Dedication

We dedicate this case study to our clinical instructors, who have been very patient with us all throughout , to our parents who have been very supportive to us while creating this. To our group mates who have been very cooperative though we didnt really have the pleasure of time while doing this case study. And most of all, to god who blessed us with the gift of knowledge, patience and understanding.

III. Table of Contents I. Title Page II. Dedication Sheet III. Table of Contents IV. Introduction V. Patient Profile a. Biographic Data b. Hospital Data c. Nursing History VI. Anatomy and Physiology VII. Drug Study (Medication Therapy) VIII. Laboratory Studies/Ancillary studies IX. Nursing Care Plan X. Bibliography

IV. Introduction

The purpose of medicine is to prevent significant diseases, to decrease pain and postpone death Technology has to support this goals; if not it may even be counterproductive. Dr. Joel J. Nobel 2001, Founder and President,ECRI.

V. PATIENTS PROFILE

A. BIOGRAPHIC DATA Name Age : : Papa, Gilbert Robio 43 y/o

Address Birth Date Birthplace Gender Nationality Religion Informant

: : : : : : :

Minahan, Malanday M/C 6-10-63 ARMMC Male Filipino Roman Catholic Friend

B. HOSPITAL DATA Ward Room/Bed : SOB Ward Multiple Gun Shot Wound Gun Shot Wound Dr. Gary Uson No known allergies to any medications (antibiotics) or

Admitting Diagnosis : Chief Complaint :

Admitting Physician : Allergies food Date of Admission : :

August 15, 2011; 2:45 am

C. NURSING HISTORY Chief Complaint

Gun Shot Wound History of Present Illness Few minutes prior to admission, patient was allegedly shot by unknown gunman sustaining injury to abdomen and left leg resulting multiple gunshots wound. Past History of Illness Client had no known other illness except for his current illness. Client doesnt also have any known allergies when it comes to antibiotics or any foods. Diagnosis Acute Abdomen 2 to gunshot wound LLQ area

VI. ANATOMY AND PHYSIOLOGY

The Abdomen The abdomen is the largest cavity in the body. It is of an oval shape, the extremities of the oval being directed upward and downward. The upper extremity is formed by the diaphragm which extends as a

dome over the abdomen, so that the cavity extends high into the bony thorax, reaching on the right side, in the mammary line, to the upper border of the fifth rib; on the left side it falls below this level by about 2.5 cm. The lower extremity is formed by the structures which clothe the inner surface of the bony pelvis, principally the Levator ani and Coccygeus on either side. These muscles are sometimes termed the diaphragm of the pelvis. The cavity is wider above than below, and measures more in the vertical than in the transverse diameter. In order to facilitate description, it is artificially divided into two parts: an upper and larger part, the abdomen proper; and a lower and smaller part, the pelvis. These two cavities are not separated from each other, but the limit between them is marked by the superior aperture of the lesser pelvis. The abdomen proper differs from the other great cavities of the body in being bounded for the most part by muscles and fasci, so that it can vary in capacity and shape according to the condition of the viscera which it contains; but, in addition to this, the abdomen varies in form and extent with age and sex. In the adult male, with moderate distension of the viscera, it is oval in shape, but at the same time flattened from before backward. In the adult female, with a fully developed pelvis, it is ovoid with the narrower pole upward, and in young children it is also ovoid but with the narrower pole downward. Boundaries.It is bounded in front and at the sides by the abdominal muscles and the Iliacus muscles; behind by the vertebral column and the Psoas and Quadratus lumborum muscles; above by the diaphragm; below by the plane of the superior aperture of the lesser pelvis. The muscles forming the boundaries of the cavity are lined upon their inner surfaces by a layer of fascia. The abdomen contains the greater part of the digestive tube; some of the accessory organs to digestion, viz., the liver and pancreas; the spleen, the kidneys, and the suprarenal glands. Most of these structures, as well as the wall of the cavity in which they are contained, are more or less covered by an extensive and complicated serous membrane, the peritoneum.

The Apertures in the Walls of the Abdomen.The apertures in the walls of the abdomen, for the transmission of structures to or from it, are, in front, the umbilical (in the fetus), for the transmission of the umbilical vessels, the allantois, and vitelline duct; above, the vena cava opening, for the transmission of the inferior vena cava, the aortic hiatus, for the passage of the aorta, azygos vein, and thoracic duct, and the esophageal hiatus, for the esophagus and vagi. Below, there are two apertures on either side: one for the passage of the femoral vessels and lumboinguinal nerve, and the other for the transmission of the spermatic cord in the male, and the round ligament of the uterus in the female.

The Leg

Muscles

The lower leg is divided into four compartments that contain the various muscles of the lower leg.

The

anterior

compartment

(the front of the shin) holds the tibilais anterior, the extensor digitorum longus, the extensor hallucus longus and the peroneus tertius muscles. These muscles dorsiflex the foot and toes (pull the foot and

toes upward). The tibialis anterior also assists turning the foot inward. To feel these muscles contract, place your hand just to the outside of the tibia and pull the foot up.

The

lateral

compartment

is along the outside of the lower leg. It contains the peroneus longus and peroneus brevis muscles. These muscles pull the foot outward. They also help with plantar flexion (pointing the foot). To feel these muscles contract, place your hand on the outside of your shin and turn your foot out.

The

posterior

compartment

holds the large muscles that are most commonly known as the calf muscles (the gastrocnemius and soleus). It also contains plantaris muscle. The gastrocnemius is shorter, thicker and has two attachments (inner and outer). It is the most visible of the calf muscles. The soleus lies underneath. These three muscles attach to the Achilles tendon. They all aid with plantar flexion.

The

deep

posterior

compartment

is deep within the back of the lower leg. They are the tibialis posterior, flexor digitorum longus, and flexor hallucus longus. Tibialis posterior pulls the foot inward, flexor digitorum longus flexes the toes, and flexor hallucus longus flexes the big toe. All three aide in plantar flexion.

VII. Medication Management

Metronidazole

TIV q 8 Anst -

Supplenex

x8hrs OD

Cefuroxime

750mg IV q 8

Ranitidine

5mg IV q 8

Ketorolac

30mg IV q 8

Metronidazole

500mg q 8 PO

Ketorolac

10mg PO

VIII. LABORATORY RESULT

Date ordered 08-17-2011

Test Hematology Hemoglobin

Result

Normal Value

14.0 g/dl

10.0- 18.0 g/dl

12.0-16.0 g/dl Hematocrit 42.0 vol.% 40.0-50.0% 35.0-47.0% WBC Platelet 14.2 252 5-10x 10L 150-140x 10L

Differential Count

Segmenters Lymphocytes

0.55 0.37

0.45-0.65 0.20-0.35

Medical Management

Exploratory laparotomy small bowel resection with end to end anastomosis, debridement lavage.

Surgical Management Intra Operative management: Check t h e airway. Be prepared to pass an end tracheal tube, or to t h e breathing, place a chest tube or a wide-bore needle

perform tracheotomy. C h e c k

in patients with an evident tension pneumothorax. Cover and seal a sucking chest wound. Arrest haemorrhage (circulation).P l a c e a n and possible intravenous cannula, cross-matching and start take

blood for blood grouping crystalloids.

intravenous penicillin 5

Start treatment of shocked patients immediately.

Give benzyl

million units intravenously.

Pre Operative management:

The skin is prepared with an antiseptic solution and the operative field is draped in accordance with the planned procedure. Drapes with holes should be used only for the smallest and most superficial wounds when there is no likelihood of the wound being widely extended. It must be borne in mind, however, that the surgical wound is always more extensive than the initial wound. Provision should be made for possible extension of the wound by incision. The surgical objective is the removal of all dead and severely contaminated tissue and all loose foreign material which would serve as a culture medium for bacterial growth. An important

consequence of wound surgery is that it allows decompression of adjacent healthy tissues. Failure to remove dead and contaminated tissue causes most post-operative wound infection. As little skin as possible should be removed. It is an elastic tissue which resists damage. Non viable skin only should be removed around the edges of the wound. If retraction of the skin edges is insufficient to visualize hidden and deeper damaged structures, then the wound may have to be extended by incision. Extension incisions should be in the axis of the limb, and obliquely or transversely across joints.

Post Operative management:

Post-operative orders are essential and include antibiotic protocols, intravenous fluid regimes, nursing positions, and instructions about physiotherapy. Patients with head o r chest wounds should be nursed sitting up. Legs and amputation stumps are best elevated on pillows or Braun frames and passive mobilization of joints should be started early.

Definition of terms: Incision

Means Cutting into, a n d i s u s e d w h e n a s u r g e o n e x t e n d s a w o u n d b y cutting into healthy tissue to gain visibility or to decompress tissue. Excision

Means Cutting away or Cutting out, and is used to mean the surgical act of removing, with scissors or scalpel, dead and severely contaminated tissue. Debridement

Medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. and Removal may be surgical, certain mechanical, species of

chemical, autolytic (self-digestion),

by maggot

therapy,

where

live maggots selectively eat only necrotic tissue.

Lavage The wound is generously washed out with saline. This is all that is required. Access a n d e f f e c t a r e i m p r o v e d w i t h a n i m p r o v i s e d j e t l a v a g e us i n g a s y r i n g e . A n t i s e p t i c solutions in a fresh wound after excision are of doubtful value. If hydrogen peroxide

IX. Drug study and NCP

DRUG STUDY Name Metronidazol e Classificatio n Antiinfective Nursing Intervention IntaDirect-acting GI Tell the abdominal amebicide/trichomonacid discomfort, patient to infections, e nausea, increase pre and headache, oral fluid postdizziness, intake. operative diarrhea, Administer prophylaxis rash oral and in GI topical surgery medications . Encourage bed rest. Perioperativ Bacterial cell death GI Take note e disturbances of the prophylaxis , nausea, amount, vomiting consistency and color of vomitus. Ask the patient to increase fluid intake Ensure adequate bed rest and nutrition Used in Inhibits gastric acid Cardiac Provide management secretion arrhythmias, oxygenatio of various bradycardia, n and GI constipation, ventilation. disorders. fatigue Administer Prophylaxis medication of GI for hemorrhage constipation and in Encourage patients at bed rest and Indication Action Side Effect

Cefuroxime

Antibiotic

Ranitidine

H2-Receptor Antagonist

Ketorolac

Analgesic

risk of developing acid aspiration during general anesthesia Short term Anti-inflammatory and management Antipyretic of moderate to severe acute postoperative pain

adequate nutrition

Sweating, hypertension , edema, headache, drowsiness, GI disturbances , nausea

Encourage bed rest. Provide proper ventilation. Tell the patient to increase oral fluid intake

NCP Assessment Objective BP: 180/100 BMI: 32kg/m2 Diagnosis Imbalanced nutrition: more than body requirements as evidenced by BMI of 32 kg/m2 and BP of 180/100 Planning Intervention After 3 days Continuous of nursing vital signs intervention, monitoring the patient will Administer able to: prescribed medications show signs Instruct of adequate improvem diet ent Weigh daily towards normal values in BMI and his blood pressure Rationale -To take note of changes in BP -To help control the manifestations -To avoid complications -To monitor signs of improvement Evaluation After 3 days of nursing intervention, the patient was able to improve his BMI and BP.

Assessment Subjective Ang sakit ng tahi ko as verbalized by the patient. Objective Patient points his finger to his wound with face grimaced.

Diagnosis Acute pain r/t physical injury

Planning After 8 hours of nursing intervention, the patient will be able to: Relieve the pain Improve his mobility

Intervention Administer pain medications Instruct the patient to do passive range of motion Advise the patient to clean his wound everyday

Rationale -To promote comfort and relieve pain -To improve his mobility -To avoid inflammation and itching

Evaluation After 8 hours of nursing intervention, the patient was able to relieve his pain and showed improvement in his mobility

Assessment Objective Poor skin integrity; Redness of the surrounding skin

Diagnosis Impaired tissue integrity r/t gunshot wound

Planning After 3 days of nursing intervention, the patient will be able to: Minimize redness Improve skin integrity

Intervention Advise the client to clean wound everyday as told by the doctor Administer topical ointment if prescribed

Rationale -To improve the integrity of the skin and avoid itching

Evaluation After 3 days of nursing intervention, the patient was able to minimize the redness of his -To minimize skin and redness of the improved his skin skin integrity.

Assessment Objective

Diagnosis Risk for infection r/t Redness of the tissue skin; Poor skin destruction integrity

Planning After 4 hours of nursing intervention, the patient was able to: Minimize risk for infection

Intervention Administer medications as prescribed Tell the patient to avoid covering wound with bandage Instruct the client to clean the wound everyday

Rationale -To provide defenses against infection -To promote wound healing and avoid further infection -To promote skin integrity

Evaluation After 4 hours of nursing intervention, the patient was able to minimize his risk for infection

Assessment Objective Pale; wounded

Diagnosis Risk for deficit fluid volume r/t excessive loss through normal routes

Planning After 2 hours of nursing intervention, the patient will be able to: promote adequate fluid intake

Intervention Instruct the client to increase fluid intake as tolerated. Administer IV fluids as prescribed by the doctor

Rationale -To replace fluids lost -For fluid and electrolyte imbalance

Evaluation After 2 hours of nursing intervention, the patient was able to promote adequate fluid intake