CASE PRESENTATION

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CASE PRESENTATION

• PREPARED BY SANDHYA KS

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DEMOGRAPHIC DATA

• 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
•  

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GENERAL

• Patient is intubated.
• Looks weak and fatigue.
• Unable to mobilize.
• Upper teeth fracture.
• Two drainage tubes from both sides of abdomen.
•  

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SKIN

• Skin is warm.
• Post operative scar present on abdomen.
• Noted abrasion on upper and lower extremities.
• Post operative scar on right leg.

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HEAD and NECK

• Hair is equally distributed.
• Absence of dandruff.
• Abrasions on face.
• Patients 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.

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CARDIOVASCULAR

• 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.
•  

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THORAX

• Thorax is sympathetic on inspection

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Genito urinary system

• With Foleys catheter FG.16present

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Gastrointestinal System

• Patient is old RTA with abdominal trauma
  tenderness present.
• Two drainage tubes present from both sides of
  abdomen.
•  

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MUSCULOSKELETAL SYSTEM

• 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

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NEUROLOGIC

• Patient is on ventilator under sedation
• Old RTA with spine fracture
• GCS 15/15

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PATIENT HISTORY

• PAST MEDICAL HISTORY
• Patient is old RTA with polytrauma
• Poor lung condition
• Fracture tibia and thoracic spine
• ORIF tibia done two months ago

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PRESENT MEDICAL HISTORY

•  
• Patient is presented with post exploratory
  laparotomy with small bowel resection with
  anastomosis.
•  

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PRESENT SURGICAL HISTORY

• He undergone exploratory laparotomy and small
  bowel resection with anastomiosis done under
  general anesthesia on 11/01/13

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PAST SURGICAL HISTORY

• He undergone ORIF tibia done under general
  anesthesia on 01/11/12.

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VITAL SIGNS

• BP- 120/86mmhg
• PR- 66 bpm
• Temperature- 36.4C
• SPO2- 98

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MEDICATION
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
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INVESTIGATIONS
Investigations Patients 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
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INTRODUCTION

• 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.

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ANATOMY AND PHYSIOLOGY
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ANATOMY AND PHYSIOLOGY
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DISEASE CONDITION Peritonitis

• 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
  non-infectious process.
•  

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•  
• 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 di
  verticulitis 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.

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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

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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, diverticu
  litis, Meckl diverticulum, inflammatory bowel
  disease (IBD), intestinal infarction, intestinal
  strangulation, colorectal carcinoma, meconium
  peritonitis), or of the gallbladder (cholecystitis

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• 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 Gram-negative bacilli (e.g., Escher
  ichia coli) and anaerobic bacteria (e.g., Bacteroi
  des 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.

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• Disruption of the peritoneum, even in the absence
  of perforation of a hollow viscus, may also cause
  infection simply by letting micro-organisms into
  the peritoneal cavity. Examples
  include trauma, surgical wound, continuous
  ambulatory peritoneal dialysis, and
  intra-peritoneal 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.

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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.  
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  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., s
alpingitis), pancreatic 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, sp
onge). Much rarer non-infectious causes may
include familial Mediterranean fever, TNF
receptor associated periodic syndrome, porphyria,
and systemic lupus erythematosus.
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DIAGNOSIS

• 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, hypokalemi
  a, 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.

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PATHOLOGY

• In normal conditions, the peritoneum appears
  greyish and glistening it becomes dull 24 hours
  after the onset of peritonitis, initially with
  scarce serous or slightly turbid fluid. Later on,
  the exudate becomes creamy and evidently suppurati
  ve 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 features
  infiltration by neutrophils with fibrino-purulent
  exudation.

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TREATMENT

• Depending on the severity of the patient's state,
  the management of peritonitis may include
• General supportive measures such as
  vigorous intravenous rehydration and correction
  of electrolyte disturbances.

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ANTIBIOTICS

• Antibiotics  are usually administered intravenousl
  y, but they may also be infused directly into the
  peritoneum. The empiric choice of broad-spectrum
  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.
•  

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EMPIRIC THERAPY

• Gram positive and gram negative organisms must be
  covered. Out of the Cephalosporin, cefoxitin and c
  efotecan can be used to cover gram positives,
  gram negatives, and anaerobes. Beta-lactams with
  beta lactamase inhibitors can also be used,
  examples include ampicillin/sulbactam, piperacilli
  n/tazobactam, and ticarcillin/clavulanate.2Carba
  penems 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

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SURGERY

• (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.
•  

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PROGNOSIS

• If properly treated, typical cases of surgically
  correctable peritonitis (e.g., perforated peptic
  ulcer, appendicitis, and diverticulitis) have
  a mortality rate of about lt10 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.
•  

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COMPLICATIONS

• 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.
•  

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DISEASE CONDITION GASTROINTESTINAL PERFORATION

• 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.
•  
•  
•  

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SIGNS AND SYMPTOMS

• Sudden attack of pain in epigastrium to the right
  of midline
• burning pain in epigastria, flatulence and dyspeps
  ia
• rigidity of abdomen
• tenderness, and rebound tenderness
• nausea and vomiting
• fever and or chills.
•  

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CAUSES

• gastric ulcer
• appendicitis
• gastrointestinal cancer
• diverticulitis
• superior mesenteric artery syndrome 
• trauma, ascariasis
• Typhoid fever
• non-steroidal anti-inflammatory drugs
•  ingestion of corrosives 

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DIAGNOSIS

• x-rays (free gas/air may be visible in the
  abdominal cavity)
• computed tomography
• White blood cells are often
• ridged abdomen on palpation

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SURGICAL INTERVENTIONS

• exploratory laparotomy and closure of perforation
  
• If patient is in case nontoxic and clinically
  stable, they can be treated with intravenous fluid
  s, antibiotics, nasogastric aspiration
  and bowel rest
•  

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EXPLORATORY LAPAROTOMY

• 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.

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PURPOSE

• 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.

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• 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.

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• 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.

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INCISION

• 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.

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ABDOMINAL EXPLORATION

• 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

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• 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.

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CLOSURE

• 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.

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DIAGNOSIS

• 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
  three-quarters 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.

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AFTER CARE

• The patient will remain in the postoperative recov
  ery 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.

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RISKS

• 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).

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SMALL BOWEL RESECTION

• 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).

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INTESTINAL OBSTRUCTION

• 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.

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• 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

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DESCRIPTION

• 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.

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OPEN RESECTION

• 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.

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DIAGNOSIS

• 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

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AFTERCARE

• 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.

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RISKS

• 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.

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PRIORITIZATION OF NURSING PROBLEMS

• 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.
•  

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NURSING CAREPLAN
Subjective   Im shivering and I feel weak as verbalized by patient.   Objective Fever T- 38C chills leakage from the wound of dressing increased pulse rate PR- 98bpm pain on the surgical site abdominal distention     High risk for infection related to large surgical incision. Patient shows no evidence of infection as manifested by Stable vital signs Afebrile Patient is stable and oriented No leakage from the wound dressing No abdominal distention   Minimized the movement of the patient Done dressing daily with aseptic technique and check the dressing site for oozing Suction done to clear secretions and 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 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 of infection 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 after 24 hours Nursing order/action Rationale for action Evaluation
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Assessment     Planning Implementation   Evaluation
Cues/Evidence   Nursing Diagnosis Goals and desired outcome Nursing order/action Rationale for action Evaluation
Subjective   I cannot move properly and Im having pain during motion as verbalized by patient.   Objective Limited range of motion Inability to perform action as instructed       Impaired physical mobility, acute pain secondary to exploratory and laparotomy and bowel resection with anastamosis. 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 independently Intact skin and absence of complications Normal bowel pattern 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 ulcer. 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 independently or with assisting devices as needed. Free of complications of immobility as normal bowel pattern.  
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PATIENT EDUCATON

• 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.

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CONCLUSION

• 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.

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BIBLIOGRAPHY

• Lippincott manual of Nursing Practice 9th edition
• www.localhealth.com
• www.healthtype.com
• www.drugs.com 

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• Thank you!! ?