Presented by:BSN II Group A

Peptic Ulcer is circumscribed erosion in or loss of, the mucous membrane lining in the gastrointestinal tract. It may occur in the esophagus (esophageal ulcer), stomach (gastric ulcer), duodenum (duodenal ulcer) or jejunum (jejunal ulcer). The stomach and duodenum is the most common sites.

Peptic Ulcer may result from excess acid production or from a breakdown in the normal mechanisms protecting the mucous membranes. It is also associated with stress and intake of certain drug (eg. Corticosteroids and certain NSAIDs).

Helicobacter pylori, a spiral shaped bacterium found in the stomach is generally acknowledged as the main cause for most peptic ulcers and many cases of chronic gastritis.

Duodenal Ulcer Gastric Ulcer

Age: 25-50Male:Female= 2-3:188% of peptic ulcer are duodenal

Usually 50 and overMale:Female = 1:115% of peptic ulcer are gastric

Signs and Symptoms, Clinical Findings

-Hypersecretion of stomach acid (HCL)-May have wt gain-Pain occurs 2-3 hrs after a meal; often awakened 1-2am; ingestion of food relieves pain-vomiting uncommon-hemorrhage less likely than with gastric ulcer, but if present, melena more than hematemesis-more likely to perforate than gastric ulcers-Common on type O

-Normal-hyposecretion of stomach acid (HCL)-wt loss may occur-pain occur ½ to 1 hr after a meal; rarely occurs at night; may be relieved by vomiting; ingestion of food does not help, sometimes increases pain-vomiting common-Hemorrhage more likely to occur than with duodenal ulcer; hematemesis more common than melena.

Duodenal Ulcer Gastric Ulcer

•H. Pylori•Alcohol

•Smoking•Cirrhosis

•Stress

•H. Pylori•Gastritis•Alcohol

•Smoking•Use of NSAID’s

•Stress

Over the past few decades,the incidence of peptic ulcer disease and ulcer complication has decreased.

There has however,been an increase in ulcer bleeding,especially in elderly patients.

At present,there are several management issue that need to be solved.

For more than a century,peptic ulcer disease was most often managed surgically,with resulting high morbidity and mortality rates.

Effective pharmacologic suppression of gastric acid secretion began with the introduction of histamine H2-receotor antagonists(H2RAs) in the 1970s,which greatly improved clinical outcome .

During the 1980s elective peptic ulcer surgery declined by 85%,which can be mainly attributed to the use of the H2RAs cimetidine and ranitidine.

To improve the quality of life and promote health for those who have peptic ulcer disease.

Recognize the potential causes of peptic ulcer disease.

Gain the necessary information about the prevalence of peptic ulcer disease.

To be able to demonstrate acceptance of the disease that will motivate compliance with the treatment.

To prevent a plan of care for the prevention and management for peptic ulcer disease and its complications.

Name: AAAddress: Sta. Maria, BulacanAge: 49Status: MarriedGender: FemaleReligion: CatholicDate of Admission: March 12, 2010Time of Admission: 5 amAttending Physician: Dra. VirayDiagnosis: Severe Anemia secondary to UGIB

secondary to BPUD

Biographical Data

Pt AA, 49 years old female, married with7 children, an active roman catholic, a former business woman, currently residing at Sta.Maria, Bulacan was admitted for the second time at Cong. Rogaciano M. Mercado Memorial Hospital last March 12, 2010 at around 9:49 am.

Chief Complaint

Pt was complaining of severe abdominal pain, difficulty of breathing and stool with dark red blood color (1 cup).

History of Present Illness

One week prior to admission, Pt seek for medical check up at RMMMH OPD due to recurrence of blood in her stool and abdominal pain. But because of frustration from waiting for her turn to be examine, Pt left and went to a small clinic (TAXI clinic). Pt was refused by the doctor of the said clinic and was requested to be admitted to any hospital that can provide her the proper management for her condition. Pt did took mefenamic acid to relieve her pain. One day prior to her admission, Pt experienced severe abdominal pain and weakness and so her husband took her at the emergency room at Rogaciano Hospital.

History of Past Illness

Pt AA had her first confinement 7 years ago at the same hospital due to difficulty of breathing and abdominal pain. Pt does not recover any medicines that was given to her during her confinement.

Socio Economics

Pt AA and her husband has a small feather business. They travel most of the time delivering chicken feathers to different places. Pt has 7 children and due to this, the couple work extra in order to provide the needs of their children.

Lifestyle

Pt AA has a very hectic schedule. She sleeps at midnight and wakes up at 3am, drinks coffee then start doing her house chores before leaving the house. Pt AA has no hobbies or any extra activity. She’s always under stress and has no time to rest. Since Pt AA always travel, she continuously skip meals or eat late.

Heredo Familial

Pt’s father side has history of HPN and her mother side has history of anemia.

March 12 (7-3 Shift)Pt is admitted at ICU because of DOB,

pallor, and (+) melena. Consent is secured, seen and examined by Dra. Viray and TPR q4h is taken. Initial BP is 100/60 and temp of 36.8ºC. Pt was requested to have CBC, blood typing, urinalysis, creatinine, SGOT and ECG done. Pt IVF is PNSS 1L to run for 12 hrs and was hooked at left metacarpal vein, NPO was ordered, Omeprazole 40mg IV q12 was given at 10:30am and tranexamic acid 1amp q8 IV at 10:35am. Pt was ordered to have BT of 3units of PRBC type O +.

(3-11pm)1st unit of packed RBC type O+ with

serial # PNRC 402356 was hooked as side drip at 6:15pm. Pt has no negative reactions toward BT and BT precaution was observed.

(11-7am)Pt on bed, awake with IVF of PNSS 1L

@ 400 cc level with 20 gtts/min. Pt is experiencing mild DOB. BP is 110/70 and temp of 36.5. 2nd unit PRBC was transfuse at 4:15am with serial # 402363 and was hooked as side drip.

March 13 (7-3pm)Pt has an ongoing blood transfusion

(2nd unit type O+ serial # 402363) as side drip. No negative reaction and v/s is recorded. 3rd unit of PRBC type O+ with serial 402399 was transfuse.

(3-11pm)Pt had Hgb and Hct done after 3rd unit

was consumed. From NPO pt was shifted to clear liquid diet. Medication was given and v/s are taken. Furosemide 20mg IV was given at 3:30pm.

(11-7am)Pt has (-) melena, afebrile and kept for

observation.

March 14 (7-3pm)Pt is awake, seen by Dra. Viray and

diet shift to soft diet. (3-11pm)

Tranexamic acid was discontinued. Lysmix 1 amp TIV q12 was given. IVF was change to D5NM 1L KVO.

March 15Received Pt with BP of 100/70 and

temp of 37.1. The Doctor prescribed Amoxicillin 500mg 1 tab TID PO and Clarithromycin 500mg 1 tab BID PO. Pt was order to transfer to female ward after getting Hgb level. Pt is pallor as manifested by pale conjunctiva.

March 16Received Pt on bed without IVF. Pt is

transferred at Female Medical Ward around 10am. Due meds were given. Soft diet maintained.

March 17May go home is ordered by the doctor.

Patient AA is conscious and coherent, lying on bed. She is overweight with BMI of 32.06 derived from her height of 5 feet 1 inch and weight of 76 kg. She has foul smelling odor from her body and from her mouth, her fingernails and toenails were long and dirty. Her clothes were soiled and the bed linen was soiled, too. She had ongoing intravenous fluid line of D5NM at 900cc level regulated at KVO (10-15 gtts/min), infusing well at left metacarpal vein with no signs of infiltration and phlebitis.

BODY PARTS ACTUAL FINDINGS INTERPRETATIONI. Integumentary1. skin warm to touch, no edema,

drydeviation from normal, possible dehydration due to blood loss, no moisturizer

II. Head1. hair evenly distributed curly hair normal

2. scalp with flakes, no nits infestation

deviation from normal, dry scalp

3. cranium normocephalic, absence of nodules and masses

normal

4. face symmetrical and freely movable

normal

5. eyesa. outer eye eyelids close symmetrically,

eyelashes evenly distributed, no discharges

normal

b. globe pupil 3mm PERRLA, white sclera, pale conjunctiva

deviation from normal, due to decreased blood volume and oxygenation

6. earsa. external ear color same as facial skin,

symmetrical, firm not tender and recoils

normal

b. external auditory with light cerumen, tymphanic membrane pearly gray color, semi transparent

normal

c. hearing acuity normal voice tone audible, Weber test: negative, Rinne test: AC>BC

normal

7. nose symmetric and straight, no discharge, not tender, no lesions, air is present in both nares, no flaring, inner part with hair and pink mucosa, sinuses not tender

Normal

8. mouth and oropharynxa. lips, buccal mucosa and gums

smooth, pale and moist deviation from normal due to decreased blood volume and oxygenation

b. roof of mouth hard, pale and moist normalc. tongue central position, smooth

lateral margins, no lesion, moves freely

normal

d. throat pink, moist, uvula midline, symmetrical

normal

e. teeth 26 teeth available, yellowish-white, front incisor teeth were in slanting position

deviation from normal due to poor oral hygiene

III. Neck1. carotid artery mild pulsations normal2. jugular vein not distended normal3. trachea midline, distinct rings normal4. thyroid not visible, smooth normal5. cervical lymph nodes not palpable normal

IV. Upper Extremities with ongoing IVF line on left metacarpal vein

1. nails intact epidermis around the nail, convex shape smooth texture, long and dirty,

deviation from normal, needs to be trim

a. blanch test slow capillary refill, 5 seconds deviation from normal, may indicate circulatory impairment

2. muscle strength and tone symmetrical, equal strength, poor muscle turgor, sagging skin

deviation from normal, may indicate poor nutrition intake

3. joint range and motion movable, can be bend, flex, coordinated movement

normal

4. brachial and radial pulses present, 78 bpm normal5. sensation able to differentiate sensation normalV. Chest and Back1. thorax chest symmetric normal2. posterior thorax and lungs quiet, rhythmic and

symmetricnormal

3. heart PMI can be palpated normal4. Breast no discharge, no masses or

nodules, big fatty breastnormal

5. axillae with hair, no tenderness or masses, slight unpleasant odor, dark in color

deviation from normal, odor may due to poor hygiene

VI. Abdomen soft and sagging normal1. skin blemished skin, uniform

color, with stretch marksdeviation from normal due to G7007

2. sound audible 12 bowel sounds/min

normal

VII. Genitals left and right labia majora are intact, no lesions, pubic hair distribution in inverted triangle, opening appears stellate/slit like and is midline

normal

VIII. Anus and Rectum Looks moist and hairless, no lesions and dark pink to brown and closed, smooth not tender

normal

IX. Lower Extremities1. toenails intact epidermis around

the nail, convex shape smooth texture, long and dirty

deviation from normal, needs to be trim

2. gait and balance can walk alone but needs to be guided

deviation from normal, may be due to prolonged bed rest in hospital

3. joint range and motion

movable, no stiffness normal

4. popliteal and pedal pulses

present normal

5. tendon and plantar reflexes

(-) babinski(+) deep tendon reflexes

normal

I. olfactory

II. optic

able to identify different smells

visual field intact

normal

normal

III. oculomotor PERRLA, convergence

normal

IV. trochlear inward and downward eye movement

normal

V. trigeminal clenching of teeth, symmetric jaw movement, face, scalp, nasal mucous membranes and cornea

normal

VI. abducens lateral eye movement normalVII. facial able to make facial

expressions, able to close eyes

normal

VIII. acoustic nerve hearing acuity within normal range

normal

IX. glossopharyngeal able to swallow normalX. vagus able to swallow and

has talking muscles of the palate, pharynx and larynx

normal

XI. spinal accessory able to move trapezius and sternocleidomastoid muscles

normal

XII. hypoglossal able to move tongue normal

The gastrointestinal tract is a 23-25 foot long pathway that extend from the mouth to the esophagus, stomach, small intestine, large intestine and rectum to the terminal structure the anus.

Mouth Esophagus

StomachFour anatomic region:

-Cardia (entrance)-Fundus-body-pylorus (outlet)

Small Intestine3 sections : duodenum-proximaljejunum-middleileum-distal

Large IntestineCompleting terminal portion:Sigmoid colonRectumAnus

GI tract receives blood from the arteries that originate along entire length of the thoracic and abdominal aorta and veins that return blood from the digestive organs and the spleen.

Portal venous system is composed of 5 large veins: superior mesenteric, inferior mesenteric gastric, splenic and cystic veins which eventually form the vena portae that enters the liver.

Once in the liver, the blood is distributed throughout and collected into hepatic veins that then terminate in the inferior vena cava.

Oxygen and nutrients are supplied to the stomach by the gastric artery and to the intestine by the mesenteric arteries.

Blood flow to the GI tract is 20% of the total cardiac output and increases significantly after eating.

Both sympathetic and parasympathetic portions of the Autonomic nervous system innervate the GI tract.

Primary Functions are: Breakdown of food particles into the

molecular form for digestion. Absorption into the bloodstream of small

nutrient molecules produced by digestion. Elimination of undigested unabsorbed food

stuffs and other waste products.

The stomach, which stores and mixes food with secretions, secretes highly acidic fluid in response to the presence or anticipated ingestion of food.

Hydrochloric Acid Pepsin Intrinsic Factor Peristalsis in the stomach and contractions of

the pyloric sphincter allow the partially digested food to enter small intestine at a rate that permits efficient absorption of nutrients.

The digestive process continues in the duodenum. Duodenal secretions come from the accessory organs (pancreas, liver and gallbladder) and the glands in the wall of the intestine itself.

These secretions contains digestive enzymes: Amylase Lipase Bile

Intestinal secretions total approximately: 1L/day of pancreatic juice 0.5L/day of bile 3L/day of secretions from the glands of

small intestine

Two types of contraction occur regularly in small intestine

Segmentation contraction Intestinal peristalsis

Absorption is the primary function of the small intestine. Process of absorption begins in the jejunum and is accomplished by both active transport and diffusion across the intestinal wall into the circulation.

Nutrients are absorbed at specific locations throughout the small intestine and duodenum, whereas fats, proteins, carbohydrates, sodium, chloride are absorbed in the jejunum. Vitamin B12 and bile salts are absorbed in the ileum. Magnesium, phosphate and potassium are absorbed throughout the small intestine.

Increase HCl production

Increase HCl production

Contributory Factors-skipping meals

-Diet: Coffee-Stress and over work

-use of NSAID’s (mefenamic acid)

Contributory Factors-skipping meals

-Diet: Coffee-Stress and over work

-use of NSAID’s (mefenamic acid)

Predisposing Factors-Age: 49 y/o

Gender: Female

Predisposing Factors-Age: 49 y/o

Gender: Female

Irritation of the lining (mucosa) of the stomach,

duodenum, proximal of small intestine.

Irritation of the lining (mucosa) of the stomach,

duodenum, proximal of small intestine.

Precipitating Factors-Lifestyle

-Work-Diet

Precipitating Factors-Lifestyle

-Work-Diet

Abdominal painAbdominal pain

Mesenteric insufficiencyMesenteric

insufficiency

Mucosal ErosionMucosal Erosion

Ulceration of the liningUlceration of the lining

Bleeding/ HemorrhageBleeding/ Hemorrhage (+) Melena (+) Melena

↓ Blood vol↓ Blood vol ↓ Hgb (.42)and Hct (.12)↓ Hgb (.42)and Hct (.12)

AnemiaAnemia

PallorPallor LightheadednessLightheadedness WeakWeak

↓ O2 carrying capacity

↓ O2 carrying capacity

↓ Blood volume↓ Blood volume

↓ Cardiac Output↓ Cardiac Output

Compensatory mechanism

Compensatory mechanism

Shifting of bld to vital organs (ex.

Heart)

Shifting of bld to vital organs (ex.

Heart)

↓ bld flow to GI ↓ bld flow to GI

Decrease peristalsisDecrease peristalsis

Bowel obstruction

Bowel obstruction

Bp: 100/60PR: 78

Bp: 100/60PR: 78

constipationconstipation

Name of Drug: Furosemide 20mgIV after each unit Time Given: March 13, March 14Classification: Loop DiureticAdverse Effect: CNS: dizziness, vertigo, paresthisias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing lossCV: orthostatic hypotension, volume depletion, cardiac arrhythmiasDermatologic: rash, photosensitivity, pruritus, urticaria, pupura, exofoliative dermatitis, erythema multiformeGI: nausea, vomiting, anorexia, oral and gastric irritation, constipation, diarrhea, acute pancreatitis, jaundiceGU: polyuria, nocturia, glycosuria, urinary bladder spasmHematologic: leukopenia, anemia, thrombocytopenia, fluid and electrolyte imbalance, hyperglycemia, hyperuricemiaOther: muscle cramps and muscle spasm

Indication: -treatment of edema associated with CHF, hepatic cirrhosis, renal disease and hypertensionContraindication: -contraindicated with allergy to furosemide, sulfonamides-allergy to tartrazine-anuria, severe renal failure, hepatic coma-pregnancy and lactation-use cautiously with SLE, gout and DMNursing Consideration: -profound diuresis with water and electrolyte depletion can occur; careful medical supervision is required-administer with food or milk to prevent GI upset-reduce dosage if given with other antihypertensive; readjust dosage gradually as BP respond-give early in the day so that increased urination will not disturb sleep-avoid IV use if oral is at all possible-discard diluted solution after 24 hours-refrigerate oral solution-measure and record weight to monitor fluid changes-arrange to monitor serum electrolytes, hydration, liver, and renal function-arrange for potassium-rich diet or supplemental potassium is needed

Name of Drug: Omeprazole 40mg IV q12Time Given: March 12 (6am and 6pm) Omeprazole 40mg IV ODTime Given: March 13 (6am) March 14 (6am) March 15 (6am) Omoprazole 200mg 1tab BIDTime Given: March 16 (6am) Classification: Antisecretory Drug, Proton Pump Inhibitor, Pregnancy Category CAdverse Effect:CNS: headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalitiesDermatologic: rash, inflamation, urticaria, pruritus, alopecis, dry skinGI: diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophyRespiratory: URI symptoms, cough, epistaxisOther: cancer in preclinical studies, back pain, fever

Indication: -short term treatment of active duodenal ulcer-first-line therapy in treatment of heartburn or symptoms of GERD-short –term treatment of active benign gastric ulcer-to maintain healing of erosive esophagitis-in combination to clarithromycin to eradicate H. pylori; use clarithromycin and amoxicillinin combination with omeprazole in patients with a 1 year history of duodenal ulcers or active duodenal ulcers to eradicate H. pylori-Zegerid oral suspension: reduction of risk of upper GI bleeding in critically ill patients-Prilosec OTC: treatment of frequent heartburn Contraindication:-contraindicated with hypersensitivity to omeprazole and its components-use cautiously with pregnancy and lactation-combination therapy with clarithromycin should not be use in pt with hepatic impairment

 

Nursing Consideration:-take drugs before meals. Swallow the capsules whole; do not chew, open or crush them. If using oral suspension, empty packet into a small cup containing 2 tbsp of water. Stir and drink immediately; fill cup with water and drink the water. Do not use any other liquid or food to dissolve packet. This drug will need to be taken for up to 8wks (short term therapy ) or for a long period (more than 5 yrs)-if you take Prilosec capsules and cannot swallow them whole, capsules contents will be added to or sprinkle with 1 tbsp of apple sauce. Mix with apple sauce, swallow immediately with chewing pellets, and follow it with a glass of water. Zegerid capsules should not be opened or added to food-have regular medical follow up visits.-you may experience this side effects: dizziness, headache, nausea, vomiting, diarrhea; symptoms are URI, cough-report severe headache, worsening of symptoms, fever and chills

Name of Drug: Clarithromycin 500mg 1tab BIDClassification: Macrolide AntibioticAdverse Effect: CNS: dizziness, headache, vertigo, somnolence, fatigueGI: diarrhea, abdominal pain, nausea, dyspepsia, flatulence, vomiting, melena, pseudomembranous colitis, abnormal tasteOther: superinfections, increased PT, decreased WBCIndication: -treatment of URIs caused by Streptococcus pyogenes, Streptococcus pneumoniae-treatment of lower respiratory infections caused by Mycoplasma pneumonia, Haemophilus influenzae, Moraxella Catarrhalis-treatment of skin and skin-structure infections caused by Staphylococcus aureus and S. pyogenes-treatment of active duodenal ulcer associated with H. pylori in combination with proton pump inhibitorContraindication: -contraindicated with hypersensitivity to clarithromycin, erythromycin, o any macrolide antibiotic-use cautiously with colitis, hepatic or renal impairment, pregnancy, lactation

Nursing Consideration:-do not crush or cut, and ensure that pt does not chew ER tablets-monitor pt for anticipated response-take drug with food if G effects occur. Take the full course of therapy-do not drink grape fruit juice while taking this drug-shake suspension before use; do not refrigerate; do not cut, crush or chew extended release tablets; swallow them all-you may experience these side effects: stomach cramping, discomfort, diarrhea, fatigue, headache, additional infections in the mouth or vagina-report severe or watery diarrhea, severe nausea, vomiting, rash or itching, mouth sores, vaginal sores

Name of Drug: Tranexamic Acid 1g IV q8Time given: March 12 (6am, 2pm, 6pm)March 13 (6am, 2pm, 6pm)March 14 (6am; stopped)Adverse Effect: -gastrointestinal disturbances-hypotension, particularly after rapid IV administration. Thrombotic complications have been reported. Instances of transient disturbance of color vision associated with its use.Indication: -treatment and prophylaxis of hemorrhage associated with excessive fibrinolysis-prophylaxis of hereditary angioedemaContraindication: -hypersensitivity-patients with active intravascular clotting because of the risk of thrombosis-severe renal insufficiency-patients with microscopic hematuria

Nursing Consideration: Assessment:-assess patients history, if with active intravascular clotting, predisposed to thrombosis; hemorrhage due to disseminated intravascular coagulation.-monitor anti-coagulant cover-perform eye examination-perform liver function tests-perform blood test-obtain prothrombin time of the pt -reduce dose for pt with renal impairment and children IV injection or infusion: give 3x a day and maybe mixed with most solutions but not with penicillins -Should not be used in pt with active intravascular clotting-possibility with skin reaction such as wide spread, patchy rash with associated blisters-advice pt to report visual abnormalities to the physician

Name of Drug: Amoxicillin 500mg1tab TID Classification: Antibiotic (Penicillin- Ampicillin type)Adverse Effect: CNS: lethargy, hallucination, seizureGI: glossitis, stomatitis, gastritis, sore mouth, furry tongue, nausea, vomiting, diarrhea, abdominal pain, bloody diarrhea, enteroclolitis, pseudomembranous colitis, non-specific hepatitisGU: nephritisHematologic: anemia, thrombocytopenia, leucopenia, neutropenia, prolonged bleeding timeHypersensitivity: rash, fever, wheezing, anaphylaxisOther: super infections- oral and rectal moniliasis, vaginitisIndication: -infections due to susceptible strains of Haemophilus influenza, E. coli, Neisseria Gonorrhea, Streptococcus pneumoniae, Enterococcus fecalis, Streptococci, non-penicillinase producing staphylococci-H. pylori infection in combination with other agents-post exposure prophylaxis against Bacillus Anthacis

Contraindication: -contraindicated with allergies to penicillins, cephalosporins and other allergens.-use cautiously with renal disorders, lactationNursing Consideration: -give in oral preparations only; amoxicillin is not affected by food-continue therapy for at least 2days after signs of infection have disappeared; continuation for 10 full days is recommended-use corticosteroids or anti histamines for skin reactions-take antibiotic around-the-clock-this antibiotic is specific for this problem and should not be used to self-treat other infections-you may experience these side effects: nausea, vomiting, GI upset, diarrhea, sore mouth-report unusual bleeding or bruising, sore throat, fever, rash, hives, severe diarrhea, DOB

Blood Chemistry (March 12, 2010)SI Unit Traditional SI Unit Traditional Interpretation

Glucose (FBS) 4.18-6.05 mmol/L 65-110 mg/dl

Blood Urea Nitrogen 2.5-6.43 mmol/L 7-18 mg/dl

Uric Acid (male) 0.15-0.4 mmol/L 2.6-7.2 mg/dl

(female) 0.09-0.35 mmol/L 1.5-6.0 mg/dl

Creatinine 1.1 mg/dl 35.4-124 mmol/L 0.4-1.4 mg/dl NORMAL

Cholesterol 3.64-3.24 mmol/L 140-240 mg/dl

Triglyceride 0.40-1.88 mmol/L 35-166 mg/dl

HDL- Cholesterol 0.72-1.95 mmol/L 30-75 mg/dl

LDL-Cholesterol 1.56-4.6 mmol/L 27-77 IU

Sodium 3.5-5.3 mmol/L 135-155 mg/LPotassium 0.190 unit 3.6-5.5Chloride 2.1-2.55 mmol/L 110-114 mEq/L

SGPT 4-39 IU/LSGOTInfant Up to 67Children Up to 40Adult 8.8 iu/L 5-43iu/L Up to 40 Normal

Hematology March 12, 2010

Normal Value Found Value Interpretation

Hemoglobin M: 155- 175g/LF: 115- 135g/L

42.0 May indicated anemia from blood loss, dietary defeciency

Hematocrit 40-52 0.12 May indicated anemia from blood loss, dietary defeciency

WBC count 4.0 – 11.0 x 10/L 8.9x10 g/L NORMAL

Platelet Count 150-400 x 10/L

Bleeding Time

Clotting Time

Differential Count

Segmenters 0.59 NORMAL

Lymphocytes 0.35 NORMAL

Monocytes 0.06 NORMAL

Blood type O+

HbsAg

Others

March 13, 2010 (9pm)Normal Value Found Value Interpretation

Hemoglobin M: 155- 175g/LF: 115- 135g/L

95.2 g/L May indicated anemia from blood loss, dietary defeciency

Hematocrit 40-52 0.28 May indicated anemia from blood loss, dietary defeciency

WBC count 4.0 – 11.0 x 10/L

Platelet Count 150-400 x 10/LBleeding TimeClotting Time

Differential Count

SegmentersLymphocytesMonocytesBlood typeHbsAgOthers

Urinalysis March 13, 2010

Interpretation

Color Yellow Normal

Characteristic Clear Normal

Reaction NO STRIP

SP. Gravity NO STRIP

Albumin NO STRIP

Sugar NO STRIP

Pregnancy Test NO STRIP

WBC 1-3 HPF (range: 0-5)

RBC 0-2 HPF (range: 0-3) Normal

Epith. Cell Few Normal

Cast

Bacteria Few May indicate infection

Crystals

Miscellaneous

Health perception/Health Management

Nutritional /Metabolic

Elimination

Activity/Exercise

Sleep/Rest

Cognitive Perceptual

Roles/Relationship

Self-Perception/Self-Concept

Coping/Stress Tolerance

Value/Belief

Sexuality/Reproductive

Assessment Diagnosis Planning Intervention Evaluation

Subjective“Hindi ako nakaligo simula nung naospital ako”, as verbalized by the pt.

Objective-soiled clothing-foul smelling body odor-(+) halitosis-yellowish white teeth with tartar-long and dirty fingernails and toenails-uncombed hair with flakes

Self care deficit related to weakness as manifested by soiled clothing, foul smelling body odor, halitosis, yellowish white teeth with tartar, long and dirt fingernails and toenails and uncombed hair.

STG-After 4 hrs of rendering nursing intervention and health teaching, the pt will be clean and free of foul smelling body odor.

LTG-After a week of RNI and health teaching, the pt will perform self care activities within level of own ability.

-Establish rapport to patient-Assist in sponge bathing-Assist in changing clothes-Encourage the pt to brush her teeth-Encourage the pt to take a bath and explain the importance of everyday bathing to health-Comb her hair-Trim nails in fingernails-Health teach patient about:*proper diet for her illness (iron rich foods, soft foods)*enough rest and sleep everyday*how to manage stress

STG-After 4 hrs of RNI and health teaching, the pt is clean and free of foul smelling body odor.

LTG-After a week of RNI and health teaching, the pt can perform self care activities within level of own ability.

Assessment Diagnosis Planning Intervention Evaluation

Subjective“Bakit ka naka-mask, hindi naman nakakahawa ang sakit ko”, as verbalized by the pt.

Objective-exposed to a ICU room filled with pt with different kinds of illness/infection-weakness-Hgb-Hct-WBC

Risk for infection related to increased environmental exposure to pathogens as manifested by exposed to ICU room filled with pt with different kinds of illness, weakness, decrease Hgb, Hct and WBC.

STG-After 4 hrs of rendering nursing intervention and health teaching, the pt will identify interventions to prevent or reduce the risk of infection.

LTG-After a week of RNI and health teaching, the pt will be able to demonstrate techniques to promote safe environment.

-Establish rapport to patient-Health Teach and encourage hand washing before and after eating-alcoholized hands whenever needed-encourage soiled bed linen should be changed-encourage soiled clothing should be put in a plastic bag and bring it home by the SO.-encourage pt to wear a mask-used eating utensils should be wash immediately after using to prevent flies and cockroaches in contaminating them-proper hygiene should be observe

STG-After 4 hrs of rendering nursing intervention and health teaching, the pt can identify interventions to prevent or reduce the risk of infection.

LTG-After a week of RNI and health teaching, the pt can be able to demonstrate techniques to promote safe environment..

Assessment Diagnosis Planning Intervention Evaluation

Subjective“Nahihirapan ako sa ngipin ko pagkumakain, hindi ako makakagat ng mabuti”, as verbalized by the pt.

Objective-halitosis-tooth enamel discoloration-excessive plaque-tooth fracture-loose tooth-missing teeth

Impaired dentition related to ineffective oral hygiene as manifested by halitosis, tooth enamel discoloration, excessive plaque, loose tooth, missing teeth.

STG-After 4 hrs of rendering nursing intervention and health teaching, the pt will demonstrate effective dental hygiene skills.

LTG-After a week of RNI and health teaching, the pt will be encourage to visit a dentist for a dental check up for appropriate dental care.

-Establish rapport to patient-inspect oral cavity-health teach patient about proper oral hygiene: >encourage everyday brushing after eating before bedtime>limit sweets-advice patient to seek a dental help to have a denture so she can eat different foods.

STG-After 4 hrs of rendering nursing intervention and health teaching, the pt can demonstrate effective dental hygiene skills.

LTG-After a week of RNI and health teaching, the pt was encourage to visit a dentist for a dental check up for appropriate dental care..

M- otivate Pt to have regular check up

E- ncourage Pt not to skip meals

L- essen work load and stress

E- ncourage Pt to eat nutritious food(ex: Iron rich foods – malunggay, ampalaya, internal organs)

N- o to vices such as drinking alcohol, smoking and using of illegal drugs.

A- void spicy and sour foods