SCHISTOSOMIASIS ______________________________________

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN MSN 304 INDIVIDUAL CASE PRESENTATION

__________________________________

Giovanni B. Juan, RN

3RD TRIMESTER SY 2010-2011

TABLE OF CONTENTS Content Title Page Table of Contents Introduction Theories Patients Profile Health History Physical Assessment & Review of Systems Anatomy and Physiology Diagnostic Tests Pathophysiology Nursing Care Plan Medical Management Surgical Management Prognosis and Complications Discharge Plan Reference Page Number 1 2 3 5 7 8 13 21 32 38 42 54 59 63 68 72

INTRODUCTION An alarming number of patients in various hospitals in Bukidnon are diagnosed of having Schistosomiasis. In Philippines alone, Schistosomiasis accounts for the high incidence of deaths. It is considered as one of the most important tropical diseases and among the leading causes of morbidity, it is outranked only by malaria and tuberculosis. In 1988 schistosomiasis is endemic in 167 municipalities of 24 provinces. Dr. Renato Cerdena reported that within the 24 provinces where schistosomiasis occurs, there are 1,152 endemic villages. The total exposed population, defined as the population of endemic municipalities, is estimated at more than 7 million, or about 10 percent of the Philippine population. persists Despite in annual chemotherapy, areas schistosomiasis many

(http://l05.cgpublisher.com/proposals/1215/index_html). Schistosomiasis (aka bilharzia or snail fever), is a chronic parasitic illness that affects between 200 to 300 million people in at least 74 countries across the world. Of these, approximately 120 million people have symptoms, and 20 million are severely ill. Disease prevalence is heterogeneous in vulnerable locales and tends to be worse in areas with poor sanitation, increased freshwater irrigation usage, and heavy schistosomal infestation of human and/or snail populations. Schistosomal species vary with geographic region: S mansoni and S haematobium infections predominate in sub-Saharan Africa. S mansoni is endemic in parts of South America and the Caribbean while, S japonicum is restricted to the Pacific region including China, Indonesia and the Philippines. Aside from that, there are also different hosts for every type of schistosoma. S. haematobium is mainly

transmitted by Bulinus snails, S. mansoni by Biomphalaria, and S. japonicum by amphibious Oncomelania snails. Schistosoma japonicum continues to pose a public health problem in Asia, particularly in parts of China and the Philippines. In our country, it is a major public health problem with an estimated national prevalence of 3%, i.e., 200,000 infected individuals. Children have the highest prevalence and intensity of infection, but the consequences of chronic schistosomiasis, such as growth stunting, anemia, hepatic fibrosis, and impaired cognitive development, continue to have an effect throughout adulthood (http://jn.nutrition.org/cgi/content/full/136/1/183). Infection (in humans) begins with cercariae penetration of the skin or buccal mucosal from contaminated water source. Basically, people are infected when they come in contact with water where infected snails live. Once inside a human host, cercariae (larval forms of the parasite) transform into schistosomula and are transported to the portal circulation of the liver, where they mature and mate. Subsequently, adult worms of S. japonicum migrate to the mesenteric vessels while parasite eggs (released by female worms) deposit in several tissues, primarily the liver, the bladder and the urinary tract (http://www.who.int/tdr/diseases/schisto/diseaseinfo.htm). Within days after becoming infected, person may develop a rash or itchy skin. Fever, chills, cough, and muscle aches can begin within 12 months of infection. However, most people have no symptoms at this early phase of infection.

THEORIES 1. Nightingales environmental theory Florence Nightingale, often considered the first nurse theorist, defined nursing more than 100 years ago as the act of utilizing the environment of the patient to assist him in his recovery (Nightingale,1860/1969). She linked health with five environmental factors: (1) pure or fresh air, (2) pure water (3) efficient drainage (4) cleanliness (5) light. Deficiencies in these five factors produced lack of health or person will become ill. The patient failed to maintain pure water, drainage and sanitation. As verbalized by the patient he was infected with Schistosoma japonicum right at his work place with contaminated water. In considering the present environment of the patient whos still in the hospital, the cleanliness, good lighting, efficient drainage, pure water and pure air are given highest importance in the institution. It is important for the nurse to maintain a noise free environment, and attending to the clients diet in terms of assessing intake, timeliness of the food and its effect on the person. 2. Orems Self care deficit theory Dorothea Orems theory includes three related concepts: self care, self care deficit and nursing systems. Orems self care deficit theory explains not only when nursing is needed but also how people can be assisted through five methods of helping: acting or doing for, guiding, teaching, supporting, and providing an environment that promotes an individuals abilities to meet current demand. Nursing care is necessary only if client is unstable to fulfill biological, psychological, development or social needs. Nursing is needed when the self care demands are greater than the self-care abilities.

There

are three types of nursing system as indicated by Orems

self care deficit theory: Wholly compensatory, partly compensatory and supportive-educative systems. The patient belongs to partly compensatory wherein it is designed for individual who are unable to perform some but not all, self care activities. He can clean and dress his colostomy, he can urinate on his own and perhaps change clothes but he still needs assistance from others. Health teachings are emphasized to guide and assist him to promote independence. 3. Watsons Human Caring theory Jean Watson (1979) believes the practice of caring is central to nursing; it is the unifying focus for practice. Nursing is concerned with promoting health, preventing illness, caring for the sick and restoring health. Caring is defined as the nurturing way of responding to a valued client towards whom the nurse feels a personal sense of commitment and responsibility. Caring accept the person as what s/he may become in a caring environment. Watsons carative factors are the following: forming a humanistic-altruistic system of values, instilling faith and hope, cultivating sensitivity to ones self and others, developing a helping trust relationship, promoting and accepting the expression of positive and negative feelings, and systematically using the scientific problem solving methods for decision making. Caring is the basic concept of nursing that primarily focused on the needs of the patient. Patient in severe case of schistosomiasis needs a focused caring not only from the nurse but also from the concern family. A caring attitude is shown on being responsive to the needs of the patient physically, emotionally and mentally and these are greatly emphasized by the nurse. Despite of the length of hospitalization and bills, his family continues to support him all throughout his treatment since the patient truly needs help not only from the health care provider but also from his immediate family.

PATIENTS PROFILE Clients Name: Address (past and present): Boy Tigas (not real name) Esperanza, Agusan Del Sur; Davao del Norte; Kalasangan, Surigao Del Sur; Cotabato and Purok 9B, Crystal, North Poblacion, Maramag, Bukidnon 28 years old Male Married Filipino Bisaya (Cebuano) December 24, 1983 Esperanza, Agusan Del Sur Candy (not real name) Patient himself, wife, chart, nurses, Contractual Worker; Body Guard Roman Catholic PhilHealth 54 30 Kg February 24, 2011 4:40 AM Severe pain at anal area; (+) inability to defecate; verbalized Sakit ang gioperahan sa akong tiyan ug ang akong lubot sakit kay dili nako kalibang Dr. Surge Rectal Fibrosis secondary to Schistosomiasis

Age: Gender: Marital Status: Race: Primary Language: Date of Birth: Place of Birth: Significant Others (Wife): Source of Information: doctors Occupation: Religion: Health Care Financing: Height: Weight: Date Admitted: Time Admitted: Chief Complaints:

Attending Physician: Admitting Diagnosis:

HEALTH HISTORY History of Present Illness As verbalized by the patient (Boy Tigas), he was asymptomatic until early 2008. The signs and symptoms of the Schistosomiasis disease started its gradual onset later that year. The first sign occurred when he suffered body malaise while at home. He was feeling well before the onset. It occurred in almost a day for nearly seven months which continued even when he slept. The sign affected his daily activities at home and in work. He fell asleep while doing his job. The heavy work in the shop had precipitated the long-period body malaise which oftentimes aggravated by warm weather. He rested and slept most of the times to relieve the sign. Once during the bout of body malaise, he consulted one of the doctors in St. Joseph Southern Bukidnon Hospital, Maramag, Bukidnon and was given tablet and liquid forms of medications in which the patient cannot recall the name. The medications then relieved the symptom of body malaise. Sometime in February 2009, the patient had diarrhea when he was at home. He felt abdominal pain before he suffered diarrhea. It was intermittent that he almost spent his whole day at the comfort room. The feces were loose and watery with black and thin particles and red streaks of blood on it. He approximately defecated 10 glasses (2,500 mL) the whole morning as related by the patient. It was accompanied by intermittent abdominal and anal pain. The pain was searing in both areas (di na jud to makaya maam as he verbalized) which had a pain scale of 10/10. The pain worsens when he defecates and gets better when it stops. He was later hospitalized that made his loose bowel movement palliated. Last January 2010, while at home recuperating, he defecated pea-sized black feces with blood on it. He related during the interview that it occurred almost 20 times a day even when he was sleeping. He

felt sharp pain (grabe na jud to kasakit maam as he verbalized) on his abdomen and anal area with a pain scale of 9/10 as verbalized by the patient. The loss of control to defecate resulted to pain at the anal area which radiates towards the buttocks. Again they admitted him to the hospital due to this reason. On July 2010, Boy Tigas said that he experienced distention of the abdomen at home. It lasted for a minute then returns to its normal size. It occurred irregularly for approximately 3 times a month. The distention was likened to that of a 3-month pregnant woman according to Candy. It was painless and occurred abruptly without any known precipitating factors. No interventions were made on this sign. On the same month, he was admitted at St. Joseph Southern Bukidnon Hospital because of inability to control defecation and blood in the feces. He was then referred to Northern Mindanao Medical Center, Cagayan De Oro City. On August 2, 2010, anoscopy with biopsy was performed. The specimen was then sent for examination at the Department of Pathology and Clinical Laboratories, Northern Mindanao Medical Center, Cagayan De Oro City. The examination showed the presence of Schistosoma eggs on the colonic tissues. On the same month, proctosigmoidoscopy with biopsy on the sigmoid colon for suspicion of possible malignancy was performed. The specimen was sent for examination at the Department of Pathology and Clinical Laboratories, Northern Mindanao Medical Center, Cagayan De Oro City for neoplastic analysis. Results were negative of malignant cancerous growth. After being discharged from NMMC, Cagayan de Oro City the patient experienced vertigo and dizziness, while en route to their home in Maramag, Bukidnon. He, then, experienced trembling for approximately 10 minutes as verbalized by Candy. He was then readmitted at the St. Joseph Southern Bukidnon Hospital. He had

shortness of breath for almost 5 minutes and recovered after being administered with oxygen as verbalized by Candy. In addition, he had searing pain (di jud to makaya bah! as he verbalized) on his abdomen and anal area with pain scale of 10/10. On December 29, 2010 the patient underwent exploratory laparotomy and double barrel sigmoid colostomy. Dr. Surge examined his abdomen and created two separate stomas on the abdominal wall of the patient. Last March 15, 2011, the patient underwent fistulectomy under Dr. Surge because of the patients complaints of pain on his anal area.

Past Health History Immunization Patient could not give exact childhood immunizations. Past Illnesses The patient had a bout with Chickenpox during childhood. He had minor illnesses such as fever, cough and colds but never undergone surgery (minor/ major). He only had diarrhea as a serious or chronic illness. When he was 18 years old, he and a childhood friend fell into a cliff while riding a motorcycle at Kalasangan, Surigao Del Sur. He had a bruise at the side of the left eye. He has no known allergies to certain drugs, animals, insects or other allergogenic agents. Genogram Emelita ^
Legend:

Tiopelo ^ <

-Hypertension -Heart Failure ^- Deceased -Female -Male -Mother <-Father -patient

Boy Tigas

Emelita, the mother of Boy Tigas, was hypertensive and died because of heart failure. The father, Tiofelo had no known disease and cause of death was not known. Boy Tigas, the patient, has no known herido-familial disease.

Functional History Physical The health of the patient was generally good. He had not experienced any difficulty in breathing. His plane of nutrition was also good. He ate his regular meals, 3 times with snacks, 2 times daily. He did not take any vitamin supplements. His weight was 58 kg. He was not picky on foods and ate almost any kind of food. He had not been into a special diet or any dietary restrictions. His usual eating time was 7am-11am-6pm daily pattern. He drank 8-10 glasses of water a day. He didnt have any food allergies and never had assistance in eating. He had a poor oral condition. He had cavities and although his teeth werent complete he didnt wear dentures. He had no difficulty in voiding urine and hadnt experienced incontinence, had no sense of urgency, frequency, pain on urination, foul-smelling urine, cloudy urine, burning on urination or bloody urine. He didnt need assistance in urination. He had a regular bowel habit. He defecate everyday during morning. If he had problems on defecation such as diarrhea, he took over the counter medications. He experienced diarrhea and

constipation but not frequent. This only happened depending on the kind and quantity of food intake. He can go to the bathroom alone. He slept from 7pm to 4am and would feel rested after sleep. He had no difficulty sleeping at night. He turned off light before sleeping. He was physically comfortable because of his good physique. He was big boned person. He had good personal hygiene/ grooming. His vision was good. He wasnt using eyeglasses or contact lenses. His hearing was very good and no pain experienced on either ear. His sexual functioning was active. Psychosocial The patient got married at age of 24 years. He has 2 children (male-4yrs. old; female-3 yrs old). His coping abilities were very good. When upset, he dealt with it immediately and most of the time, it helped. When crises arise, the patient together with family members cooperate in solving the problem. The most important persons in his life were his family. He had lots of good friends but also some rivals at work as a body guard. Environmental The patient and his family lived in an elevated small house with a 3-step stairs. The floor was covered with lumber and had a corrugated galvanized iron sheets as roof. They had 2 rooms. Their dining table was near the bedroom. Their comfort room was located outside the house; it had the water-sealed bowl. They sleep in one room. Economic/Vocational His previous jobs were mostly on contractual basis and lately as a body bodyguard. He transferred from one place to another in search of a job and depending on the location of his contract. He had been to

Kalasangan, Surigao Del Sur, Cotabato and finally settled in Purok 9B, Crystal, North Poblacion Maramag, Bukidnon where his family is now living. His financial resources were very good. His annual income was Php 72,000.00. His highest educational attainment was 1st year high school. Cultural/Spiritual History The patient was born and practicing Roman Catholic. He had no religious rituals that may affect the health of the patient. He consulted physician if any deviations of health is noted. The patient believed that the disease was not cause of any curse or bad luck but because of a parasite was developing inside his body that created his chronic condition.

PHYSIOLOGIC ASSESSMENT/ REVIEW OF SYSTEMS General Survey The patient was an ectomorph; had a flat chest, and lightly muscled body. He was 54 tall and weighed 30kg as reflected in the chart. He was grossly emaciated. He had a tensed and bent posture. He had a slouch standing, sitting, and walking stance. He has altered physical mobility. The patients overall hygiene and grooming was generally unclean and unkempt. There was a foul body odor due to the present fistulae and aggravated by unhealthy practices such as not cleaning body parts everyday. He also had foul breath due to lack of oral hygiene. There were signs of distress such as hyperventilation during bouts of pain and emitted sounds of pain such as uuuhhhh. He winced, shouted, bent over and grasped on object tightly because of pain. He skin was generally pallid in appearance. The patients attitude was cooperative but withdrawn. His affect/mood were appropriate reflective to his situation. The speech of the patient was slow paced, gentle, understandable and exhibited thought association. Vital signs
Day Time Temperature (C) Pulse (bpm) Respiratory Rate (cpm) Blood Pressure (mmHg) Pain scale

1 2 3 4

10a m 2pm 10a m 2pm 10a m 2pm 10a

37.1 36.1 36.9 37.1 36.4 36.9 36.4

83 100 94 100 103 125 104

14 12 16 19 16 40 21

140/90 140/90 140/90 150/90 140/90 150/100 150/100

9/10 10/10 9/10 10/10 8/10 10/10 10/10

5 6

m 2pm 10a m 2pm 10a m

36.6 36.1 36.2 36.6

98 102 92 106

14 14 14 16

140/90 130/90 120/80 130/90

7/10 10/10 10/10 10/10

Height and Weight The patient was 54 tall and weighed 30 kg. The Integuments Skin The skin was pallid, but not cyanotic or jaundiced, not erythemic, with no noticeable vitiligo; the skin tone was light brown and was not generally uniform, there were areas of hyperpigmentation (of varying size and shape with brown to light brown spots); there were fissure and crusts noted at the corner of his lips, hands and feet. Muscle atrophy was observed. There was wound on his left lower abdominal area of the abdomen due to the colostomy operation and on his left buttocks due to the fistulectomy operation; the fistulectomy wound was approximately 2-inch depressed and has serosanguinal discharge. No moisture in skin folds and axillae were noted due to the cooler environment temperature; normal skin temperature in upper extremities while cold sensation was palpated in the lower extremities were noted; skin returned back slowly during checking of skin turgor in the lower extremities while skin on the upper extremities sprung back immediately to previous state. Hair Patient had no hair on axilla since birth; scalp hair growth was not evenly distributed and there were small areas that had no hair; he

had a thin and brittle hair; there were no infections and infestations noted. Nail The fingernail and toenail were smooth in texture, the fingernail plate shape was convex curvature, the fingernail bed was light pink in color and toenail bed was pallid, the tissues surrounding nails was intact. When blanch test was performed, there was a 2-second return of pink color in the fingernail bed and 5-second return in toenail. The Head Skull and Face The skull was rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences) and had smooth skull contour. It had a smooth, uniform consistent skull; with absence of nodules noted. The facial feature was symmetric. There was no eye edema but sunken eyes were observed. There were symmetrical facial movements. Eye Structures and Visual Acuity The hairs in the eyebrows were evenly distributed and eye skin was intact. Eyebrows were symmetrically aligned and had equal movement; Eyelashes were evenly distributed and curled outwardly; the skin in the eyelids were intact and had no discharges; lids closed symmetrically; blinking reflex was present; sclera on both eyes appeared white; the palpebral conjunctiva was shiny, smooth and pallid; the corneal surfaces on both eyes were shiny; details of iris were visible; pupils were black in color, equal in size, and round; both pupil reacted to light; peripheral visual fields and ocular movement were normal on both eyes.

The Ears and Hearing Auricles color were the same as facial skin, these were also symmetrical and were aligned with the outer canthus of the eye; the auricles were mobile, firm, and not tender; pinna recoiled after folded; with dry cerumen noted. Normal voice tones were audible. Nose and Sinuses The external nose was symmetric and straight; there were hyperpigmentation in some areas and had no discharge It had no tenderness or lesions; the mucosa was pink and no lesions noticed. The nasal septum was intact in the midline and the maxillary and frontal sinuses were not tender. Mouth and Oropharynx The outer lips were pallid, had fissures, scales and crusts and were able to be pursed; the inner lips are likewise pallid; the gums are pallid and were dry. He had 6 yellowish and black teeth; patient had no dentures. The tongue was in central position, had no nodes, ulcerations, discolorations and areas of tenderness. There was mobility of the uvula and tonsils appeared pallid. Neck Neck muscles were equal and were flexible; head movement were coordinated; head hyperextended, head flexed, head laterally flexed, head laterally rotated; muscle strengths were equal but minimal in strength due to present condition; lymph nodes in the neck werent palpable. Thorax and Lungs Posterior Thorax

Spine was vertically aligned with left and right shoulders and hips were at the same height. The skin and chest wall were intact and there were no tenderness and masses noted. Anterior Thorax Tachypnea and hyperventilation (RR: 40cpm) were noted; the rib cage was well-defined due to emaciation. Breast and Axillae Breast were even with chest wall; slightly unequal in size but generally symmetric; the skin on the breasts had hyperpigmentation (of varying size and shape of brown to light brown spots); areola appeared round and bilaterally the same, dark brown in color and had irregular placement of sebaceous glands on the surface; it had no tenderness, masses, or nodule and no tenderness, masses, nodules, or nipple discharge noted. Abdomen The skin abdomen was not uniform in color, there was hyperpigmentation (of varying size and shape of brown to light brown spots) present, was tensed and slightly glistened. Abdominal contour was prominent. When patient took a deep breath, distention on the lower area of left rib was palpable. There were distended veins and depression in area over the right portion of the abdomen below the right rib cage; tenderness was present on left and right lower area of the rib; there was an audible bowel sounds of 11; rib cage was wellformed due to gross emaciation; the lower 4th-9th regions (umbilical, left lumbar, right lumbar, hypogastric, left iliac and right iliac regions) of the abdomen were depressed. Genitourinary System

Patient verbalized dugay ko kaihi maam pero dili man pud siya sakit; he is not using any assistive devices; no abnormal discharges noted. Urine color is light yellow with presence of cloudy precipitate. Gastrointestinal System The patient has an attached improvised colostomy bag on his left lower quadrant. Feces are loose and watery with greenish and thin particles and red streaks of blood on it. Musculoskeletal (Muscles, Bones, Joint) The muscles were atrophied; no contractures noted; tremors can be seen when arms and legs were put forward; had 75% of normal strength. There was no palpable deformities on the bone but had tenderness on left buttock area. Sometimes, pain on left hip joint was noted; there was a limited range of motion in all joints of the body. Neurologic System Speech: Slurred Orientation: Mostly oriented to time, place, person and event Attention span: Relatively good except during incidences of pain; Mental Status: Conscious, coherent and restless most of the time GCS: 15 Language Spoken: Bisaya (Cebuano) Ability to Read: Yes Ability to Speak English: No.

Table 1. Summarized Deviation from the Normal based on the Review of Systems presented above. Assessment Deviation from Normal Pallid Skin tone is not generally uniform there were areas of hyperpigmentation (of varying size and shape with brown to light brown spots) fissure and crusts noted at the corner of his lips, hands and feet Muscle atrophy wound on his left lower abdominal area of the abdomen due to the colostomy operation and on his left buttocks due to the fistulectomy operation fistulectomy wound was approximately 2-inch depressed and has serosanguinal discharge cold sensation was palpated in the lower extremities skin returned back slowly during checking of skin turgor in the lower extremities Scalp hair growth was not evenly distributed and there were small areas that had no hair Thin and brittle hair Toenail bed was pallid 5-second return in toenail None Palpebral conjunctiva was pallid No impairment Hyperpigmentation in some areas Outer lips were pallid, had fissures, scales and crusts

Skin

Hair

Nail The Head Skull and Face Eye structures and Visual Acuity The Ears and Hearing Nose and Sinuses Mouth and Oropharynx

Neck Posterior Thorax Anterior Thorax

Breast and Axillae

Abdomen

The inner lips were pallid 6 yellowish and black teeth Gums were pallid and were dry Muscle strengths were equal but minimal in strength due to present condition No impairment Tachypnea and hyperventilation noted Ribs were well-defined due to gross emaciation. Skin on the breasts had hyperpigmentation (of varying size and shape of brown to light brown spots) Wound on his left lower abdominal area of the abdomen due to the colostomy operation and on his left buttocks region due to the fistulectomy operation There was hyperpigmentaion (varying size and shape of brown to light brown spots) present Tensed and slightly glistening skin Noticeable contour on the lower area of left rib was palpable Distended veins over the right portion of the abdomen below the rib cage Tenderness on both right and left area of rib Rib cage is well-defined due to emaciation the lower 4th-9th regions (umbilical, left lumbar, right lumbar, hypogastric, left iliac and right iliac regions) of the abdomen were depressed. Muscles atrophied Observable tremors when arms and legs were put forward 75% of normal strength Tenderness on left buttocks area

Musculoskeletal Muscles

Bones

Joint Neurologic System

Pain on left hip joint was noted Limited range of motion in all joints of the body Speech: Slurred Ability to Speak English: No

ANATOMY AND PHYSIOLOGY 1. Circulatory System Systemic Circulation The systemic circulation includes the arteries and arterioles that carry oxygenated blood from the left ventricle to systemic capillaries, plus the veins and venules that return deoxygenated blood to the right atrium. Blood leaving the aorta and flowing through the systemic arteries is a bright red color. As blood flows through capillaries, it loses some of its oxygen and picks up carbon dioxide, becoming a dark red color. All systemic arteries branch from the aorta completing the circuit, all veins of the systemic circulation drain into the superior vena cava, inferior vena cava, or the coronary sinus, which turn in empty into the right atrium. The bronchial arteries, which carry nutrients to the lungs, also are part of the systemic circulation.

Figure 1. Describes the main arteries and veins of the systemic circulation. The blood vessels are organized in the exhibits according to body regions.

Hepatic Portal Circulation The hepatic portal circulation carries venous blood from the gastrointestinal organs and spleen to the liver. A vein that carries blood from the one capillary network to another is called a portal vein. The hepatic portal vein (hepat- = liver) receives blood from the capillaries of gastrointestinal organs and the spleen and delivers it to the sinusoid of the liver. After a meal, hepatic portal blood is rich in nutrients absorbed from the gastrointestinal tract. The liver stores some of them and modifies others into the general circulation. For example, the liver converts glucose into glycogen for storage, reducing blood glucose level shortly after a meal. The liver also detoxifies harmful substance, such as alcohols, that have been absorbed from the gastrointestinal tract and destroys bacteria by phagocytosis.

Figure 2. The hepatic portal system.

The superior mesenteric and splenic veins unite to form the hepatic portal vein. The superior mesenteric vein drains blood from the small intestine and portion of the large intestine, Stomach, and pancreas through the jejuna, ileac, elohcecal, right colic, middle colic, pancreaticodoudenal, and right gastrorpiploic veins. The splenic vein drains blood & from the stomach, pancreas, and portions of the large

intestine through the short gastric, left gastroepiploic, pancreatic, and inferior mesenteric veins. The inferior mesenteric vein, which passes through the splenic vein, Drains portion of the large intestine through the superior rectal, sigmoid`, and left colic veins. The right and left gastric veins, 7hich open directly into the hepatic portal vein, drains the gallbladder. At the same time the liver is receiving nutrients but deoxygenated blood via the hepatic portal vein, it also is receiving oxygenated blood via the hepatic artery a branch of the celiac trunk. The oxygenated blood mixes with the deoxygenated blood in sinusoids. Eventually, blood leaves the sinusoid of the liver through the hepatic veins, which drains into the inferior vena cava. Pulmonary Circulation The pulmonary circulation (pulMo- = lung) carries deoxygenated blood from the right ventricle to the air sacs (alveoli) within the lungs and returns oxygenated blood from the air sacs to the left atrium. The pulmonary trunk emerges from the right ventricle and passes superiorly, postdpiorl and to the left. It then divides into the two branches: the right pulmonary artery to the right Lung and28the left pulmona2x artery to the left lung. After bi2th, the pulmonary arteries are the only arteries that carry deoxygenated blood. On entering the lung, the branches divide and subdivide until finally they form capillaries around the air sacs (alveoli) within the lung. CO2 passes from the blood into the air sacs and is exhaled. Inhaled O2 passes from the air within the lungs into the blood. The pulmonary capillaries unite to form venues and eventually pulmonary veins, which exit the lungs and carry the oxygenated blood to the left atrium. Two left and two right pulmonary veins enter the left atrium. After birth, the contraction of the left ventricle then ejects the oxygenated blood into the systemic circulation.

Figure 3. The pulmonary circulation

2. Erythropoiesis Erythropoiesis, the production of RBCs starts in the red bone marrow with a precursor cell called a proerythroblast. The proerythroblast divides several times, producing cells that begin to synthesize hemoglobin. Ultimately, a cell near the end of the development sequence ejects its nucleus and becomes a reticulocyte. Loss of the nucleus causes the center of the cell to shape. Reticulocyte retains some mitochondria, ribosomes, and endoplasmic reticulum. They pass from red bone marrow into the blood stream by squeezing between the endothelial cells of blood capillaries. Reticulocytes develop into mature red blood cells within 1 to 2 days after their release from the red bone marrow.

Normally, Erythropoiesis and red blood cell destruction proceed at roughly the same pace. If the oxygen-carrying capacity of the blood falls because erythropoeisis is not keeping up with the RBC destruction, a negative feedback system steps up RBC production. The controlled condition is the amount of oxygen delivered to the body tissues. Cellular oxygen deficiency, called hypoxia, may occur if too little oxygen enters the blood. For example, the lower oxygen content of the air at high altitudes reduces the amount of oxygen in the blood. Oxygen delivery may also fall due to anemia, which has many causes: lack of iron, lack of certain amino acids, and lack of vitamin B12 are but a few. Circulatory problems that reduce blood flow to tissue may also reduce problems that reduce oxygen delivery. Whatever the cause, hypoxia stimulates the kidneys to step up the release of erythropoietin, which speeds the development of proerythroblast into reticulocytes in the red bone marrow. As the number of circulating RBCs increase, more oxygen can be delivered to body tissues. Premature newborns often exhibit anemia, due in part to inadequate production of erythropoietin. During the first weeks after birth, the liver, not the kidneys, produce most EPO. Because the liver is less sensitive than the kidneys
Figure 4. The life cycle of a red blood cell. smaller EPO response to a) Kidneys respond to a lower than normal anemia. oxygen concentration in the blood by releasing the hormone erythropoietin. b) Erythropoietin travels to the red bone marrow and stimulates an increase in the production of red blood cells (RBCs). c) The red bone marrow manufactures RBCs from stem cells that live inside the marrow. d) RBCs squeeze through blood vessel membranes to enter the circulation. e) The heart and lungs work to supply continuous movement and oxygenation of RBCs. f) Damaged or old RBCs are destroyed primarily by the spleen.

to hypoxia, newborns have a

3. Digestive System Absorption Absorption is the movement of molecules across the gastrointestinal (GI) tract into the circulatory system. Most of the end-products of digestion, along with vitamins, minerals, and water, are absorbed in the small intestinal lumen by four mechanisms for absorption: (1) active transport, (2) passive diffusion, (3) endocytosis, and (4) facilitative diffusion. Active transport requires energy. Nutrient absorption is efficient because the GI tract is folded with several surfaces for absorption and these surfaces are lined with villi (hairlike projections) and microvilli cells. Protein, carbohydrate, lipid, and most vitamin absorption occur in the small intestine. Once proteins are broken down by proteases they are absorbed as dipeptides, tripeptides, and individual amino acids. Carbohydrates, including both sugar and starch molecules, are broken down by enzymes in the intestine to disaccharides called sucrose, lactose, and maltose, and then finally into the end-products known as glucose, fructose, and galactose, which are absorbed mostly by active transport. Lipase, an enzyme in the pancreas and the small intestine, and bile from the liver, break down lipids into fatty acids and monglycerides; these end-products then are absorbed through villi cells as triglycerides.

Coordination and Transport of Nutrients into the Blood or to the Heart

Hormones and the nervous system coordinate digestion and absorption. The presence of food, or the thought or smell of food, can cause a positive response from these systems. Factors that can inhibit digestion include stress, cold foods, and bacteria. After foods are digested and nutrients are absorbed, they are transported to specific places throughout the body. Water-soluble nutrients leave the GI tract in the blood and travel via the portal vein, first to the liver and then to the heart. Unlike the vascular system for water-soluble nutrients, the lymphatic system has no pump for fatsoluble nutrients; instead, these nutrients eventually enter the vascular system, though they bypass the activity of the liver at first.

Figure 5. Pathway of digestion.

4. The Lymphatic System The lymphatic system functions 1) to absorb excess fluid, thus preventing tissues from swelling; 2) to defend the body against microorganisms and harmful foreign particles; and 3) to facilitate the absorption of fat (in the villi of the small intestine). Capillaries release excess water and plasma into intracellular spaces, where they mix with lymph, or interstitial fluid. "Lymph" is a milky body fluid that also contains proteins, fats, and a type of white

blood cells, called "lymphocytes," which are the body's first-line defense in the immune system. Lymph flows from small lymph capillaries into lymph vessels that are similar to veins in having valves that prevent backflow. Contraction of skeletal muscle causes movement of the lymph fluid through valves. Lymph vessels connect to lymph nodes, lymph organs (bone marrow, liver, spleen, thymus), or to the cardiovascular system.

Lymph nodes are small irregularly shaped masses through which lymph vessels flow. Clusters of nodes occur in the armpits, groin, and neck. All lymph nodes have the primary function (along with bone marrow) of producing lymphocytes.

The spleen filters, or purifies, the blood and lymph flowing through it. The thymus secretes a hormone, thymosin that produces T-cells, a form of lymphocyte.

Figure 6. Lymphatic system

5. Histology and Blood Supply of the Liver The lobes of the liver are made up of many functional units called lobules. A lobule is typically a six-sided structure (hexagon) that consists of specialized epithelial cells, called hepatocytes, arranged in irregular, branching, interconnected plates around a central vein. In addition, the liver lobule contains highly-permeable capillaries called sinusoids, through which blood passes. Also, present in the sinusoids are fixed phagocytes called stellate reticuloendothelial (Kupffer) cells, which destroy worn-out white blood cells and red blood cells, bacteria, and other foreign matter in the venous blood draining from the gastrointestinal tract. The liver receives blood from two sources. From the hepatic artery it obtains oxygenated blood, and from the hepatic portal vein it receives deoxygenated blood containing newly absorbed nutrients, drugs, and possibly microbes and toxins from the gastrointestinal tract. Branches of both the hepatic artery and the hepatic portal vein carry blood into liver sinusoids, where oxygen, most of the nutrients, and certain toxic substances are taken up by the hepatocytes. Products manufactured by the hepatocytes and nutrients needed by other cells are secreted back into the blood, which drains into the central vein and eventually passes into a hepatic vein. Because blood from the gasatrointestinal tract passes through the liver as part of the hepatic portal circulation, the liver is often a site for metastasis of cancer that originates in the GI tract. Branches of the hepatic portal vein, hepatic artery, and bile duct typically accompany each other in their distribution through the liver. Collectively, these three structures are called a portal triad. Portal triads are located at the corners of the liver lobules.

Figure 7. Anatomy of the liver lobule

DIAGNOSTIC TEST

1. Pathologic Test: ANOSCOPY WITH BIOPSY Definition: An anoscopy is an examination of the rectum in which a small tube (anoscope) is inserted into the anus to screen, diagnose, and evaluate problems of the anus and anal canal. A biopsy is the removal of a sample of tissue from the body for examination. The tissue will be examined under a microscope to assist in diagnosis. Date performed: August 2, 2010 Name & Address of the Laboratory: Department of Pathology and Clinical Laboratories, Northern Mindanao Medical Center, Cagayan De Oro City Clinical Impression: Rectal new growth Specimen Used: Rectal mass Interpretation and Histopathologic Diagnosis: Colonic tissue with chronic inflammation and presence of Schistosoma eggs. Gross Description: The specimen consist of several red brown soft tissues altogether measuring 0.5 x 0.5 cm. Microscopic description: Micro sections of rectal mass disclose colonic tissues showing several calcified Schistosoma eggs from the mucosa to the muscular layer. Mild to moderate chronic inflammation, cells are seen in the edematous and congested stroma. 2. Pathologic Test: PROCTOSIGMOIDOSCOPY WITH BIOPSY Definition: A visual examination of the rectum and sigmoid colon using a sigmoidoscope. A biopsy is the removal of a sample

of tissue from the body for examination. The tissue will be examined under a microscope to assist in diagnosis. Date performed: August 16, 2010 Name & Address of the Laboratory: Department of Pathology and Clinical Laboratories, Northern Mindanao Medical Center, Cagayan De Oro City Specimen Used: Rectal mass Interpretation and Histopathologic Diagnosis: Chronic inflammation: No evidence of malignant neoplastic growth. Gross description: The specimen consists of tan-white firm tissue fragments measuring 0.4cm. Microscopic description: Micro sections disclose a rectal tissue with presence of seen. 3. ULTRASOUND IMAGING Definition: The use of sound waves at the very high frequency to image internal structure by the differing reflection signals produce when a beam of sound waves is projected into the body and bounces back at interfaces between those structures. Date performed: February 25, 2011 Name & Address of the Laboratory: Radiology Department, St. Joseph Southern Bukidnon Hospital Maramag, Maramag, Bukidnon Ultrasound Report: abundant lymphoplasmacytic cells in the lamina propria. No evidence of malignancy nor nuclear atypia

 Whole abdomen Moderate free intraperitoneal fluid collection in the hepatorenal and splenorenal spaces. The liver is normal in the size with coarsened and lacelike parenchymal echotexture. No focal mass lesions demonstrated. The intrahepatic ducts are not dilated. The gallbladder is well distended with no intraluminal echoes. The pancreas is obscured by overlying bowel gas. The spleen is markedly enlarged measuring 11.9 x 11.9cm. Both kidneys are normal in size hyperechoic parenchymal echo pattern. The right kidney measures 9.0cm x 5.1cm x 4.1cm (LWT) with cortical thickness of 1.0cm. The left kidney measures 9.7cm x 4.9cm x 5.0cm (LWT) with cortical thickness 1.2cm. No masses demonstrated. Both pelvocalyceal system and ureters are not dilated. No definite calculi seen. No abdominal lymphadenopathy. The visualized intestinal segments are fecal filled. The urinary bladder is underfilled. The prostate gland is normal in size with homogeneous Parenchymal echotexture. There is an irregular heterogeneous focus seen in the rectal area measuring 6.6cm x 6.1cm (LW).

IMPRESSION: Moderate ascites Liver parenchymal disease Bilateral renal parenchymal disease Splenomegaly Fecal filled intestinal segments Heterogenous focus in the rectal area Sonographically normal gallbladder, biliary ducts and prostate gland 4. COMPLETE BLOOD COUNT

Definition: A determination of the number of red and white blood cells per cubicmillimeter of blood. A CBC is one of the most routinely performed tests in a clinical laboratory and one of the most valuable screening and diagnostic test.

DATE PERFORMED

COMPONENT

RESULTS

NORMAL VALUES

SIGNIFICANCE

Date: February 24, 2011

Hematocrit Hemoglobi n

31.7% 10.3 g/dL

42-51% 13-18 g/dL

WBC Neutrophils Lymphocyt es Monocytes Platelets

5,700/ mm3 75% 20% 5% 343,200

5,00010,000/mm
3

Decreased: Hemodilution, Anemia Decreased: Insufficient carrier of oxygen,hemodiluti on, Anemia Normal Increased: There is bacterial infection Decreased: There is a viral invasion Increased: There is a viral infection Normal

55-65% 25-35% 2-4% 150,000450,000/m m3

NORMAL VALUES

DATE PERFORMED

COMPONENT

RESULTS

SIGNIFICANCE

Date: March 10, 2011

Hematocrit Hemoglobi n WBC Neutrophils Lymphocyt es Monocytes

18.6 % 5.6 g/dl 5,900/ mm3 68% 26% 6%

42-51% 13-18 g/dL 5,00010,000/mm

3

Decreased: anemia,hemodiluti on Decreased: anemia,hemodiluti on kidney disease Normal Increased: There is bacterial infection Normal Increased: There is viral infection

55-65% 25-35% 2-4%

Platelets

308,000/ mm3

150,000450,000/m m3

Normal

5. URINALYSIS Definition: Ionizing a physical microscopic, or a chemical examination of urine.

DATE PERFORMED CHARACTERISTICS RESULTS NORMAL VALUES SIGNIFICANCE

Date: February 25, 2011

Color Transparency Specific gravity Albumin RBC

Straw Clear 1.010 Negativ e 0-3/hpf

Yellow, straw, amber Clear 1.0101.025 Negative 0-2/hpf

Normal Normal Normal Normal Renal parenchymal alteration

Pus cells

1-3/hpf

0-1/hpf

Inflammation in the Urinary tract Normal

Epithelial cells

Few

Normally in small amount

6. FECALYSIS/STOOL EXAMINATION Definition: Stool examination is a procedure where fecal matter is collected for analysis to diagnose the presence or absence of a medical condition.
DATE PERFORMED CHARACTERISTICS RESULTS NORMAL VALUES SIGNIFICANCE

Date: February 25, 2011

Color

Reddish

Brown

Bleeding from GI tract; melena

Consistency

Watery

formed, soft,semiso lid,moist

RBC Pus cells Bacteria

Plenty Plenty Moderat e

Absent Absent Few

Increased intestinal motility due to irratation of the colon by bacteria(diarrhe a) GI bleeding; hematochezia Bacterial infection Bacterial infection

DATE PERFORMED

CHARACTERISTICS

RESULTS

NORMAL VALUES

SIGNIFICANCE

Date: March 8, 2011

Color Consistency RBC Pus cells Bacteria

Brown Soft Plenty 2-6/hpf Plenty

Brown Formed, soft,semis olid,moist Absent Absent Few

Normal Normal GI bleeding; hematochezi a Bacterial infection Bacterial Infection

Parasites

No intestinal parasites and ova seen

Absent

Normal

PATHOPHYSIOLOGY
Modifiable factors: - Occupation (Efren and his father) - Exposure to contaminated bodies of water Non-Modifiable factors: -Gender: Male (affects more men than women) -Geographical location (endemic

Penetration of S. japonicum cercariae to the skin Uses an enzyme to force its head inside S. japonicum cercariae loses its tail during penetration & become schistosomulae Locates a post-capillary venule & enters to it Along with blood, travels towards the heart, then, to the lungs Undergoes further developmental changes necessary for migration Migrates to the liver sinusoids Juvenile S. japonicum worms develop an oral sucker after at the liver Begins to feed on blood Nearly-matured S. japonicum pair with each other; with female longer than male Pairs of S. japonicum relocate to the mesenteric & rectal veins Parasites reach maturity

Anemi

Poor peripheral circulation

Legend: - clinically manifested by patient during the course of his disease

SCHISTOSOMIA
Produce & lay eggs Eggs pass through the wall of blood vessels

Poor blood and oxygen supply to the peripheral extremities

Skin pallor, poor capillary refill, cold sensation on lower extremities and skin turgor

Matured eggs crosses into the digestive tract through the release of proteolytic enzymes

Other eggs become trapped within the mesenteric & rectal veins

Some will be excreted in stool

Others will remain in the

Eggs trapped in the mesenteri

Eggs washes back into the liver through the

(will be continued on page 40)

(w i l l

be

c o n tI n u e d a g e 41)

o n

Some will be excreted in

Irritates intestinal mucosa Increase gastric motility Diarrhe

Others will remain in the intestinal

Immune response of the body Cellular infiltration Inflammatory response of the body Inflammati

Causes ulceration to the intestinal mucosa including the rectum Melena & hematoche Anemia As lesion progresses, it developed Narrowing of lumen Obstructio n Formation of abnormal passages - clinically manifested by patient during the course of his disease Pea-sized

Anal abscess Pus in stool

Legend:

Multiple anal

48

Eggs trapped in the mesenteric & rectal veins Eggs matures normally Secretes antigens that illicits a vigorous Cellular infiltration Inflammati Eggs in the heart Immune response of the body causes cellular infiltration, then, Causes lesions that leads to fibrosis Liver parenchymal Reduces the livers ability to synthesize normal amounts of Hypoalbumin emia Loss of oncotic pressure Blood volume decreases Increase secretion of aldosterone Liver is unable to inactivat e Stimulate the kidney to retain sodium & water Fatigue, body malaise, muscle atrophy, atonia, flaciddity, Shifting of fluid from intravascular to peritoneal Decrease protein and carbohydra te

Eggs washes back into the liver through the portal system Eggs being dislodged in the portal system Occlusi on Blocks the blood flow through the liver sinusoids to the hepatic veins Increased venous pressure in the portal circulation Increase amino acid tyrosine Increas e melani Hyperpigmen Leakage of plasma proteins into the Portal hypertension Congesti on of lymph channels Systemic hypertensi

Pain

Can cause SOB, chest pain, tachypnea, hyperventilat

Tachycardi

Splenomeg

As this progresses, it lead to Bilateral renal parenchymal

Ascite Legend: - clinically manifested by patient during the course of his disease

49

NURSING CARE PLANS

Cues Subjective: Sakit ang gioperahan sa akong tiyan ug ang akong lubot sakit kay dili nako kalibang, as verbalized by patient Sakit akong lubot, murag makapatay, pati akong bukog murag gakutkuton, as verbalized by patient emitted sounds of pain such as uuuhhhh as noted Objective: winces, shouts, bends over and grasps an object tightly as noted facial grimace noted Nursing Diagnosis Altered Comfort: severe pain related to presence of stoma at the left lower quadrant and wound at the left buttocks area Objective Intervention Assessed pain including location, characteristic, duration and quality Accepted clients description of pain Observed for nonverbal cues At the end of 2 days nursing care, patient will be able to demonstrate the use of relaxation techniques in minimizing level of pain of the patient Rationale To rule out worsening of underlying condition of complication Pain is subjective experienced and cant be felt by others It may not be congruent with verbal reports indicating need for further evaluation To divert attention to pain To calm patient Reduce level of anxiety To provide non pharmacologica l pain management Evaluation

Within 8 hours
nursing care, patient will be able to reduce pain

Within 8
hours nursing care, patient was able to felt reduced pain with appropriate nursing intervention and pharmacologic management.

Performed diversional activities such as massage Taught deep breathing exercises Provided quiet environment by limiting noise and visitors Provided comfort measures by teaching deep

At the end of 2 days nursing care, patient was able to use some of the relaxation techniques introduce to help minimize level of pain such as deep breathing when pain occurs

50

 intermittent searing pain on abdominal area and scalding pain on anal area with pain scale of 10/10 as noted

breathing exercises To maintain acceptable level of pain

Dependent: Administered nalbuphine HCl 5mg IVTT q6h PRN for severe pain as ordered by AP

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9th edition, 2004 Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994

51

Cues Subjective: Galisod ko ug ginhawa, as verbalized by patient

Nursing Diagnosis Impaired gas exchange related to immobility secondary to complications of schistosomiasis

Objective Within 8 hours nursing care, patient will be able to achieve adequate oxygenation and reduce RR to 15 cpm

Objective: Shortness of breath noted Hyperventil ation noted Increased respiratory rate to 40 cpm Pallor skin noted Nasal flaring noted

At the end of 2 days nursing care, patient will be able to demonstrate interventions in improving gas exchange

Intervention Monitored and recorded vital signs Assessed energy level by asking the pt level of activity Elevated head of bed Taught frequent position changes, deep breathing and coughing exercise and allowed pt to perform Advised SO to limit activities such as walking and roaming and limit hospital noise by minimizing visitors around to within pts tolerance Recommended energy conservation techniques such as

Rationale Check for alterations To determine degree of movement To maintain airway Promote optimal chest expansion

Evaluation

Within 8
hours nursing care, patient was able to achieve adequate oxygenation through compliance of therapeutic regimen and reduce RR to 16 cpm

Helps limit oxygen consumption

To reduce oxygen demands

At the end of 2 days nursing care, patient was not able to meet the long term objective due to occurrence of pain

52

adequate bed rest

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9th edition, 2004 Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994

53

Cues Subjective: Maglisod ko ug ginhawa sa kasakit sa akong gibati, as verbalized by patient Objective: Shortness of breath noted Increased respiratory rate to 40 cpm Used of accessory muscles: nasal flaring Decreased chest expansion Pallor skin noted

Nursing Diagnosis Ineffective breathing pattern related to pain

Objective At the end of 3 hours nursing care, the patient will be able to demonstrate effective breathing pattern with proper nursing intervention and pharmacologic management and reduce RR to 15 cpm

Intervention Assessed for discomfort. Elevated Head of bed Taught patient deep breathing exercise Positioned pt in a comfortable position Maintained calm environment through limiting visitors of pt Provided adequate rest periods Limited walking and moving around Administered nalbuphine HCl 5mg IVTT q6h PRN for severe

Rationale To know any restriction in the respiratory tract. To promote physiologic ease of maximal inspiration. To help increase oxygen intake. Reposition client frequently in a comfortable position To limit level of anxiety. To limit fatigue

Evaluation At the end of 3 hours nursing care the patient was able to verbalize understanding of awareness of factors affecting breathing pattern and reduced RR to 17 cpm

At the end of 2 days nursing care the patient will be able to establish a normal or effective respiratory pattern though following proper therapeutic regimen when pain occurs

To decrease
oxygen demands & conserve energy

At the end of 2 days nursing care the patient felt decrease occurrence of shortness of breath.

54

pain as ordered by AP

To maintain acceptable level of pain

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9th edition, 2004 Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994
Cues Subjective: Sakit kaau ako dughan murag gakomoton as verbalized by patient. Objective: Fatigue noted atonia, muscle atrophy and flaccidity noted cold, clammy skin pallor noted hair loss noted capillary refill time in the lower extremities of 5 seconds Increased respiratory rate Nursing Diagnosis Decreased cardiac output related to dislodgement of schistosoma eggs in the portal system Objective Within 8 hours nursing care, patient will minimize fatigue Intervention Monitored baseline vital signs/ hemodynamic parameters including peripheral pulses and recorded Promote adequate rest by providing quiet environment and minimize visitors Monitored rate of IV drugs closely Encouraged relaxation techniques Provided diet high in carbohydrates, proteins and Rationale Provides opportunities to track changes Evaluation At the end of 8 hours nursing care, patient was not able to meet short term objective

At the end of 2 days nursing care, patients cardiac output will increase as evidenced by pts muscle movement and stable vital signs

To limit fatigue At the end of 2 days nursing care, patient participated in the interventions to increase cardiac output following proper relaxation technique

To prevent bolus or overdose To reduce anxiety To maintain adequate nutrition and fluid balance

55

to 40 cpm Increased pulse rate to 125 bpm Elevated Blood pressure of 150/100mmHg

less fatty foods

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9th edition, 2004 Gulanick, et.,al., Nursing Care Plans, 3rd edition, 1994

56

Cues Subjective Sakit kaau ako dughan murag gakomoton as verbalized by patient. Objective tachycardia with pulse rate of 125beats per minute shortness of breath used accessory muscles; nasal flaring increased BP to 150/100mmHg capillary refill time in the lower extremities is 5 seconds

Nursing Diagnosis Altered tissue perfusion: cardiopulmunary related to interruption of blood flow secondary to complications of schistosomiasis

Objective

Within 8 hours
nursing care, patient will be relieved of hyperventilatio n

Intervention Independent: Monitored baseline data (vital signs) and recorded Provided quiet and peaceful environment by limiting visitors Cautioned client to avoid activities that may increase cardiac workload like unnecessary movement Encouraged relaxation techniques like deep breathing exercises Elevated head of bed at night

Rationale Provides comparison with current findings

To conserve energy and lower oxygen demands Lower oxygen demands

Evaluation Within 8 hours nursing care, patient felt reduced hyperventilatio n with proper nursing intervention and pharmacologic management.

At the end of 2
days nursing care, patient will be able to verbalize awareness of causative factors and initiate needed lifestyle changes

To decrease tension level

To increase gravitational blood flow

At the end of 2 days nursing care, patient was able to verbalized awareness of factors contributing to causes of interruption of blood flow

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9th edition, 2004 Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994

57

Cues Subjective: Sakit ang akong gioperahan Maam, as verbalized by patient

Nursing Diagnosis Risk for Infection related to site for organism invasion secondary to colostomy and fistulectomy

Objective

Within 8 hours
nursing care the patient will be able to identify interventions that will decrease or lower the risk of infection and demonstrate techniques and lifestyle changes to promote a safe environment.

Objective: Increased segmenters to 68-75% and monocytes to 5-6% Presence of pain at doublebarrel colostomy at Left Lower Quadrant with watery and greenish fecal discharges Presence of wound soaked with serous sanginous discharge with foul odor at the buttocks area

At the end of 2 days nursing care the patient will be able to achieve timely wound healing and be free of purulent drainage or erythma.

Intervention Assessed characteristics of wound Monitored vital signs and recorded Taught proper hand washing techniques to pt and SO Maintained sterile technique during evasive procedures. Dressing done with aseptic technique and covered dressing with sterile gauze Administere d Cefuroxime 750mg IVTT q8h as ordered by AP

Rationale To assess the patients current status. To monitor alterations To minimize transmission of microorganism s To minimize transmission and to insure sterility. Prevent contamination from fecal discharges from colostomy. To prevent return of infection.

Evaluation within 8 hours nursing care the patient was able to verbalize learning towards interventions to decrease infection.

At the end of 2 days nursing care the patient was able to demonstrate changes to promote a safe environment.

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9th edition, 2004

58

Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994

59

Cues Subjective Wala koy gana sa pagkaon as verbalized by patient. Nangalagas ang iyang buhok last week as verbalized by significant other Objective Loss of weight from 58kg to 30kg (48%) Weakness of muscles noted Hair loss noted Decrease subcutaneous fats noted. Loss of muscle strength Body malaise noted

Nursing Diagnosis Imbalanced Nutrition less than body requirements related to inability to absorb proper nutrients secondary to schistosomiasis

Objective Within 8 hours nursing care the patient will be able to consume food RDA

Intervention Assessed weight, age, activity and rest level. Recorded total daily intake.

Rationale This would provide a baseline data. To reveal changes that should be made in clients dietary intake. To increase stores of energy giving foods. Increase fluid intake Emphasis of well balanced nutritional diet.

Evaluation within 8 hours nursing care patient was able to consume 3 table spoons per meal At the end of 2 days nursing care the patient was not able to meet objective

At the end of 2 days nursing care the patient will be able to Demonstrate progressive weight gain toward the goal.

Encouraged intake of carbohydrates (rice), proteins (meat) and fiber (vegetables) diet Promoted adequate fluid intake of 8-10 glasses per day. Provided information regarding nutritional needs.

60

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9th edition, 2004 Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994

61

Cues No subjective cue.

Objective: Tachycardia with pulse rate of 125bpm Dry mucous membranes with fissure in the lips as noted Sunken eyeballs noted Weight loss of 48%

Nursing Diagnosis Fluid Volume Deficit related to chronic illness and malnutrition

Objective

Within 8 hours
nursing care, patient will be able to consume fluid as indicated

At the end of 2 days nursing care, patient will be able to demonstrate behaviors to monitor and correct deficit as indicated when condition is chronic such as recovery from sunken eyeballs

Intervention Independent: Monitored color and consistency of fecal discharges hematochezia Provided nutritious diet and give adequate fluid (8-10 glasses per day) Moistened lips with cotton swabs Changed position q2h Identified and instructed nutritional needs

Rationale

Check for
presence of hematochezia

To restore fluid
losses

Evaluation within 8 hours nursing care, patient was able to consume 2 glasses of fluid per day

To prevent
injury from dryness Promote comfort

To promote
awareness

Administered
D5NSS 1L @ 30gtts\min

restore electrolyte losses and goes directly into intravascular fluid

At the end of 2 days nursing care, patient was able to demonstrate increased awareness of ways to correct fluid volume deficit

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9 edition, 2004 Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994
th

62

Cues Subjective Luya kaayo ako pamati karon, as verbalized by patient. Objective Poor skin turgor. Generalized weakness Needs assistance in walking and standing as noted Tensed and bent posture noted Fatigue noted Body malaise

Nursing Diagnosis Activity intolerance related to general weakness.

Objective

Within 8
hours nursing care the patient will be able have adequate rest and to increase energy

At the end of 2 days nursing care the patient will be able to increase activity tolerance

Intervention Noted presence of factors contributing to fatigue. Provided comfort measures like deep breathing exercises Noted patients reports of weakness and fatigue. Monitored vital signs and recorded Planned care with rest periods between activities. Promoted comfort measures. Encouraged patient to maintain positive attitude.

Rationale To assess the patients condition To enhance ability to participate. To provide comparative baseline. To identify alterations. To reduce fatigue To enhance activity and to perform ADL. To enhance sense of wellbeing.

Evaluation within 8 hours nursing care the patient was able to identify negative factors that may affect ability to perform ADL At the end of 2 days nursing care the patient will be able to demonstrate factors to increase activity tolerance.

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9th edition, 2004 Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994

63

64

Cues Subjective: Dili ko ganahan maligo tungod sa akong gabatiun, as verbalized by patient Objective: Generally unclean Unkempt appearance noted Noted foul odor due to presence of colostomy Foul breath noted Poor personal hygiene as noted Unchanged clothing noted

Nursing Diagnosis Self-care deficit: hygiene and toileting related to presence of stoma and pouch

Objective Within 8 hours nursing care, patient will be able to take a bed bath

Intervention Assessed barriers to participation in regimen Established contractual partnership for patients Promoted participation in problem identification and decision making Planned time to listen to patient Encouraged food and fluid choices Provided information on stoma cleaning Reviewed safety concerns

Rationale Assessed lack of information and psychological problems affecting condition To promote trust and cooperation Enhances commitment to plan, optimizing outcome To discover barriers to participation in regimen To meet nutritional needs To minimize risk for infection To reduce risk to injury

Evaluation Within 8 hours nursing care, patient was able to take a bed bath

At the end of 2 days nursing care, patient will increase willingness to perform daily self-care as assisted by SO

At the end of 2 days nursing care, patient was able to increase willingness to perform daily self-care as assisted by SO

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9th edition, 2004

65

Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994

66

Cues Subjective: Dili kayo ko makalihok ug tarong kay luya akong lawas, as verbalized by patient Objective: Postural instability in performing ADLs Slowed movements Limited range of motion Generalized weakness Decrease muscle strength

Nursing Diagnosis Impaired physical mobility related to decreased muscle strength and endurance

Objective Within 8 hours nursing care, patient will be able to participate in performing PassiveAssistive ROM exercises

Intervention Assessed muscle strength Performed PassiveAssistive Rom exercises with pt Changed position q2h Participated in self-care activities like ADLs Provided progressive mobilizations Provided adequate rest periods by limiting visitors Placed pt in a safe position

Rationale To determine degree of immobility To increase muscle strength To provide comfortable position Enhance selfconcept and sense of independence To increase tolerance To reduce fatigue To avoid risk for injury

Evaluation Within 8 hours nursing care, patient was able participate in performing PassiveAssistive ROM exercises

At the end of 2 days nursing care, patient will increase muscle strength as evidenced by 85% muscle strength

At the end of 2 days nursing care, patient was not able to meet objective

Reference: Doenges, M., et.,al., Nurses Pocket Guide, 9th edition, 2004 Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994

67

MEDICAL MANAGEMENT Date February 24, 2011 Doctors Order Admit Consent Rationale Due to the present complaints of the patient, he needs an intensive care. This requirement protects clients from form having any medical procedure they do not want or do not understand. It also protects the hospital and the health care provider from a claim by the client or the family that permission was not granted. Vital signs reflect the patient's condition-and changes in the patient's condition or in the patients body function that otherwise might not be observed. High fiber- for healing; low fat-to prevent cardiovascular complications; 1 egg per day -egg contains albumin protein for wound healing Plain Lactated Ringers Solution- a fluid and electrolyte replenisher prescribed for correction of extracellular volume and electrolyte depletion Routine blood examination is needed to determine values of

TPR & BP q 4 hours

DAT; high fiber, low fat

Start IVF of PLR 1 liter, fast drip 200 cc, then regulate @ 40 gtts/min; TF: D5 NM 2 liters @ same rate Labs: CBC, Blood typing

Meds: 1. Nalbuphine 1 amp. IVTT q 8 hours, then PRN

68

 Refer Anesthesiologist February 25, 2011 IVFTF: D5 NM 1 liter @30 gtts./min

blood components. 1. For moderate to severe pain since patient was having a 10/10 pain scale For evaluation of pain

Cefuroxime 750 mg. IV q 8 hours. February 26, 2011 February 27, 2011

D5NM- is a hypertonic solution that draws fluid out of the intracellular and interstitial compartments into the IVTF: D5 NM 1 liter @ SR. vascular compartment, expanding vascular Cont. Meds. volume. Prophylaxis IVFTF with D5 NM 1 liter @ 20 gtts/min Diazepam 5 mg. 1 tab. @ h.s PRN for pain. Same as above To sustain patients medication Same as above For pain

February 28, 2011

Nalbuphine 5 mg. IVTT now Diazepam 5 mg. IVTT now IVF @ D5 NM 2 liters @ SR Revise Nalbuphine to 10 mg IV PRN for moderate to severe pain. Cont. All meds. IVTF: D5 NM 2 liters @ 20 gtts/min Cont. Meds Ketorolac 30 mg. IV q 6

March 1, 2011

For mod. pain For pain

to

severe

March 4, 2011 Same as above For moderate severe pain to

March 5, 2011

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March 7, 2011

hours RTC. IVFTF: D5 NM 1 liter @ 20 gtts/min. Schedule for Fistulectomy March 15, 2011 at 1 pm. Secure consent, signed

Same as above Same as above Same as above For severe pain Same as above

To remove anal fistula This requirement protects clients from form having any medical procedure they do not want or do not understand. It also protects the hospital and the health care provider from a claim by the client or the family that permission was not granted. For them to be informed and be prepared for the operation

March 8, 2011

Notify OR and Anesthesiologist

March 9, 2011

IVTF: D5 NM 2 liters @ SR Metroclopromide 1 amp. IVTT now q 8 hours, PRN for vomiting

March 10, 2011

TF: D5 NM 2 liters @ SR. Same as above May use Diazepam 5 mg. For vomiting IVTT q 8 hours, PRN for pain Morphine Sulfate 10 mg controlled- release 1 tab BID Same as above For pain IVTF: D5 Nm 2 liters @ 15 gtts/min Diazepam 5 g. IVTT now For severe and chronic pain

March 14, 2011

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 IVTF: D5 NM 1 liter @ SR Cont. All meds March 15, 2011

Same as above Same as above Same as above Same as above

POST OP NOTES Soft diet Supine in bed x 6 hours O2 via nasal cannula at 2LPM V/s q 15 mins Regulate present IVF @ 30 gtts IVTF: D5 NM 2 liters @ SR Meds: Nalbuphine 2 tab Nalbuphine 5 mg. IVTT now, q 8 hours IVTF: D5 LR @ SR Cont. Meds. Hot sitz bath for 15 mins QID

March 16, 2011

Low residue and easily digested and well tolerated To prevent aspiration To relieve tachypnea Same as above Same as above Same as above Same as above Same as above Same as above Same as above to decrease pain and prevent inflammation after fistulectomy. Same as above Same as above For fever- temperature of 38.1C D5NSS-It is an efficient and effective method of supplying fluids

March 18, 2011

March 21, 2011

Morphine Sulfate 1 tab 10 mg. TID IVF decreased @ 15 gtts/ min Meds: PCM 600 mg. IV now IVTF: D5 NSS 1 liter @ SR

March 22, 2011

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 IVTF: D5 NSS 1 liter @ SR

March 23, 2011

March 24, 2011 Nalbuphine 10 g. IVTT IVTF: D5 NM 1 liter @ SR Refer to Anesthesiologist for eveluation of pain. March 25, 2011 Discontinue Tramadol IVTT May give Nalbuphine 5 mg. IVTT q 6 hours PRN for severe pain IVF: D5 NM @ SR IVF: D5 NM 1 liter + 1 mg Amino Acid @ 20 gtts/ min Shift Cefuroxime IV to 500 mg BID PO IVF: D5 NM 1 liter @ SR 1 egg/day Tramadol 50 g 1 cap TID Cont. Meds IVTF: D5 NM 1 liter + 2 amp. Morphine Sulfate @

directly into the intravascular fluid compartment and replacing electrolyte losses. D5NSS or 5% dextrose in normal saline is a hypertonic solution that draws fluid out of the intracellular and interstitial compartments into the vascular compartment, expanding vascular volume.

Same as above Same as above For evaluation of pain

Patient was tolerant to drug Same as above Same as above Same as above, amino acids are building blocks of proteins For infections

March 26, 2011

March 28, 2011

Same as above egg contains albumin protein for wound healing

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SR Refer to Anesthesiologist for pain management Provide medical abstract c/o NOD IVTF: D5NM 1 liter @ 20 gtts/ min

Same as above Same as above Same as above To collect data Same as above

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SURGICAL MANAGEMENT Title of Operation Performed: Exploratory Laparotomy, Double Bowel Sigmoid Date Performed: December 29, 2010 Surgeon: Dr. Surge Exploratory laparotomy. An abdominal exploration Colostomy

(laparotomy) is done while patient is under general anesthesia, which means patient is asleep and thus shall feel no pain during the procedure. In this procedure, the surgeon makes a cut into the abdomen and examines the abdominal organs. The size and location of the surgical cut depends on the specific health issue. The surgery on Boy Tigas was primarily performed to examine his abdominal organs and determine the location of his bowel obstruction prior to colostomy Usually, patients can resume normal eating and drinking about 2 - 3 days after the surgery. Complete recovery usually takes about 4 weeks

Colostomy is a surgical opening of the colon brought to the surface of the abdomen. A colostomy is not a disease rather it is a change in anatomy. This results in a change of normal body function to allow elimination of bowel contents following disease or injury. Double-barrel colostomy was used in the operation of Boy Tigas. This colostomy involves the creation of two separate stomas on the abdominal wall. The proximal (nearest) stoma is the functional end that is connected to the upper gastrointestinal tract and will drain stool. The distal stoma, connected to the rectum which is also called a mucous fistula, drains small amounts of mucus material.

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This is most often a temporary colostomy performed to rest an area of bowel, and to be later closed.

Aftercare of Colostomy Post-operative care for the patient with a new colostomy, as with those who have of blood had any major surgery, involves pressure, pulse, respirations, and monitoring

temperature. Breathing tends to be shallow because of the effect of anesthesia, the patient's reluctance to breathe deeply and the experience of pain caused by the abdominal incision. The operative site is observed for color and amount of wound drainage. For the first 24-48 hours after surgery, the colostomy will drain bloody mucus. Fluids and electrolytes are infused intravenously until the patient's diet is can gradually be resumed, beginning with liquids. Usually within 72 hours, passage of gas and stool through the stoma begins. Initially the stool is liquid, gradually thickening as the patient begins to take solid foods.

Title of Operation Performed: Fistulectomy Date Performed: March 15, 2011 Surgeon: Dr. Surge Fistulectomy is the surgical excision of a fistula. Also called

syringectomy. In this surgery, the fistula tract is totally taken out. The resultant wound is generally not closed and left open to heal of its own. Thus, this leads to a large wound from the anal opening to the buttock. Boy Tigas was diagnosed with mutiple in-ano fistula thus fistulectomy was performed. A two-inch wound is located at his

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left buttock area as a result of the fistulectomy. Understandably this leaves the patient with lot of pain. Complete fistulectomy creates larger wounds that take longer to heal and offers no recurrence advantage over fistulotomy.

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Title of Operation Performed: Anoscopy with biopsy Date Performed: August 2, 2010 Surgeon: Dr. Gacus Anoscopy is a method to view the rectal area, including the

anus, anal canal, and lower rectum. A digital rectal exam is first done to make sure there isn't anything blocking the rectal area. After this is done, a lubricated instrument (anoscope) is placed a few inches into the rectum. Patient will feel some pressure when this is done. The anoscope has a light on the end, so the health care provider can see the entire anal canal. A laxative, enema, or other preparation may be given prior to the procedure so that patient can completely empty bowels. A specimen for biopsy can be taken if needed.

Title of Operation Performed: Proctosigmoidoscopy with biopsy Date Performed: August 16, 2010 Surgeon: Dr. Llosa Sigmoidoscopy also called proctosigmoidoscopy or

proctoscopy, is the inspection of the rectum and lower colon using a thin lighted tube called a sigmoidoscope. Samples of tissue or cells may be collected for examination under a microscope. During the test, patient is positioned on his left side with knees drawn up toward chest. A gastroenterologist or surgeon will perform the test. First, the doctor does a digital rectal exam by gently inserting a gloved and lubricated finger into the rectum to check for blockage and to dilate (gently enlarge) the anus.

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Next, the sigmoidoscope -- a hollow tube with a camera on the end -- is inserted into the rectum. Air is introduced into the colon to expand the area and help the doctor see better. The air may cause the urge to have a bowel movement. The sigmoidoscope is advanced, usually as far up as the sigmoid colon or descending colon. Then, as the scope is slowly removed, the lining of the bowel is carefully examined. The hollow channel in the center of the scope allows for the passage of forceps for taking biopsies or for other instruments for therapy. During a proctoscopy, a slightly longer instrument than the anoscope is used to view the inside of the rectum. Patient usually will have to undergo enemas or use laxatives to empty the colon before the test is done.

Biopsy or tissue sampling is the removal of a small piece of tissue for laboratory examination. A needle (percutaneous) biopsy removes tissue using a hollow tube called a syringe. A needle is passed thru the syringe into the area of concern. The tissue is taken out using this needle. Needle biopsies are often performed using x-rays (usually CT scan), which guide the surgeon to the appropriate area. Rectal biopsy was performed to Boy Tigas. This is a procedure done to remove a small piece of rectal (anal) tissue for examination. It is usually part of anoscopy or sigmoidoscopy. A digital rectal exam is first done to make sure there isn't anything blocking the rectal area. After this is done, a lubricated instrument (anoscope, rectal speculum, or proctoscope) is placed into the rectum.

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Rectal biopsy is useful in cases with light, chronic, or inactive infections. It is also beneficial in assessing the response to chemotherapy. Biopsy is helpful when stool sample findings are negative infection. Obtain multiple biopsy samples and crush them between slides (to increase egg-detecting sensitivity).

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PROGNOSIS & COMPLICATIONS 1. Schistosomiasis If treated early, prognosis is very good and complete recovery is expected. The illness is treatable, but people can die from the effects of untreated schistosomiasis. The severity of the disease depends on the number of worms, or worm load, in addition to how long the person has been infected. With treatment, the number of worms can be substantially reduced, and the secondary conditions can be treated. The goal of the World Health Organization is to reduce the severity of the disease rather than to completely stop transmission of the disease. There is, however, little natural immunity to reinfection. Treated individuals do not usually require retreatment for two to five years in areas of low transmission. The World Health Organization has made research to develop a vaccine against the disease one of its priorities. Almost all patients improve with treatment. Most patients with early disease or without severe end-organ complications recover completely. Surprisingly, patients with hepatic and urinary disease, even with fibrosis, may improve significantly over months or years following treatment. Resolution of pulmonary disease is less well documented. o Patients with heavier worm burdens are less likely to improve and are more likely to require re-treatment. o Treatment is indicated for patients with end-stage complications of portal hypertension and severe pulmonary hypertension, but these patients are much less likely to benefit.

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 Co-infection (with malaria, HIV, or hepatitis) worsens the prognosis. 2. Anal fistula, abscess, fissures and strictures In most cases, the prognosis is excellent. Almost all acute fissures heal quickly with conservative treatment, and almost all fistulas and chronic fissures can be corrected with surgery. Appropriate treatment of anal strictures will allow stool to pass easily and comfortably. Most anal abscesses heal after being drained by a doctor. Some develop into anal fistulas. If a fistula does complicate the healing of an abscess, a fistulotomy will totally eliminate both the fistula and any remaining abscess in most patients. Approximately two thirds of patients with rectal abscesses treated by incision and drainage or by spontaneous drainage will develop a chronic anal fistula. The recurrence rate of anorectal fistulas after fistulotomy, fistulectomy, or use of a Seton is about 1.5%. The overall incidence of major fecal incontinence after surgical management of complex suprasphincteric fistulas is estimated at approximately 7%. 3. Splenomegaly Past history in a group of 159 individuals with schistosomal splenomegaly revealed hematemesis in 12.6 percent and ascites, edema and/or jaundice in 1.9 percent. One hundred nine patients were followed for an average of 3.6 years. During this time liver failure was observed in eight and hematemesis in eleven (five of these had experienced bleeding prior to the beginning of the study). Liver failure was more often lethal than 81

was gastrointestinal hemorrhage, death in the latter usually occurring after a series of such events. Fifteen (9.4%) patients died during follow-up. Death occurred in four shortly after a voluminous hematemesis; in five it was a result of liver failure and in six it was the result of other diseases or accidents. Since the complications of schistosomal splenomegaly are not as frequent as they are in other diseases leading to portal hypertension, we believe that the policy of prophylactic venous shunts in individuals who have never experienced hematemesis should be seriously questioned. 4. Portal Hypertension Mortality during acute variceal hemorrhage may exceed 50%. Prognosis is predicted by the degree of hepatic reserve and the degree of bleeding. For survivors, the bleeding risk within the next 1 to 2 yr is 50 to 75%. Ongoing endoscopic or drug therapy lowers the bleeding risk but decreases long-term mortality only marginally. 5. Ascites The prognosis depends upon the condition that is causing the ascites. Carcinomatous ascites has a very bad prognosis. However, salt restriction and diuretics can control ascites caused by liver disease in many cases. Therapy should also be directed towards the underlying disease that produces the ascites. Cirrhosis should be treated by abstinence from alcohol and appropriate diet. The new interferon agents maybe helpful in treating chronic hepatitis. 6. Anemia 82

 Usually, the prognosis depends on the underlying cause of the anemia. However, the severity of the anemia and the rapidity with which it developed can play a significant role. Similarly, the age of the patient and the existence of other comorbid conditions influence outcome. The most serious complications of severe anemia arise from tissue hypoxia. Shock, hypotension, or coronary and pulmonary insufficiency can occur. This is more common in older individuals with underlying pulmonary and cardiovascular disease. Hemolytic transfusion reactions and transmission of infectious disease are risks of blood product transfusions. Patients with autoimmune antibodies against RBCs are at greater risk of a hemolytic transfusion reaction because of difficulty in crossmatching the blood. Occasionally, the blood of patients with autoimmune hemolytic anemia cannot be cross-matched in vitro. These patients require in vivo cross-matching in which incompatible blood is transfused slowly, and periodic determinations are made to ensure the patient is not developing hemoglobinemia. This method should only be used in patients with either significant hypoxia from the anemia or evidence of coronary insufficiency. 7. Seizures About 30% of patients with severe seizures (starting in early childhood), continue to have attacks and usually never achieve a remission state. In the United States, the prevalence of treatment-resistant seizures is about one to two per 1,000 persons. About 6070% of persons achieve a five-year remission within 10 years of initial diagnosis. Approximately half of these patients become seizure-free. Usually the prognosis is better if

83

seizures can be controlled by one medication, the frequency of seizures decreases, and there is a normal EEG and neurological examination prior to medication cessation. People affected by seizure have increased death rates compared with the general population. Patients who have seizures of unknown cause have an increased chance of dying due to accidents (primarily drowning). Other causes of seizureassociated death include abnormal heart rhythms, water in the lungs, or heart attack. 8. Liver Parenchymal Disease Historically mortality has been unacceptably high, being in excess of 80%. In recent years the advent of liver transplantation and multidisciplinary intensive care support have improved survival significantly. At present overall short term survival with transplant is more than 65%.

9. Colostomy complications

Death (necrosis) of stomal tissue. Caused by inadequate blood supply, this complication is usually visible 12-24 hours after the operation and may require additional surgery.

Retraction (stoma is flush with the abdomen surface or has moved below it). Caused by insufficient stomal length, this complication may be managed by use of special pouching supplies. Elective revision of the stoma is also an option.

Prolapse (stoma increases length above the surface of the abdomen). Most often results from an overly large opening in the abdominal wall or inadequate fixation of the bowel to the

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abdominal wall. Surgical correction is required when blood supply is compromised.

Stenosis (narrowing at the opening of the stoma). Often associated with infection around the stoma or scarring. Mild stenosis can be removed under local anesthesia. Severe stenosis may require surgery for reshaping the stoma.

Parastomal hernia (bowel causing bulge in the abdominal wall next to the stoma). Usually due to placement of the stoma where the abdominal wall is weak or creation of an overly large opening in the abdominal wall. The use of an ostomy support belt and special pouching supplies may be adequate. If severe, the defect in the abdominal wall should be repaired and the stoma moved to another location.

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DISCHARGE PLAN Medications Drug : Praziquantel Dose and frequency: Three doses of 20 mg/kg as a 1day treatment with an interval between doses not less than 4 hours or more than 6 hours Indication: Schistosomal infections due to S. japonicum Nursing Precaution: Swallow tablets unchewed with liquid during meals. Keeping the tablets in the mouth may cause gagging or vomiting; do not chew the tablets as their bitter taste can cause retching and vomiting. Use caution while driving or performing tasks requiring alertness; may cause dizziness/drowsiness. Schistosomal worms are usually dead 7 days following treatment. However, re-infection of the parasite is very possible, especially if the skin has contact with contaminated bodies of water. Drug: Ferrous sulfate Dose and Frequency: 1 cap OD Indication: Iron deficiency Nursing Precaution: GI upset may be related to dose Between-meal doses are preferable. Drug can

be given with soft foods, although absorption may be decreased. Monitor hemoglobin level, hematocrit and reticulocyte count during therapy.

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Tell patients to take tablet with juice (preferably

orange juice) or water, but not with milk or antacids. Exercise Instruct patient not to crush or chew extended release form. Deep breathing exercises to promote relaxation. Places hands palm down on the border of the rib cage and inhale slowly and evenly through the nose until the greatest chest expansion is achieved. Hold the breath for 2-3 seconds, exhale slowly through the mouth with pursed lips and continuous exhalation until maximum chest expansion is achieved. ROM exercise Neck: flexion, extension, hyperextension, lateral flexion, rotation. Elbow: flexion and extension, supination, pronation. Wrist: flexion, extension, hyperextension, radial flexion, ulnar flexion Fingers: flexion, extension, hyperextension, abduction adduction. Thumb: flexion, extension, abduction, adduction, opposition. Passive ROM exercise Hip: instruct significant other to move each leg forward and up (flexion), move the leg back beside the other (extension) and move the leg back behind the body (hyperextension). Move each leg out to the side (abduction) and move each leg back to the other leg and beyond in front of it (adduction). Then move each Treatment leg backward, up, to the side, and down in a circle. Educate patient and significant others how to clean 87

the stoma and changing or emptying of the pouch to prevent contamination of the fecal discharges of the stoma to the wound. Heath Teachings Teach patient and significant others to maintain hygienic measures during cleaning of the stoma. Encourage patient to change position every 2 hours (side lying position is advised) Position patient in a semi-fowlers position with pillows to support the back, to maximize lung expansion. Caution patient to avoid anything that may increase cardiac workload. Weigh patient weekly in a RHU. Discuss eating habits and food reference. Instruct to position patient in a side lying position to avoid injury in the colostomy and wound. Provide patient with information regarding proper positioning and diversional activities. Provide patient with information regarding proper hand washing and infection control. Instruct significant others to report any unusualities. Inform patient to avoid strenuous activities that will cause abdominal muscle contraction. Maintain calm attitude to limit anxiety. Encourage patient to stay in a quiet and peaceful environment to promote relaxation and rest, Stress proper hand washing techniques. Encourage patient to use diversional activities. Provide information on proper stoma cleaning. Teach patient and significant others proper wound dressing techniques. 88

Out-patient check-up

Stress proper safety precaution. Appropriate consultations depend on complications but may include an physician, urologist, or gastroenterologist.

the

suspected disease

infectious

Diet

Low salt diet High Protein Diet

o

From meat like chicken meat, beef meat, To increase muscle tone and to help in the

red and white meat and from fish. o tissue repair. High Carbohydrate Diet o From rice, corn, bread, camote.

To help sustain patients needs for metabolic activities. Take Vitamin C o Take at least 1-2 servings of vitamin c rich fruits such as calamansi and lemon. Add 1 egg to every meal to increase protein and albumin.

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REFERENCE Books o Black, et. al. 2005. Medical Surgical Nursing: Clinical Management for Positive Outcomes. Vol. 1 & 2. 7th edition. Elsevier Inc. o Doenges, et. al. 1993. Nurses Pocket Guide: Nursing Diagnosis with Intervention. 4th edition. Merriam & Webster Bookstore, Inc. o Govan, et. al. 1981. Pathology Illustrated. International Student edition. Churchill Livingstone. Longman Group Limited. o Gulanick, et. al.1994. Nursing Care Plans. 3rd edition. o Guyton. 1991. Textbook of Medical Physiology. 8th edition. W.B. Saunders Company. Harcourt Brace Jovanovich, Inc. o Karch. 2007 LIPPINCOTTS Nursing Drug Guide. Lippincott Williams & Wilkins Pub. Company. o Kozier, et al. 2004. Fundamentals of Nursing: Concepts, Process, and Practice. 7th edition. Pearson Education, Inc. o McVan, et. al. 1988. Diseases and Disorders Handbook. Springhouse Corporation. Springhouse, Pennsylvania. o 2006. Mosbys Pocket Dictionary of Medicine, Nursing & Health Professions. 5th edition. Mosby, Inc. o Nursing 2007 Drug Handbook. Lippincott Williams & Wilkins. o Price, et. al. 1992. Pathophysiology: Clinical Concepts of Disease Process. 4th edition. Mosby-Yearbook, Inc. o Seeley, et. al. 1991. Essentials of Anatomy and Physiology. Mosby-Yearbook, Inc.

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o Smeltzer, et al. 2008. Brunner & Suddarths Textbook of Medical-Surgical Nursing. 11th edition. Lippincott Williams & Wilkins. o Taylor, et. al. 1993. Fundamentals of Nursing: the Art and Science of Nursing Care. J. B. Lippincott Company. Philadelphia, Pennsylvania. 2nd Edition. o Tortora, et. al. 2006. Principles of Anatomy and Physiology. 11th edition. John Wiley & Sons, Inc. Web links o http://en.wikipedia.org/wiki/Schistosomiasis o http://www.answers.com/topic/schistosomiasis?cat=health o http://www.merck.com/mmpe/sec14/ch183/ch183h.html o http://www.emedicine.com/med/TOPIC2071.HTM o http://content.nejm.org/cgi/content/full/346/16/1212 o http://www.fascrs.org/patients/conditions/anal_abscess_fist ula/ o http://www.mayoclinic.org/anal-fistula/ o http://www.answers.com/topic/anal-fistula o http://www.emedicine.com/med/topic2733.htm o http://www.emedicinehealth.com/anal_abscess/page2_em. htm o http://www.gicare.com/pated/ecdgs38.htm o http://en.wikipedia.org/wiki/Cellular_infiltration o http://www.stanford.edu/group/parasites/ParaSites2008/Le ah%20Machen_Kirsten%20Rogers/SCHISTOPROJECT.htm o http://l05.cgpublisher.com/proposals/1215/index_html o http://jn.nutrition.org/cgi/content/full/136/1/183 o http://www.who.int/tdr/diseases/schisto/diseaseinfo.htm

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o http://www.nlm.nih.gov/medlineplus/ency/article/003890.ht m o http://www.webmd.com/digestivedisorders/sigmoidoscopy-anoscopy-proctoscopy o http://www.kidneyatlas.org/book3/adk3-02.QXD.pdf o http://en.wikipedia.org/wiki/Image:Gray591.png o http://health.allrefer.com/health/rbc-urine-results.html o http://www.encyclopedia.com/doc/1G2-3405200122.html

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