LICEO DE CAGAYAN UNIVERSITY R.N.P. Blvd., Carmen, Cagayan de Oro City

C O L L E G E O F N U R S I N G

A family Care Study

With

PEPTIC ULCER DISEASE

Submitted to:

Clinical Instructor

As Partial Requirement for NCM501202

Submitted by:

NCM501202 Student

January 18, 2007

Table of Contents

I. INTRODUCTION ----------------------------------------------------1 – 2

II. HEALTH HISTORY -------------------------------------------------3 – 4

III. DEVELOPMENTAL DATA ---------------------------------------5 - 6

IV. MEDICAL MANAGEMANT ---------------------------------------7 - 17

V. ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY----------18 - 22

VI. NURSING ASSESSMENT ----------------------------------------23 -25

VII. NUSING MANAGEMENT -----------------------------------------26 -35

VIII. REFERRALS AND FOLLOW-UP--------------------------------36

IX. EVALUATION AND IMPLICATIONS---------------------------37

X. BIBLIOGRAPHY -----------------------------------------------------38

I. INTRODUCTION

Overview of the Case

Too much stress, too much spicy food, and you may be headed for an ulcer or

so the thinking used to go.

A peptic ulcer is an ulcer of one of those areas of the gastrointestinal tract that

are usually acidic. A more general term, peptic ulcer disease (PUD), is also in use.

Most ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that

lives in the acidic environment of the stomach. Ulcers can also be caused or

worsened by drugs such as Aspirin and other NSAIDs. Contrary to general belief,

more peptic ulcers arise in the duodenum (first part of the small intestine, just after

the stomach) than in the stomach. About 4 % of stomach ulcers are caused by a

malignant tumour, so multiple biopsies are needed to make sure. Duodenal ulcers

are generally benign.

The common belief was that peptic ulcers were a result of lifestyle. Doctors

now know that a bacterial infection or medications — not stress or diet — cause most

ulcers of the stomach and upper part of the small intestine (duodenum). Esophageal

ulcers may also occur and are typically associated with the reflux of stomach acid.

Although stress and spicy foods were once thought to be the main causes of

peptic ulcers, doctors now know that many ulcers are caused by the corkscrew-

shaped bacterium Helicobacter pylori (H. pylori).

H. pylori lives and multiplies within the mucous layer that covers and protects

tissues that line the stomach and small intestine. Often, H. pylori causes no

problems. But sometimes it can disrupt the mucous layer and inflame and erode

digestive tissues, producing an ulcer. One reason may be that people who develop

peptic ulcers already have damage to the lining of the stomach or small intestine,

making it easier for bacteria to invade and inflame tissues.

1

The most common ulcer symptom is gnawing or burning pain in the abdomen

between the breastbone and the belly button. The pain often occurs when the

stomach is empty, between meals and in the early morning hours, but it can occur at

any other time. It may last from minutes to hours and may be relieved by eating food

or taking antacids. Less common symptoms include nausea, vomiting, or loss of

appetite. Sometimes ulcers bleed. If bleeding continues for a long time, it may lead to

anemia with weakness and fatigue. If bleeding is heavy, blood may appear in vomit

or bowel movements, which may appear dark red or black.

Objective of the Study

The objectives of this care study aims to:

1. Develop knowledge, which would make us or the readers aware on what are

the possible causative agents and the signs & symptoms manifested by the

patient on having this specific condition

2. Know the possible actions that would help alleviate or even prevent a certain

problem related to the condition of the patient for the prevention of possible

complications

3. Even give some interventions to those problems that were observed to the

patient, but are not related to its diagnosis.

4. Have a correct nursing care rendered to the patient on the entire therapy

5. Identify what are the uses of the drugs being prescribed by the patients

physician during the entire hospitalization

Scope and limitation of the Study

This study focuses mainly on the patient’s specific condition, which is bleeding

peptic ulcer and even focused more on the condition of the patient before and upon

admission to further evaluate what are the possible nursing and medical interventions

would be applied to the patient on the entire course of therapies.

II. HEALTH HISTORY

Patients Profile

The name of the patient was, male; 74 years old; a Roman Catholic; and a

Filipino citizen. He is married to Mrs. and have three siblings namely; and presently

residing at.

He was born on the. He is five feet four inches in height and 100 pounds in

weight

He is negative on food and drug allergies. His chief complains were

Hematochezia and Hemoptysis. He was diagnosed by his physician Dr. Bacal, with

T/C bleeding peptic ulcer disease.

Personal Health History

My patient has not received any blood from the past. He has no known food

and medicine allergies. He had experienced having a cough when the time he

stopped smoking and it gone out to be more severe on the following days. As his

watcher said that he was hospitalized for several times because of his condition. , is

susceptible to many diseases since the patient was to old and have vices that

precipitates lots of diseases and complications. The patient also told me that when

there were times that there is pain on his stomach, he sometimes skip his meals. As

we all know, that, skipping a meal will lessen our body’s nutrients/strength and would

become prone to diseases when the nutritive status of our body is altered. And due

to tiredness and inadequate nutrients on his body, the patient would become weak

and alters his daily activities. The above factors made my patient a susceptible

individual to a certain disease.

History of Present Illness and Chief Complains

, presently residing in was admitted at Cagayan de Oro Polymedic General

Hospital due to Hematochezia ( cause: bleeding in colon/rectum and results to loss of

blood higher in the digestive tract or through defecation of bloody stools (melena);

and also hemoptysis ( coughing up of blood from respiratory tract. Bloodsteaked

3 1

2

sputum often is presented in minor upper respiratory infection or bronchitis). The

patient was experiencing severe pain on his abdominal area when he does not eat

his meals. Since the cause the discomforts felt by the patient on his abdomen, as

well as the bloody stools during defecation, and with laboratory examination taken by

(e.g. CBC), the patient is then positive with a peptic ulcer disease. He was also noted

with acute bronchitis; the patient was not able to talk clearly because of his

productive cough or retained secretions/bronchospasm that obstructs the airway of

the patient, that’s why he has dyspnea and some manifestations of hyperventilation

and tachypnea, these was the cause why the patient has ineffective airway clearance

during his hospitalization. Few minute prior to admission the patient encountered

dizziness and brought patient to his room on a stretcher (condition upn admission)

The result of his physical assessment was that he is febrile and is in

respiratory distress. His vital signs during the first day of assessment were,

temperature: 36.3oc; pulse rate: 88bpm; respiration rate: 28 cpm; and blood pressure:

140/70 mmHg. There was no skin lesions observed upon admission. Dr. Bacal’s

admitting diagnosis to was Bleeding Peptic Ulcer Disease

4

III. DEVELOPMENTAL DATA

The stage of older adulthood is considered to begin at 65 years of age.  Many

physical, psychological, and social changes occur during later adulthood.  The critical

transition comes at the time of retirement for both the husband and the wife.  In old

age persons are moving toward completion of their life cycles.    Old age can be a

time when a person can enjoy his/her  time with his/her grandchildren and leisure

time activities, and forget about things caused him/her a great deal of stress and

anxiety in the past three or four decades . During this stage a person must adapt to

changing physical abilities. This stage is characterized by increased wisdom although

many other things are lost such as health, friends, family and independence. The

aging process of people in this stage of development varies greatly.  Ego integrity Vs

despair represents this stage in the psychosocial theory. The developmental tasks of

the older adult are: adjusting to decreases physical strength and loss of health,

adjusting to retirement and reduced income, coping with death of a husband or wife

and preparing for one's own deatheating periods.

According to Erik Erickson’s Psychosocial Development Theory lies on the

stage 8 (integrity vs. Despair), wherein, ego integrity is the ego's accumulated

assurance of its capacity for order and meaning. And despair is signified by a fear of

one's own death, as well as the loss of self-sufficiency, and of loved partners and

friends.

This stage is focused on reflecting back on the person’s life, that is, those who

are unsuccessful during this phase will feel that their life has been wasted and will

experience many regrets. The individual will be left with feelings of bitterness and

despair.

Those who feel proud of their accomplishments will feel a sense of integrity.

Successfully completing this phase means looking back with few regrets and a

general feeling of satisfaction. These individuals will attain wisdom, even when

confronting death.

In general, this is the patients time for reflecting on and reviewing how he met

previous challenges and lived his life. Adjusting to decreasing physical strength and

health; Adjusting to retirement and reduced income; Establishing an explicit affiliation

with one's age group; and Meeting social and civil obligations are the right ways on

how to establish a satisfactory physical living arrangements on his kind of stage.5

IV. MEDICAL MANAGEMANT

December 3, 200612:10 AM

Please admit to Medical Ward

TPR every four hours

For – CBC and Chest PA

(#1 IVF therapy)

Combivent 1 neb every 6 hours

Esomemeprazole (Nexium) 20mg 1 tab BID, PO

For further medical management and monitoring

For baseline data of interventions and close monitoring of patients vital signs

CBC- includes absolute number of percentages of erythrocytes, leukocytes,platelets, hemoglobin and hematocrit in blood sample. Used to evaluate blood if it is potential for infection or other disorders/abnormalities.

This medication is an intravenous (IV) solution used to supply water, calories, and electrolytes

Relaxes bronchial uterine and vascular smooth muscle by stimulating beta2 receptors that helps to prevent or treat broncho-spasm in patient with severe obstructive airway disease

Proton Pump Inhibitor that reduces gastric acid secretion and decreases gastric acidity that helps eradicate Helicobac- ter Pylori.

6

Sucralfate (Iselpin) 1g/10ml BID, PO

Isoptin 240 mg 1 tab OD, PO

Administer O2

Short term treatment of ulcer (duodenal).Maintenance therapy for duodenal ulcer

Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. For management of hypertension

For oxygen therapy of the patient since the patient cannot breath normally during admission.

December 4,2006

Lactulose (Dupholac), 20cc BID

Cefixime (Tergeof) 200mg BID, PO

Produces an osmotic effect in colon, resulting distention promotes peristalsis. For or to treat constipation

Stable in the presence of beta-lactamase enzyme. Used for acute bronchitis and acute exacerbations of chronic bronchitis

December 5,2006

IVF TF with D5NSS at 20 gtts / min

This medication is an intravenous (IV) solution used to supply water, calories, and electrolytes (e.g., sodium, chloride) to the body. 8

7

December 6, 2006

On going IVF # 5 D5NSS @ 20 gtts / min.

Terminate when consume (IVF to consume)

December 7, 2006

Discontinue Nebulization

May Go Home Tomorrow

Discontinue Isoptin

Resume spiriva 1 cap OD inhalation

This medication is an intravenous (IV) solution used to supply water, calories, and electrolytes (e.g., sodium, chloride) to the body.

The Patient is done with the Intravenous therapy and should continue his therapy with his medications.

This indicates that patient has alleviated his respiratory conditions and has change its conditions unlike before

This indicate that the patient is in good condition and return to its functional level.

The blood pressure of the patient was back on its normal ranges on a couple of days of admission. So the specific drug was discontinued.

For the total wellness of his bronchospasm.

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LABORATORY RESULTS

RADIOGRAPHIC REPORT

(CHEST PA)

December 4, 2006

The lungs are clear. The heart is enlarged (CTR:067) exhibiting inferolateral

displacement of the cardiac apex. There are crescentic calcifications in the aortic

knob.

The midline structures are not displaced. The costophrenic sulci and

hemidiaphragms are intact. The rest of the included structures are unremarkable.

CU cardiomegaly is considered. ECG correlation suggested

Atheromatous aorta

?

DPBR, Radiologist

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HEMATOLOGY REPORT

Lab no. : 600066002

Date Received: 12-04-06 (5:58)

Date Reported: 14-04-06 (7:18)

TEST RESULT UNIT REFERENCE

WHITE BLOOD CELLS

RED BLOOD CELLS

HEMOGLOBIN

HEMATOCRIT

MCV

MCH

MCHC

DIFFERENTIAL COUNT

Lymphocyte

Neutrophil

Monocyte

Eosinophils

Basophils

PLATELET

23.31

4.40

13.2

39.7

94.7

30.1

32.0

7.5

89.2

7.4

.9

.2

189

10^3/uL

10^6/uL

g/dL

%

fL

pg

g/dL

%

%

%

%

%

10^3/uL

5.0 - 10.0

4.2 - 5.4

12.0 – 16.0

37.0 – 47.0

82.0 – 98.0

27.0 – 31.0

31.5 – 35.0

17.4 – 48.2

43.4 – 76.2

4.5 – 10.5

1.0 – 3.0

0.0 – 2.0

150 - 400

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DRUG STUDY

Generic Name

Brand Name

Date ordered Classification Dose/

Frequency/ Route

Mechanism of Action

Indication Contraindication Side Effects Nursing Precaution

Verapami Isoptin December 3, 2006

Anti-hypertensive

240mg/ 1tab od/ PO

Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction.

Management of hypertension

Hypersensitivity, sick sinus syndrome

BP less than 90 mmHg

CHF, severe ventricular dysfunction

Anxiety, confusion,Dizziness, headache, nervousness, blurred vision, polyuria, vomiting

Use cautiously in severe hepatic impairement- geriatric patient.

History of serious ventricular arrhythmias.

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Generic Name

Brand Name

Date ordered Classification Dose/

Frequency/ Route

Mechanism of Action

Specific Indication

Contraindication Side Effects Nursing Precaution

Sucralfate Iselpin December 3, 2006

Antiulcer drugs

1 gram qid/ PO(befire meals at HS)

Unknown. Probably adheres to and protects surface of ulcer by forming a barrier.

Short term treatment of ulcer (duodenal)

Maintenance therapy for duodenal ulcer

Use cautiously to patient with chronic renal failure

Dizziness, headache, vertigo, constipation, nausea, gastric discomfort, diarrhea, dry mouth

Drug is minimally absorbed and causes few adverse effect

Drug contains Aluminum but isn’t classified as Antacid. Monitor patients renal insufficiency for aluminum toxicity

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Generic Name Brand Name Date ordered Classification Dose/

Frequency/ Route

Mechanism of Action

Specific Indication

Contraindication Side Effects Nursing Precaution

Esomepra-zole

Nexium December 3, 2006

Antiulcer drugs

20mg/ 1 tab bid/ PO

Proton Pump Inhibitor that reduces gastric acid secretion and decreases gastric acidity

Helicobacter Pylori eradication

Hypertensive to drug or some components of esomeprazole or omeprazole

Headache, dry mouth, diarrhea, nausea, abdominal pain, vomiting, and constipation

Give at least one hour before meals

Monitor GI symptoms for improvement or worsening.

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Generic Name

Brand Name Date ordered Classification Dose/

Frequency/ Route

Mechanism of Action

Specific Indication

Contraindication Side Effects Nursing Precaution

Combivent Salbutamol Sulfate

December 3, 2006

Broncho-dilators

1 neb q 6o

Relaxes bronchial uterine and vascular smooth muscle by stimulating beta2 receptors.

To prevent or treat broncho-spasm in patient with severe obstructive airway disease

Hypertensive to drug or ingredients

Use extended release tablets cautiously in patient with GI narrowing

Dizziness, headache, heartburn, nausea, vomiting, cough, increase sputum, tachycardia

Drug may decrease sensitivity of spirometry used for dx of asthma

Patient may use tablet and aerosol together monitor for signs of toxicity.

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Generic Name Brand Name Date ordered Classification Dose/

Frequency/ Route

Mechanism of Action

Specific Indication

Contraindication Side Effects

Nursing Precaution

Lactulose Dupholac December 4, 2006

Laxatives 20cc/ bid/ PO

Produces an osmotic effect in colon, resulting distention promotes peristalsis.

For or treat constipation

Patient with a low galactose diet

Use cautiously in patient with diabetes mellitus.

Abdominal cramps, belching, diarrhea, gaseous distention, flatulence, nausea, vomiting

Minimize sweet taste dilute with water or give with food.

Monitor sodium level for hypernatremia, especially when giving in higher doses to treat hepatic encephalopathy.

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Generic Name

Brand Name

Date ordered Classification Dose/

Frequency/ Route

Mechanism of Action

Specific Indication

Contraindication Side Effects Nursing Precaution

Cefixime Tergeof December 4, 2006

Cephalosporin / antibiotic

200mg/ bid/ PO

Stable in the presence of beta-lactamase enzyme

Used for acute bronchitis and acute exacerbations of chronic bronchitis.

Hypertensive to drugs or other cephalosporin drugs.

Flatulence, elevated alkaline phosphatase level.

Once reconstituted, keep suspension at room temperature where it maintains potency for 14 days.

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V. ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY

Digestive System, organs for changing food chemically into simple soluble substances absorbable by tissues. This process involves catalytic reactions between ingested food and enzymes secreted into the intestinal tract (see Intestine). Digestion of fatty substances appears to involve the assembly of bile salts, phospholipids, fatty acids, and monoglycerides that can pass through intestinal cells. Other nutrients such as iron and vitamin B12 are absorbed by specific “carrier proteins” that make them transferable by the intestinal cells. The process described here is typical of all vertebrates except ruminants.

Digestion includes both mechanical and chemical processes. The mechanical processes include chewing to reduce food to small particles, the churning action of the stomach, and intestinal peristaltic action. These forces move the food through the digestive tract and mix it with various secretions. Three chemical reactions take place: conversion of carbohydrates into such simple sugars as glucose (see Sugar Metabolism), breaking down of protein into such amino acids as alanine, and conversion of fats into fatty acids and glycerol (see Fats and Oils). These processes are accomplished by specific enzymes.

When food is eaten, the six salivary glands produce secretions that are mixed with the food. The saliva breaks down starches into dextrin and maltose, dissolves solid food to make it susceptible to the action of later intestinal secretions, stimulates

18

secretion of digestive enzymes, and lubricates the mouth and oesophagus for the passage of solids.

Stomach and Intestinal Action

Gastric juice in the stomach contains agents such as hydrochloric acid and some enzymes, including pepsin, rennin, and traces of lipase. (The surface of the stomach itself is thought to be protected from acid and pepsin by its mucous coating.) Pepsin breaks proteins into peptones and proteoses. Rennin separates milk into liquid and solid portions; lipase acts on fat. Another function of stomach digestion is gradually to release materials into the upper small intestine, where digestion is completed. Some constituents of gastric juice become active only when exposed to the alkalinity of the small intestine; secretion is stimulated by chewing and swallowing and even by seeing or thinking of food (see Reflex). The presence of food in the stomach also stimulates production of gastric secretions; these in turn stimulate the production of digestive substances in the small intestine.

The most extensive part of digestion occurs in the small intestine; here most food products are further hydrolysed and absorbed. Predigested material supplied by the stomach is subjected to the action of three powerful digestive fluids: pancreatic fluid, intestinal juice, and bile. These fluids neutralize the gastric acid, ending the gastric phase of digestion.

Intestinal juice is secreted by the small intestine. It contains a number of enzymes; its function is to complete the process begun by the pancreatic juice. The flow

19

of intestinal juice is stimulated by the mechanical pressure of food partly digested in the intestine.

The water-soluble substances, including minerals, amino acids, and carbohydrates, are transferred into the venous drainage of the intestine and through the portal blood channels directly to the liver. Many of the fats, however, are resynthesized in the wall of the intestine and are picked up by the lymphatic system (see Lymph), which carries them into the systemic blood flow as it returns through the vena caval system (see Heart), bypassing an original passage through the liver (see Circulatory System).

Excretion

Undigested material is formed into a solid mass in the colon by reabsorption of water into the body. If colonic muscles propel the excretory mass through the colon too quickly, it remains semi-liquid. The result is diarrhoea. Insufficient activity of the colonic musculature, on the other hand, produces constipation. The stool is held in the rectum until excreted through the anus.

Many disorders of absorption are collectively called malabsorptive states, the most profound and difficult being a condition known as spruce.

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PATHOPHYSIOLOGY

Definition:

Peptic Ulcer

A circumscribed breaks or ulcerations of the gastrointestinal mucosa and

underlying tissues caused by gastric secretions that have low pH(acid)

Predisposing Factors

Blood Type (tends to strike with type “A” blood; duodenal ulcers tends to afflict

type “O” Blood.

Genetic Predisposition/ Factors

Normal Aging

Exposure to irritants (alcohol use and tobacco smoking)

Physical trauma

Emotional stress or psychosomatic factors (e.g. chronic anxiety)

Precipitating Factors

Epigastric Pain which is burning

Piercing and periodic

Hyperacidity

Nausea or vomiting

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Schematic Diagram

HCl = Pepsin Irritants(Alcohol and tobacco)

Increase or excessive mucous or gastric acid secretions (caused by secretions stress or stimulants)

Damage of mucous membrane

PEPTIC ULCER DISEASE

S/s: Pain (burning, Aching, or gowning)Epigastric Tenderness

Bleeding at the site (GIT)Passage of tarry stools (melena)

May occur

Complications: pyloric or duodenal obstruction,

hemorrhage and perforation22

VI. NURSINS ASSESSMENT

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EENT: Impaired vision blind pain reddened drainage gums hardof hearing deaf burning edema lesions teethassess eyes ears nose throat for abnormalities no problemRESP: Asymmetric tachypnea apnea rales cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea labored wheezing pain cyanoticasses resp. rate, rhythm, depth, pattern, breath sounds, comfort noproblemCARDIO VASCULAR Arrhythmia tachycardia numbness diminished pulse edema fatigue irregular bradycardia murmur tingling absent pulses painassess heart sounds, rate rhythm, pulse, blood pressure, circ., fluid retention, comfort no problemGASTRO INTESTINAL TRACT Obese distention mass dysphagia rigidly painassass abdomen, bowel habits, swallowing, bowel sounds, comfort no problemGENITO-URINARY Pain urine color vaginalbleeding hematuria discaharge noctoriaAssess urine freq., control, color, odor, comfort/gyn-bleeding, discharge no problemNEURO Paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision gripassess motor function, sensation, LOC, strength, grip, gait, coordination, orientation,speech, no problemMUSCULOSKELETAL and SKIN Appliance stiffness itching petechiae hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed atrophy pain ecchymosis diaphoretic moistassess mobility, motion, gait, alignment, joint function/skin color, texture, turgor, integrity noproblem

Place an (x) in the area of abnormality. Comment at the space provided indicate the location of the problem in the figure if appropriate, using (x)

Pain at OD

O2 administration (nasal Cannula)

Tachypnea (RR 28cpm)Hyperventilation

Pain @ Right Knee / Leg(Arthritis)

IVF D5NSS 1l infusing at Right hand @ 20gtts/min

Abdominal Pain

Body is Weak

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EENT: Impaired vision blind pain reddened drainage gums hardof hearing deaf burning edema lesions teethassess eyes ears nose throat for abnormalities no problemRESP: Asymmetric tachypnea apnea rales cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea labored wheezing pain cyanoticasses resp. rate, rhythm, depth, pattern, breath sounds, comfort noproblemCARDIO VASCULAR Arrhythmia tachycardia numbness diminished pulse edema fatigue irregular bradycardia murmur tingling absent pulses painassess heart sounds, rate rhythm, pulse, blood pressure, circ., fluid retention, comfort no problemGASTRO INTESTINAL TRACT Obese distention mass dysphagia rigidly painassass abdomen, bowel habits, swallowing, bowel sounds, comfort no problemGENITO-URINARY Pain urine color vaginalbleeding hematuria discaharge noctoriaAssess urine freq., control, color, odor, comfort/gyn-bleeding, discharge no problemNEURO Paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision gripassess motor function, sensation, LOC, strength, grip, gait, coordination, orientation,speech, no problemMUSCULOSKELETAL and SKIN Appliance stiffness itching petechiae hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed atrophy pain ecchymosis diaphoretic moistassess mobility, motion, gait, alignment, joint function/skin color, texture, turgor, integrity noproblem

Place an (x) in the area of abnormality. Comment at the space provided indicate the location of the problem in the figure if appropriate, using (x)

Pain at OD

O2 administration (nasal Cannula)

Tachypnea (RR 28cpm)Hyperventilation

Pain @ Right Knee / Leg(Arthritis)

IVF D5NSS 1l infusing at Right hand @ 20gtts/min

Abdominal Pain

Body is Weak

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Briefly describe the patient's ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). Medications ordered by the doctor are always available and given at the right time but not similar to his diet. He seldom eat food because of his condition, as the patient stated

MGT. OF HEALTH & ILLNESS: Alcohol denied (amount, frequency)____as patient verbalized that he doesn’t drink alcoholic beverages any more __ SBE Last Pap Smear _____N/A__________ LMP: _________N/A_____________________

Comments __________ Bowel sound___________________________ ______Audible________________________ Abdominal Distension___________________ Present yes no ___________________ Urine* (color.,___________________ consistency, odor)___________________ _____________________________________ _____________________________________ _____________________________________ *if they are in place?

ELIMINATION:Usual bowel pattern urinary frequency____2 x per day___ ____Every Hour______ Constipation urgency Remedy dysuria_December 5, 2006_ hematuria Date of last BM incontinence________________ polyuria Diarrhea foly in place Character denied________________

Dentures none Full Partial With PatientUpper

Lower

NUTRITION:Diet___________________________________ N V Comments__________Character ____________________ Recent change in ____________________ wieght,appetite ____________________ Swallowing ____________________ difficulty _____________________ Denied _____________________

Heart rhythm regular irregular Ankle edema ___________________________Pulse Car. Rad. DP Fem.* R _+______+_______+______+_____+______L _+______+_______+______+_____+______Comments:_all pulses are palpable or noted during the assessment (positive) * if applicable

CIRCULATION: Chest pain Comments___________ ____________________ Leg pain ____________________ ____________________ Numbness of ____________________ Extremities ____________________ ____________________ Denied ____________________

Resp. regular irregularDescribe: __Patient exhibits hyperventilation a manifestation of tachypnea on patient_______

R _side is symmetrical during inhalation/exhalation L _side is symmetrical during inhalation/exhalation

OXYGENATION: Dyspnea Comments___________ Smoking history ___________________ _____________ __________________ cough __________________ sputum __________________ denied ___________________

Glasses languages Contact lens hearing aide R L Pupil Size ___3.0mm__ speech difficulties Reaction ____PERRLA_____

COMMUNICATION: Hearing loss Comments___________ Visual changes ____________________ Denied ____________________ ____________________ ____________________

OBJECTIVESUBJECTIVE

“maayo raman akong paminaw, sakit lang usahay akong tuo nga mata”

“gahanga- kon ko tungod sa akong ubo na grabe ang plema panalagsa”

“gapaminhod usahay and akong tiil ug usahay pud musakit tungod aning arthritis na hinungdan nganu galisod kog lakaw usahay”

Diet as Tolerated

“Dili nagyud kau ko g,a kaun wala man gyud koy gana bisag unsa nga pagkaun na ihatag sa akoa”

“sige ko ug kalibang ug tae na basa as verbalizad by the patient. Still his stool is black, tarry/bloody (melena), and wet (characteristics)

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 12-04-06 Chest X-Ray12-04-06

 Date disc.

(Still Infused)

I.V. Fluids/Blood

D5NSS 1L @20 gtts/min

Date ordered

12-05-06

Date done

12-04-06

Diagnostic/ laboratory Exams

Complete Blood Count

Date ordered

12-04-06

 SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)______100 lbs ___ Daily Weight _____N/A_______PT/OT _____N/A__________140/70 mmHg__ BP q Shift _____N/A____ Irradiation_____N/A________ Neuro vs. _____N/A____ Urine Test _____N/A____________N/A________ CVP/SG. Reading _____N/A____ 24 hour Urine collection

 Observed non- verbal behavior Always touching his jaw during my assessment when he speaks and even after coughing. The person and his phone number that can be reached any time ___________________________________________________________________

COPING:Occupation _________None _____________Members of household ___Melsa, Rebbeca Fe, Lenthi Ann____________________________Most supportive person ____ Rebbeca Fe __________________________________________

  Facial grimaces Guarding Other signs of pain __there were no other signs of pains felted by the patient during my assessment_____________________________________________Side rail release form signed ( 60 + years)_________________________________________

COMFORT/SLEEP/AWAKE: Pain Comments __________ (location) ___________________ Frequency ____________________ Remedies) ____________________ Nocturia ____________________ Sleep difficulties ____________________ Denied ____________________

  LOC and orientation _The patient is still aware of the time, date and place______________________________ Gait: walker cane other Steady unsteady____________________ Sensory and motor losses in face or extremities _______________________________ ROM limitations __cannot extremely move his right leg or even his lower extremities because of his arthritis__________________________________________________________________________________________________________________________________________________________________________

ACTIVITY/ SAFETY: Convulsion Comments ___________ Dizziness ____________________ Limited motion ____________________ Of joints ____________________ ____________________ Limitation in ____________________ Ability to ____________________ Ambulate ____________________ Bathe self ____________________ Other ____________________ Denied ____________________

  Dry cold pale Flushed warm Moist cyanotic*ashes, ulcers, decubitus (describe size, location, drainage) __tenderness/ ulcerations or rashes are not noted during the assessment

SKIN INTEGRITY: Dry Comments ___________ ____________________ Itching ____________________ ____________________ Other ____________________ ____________________ Denied ____________________

 OBJECTIVESUBJECTIVE

“wala man koy katol-katol sa akong panit, wla pud koy problema anang mga samad samad sa akong panit”

“gabatiun kog kalipong dili napud ko tanto maka lakaw lakaw. Kung magkaun ko taman rako lingkod sa akong bed o sa akong higdaanan mukaun ug ga diapers na gali ko kay lisod na kau maglakaw-lakw ”

“sigi ko ug ihi-ihi sa gabie, dili pud ko katulog ug tarong kay gaubuha ko ug mau”

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VII. NURSING MANAGEMENT

IDEAL NURSING MANGEMENT

ACTIONS/INTERVENTIONSDiarrhea Management (NIC)IndependentObserve and record stool frequency, characteristics,amount, and precipitating factors.

Promote bedrest, provide bedside commode.

Remove stool promptly. Provide room deodorizers.

Identify foods and fluids that precipitate diarrhea, e.g.,raw vegetables and fruits, whole-grain cereals,condiments, carbonated drinks, milk products.

Restart oral fluid intake gradually. Offer clear liquidshourly; avoid cold fluids.

Administer medications as indicated:Antidiarrheals, e.g., diphenoxylate (Lomotil),Loperamide (Imodium), anodyne suppositories;

RATIONALE

Helps differentiate individual disease and assessesseverity of episode.

Rest decreases intestinal motility and reduces themetabolic rate when infection or hemorrhage is acomplication. Urge to defecate may occur withoutwarning and be uncontrollable, increasing risk ofincontinence/falls if facilities are not close at hand.

Reduces noxious odors to avoid undue patientembarrassment.

Avoiding intestinal irritants promotes intestinal rest.

Provides colon rest by omitting or decreasing the stimulusof foods/fluids. Gradual resumption of liquids mayprevent cramping and recurrence of diarrhea; however,cold fluids can increase intestinal motility.

Decreases GI motility/propulsion (peristalsis) anddiminishes digestive secretions to relieve cramping anddiarrhea. Note: Use with caution in UC because they mayprecipitate toxic megacolon.

NURSING DIAGNOSIS: DiarrheaMay be related to

Inflammation, irritation, or malabsorption of the bowelPresence of toxinsSegmental narrowing of the lumen

Possibly evidenced byIncreased bowel sounds/peristalsisFrequent, and often severe, watery stools (acute phase)Changes in stool colorAbdominal pain; urgency (sudden painful need to defecate), cramping

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Bowel Elimination (NOC)

Report reduction in frequency of stools, return to more normal stool consistency.Identify/avoid contributing factors

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NURSING DIAGNOSIS: Fluid Volume, risk for deficientRisk factors may include

Excessive losses through normal routes (severe frequent diarrhea, vomiting)Hypermetabolic state (inflammation, fever)Restricted intake (nausea/anorexia)

Possibly evidenced by[Not applicable; presence of signs and symptoms establishes an actual

diagnosis.]DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Hydration (NOC)

Maintain adequate fluid volume as evidenced by moist mucous membranes, good skin turgor, and capillaryrefill; stable vital signs; balanced I&O with urine of normal concentration/amount.

ACTIONS/INTERVENTIONSFluid/Electrolyte Management (NIC)Independent

Monitor I&O. Note number, character, and amount ofstools; estimate insensible fluid losses, e.g., diaphoresis.Measure urine specific gravity; observe for oliguria.

Assess vital signs (BP, pulse, temperature).

Observe for excessively dry skin and mucous membranes,decreased skin turgor, slowed capillary refill.

Weigh daily.

Maintain oral restrictions, bedrest; avoid exertion.

Observe for overt bleeding and test stool daily for occultblood.

RATIONALE

Provides information about overall fluid balance, renalfunction, and bowel disease control, as well as guidelinesfor fluid replacement.

Hypotension (including postural), tachycardia, fever canindicate response to and/or effect of fluid loss.

Indicates excessive fluid loss/resultant dehydration.

Indicator of overall fluid and nutritional status.

Colon is placed at rest for healing and to decreaseintestinal fluid losses.

Inadequate diet and decreased absorption may lead tovitamin K deficiency and defects in coagulation,

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Note generalized muscle weakness or cardiacdysrhythmias.CollaborativeAdminister parenteral fluids, blood transfusions asindicated.

Administer medications as indicated:Antidiarrheal (Refer to ND: Diarrhea);

potentiating risk of hemorrhage.

Excessive intestinal loss may lead to electrolyteimbalance, e.g., potassium, which is necessary for proper

skeletal and cardiac muscle function. Minor alterations inserum levels can result in profound and/or life-threateningsymptoms.

Reduces fluid losses from intestines.

NURSING DIAGNOSIS: Pain, acuteMay be related to

the effect of gastric acid secretion on damaged tissue Possibly evidenced by

Reports of colicky/cramping abdominal pain/referred painGuarding/distraction behaviors, restlessnessFacial mask of pain; self-focusing

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Pain Level (NOC)

Report pain is relieved/controlled.Appear relaxed and able to sleep/rest appropriately.

ACTIONS/INTERVENTIONSPain Management (NIC)IndependentEncourage patient to report pain.Assess reports of abdominal cramping or pain, notinglocation, duration, intensity (0–10 scale). Investigate andreport changes in pain characteristics.

Note nonverbal cues, e.g., restlessness, reluctance to

RATIONALE

May try to tolerate pain rather than request analgesics.Colicky intermittent pain occurs with Crohn’s diseasePredefecation pain frequently occurs in UC with urgency,which may be severe and continuous. Changes in paincharacteristics may indicate spread of disease/developingcomplications, e.g., bladder fistula, perforation, toxicmegacolon.

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move, abdominal guarding, withdrawal, and depression.Investigate discrepancies between verbal and nonverbalcues.

Review factors that aggravate or alleviate pain.

Encourage patient to assume position of comfort, e.g.,knees flexed.

Provide comfort measures (e.g., back rub, reposition) anddiversional activities.

Observe/record abdominal distension, increasedtemperature, decreased BP.CollaborativeImplement prescribed dietary modifications, e.g.,commence with liquids and increase to solid foods astolerated.

Administer medications as indicated, e.g.:Analgesics;Anti-ulscer drugs;

Body language/nonverbal cues may be both physiologicaland psychological and may be used in conjunction withverbal cues to determine extent/severity of the problem.

May pinpoint precipitating or aggravating factors (such asstressful events, food intolerance) or identify developingcomplications.

Reduces abdominal tension and promotes sense ofcontrol.

Promotes relaxation, refocuses attention, and mayenhance coping abilities.

May indicate developing intestinal obstruction frominflammation, edema, and scarring.

Complete bowel rest can reduce pain, cramping.Pain varies from mild to severe and necessitatesmanagement to facilitate adequate rest and recovery.Note: Opiates should be used with caution because theymay precipitate toxic megacolon.

Relieve spasms of GI tract and resultant colicky pain.

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ACTUAL NURSING MANAGEMENT

“Subjective”

The patient complained of difficulty of breathing because of his cough and

even verbalized that his throat was very painful when he will swallow food

“Objective”

The patient manifests tachypnea or hyperventilation during the assessment.

With a respiration Rate of 28 cpm, with a productive cough noted and shows

facial grimace upon respiration or coughing.

“Assessment”

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Ineffective airway clearance related to increased production of secretions,

retained secretions and bronchospasm.

“Planning”

At the end the interventions given to the patient, he would somehow perform

with himself the skills or techniques on how to lessen, ease, or prevent

dyspnea, cough or hyperventilation. The patient will also learn about the

reason of the condition, how it occurs and how it would be prevented and

what are the uses of the medications given by his physician.

“Implementation”

Assist patient to assume position of comfort (e.g. elevate the head part of the

bed).- Elevation of head facilitates respiratory function by use of gravity;

however patients in severe distress will seek the position that most eases

breathing.

Keep environment to a minimum (e.g. dust, smoke, and feather pillow)-

Precipitator of allergic reaction of respiratory reaction that can trigger or

exacerbate onset of acute episode

Encourage or assist with abdominal or pursed lips breathing exercise.-

provide patient with some means to cope with control dyspnea and reduces

air trapping

Increase fluid intake to 3000mL/day within cardiac tolerance. Provide

warm/tepid liquids recommended intake of fluid between, instead of during

meals.- hydration helps reduces the viscosity of secretions, facilitating

expectoration using warm liquids may decrease bronchospasm . Fluids

during meals can increase gastric distention and pressure on the diaphragm.

Administer medications as prescribed by his doctor such as bronchodilator

(e.g. ventolin, combivent)- this medication relaxes smooth muscles and

reduce local congestion, reducing airway spasm, wheezing, and mucus

production.

“Evaluation”

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At the end of a couple of interventions done to the patient, he reports reduced

difficulty in breathing that is, retained secretions are somehow lessened and

coughing was also reduced. And he will be able to prevent bronchospasm if

he continue using or performing the interventions for the wellness of his

health

“Subjective”

The patient has a complaint of bloody and dark colored stool (melena). Also

verbalized that he coughs or cough-up blood with sputum on it. And also

experiences burning epigastric pain or discomfort on his abdominal part or

area.

“Objective”

Was diagnosed with bleeding peptic ulcer disease; on his complete blood

count results found out that his hemoglobin was deceased and this is a sign

for blood loss. And regarding his discomforts felt on his abdomen, wherein

he show facial grimace when pains is felt.

“Assessment”

Increase risk of anemia due to acute GI bleeding related to ulcer

Acute pain related to pyloric obstructions complication of peptic ulcer

“Planning”

At the end of the interventions done to the patient, he will be able to perform

specific interventions with him self on how to lessen or prevent the

discomforts felt by the patient and how to manage of having a regular or

normal characteristics of stools upon defecation. By teaching patient the

methods to minimize symptoms while maintaining adequate nutrition and also

teaching patient about necessary life style changes aimed at decreasing

stress and minimizing effectiveness of coping mechanism.

“Implementation”

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Provide small and frequent meals- Food prevents distenson and release of

gastrins and has an acid neutralizing effect. Patient should eat meals on a

regular basis.

Institute measures to neutralize or buffer hydrochloric acid, inhibit acid

secretion and decreases the activity of pepsin

Administer antacids as prescribed by the physician to reduce acidity and

even anti ulcer drugs (e.g. esomeprazole)- to treat peptic ulcer or eradicate

helicobacter pylori.

Diet regulation through the use of bland foods and restriction of irritating

substances such as nicotine, caffeine, alcohol, spices, and gassy foods.

To have some bed rest to reduce physical activity and promote comfort to the

patient.

Encourage hydration to reduce anticholinergic side effects and dilute the

hydrochloric acid in the stomach

“Evaluation”

At the end of a several interventions, the patient somehow reports reduced

pain; the patient verbalizes appropriate diet modification and even

demonstrates compliance with the prescribed medication regimen in order to

reach the total health and wellness.

“Subjective”

The patient complained of pain on his right leg and even numbness, and

wasn’t able to walk with him self because of the pains and even because of

his condition, as he verbalized.

“Objective”

Has limitation on his range of motion: right leg, when tenderness is felt.

There is facial grimace when patient wants to move his leg or when pain

occurs. He was not able to ambulate by himself.

“Assessment”

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Acute Pain related to joint tenderness due to arthritis on right leg

“Planning”

The patient would somehow perform the techniques on how to exercise or

practice moving his affected area with himself and even would tolerate the

pain for a short period of time. And even the patient would be aware on what

are the significance of the said interventions and how it affects his total

condition or how it can help him on the entire course of health teachings.

“Implementation”

Elevate the affected portion or the foot of the patient with pillows under it. So

hat it would promote blood circulation.

To practice exercising his leg joints by extension or flexion of knees(range of

motion exercise)

Apply heat and colds to or on the affected area to provide relief or comfort to

the area by constriction / dilation of blood vessels

Promote rest and position of comfort to ease joint pains and encourage diet

rich in nutrients – dense food such as fruit, vegetables or legumes

Administer medications as prescribed by his doctor such as analgesics - this

drug reduces pains felt by the patient.

“Evaluation”

At the end of a couple of interventions done to the patient, he reports reduced

difficulty in breathing that is, retained secretions are somehow lessened and

coughing was also reduced. And he will be able to prevent bronchospasm if

he continue using or performing the interventions for the wellness of his

health

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VIII. REFERRALS AND FOLLOW-UP

It is important to comply regularly its medication as prescribed by his attending

physician and to continue and finish its entire therapeutic regimen. And explain to the

patient the use and side effects of the medications so that he will be aware of its effects

such as bronchodilators for the treatment of his cough that helps alleviate or prevent

bronchospasm (e.g. ventolin for Nebulization) and even anti-ulcer drugs to prevent

reoccurrence of the disease (e.g. Sucralfate).

35

He should practice moving his lower extremities to promote blood circulation and even

to improve the range of motion of his foot or feet so that he could somehow, able to

ambulate with him self in later times. To perform bed exercise such as leg exercise,

since patient is always on bed and have limitations on his physical activity because his

still weak.

The patient was instructed to avoid over work for the following days and must

have adequate bed rest to regain energy or strength. By means of anticipating the

needs on the course of healing and curing process the patient must then focused to

himself by not always depending on the interventions that are not highly needed just to

ease or prevent any health problem regarding his condition . But he should focus

entirely on how to prevent the problem on his actions by himself.

Environmental sanitation is needed to provide a healthy and therapeutic way of

curing himself. Smoking and alcohol consumption must be prevented totally by the

patient so that his problem would not be worse again..

Upon discharged, he must come back to the hospital one week after, for the

follow-up check-up to confirm if the patients condition is really restored. Also to know if

there are complications sited during the check up to know if patients condition have

worsen or not.

And lastly, he should take note of the foods that are irritating to his GI tract to

prevent reoccurrence of abdominal pain and even should eat adequate amount of foods

every meals. Eating nutritious food would somehow help the patient on regaining some

strengths or energy to his body, such as green leafy vegetables, fruits, and foods rich in

protein.

IX. EVALUATION AND IMPLICATIONS

At the end of my hospital duty, I as a student nurse was able to render care to my

patient to help him resolve his problem regarding health. Through observing the

patient’s status, I was able to identify some problems during my assessment. Because

of a couple of interventions or health teachings applied and imparted to the patient, I

was able to lessen its respiratory pattern on the patients problem of breathing

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(ineffective Airway Clearance); alleviated pains felt by the patient due to the effects of

the peptic ulcer or to the arthritis; and even have defecated a normal characteristics of

stool.

Patient was willing to pursue his medical therapy just to promote health and

wellness for the betterment of his condition. During the treatment, the patient was able

to develop or enhance health awareness on his disease and with this knowledge

instilled to his mind, he was then aware on how the disease was transmitted and what

are the proper ways or interventions done just to minimize or prevent this disease from

getting worst.

I have also made the patient realize the importance of completing the course of

therapy by taking the medicines prescribed or ordered to him by his physician. In

addition, eating healthy or nutritious foods that were prescribed to him by the health

providers was further been explained to him especially the benefits he will gain in eating

these nutritious foods.

In general, the patient was very cooperative to what health measures

administered to him by the health providers.

Moreover, these several interventions given to the patient made his body

functions different than as before

X. BIBLIOGRAPHY

Lippincott Williams and Wilkins, Nursing 2006 Drug Handbook, 26th Edition,

Barbara Kozier et al, Fundamentals of Nursing, 7th Edition,

Lippincott Williams and Wilkins, Nursing 2004 Drug Handbook, 24rd Edition,

Mosby’s Pocket Dictionary of Medicine, Nursing Allied Health, 4 th Edition,

Published in Elsevier Science (Singapore) PTE LTD

Microsoft ® Encarta ® Premium Suite 2005. © 1993-2004 Microsoft

Corporation. All rights reserved.

37

Mosby’s Comprehensive Review of Nursing, 13th Edition by:

Saxton,Nugent,Pelikan

http://www.cnn.com/HEALTH/library/DS/00583.html

Smeltzer & Bare, medical Surgical Nursing, 10th ed. Vol. 1, Lippincott

Williams & Wilkins, Philadelphia, USA pp.1015-1051

Mosby’s MEDICAL ENCYCLOPEDIA, the definitive health reference

http://www.wrongdiagnosis.com/p/peptic_ulcer/symptoms.htm

http://en.wikipedia.org/wiki/Peptic_ulcer

http://www.emedicine.com/med/topic1776.htm

http://www.gicare.com/pated/ecdgs09.htm

http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=8

LICEO DE CAGAYAN UNIVERSITY R.N.P. Blvd., Carmen, Cagayan de Oro City

C O L L E G E O F N U R S I N G

A Care Study

Moesis L. Labuntog

38

Submitted to:

Ms. Asterie Revelo, RNClinical Instructor

As Partial Requirement for NCM501202

Submitted by:

Librea, Celso R.NCM501202 Student

January 18, 2007