kasi dun bumababa yung sakit”

Elimination:-“ Di pa nga ako nakakadumi,medyo masakit pa rin kasi.”-“Nakatayo nga ako pag umiihi kasi baka masakit”

Sleep-Rest:-“Kagabi hindi talaga ako nakatulog sa sobrang sakit”

Role-Relationship:-“Sabi ni dok,pahinga daw muna ako bago magturo kasi kakapaopera pa lang sakin.”-“ito nga Iniwan ako ng mister ko nung nalaman niyang tatanggalin yung swero ko.Aasikasuhin niya muna kasi yung nga bata sa bahay.”

Coping-stress:-“oo nga eh,nililibang ko sarili ko,ito nga nakikininig ako sa music”

Values-Belief:-“Ang magssave naman kasi sayo eh yung faith mo kay Jesus eh hindi lang sa

mga mabubuting ginawa mo.”-“Lagi kaming nagsisimba.Nung katoliko, linggo-linggo ako nagsisimba pati

ngayong born again ako.”-“Hanggang ngayon hindi pa tanggap nila mama na iba na religion ko”-“Dati sa baclaran ako ngasisimba,ngayon sa firepower na”

Self-Perception:-“Medyo nakatipid naman ako ng konti kasi my Fotune card ako”

PHYSICAL ASSESSMENT(Pre-operative)

General Appearance: On supine postion with #1 D5LR1L x8o @ left metacarpal vein @ 900cc level NPO status

v/s: BP: 110/80mmHgPR:64 bpmRR:22bpmT: 36.6 C

Skin With good skin turgor, ‹ 2secs. No lesions on any part of the body Smooth to touch Warm to touch Moist skin

Hair Evenly distributed thick hair Felt itchiness for sometime Black hair with minimal white hairs Dry scalp with minimal flakes No infestation of lice Dry hair

Nails Shape is concave With capillary refill of ‹ 2 secs. Smooth, rounded long Some parts are dirty Nail polish removed

Eyes (-) sunken eyeball (-) eye discharge (-) redness, inflammation or lesions Pale conjunctivae

Ears No lesions No drainage, nodules or redness Small amount of dry cerumen Symmetric to the outer canthus of the eye

Nose Moist, pinkish mucosa Free from lesions

Mouth Moist buccal mucosa

Dry and pale lips With dentures Only wisdom teeth are present

Neck No swelling of lymph nodes Supple neck

Chest Symmetrical chest expansion RR-22bpm Clear breath sounds

Breast No discharge Undimpled. Same color as the rest of the skin

Abdomen Skin of abdomen is smooth and uniform in color

Rectal (+) hemorrhoids Defecates from soft brown stool to clear liquid

Genitalia Voids 4-5 times a day (-) Discharge (-) swelling, redness

Anus Tender and swollen mass outside Pinkish to purplish color of external hemorrhoid About 1inch of size (+) Anal Pain Anal itching

Bones-joints-muscles Well flexed (+) ROM With minimal varicosities noted on both legs

PHYSICAL ASSESMENT(Intra-Operative)

General Appearance: Received from surgery on supine postion with #1 D5LR1L x8o @ left metacarpal vein

@200cc level NPO Positioned to lithotomy during the operation

Skin With good skin turgor, ‹ 2secs. No lesions on any part of the body Smooth to touch Moist skin Cold and clammy hands

Hair Evenly distributed thick hair Black hair with minimal white hairs Dry scalp with minimal flakes No infestation of lice Dry hair

Nails Shape is concave With capillary refill of 2 secs. Smooth, rounded long Some parts are dirty Nail polish removed

Eyes (-) sunken eyeball (-) eye discharge (-) redness, inflammation or lesions Pale conjunctivae

Ears No lesions No drainage, nodules or redness Small amount of dry cerumen Symmetric to the outer canthus of the eye

Nose Moist, pinkish mucosa Free from lesions

Mouth Dry and pale lips Dentures removed Only wisdom teeth are present

Neck No swelling of lymph nodes Supple neck

Chest Symmetrical chest expansion Clear breath sounds

Breast No discharge Same color as the rest of the skin

Abdomen Skin of abdomen is smooth and uniform in color

Rectal (+) hemorrhoids Defecates from soft brown stool to clear liquid Inflamed hemorrhoids were taken

Genitalia (-) Discharge (-) swelling, redness

Anus Tender and swollen mass outside Pinkish to purplish color of external hemorrhoid About 4-5 specimen of hemorrhoid were taken out

Bones-joints-muscles Relaxed muscle especially on the lower extremities With minimal varicosities noted on both legs

PHYSICAL EXAMINATION(Post-operative)

General Appearance:

On sitting postion without IVFSkin

With good skin turgor, ‹ 2secs. No lesions on any part of the body Smooth to touch Warm to touch Moist skin

Hair Evenly distributed thick hair Felt itchiness for sometime Black hair with minimal white hairs Dry scalp with minimal flakes No infestation of lice Dry hair

Nails Shape is concave With capillary refill of ‹ 2 secs. Smooth, rounded long Some parts are dirty Nail polish removed

Eyes (-) sunken eyeball (-) eye discharge (-) redness, inflammation or lesions Pale conjunctivae

Ears No lesions No drainage, nodules or redness Small amount of dry cerumen Symmetric to the outer canthus of the eye

Nose Moist, pinkish mucosa Free from lesions

Mouth Moist buccal mucosa Dry and pale lips With dentures Only wisdom teeth are real

Neck No swelling of lymph nodes Supple neck

Chest Symmetrical chest expansion

Clear breath soundsBreast

No discharge Same color as the rest of the skin

Abdomen Skin of abdomen is smooth and uniform in color

Rectal (-) hemorrhoids (-) bowel movement (+) post-operative pain

Genitalia Voided freely (-) Discharge (-) swelling, redness

Bones-joints-muscles Well flexed (+) ROM With minimal varicosities noted on both legs With minimal tingling sensation on legs

RISK FACTORS

Low-fiber diet-The client stated that she doesn’t eat vegetable and fruits rich in fiber. Having

poor diet which is low in fiber causes constipation that decreases the volume and number of stools. When the client is constipated she experiences difficulty in evacuating the

stool. It leads her to exert more effort to evacuate that causes increase pressure in the veins of anus that causes engorgement of hemorrhoids.

Pregnancy-The client stated that she had 2 normal deliveries and 1 CS. After she gave her

first birth she noticed that her hemorrhoids got bigger than usual. During pregnancy there is an increase pressure on abdomen by the fetus and hormonal changes cause the hemorrhoidal vessels to enlarge. Then during labor, the client tries to strain and exert effort which causes decrease in venous return that leads to engorgement of hemorrhoids.

Straining during bowel movements-The client said that she experiences not defecating for one week. Straining during

bowel movement is caused by constipation. This causes in increased portal vein pressure. It causes distention of the veins that leads to varicosities. Hemorrhoids develop as a result of perianal vascular congestion caused by straining.

Age-The patient’s age is 44 y/o which is also susceptible to hemorrhoids. Ages 40-50

increases the risk of having hemorrhoids. The muscles of our body tend to decrease its function as we get older. Aging causes weakening of the support structures, which facilitates prolapse

Family history-The patient stated that her mother had hemorrhoids also. This condition of her

mother can be acquired through her genes.

Food allergy-The patient stated that she had allergy to seafood. Food allergies cause

inflammation and poor nutrient absorption. This will irritate the mucosal lining of the rectum.

Insufficient consumption of adequate fluids- The patient stated that she always drinks juices and iced tea than pure water.

Bowel movement may become increasingly painful to the extent that she hold back her bowel movements. This results in the stool remaining in the rectum, where more water is absorbed, which causes a cycle of harder, drier stools leading to more pain, and more bleeding.

Lack of exercise- One of the biggest risk factors which determine if you are going to suffer from

hemorrhoids or not is the lack of physical activity. When there is lack of activity, there is decreased in blood circulation. This way, the nutrients needed by our body are not fully transferred to every part of our body, including the anus. That’s why the vital nutrients

for strengthening the rectal vein are decreased. Inflammation of the affected area is not also corrected because of decreased venous return. It also decreases of being obese.

Stress (physical)-The patient stated that she is a teacher, one of stressful profession. She has no

time to exercise regularly because of hectic schedule and there is least of time to relax. There are a lot of different diseases and conditions that are stress related, and that are either caused by stress or aggravated by stress. One of these is hemorrhoids. Hemorrhoids and stress have been linked, with the condition being more likely to occur in times of stress.

Sitting or standing a long time-As a teacher she sits for a long time while doing lesson plans and stands for a

time when teaching inside the classroom. Sitting down or standing for long periods of time causes the blood flow to slow down and the veins in our bottoms to stretch out which can lead to the creation of hemorrhoids

PATHOPHYSIOLOGY

Non-modifiable factors: Modifiable factors-Age (44 y/o) -Constipation-Gender (female) -Low fiber diet-Family history -prolonged sitting or standing-Pregnancy -straining during bowel movement

-food allergy-insufficient consumption of fluid-lack of exercise-stress

Ineffective & painful straining in eliminating feces

Increased pressure on the abdomen Increased portal venous return affecting the hemorrhoidal plexus

distention of hemorrhoidal veins

Formed stool is filled at the rectal ampulla

Venous obstruction

Repeated pressure & obstruction Prolonged pressure and obstruction

Permanently dilation of Hemorhoidal veins

Enlarged and thrombosed bleeding and prolapsed

Spots of blood thrombosis Constriction of hemorhoidal plexus

Iron-deficiency anemia intense pain blood supply is diminished& itching By anal spinchter

Inflammation

Swollen

Severe painLess than body requirements r/t poor nutrition before surgery

Nsg.Dx: Acute pain r/t inflammation of hemorrhoids

Hemorrhoidectomy

Nsg. Dx:Mild anxiety r/t upcoming operative procedure

Nsg. Dx: Acute pain r/t post hemorhoidectomy

Nsg. Dx: Risk for urinary retention r/t perineal trauma

Nsg. Dx: Constipation r/t post-hemorrhoidectomy and anesthesia effect

DIAGNOSTICS AND LABORATORIESJuly 29, 2011

RESULT NORMAL VALUES REMARKS

Hematocrit 0.36 0.37-0.45 lowHemoglobin 121 g/L 120-150 g/L NormalRBC 3.84 X 10 g/l 4-5 X10 g/l LowWBC 5.80 X10 g/l 4-10 g/l normal

Interpretation:

Low hematocrit — also called anemia — indicates that she does not have a sufficient volume of red blood cells. The most common cause of mild anemia in healthy people is a low level of iron, which is essential for the production of red blood cells. Monthly blood loss in imbalanced diet, and frequent blood extraction can contribute to low iron levels.

Nursing consideration: To support the iron and hematocrit levels in his body, we must encourage her to increase intake of high iron foods or supplements. Foods rich in iron include:

Red meat Fish

Poultry

Liver

Iron-fortified cereals

Beans

Raisins

Prunes

Eating foods rich in vitamin C such as citrus fruits, broccoli and tomatoes helps our body absorb the iron that we eat. Also, multiple vitamin tablets often include iron.

URINALYSIS

Color: yellow Bacteria: moderateSpecific Gravity: 1.010 Transparency: HazyLeukocyte: 0-1 HPF Protein: 1.og/LRBC: 0-1 Reaction: acidicBacteria: occasional Sugar: 4.54 (3.9-6.4) mmol/LAlbumin: (-)

Nursing Consideration:Encourage to drink plenty of water. Drink at least 8 glasses per day.Avoid or limit carbonated and caffeinated drinks

COURSE IN THE WARD

July 25, 2011

8 am asleep on prone position with #8 d5imb 500cc x100 @ level of 350cc @ left metacarpal vein @ 50mcgtts/min. infusing well with soluset for CMC stand byinitial vital signs taken as: T-36.7oC, BP-90/70mmhg, PR-102bpm, RR-28bpm

8:15 am consumed half of breakfast served; macaroni with chicken sandwich8:30 am present IVF decreased to 25cc/hr as ordered

“okay lang naman po pakiramdam ko” as stated by the patient“wala na siyang rashes at pangangati, din a ri siya nilalagnat” as stated by the motherwith slightly pale conjunctivaewith good skin turgor, ‹ 2secs.with capillary refill of ‹ 2secs.moist buccal mucosareadiness to physical wellness r/t compliance to therapeutic regimen

11 am am care done like tooth brushing and changing linen of bedencouraged to continue increasing oral fluid intake to 1500mlencouraged to continue drinking of milk as prescribed by the doctorencouraged to change position frequentlyprovided diversional activities like reading books and writing

11:30 am ate ¼ of red apple12 pm consumed foods served for lunch;fish and sayote

visited by Dr. Candelaria12:15pm present IVF shifted to KVO as ordered

sleeping in crib2 pm endorsed to NOD

July 26,2011

6:45 am asleep on supine position with #8 d5imb 500cc x KVO @ level of 150cc @left metacarpal vein, infusing wellp

8 am initial v/s taken as: T-36oC, BP-90/60mmhg, PR -99bpm, RR-27bpm8:20 am consumed half of foods served for breakfast9:15 am visited by Dr. Candelaria

“okay lang naman po pakiramdam ko” as stated“matagal na rin siyang hindi nilalagnat, umiinom na rin siya ng mga vitamins at gatas” as stated by the motherwith pinkish conjunctivaewith good skin turgor, ‹2 secs.with capillary refill of ‹ 2 secs.with moist buccal mucosa

10 am vomited 50cc previously eaten food in small amountam care donereadiness to physical wellness r/t compliance to therapeutic regimenencouraged to continue increasing oral fluid intake; to change positions frequentlyprovided diversional activity like writing and readingprovided rest periods

2pm playful in bedendorsed to NOD

NCP PROBLEM NO.2

Assessment:

Objective Asleep on side-lying position With no.7 D5IMB 500cc x 10 @ the level of 300 cc @ left metacarpal vein intact and

infusing well Temp at 38 C PR-100 bpm;RR-24 bpm Flushed, warm skin noted Moist oral mucosa noted

Subjective: “kanina mataas yung lagnat niya, umabot nga ng 39 yung temperature niya eh”as stated

by the mother “nilalagnat din kasi siya pag binibigyan siya ng gamut na antibiotic”as stated

Nursing Diagnosis: Alteration in thermoregulation: Hyperthermia r/t normal body inflammatory response

Planning:At the end of 8 hours duty the patient will be able to return to its normal body

temperature as evidenced by a decreased in temperature from 38oC to 36.5-37.5oC

Interventions: Provide TSB (Tepid Sponge Bath)

Rationale: to lower body temperature by increasing evaporation from skin. Heat loss by evaporation and conduction

Maintain bed restRationale: to reduce metabolic demands/oxygen consumption

Administer antypyretics or medications to treat underlying cause such as antibiotics as ordered

Evaluation:

At the end of 8 hours duty, the patient’s temperature was able to normalize as evidenced by a decrease from 38 to 36.7 oC . Goal met!

HEALTH TEACHINGS

Health Perception and Management- Taught the mother continuous tepid sponge bath because it can cause heat loss by

means of conduction- Taught the patient to limit contact with the person who has illness- Encourage the child to express and rate pain

Nutrition and Metabolic- Instructed the client to avoid eating junkfoods and avoid drinking softdrinks- Instructed the mother to pick and wash the foods carefully- Instructed the mother to offer at least 2 glasses of milk everyday- Encouraged the mother to offer the son nutritious food always

Elimination- Encouraged the client to increase fluid intake to avoid concentrated urine and

constipation- Advised the mother to clean their restroom because it can be the cause of the illness

of her son- Instructed to wash genitalia after voiding and defecating

Activity and Exercise- Provided diversional activities like reading books and writing- Encouraged the client to socialize with other kids for him not to be isolated at home

Sleep and Rest- Encouraged at least 8 hours of sleep to increase his immune system.- Advise mother to establish clear rules for rest periods (reading or watching television

is all right; playing a game isnot,etc.)- Advised mother to manipulate her house in terms of resting time

Cognitive- Encouraged the child to study his lessons at school- Provided age related mobility- Encouraged writing and reading books

Self- perception- Encouraged to be optimistic always

Sexuality and Reproductive- Encouraged to socialize with same and opposite sex

Role and Relationship- Advised mother to bring her other children in the hospital t avoid feeling of isolation

Coping Stress Tolerance- Encouraged verbalization of feelings- Encouraged to avoid always playing with the computer

Values and Beliefs- Provided spiritual care by praying and providing Bible stories

REFERENCES/BIBLIOGRAPHY

Medical Surgical Nursingb11th editionSuzanne C. SmeltzerBrenda G. Bare

Maternal and Child health Nursing care 5th edition Vol. 2Adele Piliterri

Understanding PathophysiologySue HuetherKathryn McCance