Capitol University

College of Nursing

RECTAL PROLAPSE SECONDARY TO RECTAL NEW GROWTH PROBABLY

MALIGNANT

(NEOPLASM OR POLYPS)

In partial fulfillment of the requirements

Of RLE 7 1st semester, SY 2010-2011

PRESENTED BY:

Katrene Lequigan

PRESENTED TO:

Ma. Liwayway Salcedo, RN

CLINCAL INSTRUCTOR

AUGUST 2010

Table of Contents

Introduction……………………………………………………………………………..

Client’s Profile………………………………………………………………………….

Socio-demographic data……………………………………………………..

Vital Signs……………………………………………………………………..

Physical Assessment………………………………………………………...

Anatomy and Physiology…………………………………………………………….

Pathophysiology………………………………………………………………………

Laboratory Tests and Results……………………………………………………...

Nursing Care Plans………………………………………………………………….

Drug Studies…………………………………………………………………………

Discharge Planning…………………………………………………………………

Learning Experiences………………………………………………………………

References.......................................................................................................

Introduction

In choosing an individual case study was very easy to find and choose but

in making it was very hard. But in making ICS is not about only to pass

something or to do it for a requirement but the essential thing there is what you

learn and being contented and successful of what you have studied. For me in

choosing Rectal Prolapsed secondary to rectal new growth was very challenging.

I was very curious about the disease condition that’s why I choose it.

Rectal cancer usually develops over several years, first growing as a

precancerous growth called a polyp. Some polyps have the ability to turn into

cancer and begin to grow and penetrate the wall of the rectum. A polyp is an

abnormal growth. Polyps can vary in size, shape and location; they may be

single or multiple. Some polyps are flat and some look like a grape with a narrow

stalk, or they may take the form of many fine projections, resembling the pile of a

carpet. Tumors of the colon and rectum are growths arising from the inner wall of

the large intestine. Malignant tumors of the large intestine are called cancers.

Cancer cells can also break away and spread to other parts of the body (such as

liver and lung) where new tumors form.

(http://www.emedicinehealth.com/rectal_cancer/page3_em.htm)

The incidence rate of rectal cancer is highest in the westernized countries

of North America, northern Europe, Australia, and New Zealand. Intermediate

rates are found in southern Europe, and there are low rates in Africa, Asia, and

South America. Rectal cancer shows less international variation than colon

cancer. Usually develops over several years, first growing as a precancerous

growth. The rate of risk rises for populations that migrate from low-risk to high-

risk areas, as demonstrated clearly in Japanese immigrants in Hawaii and the

continental United States, where rates among immigrants have risen to

approximately those of the native population. The 18-fold difference in rectal

cancer rates between the country with the highest rate and the country with the

lowest rate is significantly less than the 60-fold difference in colon cancer rates.

This may reflect dietary differences in fat and fiber intake in different countries.

These differences diminish when a western-type diet is adopted. Of patients with

rectal carcinoma, 90% are older than 50 years. Only 5% of patients are younger

than 40 years. Polyps are one of the most common conditions affecting the colon

and rectum, occurring in 15 to 20 percent of the adult population.

(http://emedicine.medscape.com/article/373324-overview)

Your risk of it depends on genetic and lifestyle and factor you can’t control

is the age-older than fifty years old. Malignant tumors of the large bowel usually

occur after 50 years of age, are slightly more frequent in women than in men,

and are common in the Western world. They are rare in children; clustering in

families is common. Drinking excess alcohol and smoking may also increase the

chances of you developing polyps. Women between ages 45 and 60 develop

common polypoid adenomas. The incidence of rectal polyps rises in both sexes

after age 70. (http://medical-dictionary.thefreedictionary.com/Rectal+neoplasm)

Patient may manifest rectal bleeding, changed in bowel habits,

constipation or diarrhea. A polyp in the rectum usually has no symptoms and is

usually found by chance. Larger polyps tend to bleed quite easily; the blood can

be mixed with the stools or can be visible on their surface. You may also notice a

clear mucus, which is passed with the stool. On rare occasions the bowel may

become partially or completely blocked and you may then experience symptoms,

such as constipation, diarrhea, abdominal pain, bloating and in severe cases

vomiting. Bleeding from the anus, the anus is the opening at the end of the

digestive tract where stool leaves the body. You might notice blood on your

underwear or on toilet paper after you’ve had a bowel movements; Constipation

or diarrhea that lasts more than a week can cause rectal prolapsed; Blood in the

stool. Blood can make stool look black, or it can show up as red streaks in the

stool. (http://nursingcrib.com/nursing-care-plan/nursing-care-plan-colon-cancer-

colorectal-cancer/)

………………………………………………………..

This case study has come to realization with the primordial aim of

understanding the disease condition in order to formulate plans of effective

nursing interventions that would help bring back the patient to the normal health

status in a gradual stage. Nursing care has been rendered to patient for one-duty

shift. Hence, evaluation of the effectivity and efficiency of such nursing

interventions was not well established.

Client’s Profile

Socio-demographic Data

Patient X is a 56-year-old, female, a Filipino citizen, from Bangun, Lingati,

Bukidnon. She is religiously affiliated to Baptist religious group. She is married

with 9 children and had home delivery assisted by hilot. Her primary language is

Cebuano and she is a high school graduate. She is a chronic spicy-food lover

and drinks coffee 1 cup everyday. She also has inherited diabetes mellitus and

hypertension.

One year ago, patient X experienced and manifests chronic constipation

and abdominal pain. After several months she noticed gradual protruding mass in

anal area, blood in her stool after she defecated and with some whitish

secretions. However, due to financial constraint the patient does self medication

and sought consultation to there nearest health institution and referred to transfer

at NMMC surgical ward, admitted on August 3, 2010. She was diagnosed of

rectal prolapsed secondary to rectal new growth probably malignant. Then on

August 10, 2010 she underwent to proctosigmoidoscopy, barium enema and x-

ray was conducted to examine the colon, and underwent ultrasound of liver.

Patient X’s age is 56 years old; her mobility status is limited due to her age

and condition. She requires special nutritional needs appropriate for her age –

low fat especially low saturated fats, and sugar. She also needs to eat

vegetables and fruits.

Vital Signs

Temperature: 37.1 degrees Celcius Respiratory Rate: 22 cpm

Pulse Rate: 78 bpm Blood Pressure: 100/70 mmHg

Physical Assessment

This portion of the case study will present the deviation from the abnormal

findings of the physical assessment presented in a cephalo-caudal approach.

These data are then considered in the making of the nursing care plan.

Head

Aspect of Consideration Findings

Hair Dry Hair

Eyes

Aspect of Consideration Findings

Conjunctiva Pale

Visual Acuity Nearsighted

Wears eyeglasses

Mouth

Aspect of Consideration Findings

Lips Pallor and dry

Teeth Missing teeth with dentures

Skin

Aspect of Consideration Findings

General color Pallor

Texture Rough

Moisture Dry

Abdomen

Aspect of Consideration Findings

Percussion Fluid wave

Bowel sounds Hyperactive

Elimination Pattern

Aspect of Consideration Findings

Usual bowel Pattern 3 -4 times per day, brown or green

colored stool, watery stool with

blood, pain at anal area during and

after defecation

Bowel sounds Hyperactive

Others: LBM

Problems before

August 19, 2010

Experienced constipation

Protruding mass at anal area proba-

bly rectal prolapse

Nutrition and Metabolic Pattern:

Weight: weight loss, from 57 kg to 43 kg

Activities of Daily Living /Mobility Status

0- Total independence 3- Assist with device and person

1- Assist with device 4- Total dependence

2- Assist with person

Feeding: 0 Meal Preparation: 4 Bed Mobility: 2

Bathing: 2 Cleaning: 4 Chair /toilet transfer: 2

Dressing; 2 Laundry: 4 Ambulation: 2

Grooming: 2 Toileting: 2 ROM: 0

Cognitive – Perceptual Pattern

Aspect of Consideration Findings

Appropriate behavior/ communication Need adequate rest due to weak-

ness

Emotional state Worried, irritable

Pain

at the anal area during and after defecation and occasional abdominal

pain during bedtime

pain scale of 3/10

Sexuality-Reproductive Pattern

Menstrual pattern: Menopause

LPM: 46 years old

Pregnancy History: home delivery, assisted by hilot

Anatomy and Physiology

The Large Intestine

The large intestine is about 1.5 m (5 ft) long and is characterized by the

following components:

The cecum is a dead-end pouch at the beginning of the large intestine,

just below the ileocecal valve.

The appendix (vermiform appendix) is an 8 cm (3 in) long fingerlike

attachment to the cecum that contains lymphoid tissue and serves

immunity functions.

The colon, representing the greater part of the large intestine, consists of

four sections: the ascending, transverse, descending, and sigmoid colons.

At regular distances along the colon, the smooth muscle of the muscularis

layer causes the intestinal wall to gather, producing a series of pouches

called haustra. The epithelium facing the lumen of the colon is covered with

openings of tubular intestinal glands that penetrate deep into the thick

mucosa. The glands consist of absorptive cells that absorb water and

goblet cells that secrete mucus. The mucus lubricates the walls of the large

intestine to smooth the passage of feces. The colon is approximately five

feet (1.5 meters) in length, begins at the ileocecal valve, and ends at the

rectosigmoid junction. Arterial blood supply to the colon from cecum to

splenic flexure is through the superior mesenteric artery which gives rise to

the ileocolic, right colic, and middle colic arteries. The left and sigmoid

colon is supplied by the inferior mesenteric artery which gives rise to the left

colic and sigmoidal arteries. There can be several anatomic variations in

the colic arteries including absent middle colic artery, absent right colic

artery, common trunk for right and ileocolic artery, and the presence of an

Arc of Riolan between the middle and left colic artery. The colonic wall his-

tologically from lumen outward consists of: (1) a simple columnar epithe-

lium which forms crypts, (2) lamina propria, (3) muscularis mucosa, (4) sub-

mucosa, (5) muscularis propria formed by an inner circular and outer longi-

tudinal layer of smooth muscle, and (6) serosa. The typical colonic malig-

nancy is an adenocarcinoma. Once the neoplastic epithelial cells penetrate

the muscularis mucosa and into the submucosa, a malignant (the ability to

metastasize) adenocarcinoma is formed. The mainstay for treatment is op-

erative resection of the involved colonic segment along with the draining

lymph nodes located in the mesentery. Neoplastic cells confined by the

muscularis mucosa are termed carcinoma-in-situ or severe dysplasia and

are not as yet malignant thereby typically eliminating the need for segmen-

tal colonic resection.

The outer longitudinal smooth muscle of the colon thickens in three loca-

tions called tenia coli. The rectosigmoid junction is the point at which the three

tenia fan out and form a complete outer longitudinal layer. This anatomic point

has clinical significance. Carcinomas proximal to this point are colonic;

whereas distal tumors are rectal and as such may benefit from adjuvant radia-

tion therapy. Likewise, operative resection for classic sigmoid diverticular dis-

ease should include the rectosigmoid junction with the anastomosis located at

the upper rectum. The function of the colon is (1) absorption of water and elec-

trolytes, and (2) propulsion and storage of unabsorbed fecal waste for evacua-

tion. Approximately one liter of fluid chyme enters the cecum each day with an

average of only 100cc excreted in the feces. Parasympathetc innervation by

preganglionic vagal fibers and pelvic fibers result in colonic motility. Sympa-

thetic innervation by the superior mesenteric plexus, inferior mesenteric

plexus, and the hypogastric plexus inhibits colonic motility. It appears that the

major control of motility depends on the colonic wall intrinsic plexus (myenteric

or Auerbach’s/submucous or Meissner’s). An absence of intrinsic plexuses oc-

curs in Hirschsprung’s Disease resulting in tonic wall contraction and functional

obstruction.

The rectum is the last 20 cm (8 in) of the large intestine. The mucosa in the

rectum forms longitudinal folds called anal columns. The rectum is the terminal

portion of the large intestine beginning at the confluence of the three tenia coli

of the sigmoid colon and ending at the anal canal. Generally the rectum is 15

cm in length, is intraperitoneal at its proximal and anterior end, and is ex-

traperitoneal at its distal and posterior end. The epithelial lining or mucosa of

the rectum is of a simple columnar mucous secreting variety.

The anal canal, the last 3 cm (1 in) of the rectum, opens to the exterior at the

anus. An involuntary (smooth) muscle, the interior anal sphincter, and a

voluntary (skeletal) muscle, the external anal sphincter, control the release of

the feces through the anus. The anal canal begins a few centimeters proximal

to the classic and well visualized dentate line and it ends at the anal verge.

The anal canal is about 5 cm in length. Histologically the proximal end of the

anal canal is the point at which the columnar epithelium of the rectum becomes

a transitional epithelium. This epithelium transitions to a stratified squamous

variety at the dentate line. The distal most end of the anal canal is the anal

verge which is the point where the stratified squamous epithelium becomes

true skin marked by the presence of hair follicles and sweat glands. The anal

verge is readily identified by noting the point at which hair shafts are seen. The

anoderm is a term used to describe the zone between the dentate line and the

anal verge. Perianal skin then describes the anatomic area beyond the anal

verge. Malignancies of the perianal skin are typical skin cancers usually squa-

mous cell carcinomas. Anal canal carcinomas are described as epidermoid

carcinoma, squamous cell carcinoma, cloacogenic carcinoma, or baseloid car-

cinoma depending on their particular histologic features. The importance of lo-

cating and anatomically defining the particular malignancy of the anorectal re-

gion is in their treatment.

The functions of the large intestine include

Mechanical digestion. Rhythmic contractions of the large intestine produce

a form of segmentation called haustral contractions in which food residues

are mixed and forced to move from one haustrum to the next. Peristaltic

contractions produce mass movements of larger amounts of material.

Chemical digestion. Digestion occurs as a result of bacteria that colonize

the large intestine. They break down indigestible material by fermentation,

releasing various gases. Vitamin K and certain B vitamins are also

produced by bacterial activity.

Absorption. Vitamins B and K, some electrolytes (Na+ and Cl−), and most

of the remaining water is absorbed by the large intestine.

Defecation. Mass movement of feces into the rectum stimulates a

defecation reflex that opens the internal anal sphincter. Unless the external

and sphincter is voluntarily closed, feces are evacuated through the anus.

Pathophysiology

Predisposing Factors: refer to figure A

Precipitating Factors: refer to figure B

Rectal new growth (neoplasm or Polyps)

Pathologic Report: positive for malignancy

Intramucosal epithelial lesion

Uncontrollable cell formation

Developed chronically in the rectum

Invading of muscularis mucosa, regional lymph

nodes at the rectum, vascular structure

Invading of distant site especially liver

Formation of bowel mass of tissue arises

from bowel wall

Fatty liver grade II

Electrolyte imbalance

Nausea/

vomiting

White mucus secretions

Blood in stool

Weight loss

Abdominal pain

and cramps

Diarrhea

Watery stool

Prolonged constipation and

straining

Anemia of intestinal track lesion

Rectal prolapsed

Constrict the intestinal lumen

Protrudes into the lumen and grow slowly (large)

Prolapsed through the anus

Partial obstruction

Attack immune system

Predisposing Factors (figure A.)

Etiologic Factors Actual Rationale

Age: common in person at all ages with mean age of 50 years old and above

Patient X is an elderly, most likely she is more prone on having rectal prolapsed secondary to rectal neoplasm, age 56 years old

Elderly person tend to be more at risk on developing rectal prolapsed secondary to rectal neoplasm

Gender: Recent studies found out that the female is most commonly affected to it, with multiple pregnancies

Patient X’s gender is female with 9 children

Women are more prone to develop cancer than men.

Lifestyle: impaired physical activity; high fat diet, spicy-food lover

Problem: constipation and straining

Patient X has limited physical activity and eats fatty and spicy foods

Patient X experienced prolonged straining before due to constipation

Foreign studies found out that impaired physical activity, high fat diet, spicy food lover greatly and prolong straining increase the risk of developing the disease

Precipitating Factors (figure B.)

Etiologic Factors Actual Rationale

Developing abnormal buildup of polyps or neoplasm in the rectum

Patient X experienced constipation, abdominal pain, and blood in the stool, watery stool, vomiting and fever, protruded mass in the rectum

1 year prior to admission sudden onset of rectal bleeding associated with severe pain and gradually protruding mass

Laboratory Result

Hematology Report

8/3/10 8/8/10 8/9/10 8/12/10 8/13/10 8/17/10

WBC

5.0-10.0 10^3/uL

13.6 12.4 14.3 19.5

RBC

4.2-5.4 10^6/uL

2.87 3.61 3.86 3.21

Hgb 12.0-16.0 g/dL

10.9 7.2 8.2 9.4 10.0 8.3

Hct 37.0-47.0 %

33.5 23.1 25.1 29.0 30.9 26.1

MCV 82.0-98.0 fL

76.5 80.5 80.3 80.1 81.3

MCH 27.0-31.0 pg

24.9 25.1 26.0 25.9 25.9

RDW-CV 12.0-17.0 %

21.4 21.6

PDW 9.0-16.0 fL

7.4 7.2 7.1 6.9 6.9

MPV 8.0-12.0 fL

7.6 7.5 7.5 7.4 7.4

Platelet 150-400 10^3/uL

640 532 450 468 510

Lymphocyte

17.4-48.2 %

15.4 11.3

Eosinophils 1.0-3.0 %

0.5 0.2

Neutrophil 43.4-76.2 %

78.2

Monocyte 4.5-10.5 %

11.6

WBC Increase in various infections.

RBC Decreased RBC is usually seen in anemia of any cause with the possible exception of thalassemia minor, where a mild or borderline anemia is seen with a high or borderline-high RBC.

HGB A low hemoglobin is referred to as anemia; nutritional deficiency (iron, vitamin B12, folate)

HCT A low hematocrit is referred to as being anemic; nutritional deficiency (iron, vitamin B12, folate)

MCV Microcytic/hypochromic anemia (decreased MCV) Iron deficiency (com-mon); Anemia of chronic disease (uncommonly microcytic)

MCH Microcytic/hypochromic anemia (decreased MCH) Iron deficiency (com-mon); Anemia of chronic disease (uncommonly microcytic)

RDW-CV The RDW may also be useful in monitoring the results of hematinic therapy for iron-deficiency or megaloblastic anemias.

MPV Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow.

PLATELET Thrombocytosis is seen in many inflammatory disorders and myelo-proliferative states, as well as in acute or chronic blood loss, hemolytic anemias, carcinomatosis, status post-splenectomy, post- exercise, etc.

LYMPHOCYTE Lymphopenia is characteristic of AIDS. It is also seen in acute in-fections, Hodgkin's disease, systemic lupus, renal failure, carcinomatosis, and with administration of corticosteroids, lithium, mechlorethamine, methysergide, niacin, and ionizing irradiation. Of all hematopoietic cells lymphocytes are the most sensitive to whole-body irradiation, and their count is the first to fall in radia-tion sickness.

EOSINOPHILS Eosinopenia is seen in the early phase of acute insults, such as shock, major pyogenic infections, trauma, surgery, etc. Drugs producing eosinopenia include corticosteroids, epinephrine, methysergide, niacin, niaci-namide, and procainamide.

NEUTROPHIL Neutrophilia is seen in any acute insult to the body, whether infec-tious or not. Marked neutrophilia (>25,000/µL) brings up the problem of hemato-logic malignancy (leukemia, myelofibrosis) versus reactive leukocytosis, including "leukemoid reactions." Laboratory work-up of this problem may include expert re-view of the peripheral smear, leukocyte alkaline phosphatase, and cytogenetic analysis of peripheral blood or marrow granulocytes. Without cytogenetic analy-sis, bone marrrow aspiration and biopsy is of limited value and will not by itself establish the diagnosis of chronic myelocytic leukemia versus leukemoid reac-tion.

MONOCYTE Monocytosis is seen in the recovery phase of many acute infec-tions. It is also seen in diseases characterized by chronic granulomatous inflam-mation (TB, syphilis, brucellosis, Crohn's disease, and sarcoidosis), ulcerative colitis, systemic lupus, rheumatoid arthritis, polyarteritis nodosa, and many

hematologic neoplasms. Poisoning by carbon disulfide, phosphorus, and tetra-chloroethane, as well as administration of griseofulvin, haloperidol, and methsux-imide, may cause monocytosis.

Blood Chemistry Result

8/3/10 8/9/10 8/12/10 8/17/10

Glucose 59.9-110.1 mg/dL

117.7 129.0

BUN 4.5-23.5 mg/dL

33.8

Albumin 3.70-5.20 g/dL

2.77 2.65

Blood Sugar 60-110 mgs. %

117.7

Potassium 3.5-5.3 mmol/L

2.99

GLUCOSE Hyperglycemia can be diagnosed only in relation to time elapsed after meals and after ruling out spurious influences (especially drugs, including caffeine, corticosteroids, estrogens, indomethacin, oral contraceptives, lithium, phenytoin, furosemide, thiazides, thyroxine, and many more). Previously, the diagnosis of diabetes mellitus was made by demonstrating a fasting blood glucose >140 mg/dL (7.8mmol/L) and/or 2-hour postprandial glucose >200 mg/dL (11.1 mmol/L) on more than one occasion.

BUN Decreased serum urea nitrogen (BUN) is seen in high carbohydrate/low protein diets, states characterized by increased anabolic demand (late pregnancy, infancy, acromegaly), malabsorption states, and severe liver damage.

ALBUMIN Decreased serum albumin is seen in states of decreased synthesis (malnutrition, malabsorption, liver disease, and other chronic diseases), increased loss (nephrotic syndrome, many GI conditions, thermal burns, etc.), and increased catabolism (thyrotoxicosis, cancer chemotherapy, Cushing's disease, familial hypoproteinemia).

POTASSIUM Decreased levels of potassium indicate hypokalemia. Decreased levels may occur in a number of conditions, particularly: dehydration, vomiting, diarrhea, deficient potassium intake (rare).

Examination Results

8/3/10 8/12/10 8/17/10

Prothrombin Activity (Therapeutic range: 0-20 %)

100 % 76 % 88.6 %

APTT (activated partial thrombin time) Normal rate: 23.4-38.5 sec

41.1 secs.

Protime (Normal rate: 10.2-15.2 sec.)

16.4 sec.

PROTHROMBIN ACTIVTY A prolonged, or increased, PT means that your blood is taking too long to form a clot. This may be caused by conditions such as liver disease, vitamin K deficiency or a coagulation factor deficiency.

APTT A prolonged PTT means that clotting is taking longer to occur than expected and may be caused by a variety of factors (see the list below). Often, this suggests that there may be a coagulation factor deficiency or a specific or nonspecific inhibitor affecting the body’s clotting ability. Coagulation factor deficiencies may be acquired or inherited. Several factors are Vitamin K dependent. If a person has liver disease, for instance, or more rarely a Vitamin K deficiency, he may have one or more factor deficiencies. Inherited factor deficiencies may affect the quantity and/or function of the factor produced.

PROTIME The prothrombin time (PT) test measures how long it takes for a clot to form in a sample of blood. In the body, the clotting process involves a series of sequential chemical reactions called the coagulation cascade, in which coagulation or “clotting” factors are activated one after another and result in the formation of a clot. Prothrombin is one of the coagulation factors produced by the liver. One of the final steps of the cascade is the conversion of prothrombin (factor II) to thrombin. The PT test evaluates the integrated function of the coagulation factors that comprise the extrinsic and common pathways of the coagulation cascade, including factors I (fibrinogen), II (Prothrombin), V, VII and X. It evaluates the body’s ability to produce a clot in a reasonable amount of time and, if any of these factors are deficient, the PT will be prolonged.

Radiographic Report: August 10, 2010

Part Examined: Colon

Findings: Barium Enema

Clinical Data: Circumferential mass 5cm from the anal verge per proctosigmoidoscopy findings: Scout film shows minimal gas filled bowel loops within the abdomen without air fluid levels. The flank stripes and psoas shadows are distinct. No definite mass, organomegaly and intra-abdominal calcification is seen. Minimal spurs are seen along the lumbar spine margins. The rest of the visualised osseuos structures are intact.

Subsequent fillins following introduction of barium mixture into the ano via F24 catheter show ascert of barium from the rectum up to the cecum with minimal passage into the terminal ileum (as visualised in the decubitus study). There is a large mucosal irregularity with shouldering pattern with approximate widest diameter of 8cm noted in the rectum. No other mucosal irregularity, mass lesion effect is seen.

Post evacuation film show moderate retention of barium.

Impression:

1. Large area of mucosal irregularity with shouldering pattern in the area of the rectum—suggestive of a neoplastic process, likely malignant.

2. Moderate barium retention

3. Lumbar spondylosis

Lower gastrointestinal (GI) tract radiography, also called a lower GI or barium enema, is an x-ray examination of the large intestine, also known as the colon. This examination evaluates the right or ascending colon, the transverse colon, the left or descending colon, the sigmoid colon and the rectum. The appendix and a portion of the distal small intestine may also be included.

An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging.

The lower GI uses a special form of x-ray called fluoroscopy and a contrast material called barium or a water soluble iodinated contrast.

Fluoroscopy makes it possible to see internal organs in motion. When the lower gastrointestinal tract is filled with barium, the radiologist is able to view and assess the anatomy and function of the rectum, colon and sometimes part of the lower small intestine.

A physician may order a lower GI examination to detect: benign tumors (such as polyps). cancer.

causes of other intestinal illnesses.

The procedure is frequently performed to help diagnose symptoms such as: chronic diarrhea. blood in stools.

constipation.

irritable bowel syndrome.

unexplained weight loss.

a change in bowel habits.

suspected blood loss.

abdominal pain.

Images of the small bowel and colon are also used to diagnose inflammatory bowel disease, a group of disorders that includes Crohn's disease and ulcerative colitis.

Ultrasound Report: August 10, 2010

Findings:

The liver appears normal in size but with echogenic parenchyma. No mass or calcification seen. Intrahepatic bile ducts and common bile duct are non-dilated.

Gallbladder is normal in size. Its wall is not thickened. No intraluminal mass or lithiasis seen.

Pancrease is unremarkable.

Diagnosis:

1. Fatty liver grade II

2. Non-remarkable UTZ findings in the gallbladder and pancrease.

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 produces a picture of the organs and other structures in the upper abdomen.

A Doppler ultrasound study may be part of an abdominal ultrasound examination.

Doppler ultrasound is a special ultrasound technique that evaluates blood flow through a blood vessel, including the body's major arteries and veins in the abdomen, arms, legs and neck.

Abdominal ultrasound imaging is performed to evaluate the: kidneys liver

gallbladder

pancreas

spleen

abdominal aorta and other blood vessels of the abdomen

Ultrasound is used to help diagnose a variety of conditions, such as: abdominal pain or distention. abnormal liver function.

enlarged abdominal organ.

stones in the gallbladder or kidney.

an aneurysm in the aorta.

Additionally, ultrasound may be used to provide guidance for biopsies.

Doppler ultrasound images can help the physician to see and evaluate:

blockages to blood flow (such as clots). narrowing of vessels (which may be caused by plaque).

tumors and congenital malformation.

Discharge Planning

Medication

> Strict compliance to the drug regimen should be emphasized

> Emphasis to take home medication consistently following the right drugs,

dosage, timing & frequency, and route.

Exercise

> It is best to start the exercise program slowly until you get stronger, also find a

suitable exercise program to suit your condition.

> Exercise is important this makes your heart stronger, lowers blood pressure,

and help keep your body healthy.

> Maintaining a regular exercise will help facilitate adequate blood flow for

nourishing different parts of the body and can help to increase peristaltic

movement.

> Exercise can reduce joint pain and fatigue. It can also increase ROM and

strength.

Treatment

> Have a regular check-up with your physician regarding with your condition for

any continuing treatment and medications.

Health Teachings

> Emphasis on personal hygiene to promote comfort and prevent infection.

> Do regular exercises, eat right food, and take medications to enhance recovery

and healing as indicated by the physician.

> Adequate rest is important.

> Information about her disease condition

> Have diversional activities to alleviate pain at postoperative area

> Adequate fluid intake to prevent dehydration

> Encourage to have a low fat diet and sugar level

Out Patient

> Regular check-up for monitoring of development and if there are presence of

complication.

Diet

> Consult a nutritionist for a proper diet program.

Tips:

> Eat nutritious and healthy food, to avoid constipation. Eat foods such as

oatmeal, whole-grain breads and cereals, fruits (banana for decrease potassium

level) and vegetables.

> Drink at least 8-10 glasses of water a day; limit the amount of soda, tea and

coffee.

> Diets high in vegetables and high-fiber foods such as whole-grain breads and

cereals may rid the bowel of these carcinogens and help reduce the risk of can-

cer.

> Low fat diet and low sugar level

> High protein diet

Spirituality

>Tell the patient/client to pray for God, for him nothing is impossible. Ask for

inner strength to carry his trials

Learning Experience

In doing this case study, the essence of patience and hard working were

always there. Everything I have done entails patience, knowledge and skills in

doing research studies about the case. I have learned a lot about proper nursing

interventions, rendering care to my patients, regarding the disease conditions,

manifestations and a lot more. One should also need to analyze all the significant

data to know the relationship of other data.

While in the other hand, my experience in NMMC-Surgical Ward was

honestly a big and challenging experienced in my life. It was fortunate to have a

good relationship to my group mates, hospital staffs and to my beloved clinical

instructor as well. What happened in this rotation was a lot of new ideas, new

learning and new applications for my field. In the ward, I also learned a lot of new

procedures and I was totally amazed and proud to myself because I am confident

in doing some procedures in the ward. I admit that I have committed a couple of

mistakes, but what is more important is what I’ve learned from my mistakes.

I would like to thank, our ever grateful, God Almighty, thank you so much

for giving me strength to handle each situation confidently. To my dear CI,

Ma. Liwayway Salcedo, RN, thank you for being effective in the field. As a clinical

instructor, she emphasized the values of professionalism, respect and patience.

To my PCI that was patience and understanding, thank you Sir. To my beloved

parents who have shown support and understanding in all activities. And to the

Hospital Staffs who helped and guided me for this rotation.

References

http://www.google.com

http://www.yahoo.com

http://www.scrib.com

http://www.nursingcrib.com

http://www.wikipedia.com

http://www.webmd.com

http://www.emedicinehealth.com

http://www.medicinenet.com

http://web2.airmail.net/uthman/lab_test.html

http://www.radiologyinfo.org/en/info.cfm?pg=abdominus

http://medical-dictionary.thefreedictionary.com/Rectal+neoplasm

http://www.homehealth-uk.com/medical/polyps.htm

http://www.merck.com/mmpe/sec02/ch021/ch021g.html

http://www.procto-med.com/polyps-of-the-colon-and-rectum/

http://www.bestsyndication.com/?q=20080305_colorectal_polyps.htm

http://www.fascrs.org/patients/conditions/polyps_of_the_colon_and_rectum/

http://digestive.niddk.nih.gov/ddiseases/pubs/colonpolyps_ez/

http://www.healthline.com/galecontent/rectal-polyps/2

http://www.wrongdiagnosis.com/symptoms/rectal_prolapse/book-causes-20a.htm

http://emedicine.medscape.com/article/931455-overview

http://www.acg.gi.org/patients/women/rectal.asp

http://www.patient.co.uk/doctor/Rectal-Prolapse.htm

http://hcd2.bupa.co.uk/fact_sheets/html/rectal_prolapse.html

http://www.hemorrhoid.net/prolapse.php

http://www.embarrassingproblems.com/docspots/DocSpot-rectal-prolapse

http://www.umm.edu/ency/article/001132prv.htm

http://www.nlm.nih.gov/medlineplus/ency/article/001132.htm