Mariano Marcos State University

College of Health Sciences

Department of Nursing
Batac, Ilocos Norte

CASE ANALYSIS

Submitted by:
Zara Krizcia A. Ruiz
BSN III-A

December 16, 2010

 I. PERSONAL DATA

NAME: Milagros Ocumin Tumboc

ADDRESS: Magdalena, Claveria, Cagayan

BIRTHDATE: January 16, 1944

AGE: 66 years old

SEX: Female

CIVIL STATUS: Married

RELIGION: Roman Catholic

DATE OF ADMISSION: December 2, 2010

TIME OF ADMISSION: 3:15 PM

ADMITTING PHYSICIAN: Ma. Verena R. Remuduro,M.D/ Kristal Mendoza,M.D

ADMITTING DIAGNOSIS: Jaundice Probably 2 To Viral Hepatitis Vs Cholelithiasis

 II. HEALTH HISTORY

A. Past Health History

Mrs. Tumboc stated that she had experienced childhood illnesses like cough, colds, fever,
mumps, and chickenpox. For cough and colds, they managed it by drinking the extract of boiled
lagundi and dangla extract and OTC drugs for fever. For mumps, they used “akut-akot” which
is mixed with vinegar then applied into the affected area and according to her they found it to be
effective. In managing chickenpox, they let her eat egg to bring out all the rashes for faster
healing.

According to Mrs. Tumboc, she had received such vaccinations but wasn’t able to
remember how many and what are those vaccines and BCG scar was noted on her left
deltoid.She also claimed that she beleived in quack doctors but did not try yet to consult one. As
claimed, she has no any allergies and doesn’t experience any serious injuries except for minor
abrasions and she managed by washing it with soap.

B. Present Health History

Two weeks prior to admission, Mrs. Tomboc suffered from on and off fever, and claimed that she
just managed it by taking the OTC drug such as Paracetamol. She claimed that through these drugs, this
makes her feel well sometimes but she also said that it was not that effective because after sometime her
fever returns. One week prior to admission, Mrs. Tomboc felt dizziness and abdominal pain at her right
upper quadrant. Her husband accompanied her to consult a doctor in Cagayan who is Dr. Michael Azania.
According to Mrs. Tomboc, Dr. Azania diagnosed her to be positive in Hepatitis- B. Dr. Azania
prescribed some medications to Mrs. Tomboc but failed to enumerate those drugs. According to Mrs.
Tomboc, Dr. Azania recommended her to go to MMMH & MC for better supervision and greater
facilities to look on her Hepa-B. Mr. and Mrs. Tomboc then decided to go to the said hospital. Last
December 2, 2010 at 3:15 PM, Ma. Verena R. Remuduro,M.D/ Kristal Mendoza,M.D admitted her
with an admitting diagnosis of Jaundice Probably secondary to Viral Hepatitis Vs Cholelithiasis.
 III. DIAGNOSTIC PROCEDURES

1. Abdominal Ultrasound / Abdominal UTZ

Ultrasound imaging, also called ultrasound scanning or sonography, involves
exposing part of the body to high-frequency sound waves to produce pictures of the
inside of the body. Ultrasound exams do not use ionizing radiation (as used in x-rays).
Because ultrasound images are captured in real-time, they can show the structure and
movement of the body's internal organs, as well as blood flowing through blood vessels.
Ultrasound imaging is a noninvasive medical test that helps physicians diagnose
and treat medical conditions.
An abdominal ultrasound is an imaging procedure used to examine the internal
organs of the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys.
The blood vessels that lead to some of these organs can also be looked at with ultrasound.

Purpose:

Abdominal ultrasound was done to the patient to visualize the internal organs of the
abdomen including the liver, spleen, pancreas, kidneys and gallbladder (to look for gallstones).

Requesting Physician: Kristal Mendoza, M.D

Date Requested: December 2, 2010
Date Performed: December 3, 2010

Result:
 The liver is not enlarged with homogenous echopattern. However, the right and
left intrahepatic bile ducts are dilated but no intraluminal echoes visible.
 No parenchymal mass seen
 The gallbladder is also dilated measuring 10.8 x 4.0 x 4.0 cm. Its wall is not
thickened. No intraluminal echoes detected.
 The CBD is also dilated, the AP diameter adjacent to the pancreatic head
measures 2.86 cm. No intraluminal lithiasis observed.
 A cystic structure is also seen at the porta hepatis which measures 5 x 2.4 cm.
Impression:
 Dilated intrahepatic bile ducts, gallbladder and CBD
 Cystic structure at the porta hepatis
 Suspect choledochal cyst
Analysis:
The intrahepatic bile ducts, gallbladder and CBD are dilated because of the presence of
stone in the common bile duct. The cystic structure at the porta hepatis maybe also because in
the obstruction in the CBD.

NURSING RESPONSIBILITIES RATIONALE

Before the procedure
Inform and explain to the patient and
significant others about the procedure,
To alleviate anxiety and gain cooperation.
including where it will take place and its
expected duration.
Verify the doctor’s order and check if the
To notify the one who will perform the
laboratory form is properly filled up or not
procedure.
and send it to the laboratory.
Instruct client to have light meal few hours
For better visualization.
before the procedure.
During the procedure
Inform client that during the procedure,
To lessen anxiety to the part of the client.
they will apply a gel on his abdomen.
After the procedure
Refer to the physician the Abdominal So that the physician will be able to
Ultrasonography result once available and determine the appropriate management to
then attach it to the client’s chart. be applied to the patient.

2. ELECTROCARDIOGRAPHY / ECG
The ECG is a diagnostic tool used in assessing the cardiovascular system. It is a
graphic recording of the electrical activity of the heart. An ECG can be recorded with 12,
15, or 18 leads, showing the activity for those reference points. It is obtained by placing
disposable electrodes in standard positions on the skin of the chest wall and extremities.
The heart’s electrical impulses are recorded as a tracing on special graph paper.
Purpose:
Electrocardiography was done to the patient to determine if there are any abnormalities in
the electrical impulses in his heart that may be associated to her disease.

Requesting Physician: Dr. Urbano

Date Requested: December 2, 2010
Date Performed: December 2, 2010

Result:
Measurement
Duration: PR 0.16 sec
QRS 0.08 sec
QTa 0.40 sec
QTc
Rates Atrial 68 /min
Ventricular 68 /min
Axis Normal
Rhythm Regular Sinus Rhythm

Impression:
 Normal Axis

Analysis:
The result was found to be normal.

NURSING RESPONSIBILITIES RATIONALE

Before the procedure
Verify the doctor’s order and check if the To notify the ER/ECG nurse.
laboratory form is properly filled up or not and
give the properly filled-up form to the ER
nurse.
Inform and explain to the patient and
significant others about the procedure,
To alleviate anxiety and gain cooperation.
including where it will take place and its
expected duration.
Instruct client to have adequate rest and sleep To decrease workload of the heart not to alter
24 hours before the procedure. the result (for scheduled procedure).
Remove all jewelries from neck, arm and
For proper application of electrodes and to
wrists. Remove all clothing above the waist
avoid alteration in the result.
and keep forearms and lower legs exposed.
During the procedure
Position the client comfortably. Let them lie on
To prevent alteration on the result.
a bed.
Not to transfer microorganisms for metal
Metal electrodes that will be placed on the electrodes are reused to other clients and
client’s skin are cleaned with an alcohol swab. sometimes the transducer gel used is still
retained in the electrodes.
Shivering can create a great deal of artifact,
Make certain that the person is not chilled.
producing a poor ECG recording.
A transducer gel may be placed between the
electrodes and skin, but in many cases, To improve conduction of the electrical
disposable electrodes are used that do not impulses.
require paste or alcohol.
Several metal electrodes or “leads” are
To measure heart’s electrical activity from
attached to the skin on each arm and leg and on
different location on the chest.
the chest.
After the procedure
So that the physician will be able to determine
Refer to the physician the ECG result once
the appropriate management to be applied to
available and then attach it to the client’s chart.
the patient.

3. ABDOMINAL CT SCAN

CT stands for computed tomography. CT scanning combines special x-ray

equipment with sophisticated computers to produce multiple images or pictures of the
 inside of the body. These cross-sectional images of the area being studied can then be
examined on a computer monitor and be printed.

CT scans of internal organs, bones, soft tissue and blood vessels provide greater
clarity and reveal more details than regular x-ray exams.

Purpose:

An abdominal CT scan was done to the patient to determine any abnormalities in the
organs of the abdominal area that can be associated with her present condition.

Requesting Physician: Dr. Urbano

Date Requested: December 2, 2010
Date Performed: December 7, 2010

Result:
 Distended gall bladder. The wall are thickened, CBD is dilated which measures 2.0 cm
 Pancreatic head is deformed with blurring and loss of pancreatic margin noted
 Irregular gastric wall thickening and small bowel wall thickening noted
 Normally excreting kidneys. No mass nor lithiasis noted
 Calcified abdominal aorta
 Urinary bladder and pelvis side are unremarkable
Impression:

 Diffuse liver parenchymal disease

 Dilated intrahepatic ducts and CBD
 Consider Choledocholithiasis
 Pancreatitis
 Gastritis
 Atheromatous abdominal aorta

Analysis:
 The diffuse liver parenchymal disease may be due to Hepatitis B which was diagnosed to
the client. The intrahepatic ducts and CBD are dilated that also causes stone formation in the
CBD. There is also inflammation of her pancreas and lining of the stomach.

NURSING RESPONSIBILITIES RATIONALE

Before the procedure
Inform and explain to the patient and
significant others about the procedure,
To alleviate anxiety and gain cooperation.
including where it will take place and its
expected duration.
Verify the doctor’s order and check if the To notify the one who will perform the
laboratory form is properly filled up or not procedure.
and send it to the laboratory.
Remove all jewelries from neck, arm and
For proper application of electrodes and to
wrists. Remove all clothing above the waist
avoid alteration in the result.
and keep forearms and lower legs exposed.
Instruct client to maintain on NPO for
For better visualization.
several hours before the procedure.
Ask the client the medications she takes and
To prevent allergic reaction.
any allergies.
During the procedure
Inform client to lie flat on bed and hold still
For better visualization.
during the exam
After the procedure
Refer to the physician the Abdominal CT So that the physician will be able to
Scan result once available and then attach it determine the appropriate management to
to the client’s chart. be applied to the patient.

IV. DRUG STUDY

Generic name: Metronidazole

Brand Name: N/A
Dosage, Route & Frequency: 500mg IV every 8 hours
Date Ordered: 12-02-2010
Requesting Physician: Dr. Urbano
Classification: Anti-bacterial
Mechanism of Action: It binds to the DNA, resulting to the destruction or loss of the helical
structure, strand breakage, inhibition of the nucleic acid synthesis and cell death,
thus it inhibits the growth of bacteria.
Purpose: This drug was given to the patient to eliminate the signs and symptoms of infection and
decrease of bacterial microorganisms in the GI tract.

NURSING INTERVENTION RATIONALE

Ensure that the patient should be instructed in To enhance knowledge about drug therapy and
the appropriate dosage regimen promote compliance
Inform the client the action, use and the reason So that the client is aware of what she is
of receiving such drugs receiving and to gain cooperation during the
drug therapy.
Check the site of the IV fluid and its patency. For better infusion of the drug

Clamp IV tubing during the infusion of the It increases the concentration of the drug.
drug.
Clean the Y-port using cotton balls with To prevent the entrance of microorganisms.
alcohol.
Administer the drug slowly. To prevent tissue trauma thereby lessening
pain
Perform non-pharmacologic ways of relieving To divert the attention of the patient from pain.
pain by initiating diversional activities such as
cutaneous stimulation.
Instruct the patient that the drug may cause So that the patient will not be alarmed.
urine turn dark color.
Monitor intake & output, daily weight and Because the drug is high in Na content and to
observed for water retention assess the condition of the patient.

Generic Name: Phytomenadione

Brand Name: Vitamin K
Dosage,Route & Frequency: 1 amp IV every 8 hours
Date Ordered: 12-02-2010
Requesting Physician: Dr. Urbano
Classification: fat soluble vitamins
Mechanism of Action: This is essential for the synthesis of prothrombin by the liver and use for
coagulation disorders.
Purpose: This drug was given to our patient due to his diagnosed Jaundice and this will prevent
occurrence of bleeding tendencies.

NURSING INTERVENTION RATIONALE

Inform the patient on the purpose and action of To gain cooperation and relieve anxiety.
the drug
Check the site and patency of the IV fluid To ensure if the drug really gets into the veins.
before administering the drug.
Clean the Y-port using cotton balls with To prevent the entrance of microorganisms.
alcohol.
Instruct the patient to avoid injuries. To avoid further bleeding.
Monitor for the signs and symptoms for The drug rapidly metabolizes in the liver.
hepatotoxicity

Generic Name: Ceftazidime

Brand Name: Tazicef
Dosage,Route & Frequency: 1 gm IV every 8 hours
Date Ordered: 12-02-2010
Requesting Physician: Dr. Urbano
Classification: Bactericidal
Mechanism of Action: It inhibits cell wall synthesis promoting osmotic instability
Purpose: This drug was given to the patient to treat an intra abdominal infection that was related
to her condition.

NURSING INTERVENTION RATIONALE

Inform the patient on the purpose and action of To gain cooperation and relieve anxiety.
the drug
Check the site and patency of the IV fluid To ensure if the drug really gets into the veins.
before administering the drug.
Clean the Y-port using cotton balls with To prevent the entrance of microorganisms.
alcohol.
Administer the drug slowly. To prevent tissue trauma thereby lessening
pain
Instruct the patient to report discomfort at IV Adverse reactions may occur.
insertion site