OUR LADY OF FATIMA UNIVERSITY College of Nursing

In Partial Fulfilment of Requirements for RLE 102

U p p e r Gastrointestinal bleeding
A Individual Case Study

Presented To: MAAM AMY SANTOS MAN, RN Submitted By: MAGAT, JESSIE BOY S.

GROUP of 2Y2-2c September 24, 2012

I. INTRODUCTION I as a nursing student of OLFU provide this case study as for the purpose of this case is to be familiar with upper GI bleeds as a direct result of stress related- mucosal disease,; How it is start, what are the causes and what are the signs and symptoms; especially how to prevent, treat and manage the patient by giving medication for treatment and providing rapport. .I chose this case study because this is the most interesting case Ive encountered in the entire rotation and because some of the patients in Pedia ward 5west are having a dengue problem. I also fond to know about the important things to consider and word to discuss about this case. 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. Nonvariceal 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 antiinflammatory drugs. 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.

II. PATIENT HEALTH HISTORY

A. Personal Data: Ms. Joselle Chua Ignacio is a 13-year-old female, Filipino. She is 2nd in the family siblings. She is a Roman Catholic. Ms. Joselle Chua Ignacio is currently residing in 3017 Taliptip, Bulacan-Bulacan. She is a currently studying as a high school student. Ms. Ignacio was admitted in the hospital on September 13, 2012 at exactly 11:05 pm. Her attending physician is Dr. Foronda, M.D. She stayed at 5th floor 5 west pedia wards. B. Chief Complain: Masaki tang aking tiyan, tapos parang may pumutok na ugat, tapos yung dumi ko may dugo as verbalized by the patient. C. Principal Diagnosis: Upper Gastrointestinal Bleeding D. History of Patient illness: Ms. Joselle Chua Ignacio never had undergone any procedure before. She felt abdominal pain prior to admission but can be slightly tolerated. She has been having on and off epigastric pain, associated with occasional melena, cup in amount. Ms. Ignacio has a difficulty in defecating. 1 day prior to admission, had only 1 episode of melena, 1 spoon in amount, prompting consult, hence admitted. F. Past health History: The client stated that she has no previous hospitalization. She doesnt have any allergies and past injuries, and have complete immunizations when she was a child. She doesnt smoke and drink alcohol. She never undergoes any procedure. 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. G. Family History: The patient stated that her family has a history of Hypertension. She also stated that they dont have history of Diabetes, Tuberculosis and other hereditary disease. H. 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, She would not approach health workers not unless it is life threatening. He is pale to look at. I. Nutritional/ Metabolic Pattern The patient eats three times a day. She said that he eats a fatty and salty diet and no limit when it comes to food. She said that Hindi naman po ako mapili sa pagkain mahilig sa mga chips. During his hospitalization, she 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.

J.

Elimination Pattern According to the patient, when she is at home, she had difficulty in defecating and when he push to do so, she has a black-tary color of stool. She said that every time she defecates, her stool has a blood. During her hospitalization he defecates three to four times a day. She urinates an average of 850 cc per shift (8 hours) with yellowish colored urine. K. 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.

L. Self-Perception/ Self-Concept Pattern Ay gusto ko ng umuwi at gusto ng mga magulang kung uuwi narin 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 in daily activities, physical and emotional stress. M. Cognitive/ Perceptual Pattern Ms. Joselle Chua Ignacio is conscious, well oriented to time, place and person and is in a calm emotional state but gets irritable when discussing family matters with her parents. She exhibited appropriate behaviour and response when communicating and has not experienced any dizziness or tingling sensation. N. Role/Relationship Pattern Ms. Joselle Chua Ignacio is is singel, a student and she is 2nd in the siblings. The patient lives with his family in 3017 Taliptip, Bulacan-Bulacan.and as for his hospitalization expenses, her family especially her father find ways just to pay the bill. Her family feels worried about the situation, her mother wants to stay with her as well as her father but they cant because they need to work to earn money for his hospitalization.

O. Coping/ Stress-Tolerance Pattern nakakapagod sa hospital at boring pa dito as verbalized. Her vital support group is his family and significant others. P. Value/ Belief Pattern Ms. Joselle Chua Ignacio is a Roman Catholic. She always goes to church every Sunday with his family. He thinks that God is vital to everyone and she trusts in God on whichever turn her condition will be. She says that hospitalization truly interferes, as he cant go to church because of his illness. Q. Physical Assessment Skin: Uniform color with warm temperature, dry and smooth. No scars and hairs are evenly distributed. Nails: Pale in color, long and slightly dirty, concave in shape with capillary refill of 3 seconds. Head and Face: The skull is proportionate to body size, no tenderness. Hair is oily, thick and evenly distributed. Face is symmetrical and symmetrical facial movement. Eyes: The client has straight normal eye condition; pupil is black in color and equal in size. Have thin eyebrows. Ears: The shape is normal, hearing pattern is normal can hear whispered voice. Nose and Sinuses: The nose is in septum is in midline, mucosa is pale; both patent but have watery secretion and sinuses are non tender. Mouth: The lips are pale, symmetrical, pale mucosa, tongue is in midline. Neck: The skin is uniform in color. Neck muscles are equal in size and no tenderness. Breast and Axilla. No masses, tenderness upon palpation. Abdomen: Uniform in color, symmetrical movement, hypoactive bowel sound when percussion is dull for 3 clicks when palpate muscle guarding, usually urinary pattern is 850cc/shift. Hearth and Neck Vessels: Apical pulse has 55bpm, cardiac sound (-) murmur noted, apical and radial pulse data 55bpm , blood pressure of 90/60, pulse pressure 83.

III. 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 specialized 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 mucussecreting 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.

IV. PATHOPYHSIOLOGY

V. DIAGNOSIS A. Defination Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon. Upper GI bleeds are considered medical emergencies, and require admission to hospitalfor urgent diagnosis and management. Due to advances in medications and endoscopy, upper GI hemorrhage is now usually treated without surgery. B. Risk & Pre-Disposing Factor The condition tends to occur to Elderly, Coagulopathy is in an abnormality that affects blood coagulation patient that has Liver disease. Treatment with blood thinner medication: Coumadin (Warfarin)Heparin, Daily aspirin use,Regular or heavy use of nonsteroidal antiinflammatory medications:Ibuprofen (Motrin, Advil)Naproxen (Anaprox, Naprosyn, Aleve) Ketoprofen (Orudis), Gastritis,Colorectal cancer,Gastric cancer,Peptic ulcer disease,Esophageal varices ,Acid reflux disease

D. Signs and Symtoms Bleeding from the stomach can cause a host of signs and symptoms, some of which may clearly indicate a bleed while others can be vague and mistaken for other gastrointestinal conditions. Common signs and symptoms of stomach bleeding include:

Vomiting of red, fresh blood (hematemesis). Vomiting of old, brown to black blood which resembles coffee grounds. Presence of fresh blood in the stool (hematochezia). Black tarry stool due to the presence of old blood (melena). Epigastric pain (upper middle part of the abdomen, just below the breastbone) which may vary from sharp, stabbing pains to stomach cramps. Dizziness/lightheaded feeling.

Not all these signs and symptoms of stomach bleeding may be present and the presence of blood in the vomit (hematemesis) is sufficient to make a differential diagnosis of upper gastrointestinal bleeding. Hematemesis may be due to bleeding elsewhere, including the mouth and upper respiratory tract, so it has to be differentiated from upper gastrointestinal bleeding with an upper GI endoscopy. Other signs and symptoms of stomach bleeding includes:

Other gastrointestinal symptoms including indigestion and heartburn. General abdominal pain. Fatigue and shortness of breath in chronic bleeding. Fainting if there is significant blood loss. Lack of appetite. Loss of weight in chronic cases. Low blood pressure (hypotension). High heart rate (tachycardia). Signs of shock in cases of significant blood loss. Anemia. Pallor. Sweating.

Smell and taste of blood. This is subjective but is sometimes reported by patients with upper gastrointestinal bleeding.

VI. GROWTH AND DEVELOPMENT THEORY A. Sigmund Freuds Psychosexual Theory of Human Development Genital (Puberty onwards): Ms. Joselle Chua Ignacio belongs to this stage because this stage develops energy directed towards full sexual maturity & function & development of skills to cope with the environment.

B. Eriksons Stages of Psychosocial Development Theory Adolescence (1220 y/o Identity vs role confusion): Ms. Joselle Chua Ignacio belongs to this stage because this stage developes positive resolution like develops coherent sense of self and plans to actualize ones abilities. While negative resolution develops feelings of confusion, indecisiveness, & possible anti-social behaviour. C. Piagets Phases of Cognitive Development Formal Operation (11+years): Ms. Joselle Chua Ignacio belongs to this stage because this stage develops Able to see relationships and to reason in the abstract

VII. LABORATORY EXAM

HEMATOLOGY REPORT TEST WBC RBC Hemoglobin Hematocrit MCV MCH MCHC RDW-CV PDW MPV DIFFERENTIAL COUNT Lymphocyte % Neutrophil % Monocyte % Eosinophils % Basophils % Bands/stabs % PLATELET 331 10^3/uL 150 400 331 65.0 6.0 1.0 0.1 % % % % % 43.4 76.2 4.5 -10.5 1.0 3.0 0.0 2.0 1.0 2.0 65.0 6.0 1.1 0.1 17.9 % 17.4 48.2 17.9 RESULT 6.1 5.52 49 33.4 72.3 20.4 31.7 24.3 10.9 9.3 UNIT 10^3/uL 10^6/uL g/dL % fL Pg g/dL % fL fL REFERENCES 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 12.0 17.0 9.0 16.0 8.0 12.0 RESULT 6.1 5.52 49 33.4 72.3 20.4 31.7 24.3 10.4 8.6

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.

VIII. NURSING CARE PLAN A. Constipation related to irregular defecation habit as manifested by Verbalization for help, to help Grabe mahirap dumumi

ASSESSMENT

BACKGROUND KNOWLEDGE

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION After 8 hours of nursing intervention, goals partially met.

S: Grabe mahirap dumumi as verbalize by the patient. O: Hard, formed stool Hypoactive bowel sounds Abdominal tenderness Distended abdomen

Constipation is the most common digestive complaint It is a symptom rather than a disease and, despite its frequency, often remains unrecognized until the patient develops sequelae, such as anorectal disorders or diverticular disease.

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 behaviour or lifestyle changes to prevent recurrence of problem

INDEPENDENT Determine fluid intake Instruct the patient to viod if theres a feeling of urgency Note general oral/dental health DEPENDENT: Apply lubricant COLLABORATIVE: Encourage treatment of underlying causes.

To evaluate clients hydration status Prevent fullness

That can impact dietary intake

To soften To improve organ function

B.

Acute or chronic pain maybe related to chemical burn of gastric mucosa, oral cavity and physical response such as flex muscle spasm in the stomach wall as manifested by Verbalization for help, to help Napakasakit ng tiyan ko

ASSESSMENT

BACKGROUND KNOWLEDGE (GRAMMAR TYPE)

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

S: Napakasakit ng tiyan ko as verbalized by the patient.

O: Hard, formed stool Hypoactive bowel sounds Abdominal tenderness Distended abdomen

Acid, pepsin, and helicobacter infection play an important role in the development of gastric ulcers. The gastric mucosal barrier overlies the epithelium. The secretion of mucus and bicarbonate provides a first line defense in maintaining a nearnormal pH on the gastric epithelium and protects the mucosal barrier against acid. Gastromucosal prostaglandins increase the barriers resistance to ulceration. The integrity of the barrier is enhanced by the rich blood supply of the mucosa of the stomach and duodenum.

Acute or chronic pain maybe related to chemical burn of gastric mucosa, oral cavity and physical response such as flex muscle spasm in the stomach wall.

After 4 hours of nursing interventions The Patient verbalize s relief of pain Demonst rates relaxed body posture able to sleep or rest properly.

Independent Note reports of pain, including location, duration, and intensity (0-10 scale). Review factors that aggravate or alleviate pain. Note nonverbal pain cues. Pain is not always present, should be compared with patients previous pain symptoms. The comparison may assist in diagnosis of etiology of bleeding and development of complications. Helpful in establishing diagnosis and treatment needs.

Non-verbal cues may be both physiological and psychological and may be use in conjunction with verbal cues to evaluate extent and severity of the problem . Food has an acid-neutralizing effect and dilutes the gastric contents. Small meals prevent distention and the release of gastrin. Specific foods that cause distress vary among individuals. Spicy foods, alcohol, and coffee can precipitate dyspepsia. Reduces joint stiffness, minimizing pain and

After 4 hours of nursing interventions, the patient was able to verbalize relief of pain and demonstrate relaxed body posture and be able to sleep or rest properly.

Provide small frequent meals. Identify and limit foods that create discomfort. Assist with active and

passive range of motion exercises.

discomfort.

Provide frequent oral care and comfort measures including back rub and position change.

Halitosis from stagnant oral secretions is unappetizing and can aggravate nausea.

Collaborative Provide and implement dietary modifications. Client may receive nothing by mouth initially. When oral intake is allowed, food choices depend on the diagnosis and etiology of the bleeding. Fat in regular milk may decreases gastric secretions. The calcium and protein content especially in skim milk increases secretions.

Use regular than skim milk, if milk is allowed.

Administer medications as indicated such as analgesics.

Helps relive acute or severe pain.

IX. DRUG STUDY A. Ranitidine

GENERIC NAME

INDICATION Treatment and prevention of heartburn, acid indigestion, and sour stomach.

ACTION Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. In addition, ranitidine bismuth citrate has some antibacterial action against H. pylori.

CONTRAINDICATION Contraindicated in: Hypersensitivity, Cross-sensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance. Use Cautiously in: Renal impair- ment Geriatric patients (more susceptible to adverse CNS reactions) Pregnancy or Lactation

PRECAUTION/ ADVERSE REACTION PRECAUTION Severe and persistent headache. ADVERSE RXN Common: CNS: Confusion, dizziness, drowsiness, hallucinations, headache CV: Arrhythmias GI: Altered taste, black tongue, constipation, dark stools, diarrhea, drug-induced hepatitis, nausea GU: Decreased sperm count, impotence ENDO: Gynecomastia HEMAT: Agranulocytosis, Aplastic Anemia, neutropenia, thrombocytopenia LOCAL: Pain at IM site MISC: Hypersensitivity reactions, vasculitis

NURSING CONSIDERATION Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. Nurse should know that it may cause false-positive results for urine protein; test with sulfosalicylic acid. Inform patient that it may cause drowsiness or dizziness. Inform patient that increased fluid and fiber intake may minimize constipation. Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to

Ranitidine BRAND NAME Zantac DOSAGE 20 mg IV q8h

health care professional promptly. Inform patient that medication may temporarily cause stools and tongue to appear gray black.

B. Tranexamic Acid

GENERIC NAME

INDICATION

ACTION A synthetic derivative of the amino acid lysine. It exerts its antifibrinolytic effect through the reversible blockade of lysine-binding sites on plasminogen molecules. Antifibrinolytic drug inhibits endometrial plasminogen activator and thus prevents fibrinolysis and the breakdown of blood clots. The plasminogenplasmin enzyme system is known to cause coagulation defects through lytic activity on fibrinogen, fibrin and other clotting factors. By inhibiting

CONTRAINDICATION Contraindicated in: Allergic reaction to the drug or hypersensitivity Presence of blood clots (eg, in the leg, lung, eye, brain), have a history of blood clots, or are at risk for blood clots Current administration of factor IX complex concentrates or antiinhibitor coagulant concentrates.

PRECAUTION/ ADVERSE REACTION PRECAUTION Mild to moderate renal impairment, irregular menstrual bleeding, previous history of thromboembolic disease, haematuria. Monitor closely in disseminated intravascular coagulation. Monitor LFT and eye examination regularly during long-term use. Discontinue if disturbance in colour vision occurs. Avoid IV inj rate >1 ml/minute due to risk of hypotension. Pregnancy, lactation. ADVERSE RXN Common: Diarrhoea, nausea, vomiting, disturbances in colour vision, giddiness, hypotension (after rapid IV inj), thromboembolic events.

NURSING CONSIDERATION Unusual change in bleeding pattern should be immediately reported to the physician. For women who are taking Tranexamic acid to control heavy bleeding, the medication should only be taken during the menstrual period. Tranexamic Acid should be used with extreme caution in CHILDREN younger than 18 years old; safety and effectiveness in these children have not been confirmed. The medication can be taken with or without meals. Swallow Tranexamic

Tranexamic Acid BRAND NAME Hemostan DOSAGE 500 mg IV q0.1h

Tranexamic acid is used for the prompt and effective control of hemorrhage in various surgical and clinical areas.

the action of plasmin (finronolysin) the anti-fibrinolytic agents reduce excessive breakdown of fibrin and effect physiological hemostasis.

Acid whole with plenty of liquids. Do not break, crush, or chew before swallowing. If you miss a dose of Tranexamic Acid, take it when you remember, then take your next dose at least 6 hours later. Do not take 2 doses at once. Inform the client that he/she should inform the physician immediately if the following severe side effects occur: Severe allergic reactions such as rash, hives, itching, dyspnea, tightness in the chest, swelling of the mouth, face, lips or tongue Calf pain, swelling or tenderness Chest pain Confusion Coughing up blood Decreased urination Severe or persistent headache

Severe or persistent body malaise Shortness of breath Slurred speech Slurred speech Vision changes

X. 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. 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. Encourage patient to have a vitamins supplements. Compliance to medication regimen.

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

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. To have a fast recovery and to prevent complications.

TREATMENT

HEALTH TEACHINGS
Instruct the significant others to assess the patients incision and drainage system.

To monitor wound healing

Encourage the patient 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, foulsmelling 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. Instruct patient to eat high in protein such as meat Instruct patient to eat high in carbohydrate. Instruct patient to take vitamin K

To monitor any alternations in the patients status and ensure compliance to medication regimen. For tissue repair and faster wound healing.

DIET

For energy

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

To prevent blood clot. To provide and optimistic approach towards her problem.

XI. LEARNING EXPERIENCE When I had my first exposure in the area, last September 10, 2012 I always endeavour 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 learnings in this case study but comprising this, needs more patiences and time. As what I achieved in my studies, I also learned to be sensitive to my patients feelings and my patients conditions in order for me to impart a therapeutic service that will nurture health and wellness on their sufferings. I also acquired trust and rapport 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. So God bless me and all the patient that I encounter.

XII.REFERENCES

Book sources: 1. Black, J. and Hawks, J. Medical-Surgical Nursing: Clinical Management for Positive Outcomes. Elsevier Health Sciences: Singapore. 2008 edition 2. Karch, Amy M. Lippincotts Nursing Drug Guide. Lippincott Williams & Wilkins. Philadelphia. 2007 edition 3. Marilynn E. Doenges and Alice C. Murr: Nurses pocket guide, diagnoses, prioritized interventions and rationales. 4. Merriam Webster Dictionary. 2008 edition

Internet sources:

1. http://emedicine.medscape.com/article/417980-overview 2. http://scribd.com/GIbleeding.htm