case study achalasia with logo
TRANSCRIPT
Columban CollegeCollege of Nursing
Barretto, Olongapo City
In Partial Fulfillment of the Requirement
for the
CASE PRESENTATION
ACHALASIA
Submitted by: A1, A2
ALMONTE, ROSE ANN G. BATOON, DESIREE MAE P.
ANGOB, FREILYN M. BUENO, DEAN MIGUEL D.
AÑONUEVO, MARY RUTH T. CADAHING, REEDEN W.
ARBOLENTE, CHRISTINE JOYCE V. CANONIZADO, CRISLIE M.
AREVALO, JEFFERSON P. CONCHA, KRISTINA MAE G.
Submitted to:
Ms. Gelynne Perea, RN
Columban CollegeCollege of Nursing
Barretto, Olongapo City
I. INTRODUCTION
Columban CollegeCollege of Nursing
Barretto, Olongapo City
II. CLIENT’S PROFILE/ HISTORY/ DATA:
Name: Mr. M
Age: 22 y/o
Birth Day: August 8, 1987
Nationality: Filipino
Status: Married
Date of Admission: Dec. 1, 2009
History of Present Illness:
1 year prior to admission – patient had difficulty in swallowing solid and
liquid foods, associated with loss of appetite and weight loss.
1 month prior to admission – patient had still difficulty in swallowing.
Consult done with private endoscopy done and revealed achalasia. Patient
was referred to surgery for evaluation and management.
2 weeks prior to admission – consult done at Out Patient Department
surgery where he was advised surgical intervention, and laboratory was
up due. Due to patient condition patient opted to have the operation
hence, the admission.
History of Past Illness:
Patient has frequent tonsillitis almost every month when he was 5 until he
reach 18 years old.
Past Medical History:
No previous operation.
No known allergy to any food and drugs.
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Family History:
Denies any heredofamilial diseases
Personal/ Social History:
Tricycle driver
Smoker (20 sticks/day)
Alcohol beverage drinker
Chief Complaint:
The patient’s chief complaint is difficulty in swallowing.
Columban CollegeCollege of Nursing
Barretto, Olongapo City
III. HEAD TO TOE - SYSTEM ASSESSMENT
PRE-SURGERY assessment:
Dec. 7, 2009
*no duty
Dec. 8, 2009
VITAL SIGNS
BP:110/ 80 PR: 74
RR: 16 T: 36.3
SKIN:
- deep brown complexion - good skin turgor
- no tenderness and masses - warm to touch
HEAD a) Hair and Scalp
- well distributed - no tenderness
- ( + ) dandruff - no masses
- short and dry hair - no infestations
b) Skull
- face is proportional to head
- no tenderness and depression felt upon palpation
c) Eyes
- symmetrical in size and shape
- black eyes
Columban CollegeCollege of Nursing
Barretto, Olongapo City
d) Eyebrow
- well distributed
e) Conjunctiva
- shiny, smooth, pink to red
f) Teeth
- yellowish
- presence of decayed upper and lower
NECK
- able to move freely with ease
- centrally aligned
- lymph nodes not palpable
THORAX
- chest symmetric
- skin intact and uniform in color
- no lesion
HEART
- s1 heard at all site
- s2 heard at all site
- CR= 89bpm
NOSE
-uniform in color
Columban CollegeCollege of Nursing
Barretto, Olongapo City
- patent nares
- no discharge
- presence of NGT
- able to smell and differentiate different aromas
MOUTH a) Lips
-uniform pink in color
- dry lips
- symmetry of contour
- able to purse lips
b) Buccal Mucosa and Gums
- pinkish mucosa and gums
- ( - ) ulceration
ABDOMEN
- symmetric contour
- normal bowel sounds
- no tenderness and no masses
UPPER EXTREMITIES
- arms symmetric in size and shape
- able to flex and extend both arm
- ( + ) scars
-no tenderness, no masses
- normal capillary refill (less than 2 sec)
- able of both hands to grasp object effectively
LOWER EXTREMITIES
- legs symmetric in size and shape
Columban CollegeCollege of Nursing
Barretto, Olongapo City
- uniform in color
- ( + ) scars
- able to flex and extend both lower extremities
- no tenderness, no masses
Dec. 9, 2009
*no change except for:
VITAL SIGNS
BP: 110/80 PR: 79 bpm
RR: 21 T: 36.5ºC
POST-SURGERY assessment:
Dec. 14, 2009
GENERAL SURVEY
- conscious, coherent
- ambulatory
( - ) NGT
VITAL SIGNS
BP: 120/80 PR: 81 bmp
RR: 21 bmp T: 36.5ºC
EYESPalpebral Conjunctiva: (+) pinkish
Sclera: (+) anisteric
THORAX
( + ) CTT
( + ) tenderness Left upper quadrant; pain: 5/10
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Dec. 15, 2009
*no duty
Dec. 16, 2009
*no change
GENERAL SURVEY
- conscious, coherent
- ambulatory
VITAL SIGNS
BP: 120/80 PR: 87
RR: 19 T: 36.7
THORAX
( + ) tenderness Left upper quadrant; pain: 3/10
Columban CollegeCollege of Nursing
Barretto, Olongapo City
IV. ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY
Columban CollegeCollege of Nursing
Barretto, Olongapo City
PATHOPHYSIOLOGY
ACHALASIA
CONTRIBUTING FACTOR
AGE GENDER
PREDISPOSING FACTOR VIRAL/BACTERIAL
INFECTIONS
SMOKING and ALCOHOLISM
UNKNOWN CAUSE
LOSS OF GANGLIONIC CELLS IN AUERBACH’S (MYENTERIC) PLEXUSES
IMPAIRED RELAXATION OF THE LOWER ESOPHAGEAL SPHINCTER (LES) / CARDIOESOPHAGEAL SPHINCTER
andLOSS OF PERISTALTIC MOVEMENT OF THE LOWER TWO-THIRDS OF
THE ESOPHAGUS
REGURGITATION
VOMITING/CHOKING
ASPIRATION PNEUMONIA
DYSPHAGIA
MALNUTRITION
WEIGHT LOSS
FERMENTATION of INTRA-ESOPHAGEAL CONTENT
HEART BURN HALITOSIS
NARROWING OF THE DISTAL PORTION OF ESOPHAGUS (Bird’s Beak Sign)
Columban CollegeCollege of Nursing
Barretto, Olongapo City
VIII. RELATED JOURNALS
IX. BIBLIOGRAPHY
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Marieb, Elaine N. “Digestive System”. Essentials of Human Anatomy & Physiology. Pearson Education, Inc., Philippines, @ 2006, 8th ed., pp. 454-478.
Pillitteri, Adelle. “Achalasia”. Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Lippincott Williams & Wilkins, Inc., Los Angeles: California, @ 2007, 5th ed., vol. 2, pp. 1825.
Spratto, George R. and Adrienne Woods. “Drug Study”. Nurse’s Drug Handbook. Thomson Delmar Learning Inc., U.S.A., @ 2008, 2008th ed., pp. 273-275, 1261-1263, 1356-1359, 1590-1592.
Columban CollegeCollege of Nursing
Barretto, Olongapo City
X. CURRICULUM VITAE
Name: ROSE ANN ALMONTEROSE ANN ALMONTE
Nickname: Shaine
Birthday: September 6, 1990
Cellphone #: 09109565877
Address: Calapacuan Subic, Zambales
Status: Single
Interest: Texting and eating
Motto: What's said can't be unsaid.
EDUCATIONAL BACKGROUND
Elementary: Calapacuan Elementary School
High School: St. James High School
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Name: FREILYN ANGOBFREILYN ANGOB
Nickname: Frei
Birthday: July 03, 1991
Cellphone #: 09293949103
Address: Baltao Calapandayan Subic Zambales
Status: Single
Interest: Playing basketball, playing guitar reading horror books, soundtrip,
eating, singing and sleeping
Motto: If you trust before you try, you may repent before you die.
EDUCATIONAL BACKGROUND
Elementary: Subic Central School
High School: Subic National High School
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Name: MARY RUTH AÑONUEVOMARY RUTH AÑONUEVO
Nickname: Ruth
Birthday: October 16, 1990
Cellphone #: 09162703150
Address: #83 18th St. East Bajac Bajac Olongapo City
Status: Single
Interest: Watching Movies, Playing Cp and PC games, thinking/imagining
Motto: Obstacles are those frightful things you see when you take your eyes off
your goal.
EDUCATIONAL BACKGROUND
Elementary: St. Joseph College Elementary
High School: St. Joseph College High School
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Name: JEFFERSON AREVALOJEFFERSON AREVALO
Nickname: Jeff
Birthday: May 1, 1991
Cellphone #: 09089568828
Address: #2003 Hi-way Old Cabalan Olongapo City
Status: Single
Interest: Sleeping, Anatomy and Physiology
Motto: Better to be silent than speak ill of another.
EDUCATIONAL BACKGROUND
Elementary: Old Cabalan Elementary School
High School: St. Joseph High School
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Name: CHRISTINE JOYCE ARBOLENTECHRISTINE JOYCE ARBOLENTE
Nickname: Tin
Birthday: December 24, 1990
Cellphone #: 09086557319
Address: # 0123 Santo Tomas Subic Zambales
Status: Single
Interest: Watching TV, playing pc games, eating and sleeping
Motto: Water far away cannot put out a fire nearby.
EDUCATIONAL BACKGROUND
Elementary: Subic Central School
High School: St. James High School
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Name: DESIREE MAE BATOONDESIREE MAE BATOON
Nickname: Treng
Birthday: January 01, 1991
Cellphone #: 09083316509
Address: Tala St. Matain Subic Zambales
Status: Single
Interest: Playing badminton, eating
Motto: A wise man makes his own decisions; an ignorant man follows the public opinion.
EDUCATIONAL BACKGROUND
Elementary: Matain Elementary School
High school: St. Anthony School of Matain
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Name: DEAN MIGUEL BUENODEAN MIGUEL BUENO
Nickname: Dinoboy
Birthday: September 11, 1990
Cellphone #: 09193639018
Address: Subic Zambales
Status: Single
Interest: Nursing Care Plan
Motto: A fool... is a man who never tried an experiment in his life.
EDUCATIONAL BACKGROUND
Elementary: Love of Jesus Learning Center
High School: St. Joseph College
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Name: REEDEN CADAHINGREEDEN CADAHING
Nickname: Dhen
Birthday: June 07, 1990
Cellphone #: 0908799946
Address: Caron St. West Bajac Bajac Olongapo City
Status: Single
Interest: Playing computer games, cooking, biking
Motto: The customer is always right.
EDUCATIONAL BACKGROUND
Elementary: Nellie E. Brown Elementary School
High School: St. Joseph College
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Name: CRISLIE CANONIZADOCRISLIE CANONIZADO
Nickname: Crislie
Birthday: November 23, 1989
Cellphone #: 09204193989
Address: Brgy. Candelaria, San Narciso Zambales
Status: Single
Interest: Soundtrip, texting, watching, playing volleyball,
collecting Mickey mouse and Pooh stuff, sleeping and eating
Motto: Contentment is wanting what you have, not having everything you want.
EDUCATIONAL BACKGROUND
Elementary: Dose Martinez Elementary School
High School: Magsaysay Memorial College
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Name: KRISTINA MAE CONCHAKRISTINA MAE CONCHA
Nickname: Mae
Birthday: March 23, 1991
Cellphone #: 09086533793
Address: 7th St. New Kababae Olongapo City
Status: Single
Interest: Playing basketball, dancing and eating
Motto: Live fast, die young, and have a good-looking corpse.
EDUCATIONAL BACKGROUND
Elementary: Columban College Olongapo Main
High School: Columban College Olongapo Main
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Name: LORSELL RIGUINDINLORSELL RIGUINDIN
Nickname: Lors
Birthday: April 25, 1990
Cellphone #: 09216331263
Address: #47 National Road Baranggay Farañal San Felipe Zambales
Status: Single
Interest: Nothing that interest me.
Motto: No one knows what you can do till you try.
EDUCATIONAL BACKGROUND
Elementary: Sto. Tomas Elementary School
High School: St. Columban’s Montessori High School
VI. LABORATORY and DIAGNOSTIC EXAM
Columban CollegeCollege of Nursing
Barretto, Olongapo City
Columban CollegeCollege of Nursing
Barretto, Olongapo City
ASSESSMENT
Subjective:“Kakaopera ko
lang,” as verbalized by the patient.
Objective: (+) Redness on
the site Improper wound
dressing V/S taken:
BP= 120/90PR= 89RR= 21T= 36.7
NURSING DIAGNOSIS
Risk for infection r/t surgical incision
PLANNING
Short term: After 8 hours of nursing intervention the patient will display signs of healing w/ wound edges clean/pink.
Long term: After 72 hours of nursing intervention the patient will be free to risk of infection and achieve timely wound healing
INTERVENTION
INDEPENDENTShort Term: WOUND CARE:
1. Irrigate wound with room temperature sterile NS TID
2. Assess wound w/each dressing change. Obtain wound tracing on admission and at discharge
3. Apply wet to dry sterile dressing. Use paper tape
Long Term: INFECTION COTROL:
4. Follow wound precautions.
5. Obtain sterile specimen of wound drainage on admission.
RATIONALE
INDEPENDENTShort Term:
1.Cleans wound w/out harming delicate tissues
2.Provides information about effectiveness of therapy, and identifies additional needs
3.Keep wound clean/ minimizes cross contamination, adhesive tape may be abrasive to fragile tissues
EVALUATION
Short term:After 8 hours of
nursing intervention the patient will displayed signs of healing w/ wound edges clean/pink.
Long term:After 72 hours of
nursing intervention the patient was free to risk of infection and has achieve timely wound healing.
VII. N VII. NURSING CARE PLAN