perforated bowel?

medsport. . .ok, let me give you a little direction here. the goal, now, with the care of this patient is going to be comfort care. the nursing staff at the direction of the doctor, and most likely with the approval of the family, is going to allow the patient to die. you are going to see this happening a lot more in the acute hospitals than it used to. basically, what is being said is medical care to sustain his life is being declined, or withheld. so, you are looking for the pathophysiology of all this. what you want to do is look at what happens with a perforated bowel and carry it to it's end (death) when untreated because that is what is going to happen here. this is probably going to be different from pathophysiologies you might have done before because there is going to be no intervening treatment. so, what you are going to be looking for is, basically, how the body breaks down and fails from something like this. in addition, i am sure that there is some disease or medical problem that led up to this bowel perforation. you should mention it as the reason for the progression to the perforation. however, any treatment of that disease(s) is now irrelevant since the perforated bowel trumps it all in seriousness.

my pathophysiology book doesn't have much on a perforated bowel. you want to look at perforated bowel. when the bowel perforates, beside the pain the patient experiences, bowel contents leak out into the abdominal cavity. that includes bacteria that pours in the bowel. untreated, the patient develops peritonitis. here are some articles on the web to help you understand the pathophysiology of what is going on because this is probably what is going to ultimately cause this man's death.

• http://www.emedicine.com/med/topic2737.htm - peritonitis and abdominal sepsis. there is a lot of information in this article about the causes of peritonitis and subsequent sepsis. rupture of the bowel is included. you will find a great deal about the pathophysiology here.
  
• http://www.emedicine.com/med/topic2822.htm - intestinal perforation. one significant line in this article states, " if untreated, bacteremia, generalized sepsis, multiorgan failure, and shock may occur."
  
• http://www.fpnotebook.com/gi88.htm - has signs and symptoms of peritonitis

now, with a dementia patient, you are not necessarily going to see the patient able to verbalize his symptoms except in his behavior which may be abnormal anyway. in doing your pathophysiology of this, you want to carry this through to the sepsis, multi-organ failure and shock that is going to occur. ultimately, it all will contribute to his death. so, you will need to explore a little on each of these subjects: sepsis, multi-organ failure, and shock, and how they are going to affect him physiologically.

as for your care plan. . .since you are not going to be treating these problems, other than providing what is called comfort care, your care plan is going to primarily address self-deficit issues in performing adls, safety and some preventative care. so, look at the self-care deficit diagnoses for bathing and hygiene, grooming, and toileting. feeding you are not going to worry about. remember to address safety issues since this man does have an underlying dementia. the last thing you need is for him to roll, or try to climb, out of bed and fall. you might also want to look at risk for impaired skin integrity because he is most likely going to develop some pretty bad ascites and will be totally bedridden. if there are family members present you may also want your care plan to address any issue they have with coping with this situation. many of your nursing interventions are going to be very basic nursing care things like performing mouth care, keeping linens dry, turn and reposition the patient, etc. don't be disappointed that you won't have complicated nursing instructions on this care plan. most of it is going to be straight, basic nursing care and preparing the patient's family for the death.

one place you can look for some information on comfort care is in hospice resources. hospices have a great deal of information on the dying process from a caregiver perspective in the resources they give out to families. if your nursing textbook does not have a chapter on hospice, see if you can find something about hospice care in a library or call a couple of local hospices and see if they will give you some of the free information they give out to their new clients on providing comfort care. in my early nursing days we saved everyone in the hospital and they were put on ventilators and kept alive until their hearts gave out. that is not so today.

as you assess your patient tomorrow, really hone in on the adls. hope that helps get you started.