Download CASE PRESENTATION - Dr. Ahmad Abanamy Hospital

PREPARED BY:
SANDHYA KS











NAME: AH
AGE: 25 yrs old
SEX: Male
MR NO.: 189691
NATIONALITY: Bangladeshi
DIAGNOSIS: Small bowel perforation with peritonitis
CHIEF COMPLAINTS: complaint of severe abdominal
pain with vomiting
NAME OF SURGERY: Exploratory laparotomy and
small bowel resection with Anastomosis
DATE OF ADMISSION: 10/01/13
DATE OF SURGERY: 11/01/2013
DATE OF DISCHARGE: 18/01/2013
Patient is intubated.
 Looks weak and fatigue.
 Unable to mobilize.
 Upper teeth fracture.
 Two drainage tubes from both
sides of abdomen.

Skin is warm.
 Post operative scar present on
abdomen.
 Noted abrasion on upper and
lower extremities.
 Post operative scar on right leg.









Hair is equally distributed.
Absence of dandruff.
Abrasions on face.
Patient’s pinna is same colour as
fascial skin aligned with eye level.
Lips are pink but swollen.
Upper teeth fracture seen.
No lymph node enlargement.
CVP line present.






Old RTA with chest trauma
Airway Adequate
Heart sound : s1 and s2 normal
Upon auscultation his BP is
120/80mmHg
Pulse rate-66/mts
Lungs – bilateral vescicular sound
present.
 Thorax
is sympathetic on
inspection
With Foleys catheter
FG.16present
 Patient
is old RTA with
abdominal trauma tenderness
present.
 Two drainage tubes present
from both sides of abdomen.






Unable to mobilize his right lower limb
Has pain during examination
Cannot perform ADL
Tenderness at the site of fracture
Visible deformity
Lower extremities appears shortened
 Patient
is on ventilator
under sedation
 Old RTA with spine
fracture
 GCS 15/15
PAST MEDICAL HISTORY
Patient is old RTA with polytrauma
 Poor lung condition
 Fracture tibia and thoracic spine
 ORIF tibia done two months ago
 Patient
is presented with post
exploratory laparotomy with
small bowel resection with
anastomosis.

 He
undergone exploratory
laparotomy and small bowel
resection with anastomiosis
done under general anesthesia
on 11/01/13
He undergone ORIF tibia
done under general
anesthesia on 01/11/12.
 BP-
120/86mmhg
 PR- 66 bpm
 Temperature- 36.4C
 SPO2- 98%
Name of the
medicine
Dose
Route and
frequency
action
Inj. promosan
10mg
Iv/bid
Antiemetic and
gastroprokinetic agent
Inj risek
40mg
Iv/od
H2 receptor antagonist
Inj. ciproxin
200mg
Iv/bid
Antibiotic
Inj. flagil
500mg
Iv/tid
Antibiotic
Inj.tienan
500mg
Iv/bid
Antibiotic
Inj.vancomycin
1gm
Iv/bid
Antibiotic
Inj.tramadol
50mg
Im/tid
Analgesic
Inj.clexane
40mg
s/c,od
Anticoagulant
Investigations
Patient’s Values
Normal Values
PH
7.417
7.35-7.45
RBS
130
110-140
PCO2
38.7 mmHg
35-45 mmHg
Na
134.8 mmol/L
135 to 145 mEq/L
K
3.68 mmol/L
3.5-5.0mmol/l
Total Bilirubin
31.9
1.1-17.1 µmol/L
Direct Bilirubin
12.9
0.04-60 µmol
SGOT
16.6
10-38 µ/L
SGPT
17.8
10-41 µ/L
Alkaline Phosphate
95.6
35-129 µ/L
Protein
46.2
66-87 g/L
Albumin
25.4
34.0-48.0
Hb
11.6 gm/dl
13.7-17.5g/dl
WBC
20.27
4.23-9.07
PLT
328
163-337/ul



small intestine (or small bowel) is the part of the
gastrointestinal tract following the stomach and
followed by the large intestine, and is where much
of the digestion and absorption of food takes place.
A bowel resection is a surgical procedure in which
a part of the large or small intestine is removed.
It may be performed due to cancer, necrosis,
enteritis, diverticular disease, or a block in the
intestine due to scar tissue. Other reasons to
perform bowel resection include ulcerative colitis,
traumatic injuries, precancerous polyps, and
familial polyposis.

Peritonitis is an inflammation of
the peritoneum, the thin tissue that
lines the inner wall of the abdomen
and covers most of the abdominal
organs. Peritonitis may be localized
or generalized, and may result
from infection or from a noninfectious process.

The main manifestations of peritonitis are
acute abdominal pain, abdominal tenderness,
and abdominal guarding, which are exacerbated by
moving the peritoneum, e.g., coughing (forced cough
may be used as a test), flexing one's hips, or eliciting
the Blumberg sign place). The presence of these signs in
a patient is sometimes referred to as peritonism. The
localization of these manifestations depends on whether
peritonitis is localized
(e.g., appendicitis or diverticulitis before perforation), or
generalized to the whole abdomen. In either case, pain
typically starts as a generalized abdominal pain (with
involvement of poorly localizing innervations of the
visceral peritoneal), and may become localized later
(with the involvement of the somatically innervated
parietal peritoneal layer). Peritonitis is an example of
an acute abdomen.
COLLATERAL MNIFESTATIONS



Diffuse abdominal rigidity ("washboard
abdomen") is often present, especially in
generalized peritonitis
Sinus tachycardia
Development of ileus paralyticusi.e.,
intestinal paralysis), which also
causes nausea, vomiting and bloating
INFECTED PERITONITIS

Perforation of part of the gastrointestinal
tract is the most common cause of peritonitis.
Examples include perforation of the
distal esophagus (Boerhaave syndrome), of
the stomach (peptic ulcer, gastric carcinoma), of
the duodenum (peptic ulcer), of the
remaining intestine (e.g., appendicitis, diverticul
itis, Meckl diverticulum, inflammatory bowel
disease (IBD), intestinal infarction, intestinal
strangulation, colorectal carcinoma, meconium
peritonitis), or of the gallbladder (cholecystitis

Other possible reasons for perforation
include abdominal trauma, ingestion of a
sharp foreign body (such as a fish bone, toothpick
or glass shard), perforation by an endoscope
or catheter, and anastomotic leakage. The latter
occurrence is particularly difficult to diagnose
early, as abdominal pain and ileus paralyticus are
considered normal in patients who have just
undergone abdominal surgery. In most cases of
perforation of a hollow viscous, mixed bacteria are
isolated; the most common agents include Gramnegative bacilli (e.g., Escherichia coli) and anaerobic
bacteria (e.g., Bacteroides fragilis). Fecal peritonitis
results from the presence of feces in the peritoneal
cavity. It can result from abdominal trauma and
occurs if the large bowel is perforated during
surgery.

Disruption of the peritoneum, even in the
absence of perforation of a hollow viscus, may also
cause infection simply by letting microorganisms into the peritoneal cavity. Examples
include trauma, surgical wound, continuous
ambulatory peritoneal dialysis, and intraperitoneal chemotherapy are possible,
including fungi such as Candida.

Spontaneous bacterial peritonitis (SBP)
is a peculiar form of peritonitis occurring in the
absence of an obvious source of contamination. It
occurs in patients with ascites, in particular,
in children. See the article on spontaneous bacterial
peritonitis for more information.
Intra-peritoneal dialysis predisposes
to peritoneal infection (sometimes
named "primary peritonitis" in this
context).
Systemic infections (such
as tuberculosis) may rarely have a
peritoneal localization.
Non-infected peritonitis
Leakage of sterile body fluids into the peritoneum, such
as blood (e.g., endometriosis, blunt abdominal trauma), gastric
juice (e.g., peptic ulcer, gastric carcinoma),bile (e.g., liver
biopsy), urine (pelvic trauma), menstruum (e.g., salpingitis), pancreati
c juice (pancreatitis), or even the contents of a ruptured dermoid cyst.
It is important to note that, while these body fluids are sterile at first,
they frequently become infected once they leak out of their organ,
leading to infectious peritonitis within 24 to 48 hours.
Sterile abdominal surgery, under normal circumstances, causes
localized or minimal generalized peritonitis, which may leave behind
a foreign body reaction and/or fibrotic adhesions. However,
peritonitis may also be caused by the rare case of a sterile foreign
body inadvertently left in
the abdomen after surgery (e.g., gauze, sponge).
Much rarer non-infectious causes may include familial Mediterranean
fever, TNF receptor associated periodic syndrome, porphyria,
and systemic lupus erythematosus.

A diagnosis of peritonitis is based primarily on the clinical
manifestations described above. If peritonitis is strongly suspected,
then surgery is performed without further delay for other
investigations. Leukocytosis, hypokalemia, hypernatremia,
and acidosis may be present, but they are not specific findings.
Abdominal X-rays may reveal dilated, edematous intestines,
although such X-rays are mainly useful to look for pneumo
peritoneum, an indicator of gastrointestinal perforation. The role of
whole-abdomen ultrasound examination is under study and is likely
to expand in the future. Computed tomography (CT or CAT
scanning) may be useful in differentiating causes of abdominal pain.
If reasonable doubt still persists, an exploratory peritoneal
lavage or laparoscopy may be performed. In patients with ascites, a
diagnosis of peritonitis is made via paracentesis(abdominal tap):
More than 250 polymorphonuclet cells per μL is considered
diagnostic. In addition, Gram stain and culture of the peritoneal
fluid can determine the microorganism responsible and determine
their sensibility to antimicrobial agents.

In normal conditions, the peritoneum appears
greyish and glistening; it becomes dull 2–4
hours after the onset of peritonitis, initially
with scarce serous or slightly turbid fluid. Later
on, the exudate becomes creamy and
evidently suppurative; in dehydrated patients,
it also becomes very inspissated. The quantity
of accumulated exudates varies widely. It may
be spread to the whole peritoneum, or be
walled off by
the omentum and viscera. Inflammation featur
es infiltration by neutrophils with fibrinopurulent exudation.
Depending on the severity of the
patient's state, the management
of peritonitis may include:
 General supportive measures
such as
vigorous intravenous rehydratio
n and correction of electrolyte

disturbances.
Antibiotics are usually
administered intravenously, but they may
also be infused directly into the
peritoneum. The empiric choice of broadspectrum antibiotics often consist of
multiple drugs, and should be targeted
against the most likely agents, depending
on the cause of peritonitis (see above); once
one or more agents are actually isolated,
therapy will of course be targeted on them.


Gram positive and gram negative organisms must be
covered. Out of
the Cephalosporin, cefoxitin and cefotecan can be used to
cover gram positives, gram negatives, and anaerobes. Betalactams with beta lactamase inhibitors can also be used,
examples
include ampicillin/sulbactam, piperacillin/tazobactam,
and ticarcillin/clavulanate.[2]Carbapenems are also an
option when treating primary peritonitis as all of the
carbapenems cover gram positives, gram negatives, and
anaerobes except for ertapenem. The only fluoroquinolone
that can be used is moxifloxacin because this is the only
fluoroquinolone that covers anaerobes. Finally, tigecycline is
a tetracycline that can be used due to its coverage of gram
positives and gram negatives. Empiric therapy will often
require multiple drugs from different classes

(laparotomy) is needed to perform a full
exploration and lavage of
the peritoneum, as well as to correct any
gross anatomical damage that may have
caused peritonitis.[3] The exception
is spontaneous bacterial peritonitis,
which does not always benefit
from surgery and may be treated with
antibiotics in the first instance.

If properly treated, typical cases of
surgically correctable peritonitis (e.g.,
perforated peptic ulcer, appendicitis,
and diverticulitis) have a mortality
rate of about <10% in
otherwise healthy patients, which rises to
about 40% in the elderly, and/or in those
with significant underlying illness as
well as in cases that present late (after 48
hours). If untreated, generalized
peritonitis is almost always fatal.



Sequestration of fluid and electrolytes, as
revealed by decreased central venous
pressure, may cause electrolyte
disturbances, as well as
significant hypovolemia, possibly leading
to shock and acute renal failure.
A peritoneal abscess may form (e.g., above
or below the liver, or in the lesser omentum
Sepsi may develop, so blood
cultures should be obtained.

Gastrointestinal perforation is a complete
penetration of the wall of the stomach, small
intestine or large bowel, resulting in intestinal
contents flowing into the abdominal cavity.
Perforation of the intestines results in the
potential for bacterial contamination of
the abdominal cavity (a condition known
as peritonitis). Perforation of the stomach can
lead to a chemical peritonitis due to
leaked gastric acid. Perforation anywhere along
the gastrointestinal tract is a surgical
emergency.






Sudden attack of pain in epigastrium to
the right of midline
burning pain in
epigastria, flatulence and dyspepsia
rigidity of abdomen
tenderness, and rebound tenderness
nausea and vomiting
fever and or chills.









gastric ulcer
appendicitis
gastrointestinal cancer
diverticulitis
superior mesenteric artery syndrome
trauma, ascariasis
Typhoid fever
non-steroidal anti-inflammatory drugs
ingestion of corrosives
x-rays (free gas/air may be
visible in the abdominal cavity)
 computed tomography
 White blood cells are often
 ridged abdomen on palpation



exploratory laparotomy and closure
of perforation
If patient is in case nontoxic and
clinically stable, they can be treated
with intravenous fluids, antibiotics,
nasogastric aspiration
and bowel rest
Definition
 A laparotomy is a large incision
made into the abdomen.
Exploratory laparotomy is used
to visualize and examine the
structures inside of the
abdominal cavity.


Exploratory laparotomy is a method of abdominal
exploration, a diagnostic tool that allows
physicians to examine the abdominal organs. The
procedure may be recommended for a patient who
has abdominal pain of unknown origin or who has
sustained an injury to the abdomen. Injuries may
occur as a result of blunt trauma (e.g., road traffic
accident) or penetrating trauma (e.g., stab or
gunshot wound). Because of the nature of the
abdominal organs, there is a high risk of infection
if organs rupture or are perforated. In addition,
bleeding into the abdominal cavity is considered a
medical emergency. Exploratory laparotomy is
used to determine the source of pain or the extent
of injury and perform repairs if needed.

Laparotomy may be performed to determine the
cause of a patient's symptoms or to establish the
extent of a disease. For example, endometriosis is a
disorder in which cells from the inner lining of the
uterus grow elsewhere in the body, most
commonly on the pelvic and abdominal
organs. Endometrial growths, however, are
difficult to visualize using standard imaging
techniques such as x ray, ultrasound technology, or
computed tomography (CT) scanning. Exploratory
laparotomy may be used to examine the
abdominal and pelvic organs (such as the ovaries,
fallopian tubes, bladder, and rectum) for evidence
of endometriosis. Any growths found may then be
removed.












Exploratory laparotomy plays an important role in the
staging of certain cancers. Some other conditions that may
be discovered or investigated during exploratory
laparotomy include:
cancer of the abdominal organs
peritonitis (inflammation of the peritoneum, the lining of the
abdominal cavity)
appendicitis (inflammation of the appendix)
pancreatitis (inflammation of the pancreas)
abscesses (a localized area of infection)
adhesions (bands of scar tissue that form after trauma or
surgery)
diverticulitis (inflammation of sac-like structures in the
walls of the intestines)
intestinal perforation
ectopic pregnancy (pregnancy occurring outside of the
uterus)
foreign bodies (e.g., a bullet in a gunshot victims
Internal bleeding.

Once an adequate level of anesthesia has been reached, the
initial incision into the skin may be made. A scalpel is first
used to cut into the superficial layers of the skin. The incision
may be median (vertical down the patient's midline),
paramedian (vertical elsewhere on the abdomen), transverse
(horizontal), T-shaped, or curved, according to the needs of the
surgery. The incision is then continued through the
subcutaneous fat, the abdominal muscles, and finally, the
peritoneum. Electrocautery is often used to cut through the
subcutaneous tissue as it During a laparotomy, and an incision
is made into the patient's abdomen (A). Skin and connective
tissue called fascia is divided (B). The lining of the abdominal
cavity, the peritoneum, is cut, and any exploratory procedures
are undertaken (C). To close the incision, the peritoneum,
fascia, and skin are stitched (E) has the ability to stop bleeding
as it cuts. Instruments called retractors may be used to hold the
incision open once the abdominal cavity has been exposed.

The surgeon may then explore the abdominal
cavity for disease or trauma. The abdominal
organs in question will be examined for evidence
of infection, inflammation, perforation, abnormal
growths, or other conditions. Any fluid
surrounding the abdominal organs will be
inspected; the presence of blood, bile, or other
fluids may indicate specific diseases or injuries. In
some cases, an abnormal smell encountered upon
entering the abdominal cavity may be evidence of
infection or a perforated gastrointestinal organ


If an abnormality is found, the surgeon has the
option of treating the patient before closing the
wound or initiating treatment after exploratory
surgery. Alternatively, samples of various tissues
and/or fluids may be removed for further analysis.
For example, if cancer is suspected, biopsies may
be obtained so that the tissues can be examined
microscopically for evidence of abnormal cells. If
no abnormality is found, or if immediate treatment
is not needed, the incision may be closed without
performing any further surgical procedures.
During exploratory laparotomy for cancer, a pelvic
washing may be performed; sterile fluid is instilled
into the abdominal cavity and washed around the
abdominal organs, then withdrawn and analyzed
for the presence of abnormal cells. This may
indicate that a cancer has begun to spread.

Upon completion of any exploration
or procedures, the organs and
related structures are returned to
their normal anatomical position.
The incision may then be sutured
(stitched closed). The layers of the
abdominal wall are sutured in
reverse order, and the skin incision
closed with sutures or staples.


Various diagnostic tests may be performed to
determine if exploratory laparotomy is necessary.
Blood tests or imaging techniques such as x ray,
CT scan, and MRI are examples. The presence of
intra peritoneal fluid (IF) may be an indication that
exploratory laparotomy is necessary; one study
indicated that IF was present in nearly threequarters of patients with intra-abdominal injuries.
Directly preceding the surgical procedure, an IV
line will be placed so that fluids and/or
medications may be administered to the patient
during and after surgery. A Foley catheter will be
inserted into the bladder to drain urine. The
patient will also meet with the anesthesiologist to
go over details of the method of anesthesia to be
used.

The patient will remain in the
postoperative recovery roomfor several hours
where his or her recovery can be closely
monitored. Discharge from the hospital may
occur in as little as one to two days after the
procedure, but may be later if additional
procedures were performed or complications
were encountered. The patient will be
instructed to watch for symptoms that may
indicate infection, such as fever, redness or
swelling around the incision, drainage, and
worsening pain.

Risks inherent to the use of general anesthesia
include nausea, vomiting, sore throat, fatigue,
headache, and muscle soreness; more rarely,
blood pressure problems, allergic reaction,
heart attack, or stroke may occur. Additional
risks include bleeding, infection, injury to the
abdominal organs or structures, or formation of
adhesions (bands of scar tissue between
organs).


A small bowel resection is the surgical
removal of one or more segments of the
small intestine.
Purpose The small intestine is the part of
the digestive system that absorbs much
of the liquid and nutrients from food. It
consists of three segments:
the duodenum, jejunum, and ileum; and
is followed by the large intestine (colon).
This condition involves a partial or complete
blockage of the bowel that results in the failure of
the intestinal contents to pass through. Intestinal
obstruction is usually treated by decompressing
the intestine with suction, using a nasogastric tube
inserted into the stomach or intestine. In cases
where decompression does not relieve the
symptoms, or if tissue death is suspected, bowel
resection may be considered.


Injuries. Accidents may result in bowel
injuries that require resection.
Precancerous polyps. A polyp is a
growth that projects from the lining of
the intestine. Polyps are usually benign
and produce no symptoms, but they may
cause rectal bleeding and develop into
malignancies over time. When polyps
have a high chance of becoming
cancerous, bowel resection is usually
indicated




The resection procedure can be performed
using an open surgical approach or
laparoscopically. There are three types of
surgical small bowel resection procedures:
Duodenectomy. Excision of all or part of the
duodenum.
Ileectomy. Excision of all or part of the ileum.
Jejunectomy. Excision of all or a part of the
jejunum.

Following adequate bowel preparation, the
patient is placed under general anesthesia and
positioned for the operation. The surgeon starts
the procedure by making a midline incision in
the abdomen. The diseased part of the small
intestine (ileum or duodenum or jejunum) is
removed. The two healthy ends are either
stapled or sewn back together, and the incision
is closed. If it is necessary to spare the intestine
from its normal digestive work while it heals, a
temporary opening (stoma) of the intestine into
the abdomen ( ileostomy , duodenostomy, or
jejunostomy) is made. The ostomy is later
closed and repaired.

and help prevent postoperative infection. A nasogastric tAs with any
surgery, the patient is required to sign a consent form. Details of the
procedure are discussed with the patient, including goals, technique, and
risks. Blood and urine tests, along with various imaging tests and an
electrocardiogram (EKG), may be ordered as required. To prepare for the
procedure, the patient is asked to completely clean the bowel and is
placed on a low residue diet for several days prior to surgery. A liquid
diet may be ordered for at least the day before surgery, with nothing
taken by mouth after midnight. Preoperative bowel preparation involving
mechanical cleansing and administration of antibiotics before surgery is
the standard practice. This involves the prescription of oral antibiotics
(neomycin, erythromycin, or kanamycin sulfate) to decrease bacteria in
the intestine ubeis inserted through the nose into the stomach on the day
of surgery or during surgery. This removes the gastric secretions and
prevents nausea and vomiting. A urinary catheter (thin tube inserted into
the bladder) may also be inserted to keep the bladder empty during
surgery, giving more space in the surgical field and decreasing chances of
accidental injury

Once the surgery is completed, the patient is taken to a
postoperative or recovery unit where a nurse monitors recovery
and ensures that bandages are kept clean and dry. Mild pain at the
incision site is commonly experienced and the treating physician
usually prescribes pain medication. Postoperative care also
involves monitoring of blood pressure, pulse, respiration, and
temperature. Breathing tends to be shallow because of the effect of
anesthesia and the patient's reluctance to breathe deeply and
experience pain that is caused by the abdominal incision. The
patient is given instruction on the way to support the operative
site during deep breathing and coughing. Fluid intake and output
is measured, and the operative site is observed for color and
amount of wound drainage. The nasogastric tube remains in
place, attached to low intermittent suction until bowel activity
resumes. Fluids and electrolytes are infused intravenously until
the patient's diet can gradually be resumed, beginning with
liquids and progressing to a regular diet as tolerated. The patient
is generally out of bed approximately eight to 24 hours after
surgery. Patients are usually scheduled for a follow-up
examination within two weeks after surgery. During the first few
days after surgery, physical activity is restricted.




Risks include all the risks associated with
general anesthesia, namely, adverse reactions
to medications and breathing problems. They
also include the risks associated with any
surgery, such as bleeding or infection.
Additional risks associated specifically with
bowel resection include:
bulging through the incision (incisional hernia)
narrowing (stricture) of the opening (stoma)
blockage (obstruction) of the intestine from scar
tissue.






Acute pain related to surgical incision.
Imbalanced Nutrition less than body
requirement related to dietary modifications
after surgery.
Constipation related to surgery secondary to
decreased mobilization.
Impaired skin integrity related to surgical
incision.
Deficient fluid volume related to surgical
procedure
Risk for infection related to surgical incision.
Subjective:
“ Im shivering
and I feel weak”
as verbalized by
patient.
Objective:

Fever
T- 38⁰C

chills
Assessment:

leakage
from the
Cues/Evidence
wound of
dressing

increased
pulse rate
PR- 98bpm

pain on the
surgical site

abdominal
distention
High risk for
infection
related to
large surgical
incision.
Nursing
Diagnosis
Patient shows no
evidence of
infection as
manifested by:

Stable vital
signs

Afebrile

Patient is
stable and
oriented

No leakage
Planning:
from the
wound
Goals and
desired
dressing
outcome
after 24 hours

No abdominal
distention

Minimized the
movement of
the patient

Done dressing
daily with
aseptic
technique and
check the
dressing site
for oozing

Suction done
Implementation
to clear
secretions
and
Nursing
order/action
promote good
ventilation

Antibiotic
therapy given
like
Metronidazole
500mg IV tid,
Ciproxin
200mg IV bid

Administered
analgesics like
Tramadol
50mg IM tid



Immobilization
reduces the risk
of getting
infection
Will reduce the
risk of
infection
To encourage
adequate gas
exchange

To encourage
Rationale
for action
adequate gas
exchange
 It will reduce
the chance of
getting the
infection
 To manage the
post op pain
After 12 hrs of
nursing
interventions
the goals were
met as
evidenced by:

Normal
health
person

No signs
Evaluation
of
infection
Evaluation

Stable
vital
signs

No
oozing
from the
surgery
site

Active
signs of
wound
healing

Normal
ROM
Assessment:
Planning:
Implementation
Evaluation
Cues/Evidence
Nursing
Diagnosis
Goals and desired
outcome
Nursing
order/action
Rationale for action
Evaluation
Subjective:
Impaired
physical
mobility,
acute pain
secondary
to
exploratory
and
laparotomy
and bowel
resection
with
anastamosi
s.
Patient will be
able to perform
his physical
activity and free
of complications
as evidenced by:

Participates
in activites of
daily living

Performs
physical
activities
independentl
y

Intact skin
and absence
of
complication
s

Normal
bowel
pattern
1.
1.
To maintain position
and function and
reduce the risk of
pressure ulcers.
To identify
contributing factors
of immobility

To assess the
presence of
complications.
Promote well being
and maximized
energy usage.
Increases blood flow
to muscles to
improve muscle tone
and maintain joint
mobility.
After 12 hrs of
nursing
intervention,
the goals were
met as
evidenced by:

Patient
performs
physical
activities
independe
ntly or
with
assisting
devices as
needed.

Free of
complicati
ons of
immobilit
y as
normal
bowel
pattern.
“I cannot move
properly and
I’m having
pain during
motion” as
verbalized by
patient.
Objective:

Limited
range of
motion

Inability
to perform
action as
instructed
2.
3.
4.
Assisted
patient for
early
ambulation.
Encouraged
adequate
intake of
fluids.
Instructed or
assisted patient
with active and
passive ROM
exercises of
affected and
unaffected
limbs.
Determined
presence of
complications
related to
immobility
such as
pneumonia,
elimination
problem,
decubitus









Review signs and symptoms of wound infection so early
intervention may be instituted.
Explain signs and symptoms of other post operations
complications to report – elevated temperature , nausea, vomiting,
abdominal distention changes in bowel function and stool
consistency and color.
Instruct the patient to report promptly blood in the stool or the
coughing up of blood.
Encourage the patient to turn , cough, deep breathe use of
incentive spirometer and ambulation . discuss the importance of
these functions during the recovery period.
Review dietary changes such as increased fiber content and fluid
intake and their importance in improving bowel function.
Review actions and adverse effects of prescribed medications to
encourage compliance and understanding of management.
Assess the need for home health follow up , and initiate
appropriate referrals if indicated.







A case of post RTA polytrauma patient with
peritonitis with bowel perforation and was with
severe abdominal pain and vomiting.
Initially seen by general surgeon.
Surgical treatment exploratory laparotomy with
bowel resection and anastomosis done.
Patient is able to move.
Health education given on home care.
Patient was discharged.
Patient was told to come for follow-up after 2
weeks.
 Lippincott
manual of
Nursing Practice 9th edition
 www.localhealth.com
 www.healthtype.com
 www.drugs.com
Thank you!!
