Case Study ACHALASIA With LOGO

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



I. INTRODUCTION



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.



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.



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



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



- 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



- 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



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



IV. ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY



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)



VIII. RELATED JOURNALS

IX. BIBLIOGRAPHY



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.



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



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.


Elementary: Subic Central School

High School: Subic National High School



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.


Elementary: St. Joseph College Elementary

High School: St. Joseph College High School



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.


Elementary: Old Cabalan Elementary School

High School: St. Joseph High School



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.


Elementary: Subic Central School

High School: St. James High School



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.


Elementary: Matain Elementary School

High school: St. Anthony School of Matain



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.


Elementary: Love of Jesus Learning Center

High School: St. Joseph College



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.


Elementary: Nellie E. Brown Elementary School

High School: St. Joseph College



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.


Elementary: Dose Martinez Elementary School

High School: Magsaysay Memorial College



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.


Elementary: Columban College Olongapo Main

High School: Columban College Olongapo Main



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.


Elementary: Sto. Tomas Elementary School

High School: St. Columban’s Montessori High School

VI. LABORATORY and DIAGNOSTIC EXAM





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

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Case Study ACHALASIA With LOGO