A Case StudyOn

Upper Gastrointestinal bleeding, secondary to bleeding peptic ulcer disease

In partial FulfillmentOf the requirement in

Related Learning Experience 40 – Group 06

Presented by:

JoralynPacres

BSN-3

Presented to:

Jonathan Gesta RN

February 2011

INTRODUCTION

Upper gastrointestinal (GI) bleeding occurs when the inner lining (mucosa) of the

esophagus, stomach, or proximal small intestine (duodenum) is injured, exposing the

underlying blood vessels, or when the blood vessels themselves rupture. Upper

gastrointestinal bleeding (UGIB) is defined as hemorrhage that emanates proximal to the

ligament of Treitz. It is a common and potentially life-threatening condition. More than

350,000 hospital admissions are attributable to UGIB, which has an overall mortality rate of

10%. Although more than 75% of cases of bleeding cease with supportive measures, a

significant percentage of patients require further intervention, which often involves the

combined efforts of gastroenterologists, surgeons, and interventional radiologists.

Clinically, UGIB often causes hematemesis (vomiting of blood) or melena (passage

of stools rendered black and tarry by the presence of altered blood). The color of the

vomitus depends on its contact time with the hydrochloric acid of the stomach. If vomiting

occurs early after the onset of bleeding, it appears red; with delayed vomiting, it is dark red,

brown, or black. Coffee-ground emesis results from precipitation of blood clots in the

vomitus. Hematochezia (red blood per rectum) usually indicates bleeding distal to the

ligament of Treitz. Occasionally, rapid bleeding from an upper GI source may result in

hematochezia.

Upper gastrointestinal bleeding (UGIB) is a significant and potentially life-threatening

worldwide problem. Despite advances in diagnosis and treatment, mortality and morbidity

have remained constant.1 Bleeding from the upper gastrointestinal tract (GIT) is about 4

times as common as bleeding from the lower GIT. Typically patients present with bleeding

from a peptic ulcer and about 80% of such ulcers stop bleeding. Increasing age and co-

morbidity increase mortality. It is important to identify patients with a low probability of re-

bleeding from patients with a high probability of re-bleeding. Upper GI bleeding can range

in severity from clinically inapparent (insignificant) to large-volume, life-threatening

bleeding. A variety of conditions can cause GI bleeding, and effective treatment depends

on identification of the source of the bleeding and expeditious administration of therapy.

Upper GI bleeding can be divided into two broad categories: variceal bleeding and

non-variceal bleeding. Varices are dilated blood vessels found most frequently in the

esophagus and stomach. Non-variceal upper gastrointestinal bleeding can be caused by a

variety of conditions. Peptic ulcer is the most common cause. An ulcer bleeds when the

blood vessels at the base of the ulcer are disrupted. Ulcers are most likely to occur in the

stomach and duodenum and less frequently in the esophagus. Ulcers are caused most

commonly by an infection with the bacterium Helicobacter pylori or use of nonsteroidal anti-

inflammatory drugs.

http://emedicine.medscape.com/article/417980-overview

Indeed, I choose this case because I want to learn why gastrointestinal bleeding

occurs. To enhance my knowledge about GI bleeding. And as a health care provider I need

to know more about the disease in order for me to establish rapport to my patient and how

to deal with it.

PATIENT’S PROFILE

Patient X is a 53-year-old male, Filipino. He is married. Having three children. He is

a Roman Catholic. Patient X is currently residing in Salay, Mis Or. He is working as a

farmer there. Patient X was admitted in the hospital last February 12, 2011 at exactly 8:20

pm. His Attending Physician is Dr. Brobo, M.D. He stayed at Annex 3 Floor 2 Male Charity

Ward..

Principal Diagnosis: Upper Gastrointestinal Bleeding

CHIEF COMPLAINT

“isa nani ka tuig ga sakit akong tiyan pero abi nku ug wala ra, nya tong ning aging

adlaw kai nana man sya’y dugo ug sakit na ikalibang” as verbalized by the patient

HISTORY OF PRESENT ILLNESS

Patient X had never undergone any procedure before. He felt abdominal pain a

year ago but tolerated it. He has been having on and off epigastric pain, associated with

occasional melena, ¼ cup in amount. He never consults a doctor or having his check up

about it. He is self-medicated and only with herbal medicines. Patient X has a difficulty in

defecating.

1 day prior to admission, had only 1 episode of melena, 1 spoon in amount,

prompting consult, hence admitted. He is also positive for hematemesis

PAST HEALTH HISTORY

Patient X has no previous hospitalization. He never undergoes any procedure. He

has no allergies in foods and medication. He is not hypertensive and not diabetic. But he is

a smoker and can consume 2 packs of cigarette a day. He is also an alcoholic and drink

every time he wants especially after doing things on the farm.

Upon assessment, the following data was obtained from patient X. BP= 130/90

mmHg; Temp. = 37.7C; Pulse rate= 55 bpm; Respiratory rate= 23 cpm

HEALTH- PERCEPTION/ HEALTH MANAGEMENT PATTERN

The patient is almost generally the same as how every Filipino seeks health

assistance. Without any problem regarding his health, he would not approach health

workers not unless it is life threatening. Patient complaints pain a year ago but tolerated it.

He is pale to look at.

NUTRITIONAL/ METABOLIC PATTERN

The patient eats three times a day. He said that he eats a fatty and salty diet and

no limit when it comes to food. He said that “pobre raman me alang mamili pami unsai kan-

on, kaon jud kung unsai naa”. During his hospitalization, he is instructed with diet as

prescribed by the physician. The patient consumed whole share of food with fair appetite.

He usually drinks 5-6 glasses of water per day. And stop drinking coffee a year ago

because of abdominal pain he felt after drinking coffee. Patient’s weight was 60 kg.

ELIMINATION PATTERN

According to the patient, when he is at home, he had difficulty in defecating and

when he push to do so, he has a black-tary color of stool. He said that every time he

defecates, his stool has a blood. During his hospitalization he defecates three to four times

a day.

He urinates an average of 850 cc per shift (8 hours) with yellowish colored urine.

ACTIVITY/ EXERCISE PATTERN

He spent most of his time doing things on the farm, and sometimes talk with

friends and family. He said he drinks alcohol everytime he wants especially when some of

his friends invite him after farming. He sometimes spends his time doing his usual

household chores as his exercise. During his confinement his leisure time is talking to his

daughter.

SLEEP- REST PATTERN

The patient sleeps for an average of 8 hours per day before his confinement.

During his hospital stay, he usually sleeps for 5-6 hours and takes nap in the morning and

afternoon. He said he had difficulty in sleeping because of the pain he felt in his abdomen.

SELF-PERCEPTION/ SELF-CONCEPT PATTERN

“pobre gihapon, pero malipayon. Problima sa ibayad” as verbalized. The patient

verbalized that being hospitalized was not a change for him, but it affects to his family since

they had a big problem financially.

COGNITIVE/ PERCEPTUAL PATTERN

Patient X is conscious, well oriented to time, place and person and is in a calm

emotional state. He exhibited appropriate behavior and response when communicating and

has not experienced any dizziness or tingling sensation.

ROLE/RELATIONSHIP PATTERN

Patient X is married, a farmer and has 3 children. The eldest is married and the

two are helping him in farm.

The patient lives with his family in Salay, Misamis Oriental and as for his

hospitalization expenses, his family especially his son find ways just to pay the bill. His

family feels worried about the situation, his wife wants to stay with him as well as his

children but they can’t because they need to work to earn money for his hospitalization.

COPING/ STRESS-TOLERANCE PATTERN

“kapoy mag puyo ug hospital labi na ug wla kay kwarta ika bayad” as

verbalized.

His vital support group is his family and significant others.

VALUE/ BELIEF PATTERN

Patient X is a Roman Catholic. He always goes to church every Sunday with

his family. He thinks that God is vital to everyone and he trusts in God on whichever turn

his condition will be. He says that hospitalization truly interferes, as he can’t go to church

because of his illness.

PHYSICAL ASSESSMENT

ASSESSMENT DATA ASSESSMENT FINDINGS

SKIN

Color

Temperature

Turgor

Texture

Lesion

Integrity

Moist and pallor

37.7º C

Supple

Rough

(-) Rash

Intact

NAILS

Color

Texture

Shape

Capillary refill

Pale

Smooth

Concave

4 seconds

HAIR

Color

Texture

Black

Coarsely dry

Distribution

Quantity

Evenly distributed

Thin

HEAD

Shape

Size

Configuration

Headache

Round

Normocephalic

Symmetrical

None

EARS

Hearing

Tinnitus

Vertigo

Ear aches

Infection

Discharges

Normal shape

Can hear whispered voice

None

No vertigo

No ear aches

No infection

No discharges

NN NECK

Symmetry

Condition of trachea Thyroid

Symmetrical

Midline

Lymph nodes (-) nonpalpable

LUNG

Symmetry

A: P diameter

Shape of chest

Number of breaths

Symmetrical

1:2

Barrel

23 cpm

NOSE AND SINUSES

Frequent colds

Nasal stiffness

Nose bleed

Sinus trouble

None

None

None

Sinuses are non tender

MOUTH & THROAT

Condition of teeth

Bleeding gums

Tongue

Throat

Missing teeth

No bleeding

Midline

Non-tender

Hoarseness

Mucous membrane

Gums

(-) Hoarseness

Pallor

Pallor

AUSCULTATION:

Character of respiration (+) Crackles

HEART AND NECK VESSELS:

Apical Pulse

Cardiac Sounds

Apical/Radial pulse data

Blood pressure

Pulse pressure

Any special procedure done

55 bpm

(-) Murmurs

55 bpm

130/90 mmHg

60 mmHg

None

ABDOMEN:

Configuration

Bowel Sounds

Percussion :

Globular

Hypoactive

Dullness (3 clicks)

Palpation :

Usual urinary pattern:

Excess perspiration/ nocturnal sweats

Muscle guarding

850 cc/shift

None

MUSCULOSKELETAL SYSTEM:

Posture

ROM

Muscle Strength

Abnormal postures aren’t present

Active-passive

4/5

HEAD AND NECK:

Facial muscle symmetry

Swelling

Scars

Discoloration

Weakness

ROM

Symmetrical

None

None

None

(-) Weakness

Can turn head from side to side

Posterior neck cervical spine

Muscle spasm

Crepitus

Non-tender

(-) Spasm

(-) Crepitus heard

ANATOMY AND PHYSIOLOGY

The digestive tract (also known as the alimentary canal) is the system of organs

within multicellular animals that takes in food, digests it to extract energy and nutrients, and

expels the remaining waste. The major functions of the GI tract are ingestion, digestion,

absorption, and defecation. The picture to the right doesn't show the Jejunum. The GI tract

differs substantially from animal to animal. Some animals have multi-chambered stomachs,

while some animals' stomachs contain a single chamber. In a normal human adult male,

the GI tract is approximately 6.5 meters (20 feet) long and consists of the upper and lower

GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the

embryological origin of each segment of the tract.The first step in the digestive system can

actually begin before the food is even in your mouth. When you smell or see something that

you just have to eat, you start to salivate in anticipation of eating, thus beginning the

digestive process. Food is the body's source of fuel. Nutrients in food give the body's cells

the energy they need to operate. Before food can be used it has to be broken down into

tiny little pieces so it can be absorbed and used by the body. In humans, proteins need to

be broken down into amino acids, starches into sugars, and fats into fatty acids and

glycerol.

During digestion two main processes occur at the same time:

* Mechanical Digestion: larger pieces of food get broken down into smaller pieces while

being prepared for chemical digestion. Mechanical digestion starts in the mouth and

continues in to the stomach.

* Chemical Digestion: several different enzymes break down macromolecules into smaller

molecules that can be more efficiently absorbed. Chemical digestion starts with saliva and

continues into the intestines.

Esophagus

The esophagus (also spelled oesophagus/esophagus) or gullet is the muscular tube

in vertebrates through which ingested food passes from the throat to the stomach. The

esophagus is continuous with the laryngeal part of the pharynx at the level of the C6

vertebra. It connects the pharynx, which is the body cavity that is common to both the

digestive and respiratory systems behind the mouth, with the stomach, where the second

stage of digestion is initiated (the first stage is in the mouth with teeth and tongue

masticating food and mixing it with saliva).

After passing through the throat, the food moves into the esophagus and is pushed down

into the stomach by the process of peristalsis (involuntary wavelike muscle contractions

along the G.I. tract). At the end of the esophagus there is a sphincter that allows food into

the stomach then closes back up so the food cannot travel back up into the esophagus.

The GI System

The gastro-intestinal system is essentially a long tube running right through the

body, with specialised sections that are capable of digesting material put in at the top end

and extracting any useful components from it, then expelling the waste products at the

bottom end. The whole system is under hormonal control, with the presence of food in the

mouth triggering off a cascade of hormonal actions; when there is food in the stomach,

different hormones activate acid secretion, increased gut motility, enzyme release etc. etc.

Nutrients from the GI tract are not processed on-site; they are taken to the liver to be

broken down further, stored, or distributed.

The Stomach

The stomach is a 'j'-shaped organ, with two openings- the oesophageal and the

duodenal- and four regions- the cardia, fundus, body and pylorus. Each region performs

different functions; the fundus collects digestive gases, the body secretes pepsinogen and

hydrochloric acid, and the pylorus is responsible for mucus, gastrin and pepsinogen

secretion.

The stomach has five major functions;

Temporary food storage

Control the rate at which food enters the duodenum

Acid secretion and antibacterial action

Fluidisation of stomach contents

Preliminary digestion with pepsin, lipases etc.

The Small Intestine

The small intestine is the site where most of the chemical and mechanical digestion is

carried out, and where virtually all of the absorption of useful materials is carried out.

The whole of the small intestine is lined with an absorptive mucosal type, with certain

modifications for each section. The intestine also has a smooth muscle wall with two

layers of muscle; rhythmical contractions force products of digestion through the

intestine (peristalisis). There are three main sections to the small intestine;

The duodenum forms a 'C' shape around the head of the pancreas. Its main

function is to neutralise the acidic gastric contents (called 'chyme') and to initiate

further digestion; Brunner's glands in the submucosa secrete an alkaline mucus

which neutralises the chyme and protects the surface of the duodenum.

The jejunum

The ileum. The jejunum and the ileum are the greatly coiled parts of the small

intestine, and together are about 4-6 metres long; the junction between the two

sections is not well-defined. The mucosa of these sections is highly folded (the folds

are called plicae), increasing the surface area available for absorption dramatically.

The Pancreas

The pancreas consists mainly of exocrine glands that secrete enzymes to aid in the

digestion of food in the small intestine. the main enzymes produced are lipases,

peptidases and amylases for fats, proteins and carbohydrates respectively. These are

released into the duodenum via the duodenal ampulla, the same place that bile from the

liver drains into.

Pancreatic exocrine secretion is hormonally regulated, and the same hormone that

encourages secretion (cholesystokinin) also encourages discharge of the gall bladder's

store of bile. As bile is essentially an emulsifying agent, it makes fats water soluble and

gives the pancreatic enzymes lots of surface area to work on.

structurally, the pancreas has four sections; head, neck, body and tail; the tail stretches

back to just in front of the spleen.

The Large Intestine

By the time digestive products reach the large intestine, almost all of the nutritionally

useful products have been removed. The large intestine removes water from the

remainder, passing semi-solid faeces into the rectum to be expelled from the body through

the anus. The mucosa (M) is arranged into tightly-packed straight tubular glands (G) which

consist of cells specialised for water absorption and mucus-secreting goblet cells to aid the

passage of faeces. The large intestine also contains areas of lymphoid tissue (L); these

can be found in the ileum too (called Peyer's patches), and they provide local

immunological protection of potential weak-spots in the body's defences. As the gut is

teeming with bacteria, reinforcement of the standard surfacedefences seems only

sensible.

Gallbladder

The gallbladder is a pear shaped organ that stores about 50 ml of bile (or "gall") until

the body needs it for digestion. The gallbladder is about 7-10cm long in humans and is dark

green in appearance due to its contents (bile), not its tissue. It is connected to the liver and

the duodenum by biliary tract.

The gallbladder is connected to the main bile duct through the gallbladder duct (cystic

duct). The main biliary tract runs from the liver to the duodenum, and the cystic duct is

effectively a "cul de sac", serving as entrance and exit to the gallbladder. The surface

marking of the gallbladder is the intersection of the midclavicular line (MCL) and the trans

pyloric plane, at the tip of the ninth rib. The blood supply is by the cystic artery and vein,

which runs parallel to the cystic duct. The cystic artery is highly variable, and this is of

clinical relevance since it must be clipped and cut during a cholecystectomy.

The gallbladder stores bile, which is released when food containing fat enters the digestive

tract, stimulating the secretion of cholecystokinin (CCK). The bile emulsifies fats and

neutralizes acids in partly digested food. After being stored in the gallbladder, the bile

becomes more concentrated than when it left the liver, increasing its potency and

intensifying its effect in fats.

PATHOPHYSIOLOGY

PREDISPOSING FACTORS:Gender: Male

Age: 53 y/o

PRECIPITATING FACTORS:Diet: Raw foods,

grilled foods, spicy foods.

Smoking: 2 packs a day

Alcoholic Beverages drinker

Ulcers burrow

s

Inflammatory effect on gastric

Disruption of mucous barrier

Weakening and necrosis

of arterial

Weakened wall rapture

s

Development of pseudo anuerys

ms

peripheral

Pale nail beds. >4 sec

UGIB

Body weakness

BP= 130/90RR= 22PR=55

DIAGNOSTIC PROCEDURES And

LABORATORY RESULTS

HEMATOLOGY REPORT

DATE: 2-16-11

TEST RESULT UNIT REFERENCES

WBC 13.8 10^3/uL 5.0-10.0

RBC 5.52 10^6/uL 4.2 -5.4

Hemoglobin 10.6 g/dL 12.0 – 16.0

Hematocrit 33.4 % 37.0 – 47.0

MCV 60.5 fL 82.0 – 98.0

MCH 19.2 Pg 27.0 – 31.0

MCHC 31.7 g/dL 31.5 – 35.0

RDW-CV 19.0 % 12.0 – 17.0

PDW 10.9 fL 9.0 – 16.0

MPV 9.3 fL 8.0 – 12.0

DIFFERENTIAL COUNT

Lymphocyte % 17.9 % 17.4 – 48.2

Neutrophil % 54.9 % 43.4 – 76.2

Monocyte % 5.5 % 4.5 -10.5

Eosinophils % 21.6 % 1.0 – 3.0

Basophils % 0.1 % 0.0 – 2.0

Bands/stabs % % 1.0 – 2.0

PLATELET 605 10^3/uL 150 – 400

DATE: 2-18-11

RESULT

11.4

5.72

11.5

35.9

62.8

20.1

32.0

21.9

10.4

8.6

16.8

53.0

8.1

22.0

0.1

517

INTERPRETATION:

An elevated WBC count occurs in infection, allergy, systemic illness,

inflammation, tissue injury, and leukemia.

A Low hemoglobin and hematocrit level indicates anemia. A low MCV number in a

patient with a positive stool guaiac test (bloody stool) is highly suggestive of GI cancer.

A low MCH indicates that cells have too little hemoglobin. This is caused by deficient

hemoglobin production

ULTRASOUND REPORT

DATE: 2-16-11

FINDINGS:

The liver appears normal in size but with slightly increased parenchymal

echogenicity. No mass or calcification seen. Intrahepatic bile ducts and common bile

duct are non-dilated.

Gallbladder is normal in size. It’s wall is not thickened. No intraluminal mass or

lithiasis seen.

Pancreas, spleen and abdominal aorta are unremarkable. Right and left kidneys

measure 8.6 cm x 3.9cm and 9.0cm x 4.7cm, both with parenchymal thickness of

1.5cm. Central echocomplexes are intact. At least 3 tiny calcifications with the largest

measuring 0.5cm is seen in the left renal cortex. No stones, mass nor calfectasia noted.

Urinary bladder is moderately filled. It’s wall is thickened to 4.0mm. No

intraluminal mass or lithiasis seen.

Prostate measures 3.6cm x 2.6cm approximately 15 grams.

DIAGNOSIS:

1. Fatty liver, grade 1

2. Cortical calcifications, left

3. Non-remarkable ultrasounds findings in the gallbladder, pancreas, spleen,

abdominal aorta, right kidney, urinary bladder and prostate.

FECALYSIS

DATE: 2-14-11PHYSICAL CHARACTERISTICS:

Color and character: BrownConsistency: Formed

ABNORMAL FEATURES:

Occult blood: positiveWBC:RBC:Fecal

DRUG ORDER(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME: omeprazole

BRAND NAME: Losec

CLASSIFICATION: Antisecretory

drug Proton pump

inhibitor

DOSE: 20 g

ROUTE: PO

FREQUENCY: BID

Gastric acid-pump inhibitor. Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final stage of acid production.

short-term treatment of active duodenal ulcer

Treatment of heartburn or symptoms of GERD

Short-term treatment of active benign gastric ulcer

Contraindicated with hypersensitivity to omeprazole or its components.

CNS: headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety

GI: diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue athropy

Respiratory: URI symptoms, cough, epistaxis

Administer before meals

Swallow the capsules whole, do not chew, open or crush

Report severe headache, worsening of symptoms, fever, chills

DRUG ORDER(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME: sucralfate

BRAND NAME: Carafate

CLASSIFICATION: Antiulcer drug

DOSE: 1 gram

ROUTE: PO

FREQUENCY: QID

Forms an adherent complex at duodenal ulcer sites protecting the ulcer against acid, pepsin and bile salts, thereby promoting ulcer healing; also inhibits pepsin activity in gastric ulcer.

short-term treatment of active duodenal ulcer up to 8 weeks

maintain therapy for duodenal ulcer at reduced dosage after healing.

Contraindicated with allergy to sucralfate, chronic renal failure or dialysis ( buildup of aluminum may occur with aluminum-containing product.

CNS: dizziness, sleeplessness, vertigo

GI: constipation, diarrhea, nausea, indigestion, gastric discomfort, dry mouth

Dermatologic: rash, pruritus

Other: back pain

give drug on an empty stomach, 1 hour before or 2 hour after meals at bedtime.

Monitor pain; use antacid to relieve pain

Report severe gastric pain

DRUG ORDER(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME: rebamipide

BRAND NAME: Mucosta

CLASSIFICATION: Antigastric ulcer

DOSE: 100 mg

ROUTE: PO

FREQUENCY: TID

A mucosal protective agent and postulated to increase gastric blood flow, prostaglandin biosynthesis and decrease free oxygen radicals.

Acute gastric and acute exacerbation of chronic gastritis

Contraindicated with allergy to rebamipide

Constipation Bloating Diarrhea Nausea Vomiting Rash pruritus

administer drug before meals

report for any severe abdominal pain

ASSESMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS

(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective Cue:

“pag-malibang ko, sakit kayo ilibang” as verbalized.

Objective Cues:

pain scale= 7/10

sleep disturbance

irritability restless

Acute pain related to underlying condition

After 8 hours of nursing intervention the patient will be able to ;

report pain is relieved/ controlled

follow prescribed pharmacological regimen

demonstrate use of relaxation skills and diversional activities.

Decrease in pain scale from 7/10 to 5-6/10

INDEPENDENT:

Teach the use of non-pharmacologic techniques such as relaxation.

Instruct client to perform deep breathing exercises

Encourage adequate rest

COLLABORATIVE: Administer pain

reliever as ordered.

.use of non-invasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

To reduce tension and promote relaxation

To prevent fatique

To alleviate pain

After 8 hours of nursing intervention goals partially met.

Verbalized that pain has lessened in degree from a 7/10 scale to 6/10

RR was still elevated

ASSESMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS

(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective Cue:

“init akong lawas” as verbalized.

Objective Cues:

Temp = 37.7 Flushed skin Restless

Hyperthermia related to inflammatory response secondary to disease process

After 30 minutes of nursing intervention the patient will be able to ;

maintain temperature within normal range (37.5)

After 8 hours of nursing intervention the patient will be able to:

remain free of complications such as irreversible brain/neurological damage.

free of seizure activity

INDEPENDENT:

provide tepid sponge bath

promote surface cooling by means of understanding

Maintain bed rest

DEPENDENT: Administer

antipyretic medications as ordered

COLLABORATIVE: Administer

replacements of fluid and electrolytes.

Help decrease temperature

Heat loss by radiation and conduction

To reduce metabolic demands

To support circulating volume & tissue perfusion

Use of pharmacologic means will help decrease client temperature.

After 30 minutes of nursing intervention goals met.

Attained temperature within normal range

After 8 hours of nursing intervention goals met.

Remained free from any complications

Remain free from seizure

ASSESMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS

(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective Cue:

“ga-lisod kog kalibang” as verbalized.

Objective Cues:

Hard, formed stool

Hypoactive bowel sounds

Abdominal tenderness

Distended abdomen

Constipation related to irregular defecation habit

After 8 hours of nursing intervention the patient will be able to:

Establish/ regain normal pattern of bowel functioning

Participate in bowel program a indicated

Demonstrate behavior or lifestyle changes to prevent recurrence of problem

INDEPENDENT: Determine fluid

intake

Instruct the patient to viod if there’s a feeling of urgency

Note general oral/dental health

DEPENDENT: Apply lubricant

COLLABORATIVE: Encourage

treatment of underlying causes.

To evaluate client’s hydration status

Prevent fullness

That can impact dietary intake

To soften

To improve organ function

After 8 hours of nursing intervention, goals partially met.

DISCHARGE PLAN

MEDICATION Discuss/instruct to the patient with their significant other the importance as prescribe by the physician.

Emphasize on compliance to therapeutic and medication regimen and the information regarding side effect of the medications.

Patient with their significant other need to understand the occurrence of the drug effects in order to when, what and whom to report on any symptoms present.

ECONOMIC STATUS Pinpoint the patient their capability to purchase the medications.

The patient accessibility to the agency and should be considered with regards to follow-up.

It is important to know patient ability to afford the expected expenses.

This is to make sure that the compliance of the medication will be achieved.

To have immediate interventions when signs and symptoms occur.

To ensures the patient adherence instructions.

TREATMENT Encourage patient to have a vitamins supplements.

Compliance to medication regimen.

To have a fast recovery and to prevent complications.

HEALTH TEACHINGS Instruct the significant

others to assess the patient’s incision and drainage system.

Encourage the patient

To monitor wound healing

to prevent the stressful activity and have adequate rest.

Instruct the client and the significant others to monitor presence of infection and report immediately if signs and symptoms of infection occurs such as redness, foul-smelling drainage, temperature greater than 38.4 C.

To promote early recovery.

To monitor any signs of infection.

OUT-PATIENT Emphasize the patients to schedule for regular follow-up appointment, and discuss the importance of regular check up care.

To monitor any alternations in the patients status and ensure compliance to medication regimen.

DIET Instruct patient to eat high in protein such as meat

Instruct patient to eat high in carbohydrate.

Instruct patient to take vitamin K

For tissue repair and faster wound healing.

For energy

To prevent blood clot.

SPIRITUALITY Allow the patient to pray if possible all the time to God.

Have faith in God.

To provide and optimistic approach towards her problem.

LEARNING EXPERIENCE

When i had my first exposure in the area, last January 28, 2011 I always

endeavor to do what is finest and cool for my studies. I accomplished my requirements

that were requested to make. It is conspicuous for me to build up what i had attained

and be able to interpret what that is for. I was dazed because I was got carried away of

my nervousness. Almost all of us were nervous to handle our patient and also with their

chart because we were aghast to make our mistake. There were times that I get crap

out when an accidental situation happened to one of our patient and I did not perceived

what to do, but I was still thankful and glad that in spite of all the obstacle I had been

through our Clinical Instructor who are always at our side to help, accompany and

always intimate us what we should do to our patient.

Preparing this case study was a dare for me since it was my first time to alight

upon this kind of disease. I gained more learning’s in this case study but comprising

this, needs more patience’s and time. As what I achieved in my studies, I also learned

to be sensitive to my patient’s feelings and my patient’s conditions in order for me to

impart a therapeutic service that will nurture health and wellness on their sufferings. I

also acquired bob up on patients needs effectively.

By doing this simple things makes me realize that each and every assessment of

my patient or helping them through me, that I already step the new stage of my life as

nursing student. As I take over my responsibility in our duty, but sometimes as I go

along I encounter some difficulty during our service that can be manageable by helping

each other with my group mate. And most of all I treat them as a family and I learn how

to respect and socialize in one another. I learn also to strengthen my patience when it

comes to tiring moments of our duty and above all this learning experience I had God is

our staircase in our stairway of success.

REFERENCES

Book sources:

1. Black, J. and Hawks, J. Medical-Surgical Nursing: Clinical Management for Positive

Outcomes. Elsevier Health Sciences: Singapore. 2008

2. Karch, Amy M. Lippincott’s Nursing Drug Guide. Lippincott Williams & Wilkins.

Philadelphia. 2007.

3. Marilynn E. Doenges and Alice C. Murr: Nurses pocket guide, diagnoses, prioritized

interventions and rationales

Internet sources:

1. http://emedicine.medscape.com/article/417980-overview

2. http://scribd.com/GIbleeding.htm