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A GRAND CASE PRESENTATION Presented to the Faculty of Tarlac State University College of Nursing Tarlac City

In Partial Fulfilment Of Requirements of the Subject NCM 104 R.L.E.

Presented by BSN 4A - GROUP A4 Bagayas, Cyrene May I. Cayabyab, Bryan Jay G. Escultero, Ann Roselle Garcia, Princess Liahona Mangubat, Pamela G. Ocampo, Aura G. Patricio, Jojo C. Sese, Graciel Joyce T. Yumul, Anwar Zamora, Allan Edward T.

October 2008

INTRODUCTION 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 hospital for urgent diagnosis and management. Due to advances in medications and endoscopy, upper GI hemorrhage is now usually treated without surgery. Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, maroon stool, or hematochezia if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage. Patients may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath. The physical examination performed by the physician concentrates on the following things:

Vital signs, in order to determine the severity of bleeding and the timing of intervention Abdominal and rectal examination, in order to determine possible causes of hemorrhage Assessment for portal hypertension and stigmata of chronic liver disease in order to determine if the bleeding is from a variceal source.

Frequency United States UGIB is a common medical condition that results in high patient mortality and medical care costs. Annually, approximately 100,000 patients are admitted to US hospitals for therapy for UGIB. Peptic ulcer disease is the most common cause of UGIB. However, the proportion of cases caused by peptic ulcer disease has declined. The decrease is believed to be due to the use of proton pump inhibitors (PPIs) and H pylori therapy. International UGIB is a common occurrence throughout the world. In France, a report concludes that the mortality from UGIB has decreased from about 11% to 7%; however, a similar report from Greece finds no decrease in mortality. In a nationwide study from Spain, UGIB was 6 times more common than lower GI bleeding. Mortality/Morbidity Patients typically present with an ulcer that has bled or is actively bleeding, but approximately 80% of ulcers stop bleeding. The overall mortality rate is approximately 10%. In a retrospective chart review by Yavorski RT et al, 73.2% of deaths occurred in patients older than 60 years. In patients with UGIB, comorbid illness and not actual bleeding is the major cause of death. Comorbid illness was noted in 50.9% of patients, with similar occurrence in males (48.7%) and females (55.4%). One or more comorbid illnesses were noted in 98.3% of patients who died, and, in 72.3% of patients, comorbid illnesses were the primary cause of death. According to the American Society for Gastrointestinal Endoscopy (ASGE), the following risk factors are associated with increased mortality, recurrent bleeding, the need for endoscopic hemostasis, or surgery: age older than 60 years, severe comorbidity, active bleeding (eg, witnessed hematemesis, red blood per nasogastric tube, fresh blood per rectum), hypotension, red blood cell transfusion greater than or equal to 6 units, inpatient at time of bleed, and severe coagulopathy.

An increasing amount of evidence in the literature states that therapy with highdose PPIs (IV bolus followed by continuous infusion) may decrease the rate of rebleeding after endoscopic therapy. By increasing the gastric pH above 6, the clot is stabilized. Sex The incidence of UGIB is 2-fold greater in males than in females, in all age groups; however, the death rate is similar in both sexes. Age This patient population has become progressively older, with significant comorbidities that increase mortality. As mentioned above, the mortality increases with older age (>60 y) in both males and females. Source: www.emedicine.com

CURRENT TRENDS ABOUT UPPER GASTROINTESTINAL BLEEDING Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions, and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to be administered. Vitals signs are continuously monitored. Early endoscopy is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the lesion identifies, and can include:

injection of adrenaline or other sclerotherapy electrocautery endoscopic clipping or banding of varices

Stigmata of high risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding. Pharmacotherapy includes the following:

Proton pump inhibitors (PPIs), which reduce gastric acid production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage. These can be administered orally or intravenously as an infusion depending on the risk of rebleeding.

Octreotide is a somatostatin analog believed to shunt blood away from the splanchnic circulation. It has found to be a useful adjunct in management of both variceal and non-variceal upper GI hemorrhage. It is the somatostatin analog most commonly used in North America.

Terlipressin is a somatostatin analog most commonly used in Europe for variceal upper GI hemorrhage. Antibiotics are prescribed in upper GI bleeds associated with portal hypertension

If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested.

Source: www.wikipedia.com

IMPORTANCE OF THE CASE STUDY This case study is primarily important because it enhances the students skills, knowledge and attitude in the practice of the nursing process. It provides broader comprehension about the condition chosen through research and actual observation as it serves as a training ground and practice in developing learned skills in the assessment and management of UGIB. Through this case study, a strict and more holistic approach in assessing the patients health will be delivered, where it can be immediately attended to and given proper interventions. It serves as a way to familiarize the students with the different medical approaches toward the ongoing curative phase. This study serves as a tool for future reference of upcoming nursing students of the school. To share to other student nursing colleagues to understand the dynamics of UGIB as to the book based management and actual clinical interventions. Furthermore, this study may be used as a spring board for a more advanced and in-depth study that is in accordance to changing and developing society.

REASONS IN CHOOSING THE CASE Our group chose this case study to broaden our knowledge about the disease. Out of curiosity and interest, the case of Upper Gastrointestinal Bleeding was chosen by the group as a case study for this particular term in nursing education. The group was enthralled to know more about the disease, its causes, treatment, and the proper nursing management for patients with this kind of disease. This case study will help the group in acquiring sufficient information and apply it in the actual hospital setting to the patients with the same diagnosis. This case study will equip us nursing students with the right knowledge, skills and attitudes in caring for the individuals committed to our care. Promotion of health, prevention of diseases and illnesses, rehabilitation and restoration of good health are important in doing the case. In the accomplishment of the case study, the group will be able to know and develop more fully our skills in assessment, planning through nursing care plans, implementation/interventions and evaluation.

OBJECTIVES General The case study aimed to present a comprehensive study of the chosen patients condition called Upper Gastrointestinal Bleeding. Specifically, this study aimed to present the following objectives: 1. To present the current trends about the disease condition; the reasons for choosing such case for presentation; and the importance of the case study. 2. To come up with a comprehensive presentation of the disease condition through the nursing process namely: a. Assessment To present the Personal Data; Family History of Health and Illness; History of Past Illness; Physical Assessment using IPPA (Inspection, Palpation, and Auscultation); Diagnostic and Laboratory Procedures; Anatomy and Physiology; Pathophysiology (Client-Based and Book-based). b. Planning To formulate nursing care plans in the management of the identified health problems. c. Implementation To present the Medical Management including IVFs, etc; Drugs, Diet, Activity/ Exercise; Surgical Management; Nursing Management and the necessary nursing responsibilities that go with the different nursing interventions. d. Evaluation

To present and validate the patients daily program in the hospital in the course of the disease management.

3. To come up with conclusions in relation to: Discussions of the formulated objectives in terms of evaluation

4. To communicate recommendations pertaining to Upper Gastrointestinal Bleeding management both in the hospital and home setting. Principles, Practices, Problems, Solutions

ASSESSMENT I. A. Demographic Data Name of the Patient: Age: Sex: Civil Status: Occupation: Religious affiliation: Role Position in the Family: Address: Date of Birth: Place of Birth: Nationality: Health Care Financing: Admitting diagnosis: Date admitted: Social History The patient claimed of alcohol intake since he was 13 years old up to the age of 38. He was able to consumed 2 bottles of alcohol per day and he claimed that he usually drink alcohol everyday. The patient also verbalizes that some of those days, he drunk even without intake of foods. The patient also claimed of tobacco use. He started smoking at the age of 30 until the age of 48 years old and was able to consumed half pack (10 sticks) per day/ 9 packs per year. The patient also verbalizes the use of marijuana (2 times) at the age of 30. He claimed of euphoric experience upon using the drug. Mr. E.B.S 57 y/o Male Single Unemployed Roman Catholic Father Brgy. Buhilit, Tarlac City July 25, 1951 Caloocan, Manila Filipino None UGIB probably secondary to BPUD 09/17/08 10:08:49 a.m. PERSONAL DATA

The patient denies of any domestic and intimate partner relationship and verbalizes that he has no travel history. The patient has been living in their home for 39 years with his live-in partner and 5 children and has little modern conveniences. In the environment of the place, it was described to be free from health threats such as exposure to allergens and dust. The patient stated that he wanted fatty foods but he is controlling himself not to eat this kind of foods instead, he is taking more of vegetable foods and fish. He stated that he does not have regular check up due to financial constraints. II. FAMILY HISTORY OF HEALTH AND ILLNESS FATHER SIDE X 80 y/o No known X 65 y/o Stroke X 79y/o HPN No known X 55 y/o pneumonia MOTHER SIDE

X 72 y/o No known

X 73 y/o

65 A/ W

63 A/W HD Legend: Living femaleLiving malePatientDeceased male X

61

60 X HPN

59

58

40

30 X SLE

25 X SLE

40X stabbed

A/W

HPN/HD UGIB

HPN- hypertension SLE- systemic lupus erythematosus HD- heart disease A/W- alive and well
X

Deceased female

In the third degree of the patients family tree shows that his grandfather on the mother side had hypertension and did because of it. Towards to the father side, patients grandfather and grandmother died of no known cause. The patients father had stroke and died and his mother died of pneumonia. In the first generation of the genogram, some of the siblings manifested hypertension and some had an autoimmune disease (SLE) and heart disease. But with the condition of the patient, there was no trace found in the familys generation. III. HISTORY OF PAST ILLNESS The patient did not complete his immunization as he verbalized that there are no available vaccine for immunization at that time. When he was at the elementary level he experienced of having the following childhood illness like chickenpox, mumps and measles. 1975- The patient stated he was admitted at Jose Reyes Hospital when he undergone surgery (removal of nasal polyps). When he was 45 years old he claimed that he was admitted at Caloocan General Hospital due to high blood pressure. He was also admitted at Diosdado Macapagal Hospital and Tondo General Hospital due to high blood pressure (unrecalled date). According to the patient he took home medications and stated that he shifted his prescribed medications to Neoblocks and Aspirin, took once a day for approximately 5 years. 2006- He was readmitted at Tondo General Hospital due to high blood pressure and the physician (unrecalled) prescribed home medication (unrecalled). IV. HISTORY OF PRESENT ILLNESS One day prior to admission, the patient defecated a semi formed stool and brownish in color. After an hour, he experienced gastric pain on the epigastric region and 2 episodes of bowel movement of blood occurred. The patient described of 2 cups of blood per defecation. In this incident, the patient did not take any primary intervention for the crisis. One hour prior to admission, the patient experienced dizziness, blurring of vision and vomited approximately of one cup of blood. He asked his niece to take his blood

pressure but upon taking the BP, he collapsed. The patient then was rushed to TPH, hence, admission. 13 AREAS OF ASSESSMENT 1. Social Status The patient is a 57 year-old, and lives in a bungalow type house in Tarlac. The patient is currently unemployed because of his present condition. But in the past, he was a matadero and worked in a factory of metals. Currently, they are dependent in the help of his live-in partner and their children. The patient said that he cannot find a better job for him because he is only an elementary graduate. He is a Catholic and sometimes attend to hear the mass if he have a time. At home, they speak Tagalog and Kapampangan dialects. The patient is not affiliated to any kind of organization and he said that he has no health care services. The patient has a good and harmonious relationship with his neighbors and with his family. Analysis/Interpretation: Physical, personal and social forces all interact during the era of middle adulthood. How a person reacts to his physical view of aging affects his or her personality and selfperception. Erickson believed that the most important task for personality development is resolution of the conflict of generativity versus stagnation. Erickson believed that during the middle years adult have an urge to contribute to the next generation. This can be fulfilled by either by producing something to pass on the next generation. Thus, middle aged wants to rear their own children or to engage in other creative, socially useful work. The motivation is to nurture those who follow. (JAVIS 2004) The patient has problem in terms of financial matters. Due to his condition now, he cannot work and provide the needs of his family and because of no health care services; he has no privilege to receive assistance for his expenses in the confinement.

2. Mental Status Patient was conscious, appeared at his age with the appropriate concern for the assessment. The patient exhibited erect posture with a smooth gait and symmetrical body movements. Facial expressions are in conjunct with the content of the conversation and are symmetrical. Presented affect is euthymic and with accordance to the topics. In terms of communication abilities, the patient was able to produce spontaneous, coherent speech. Flow is with normal inflections, volume, pitch, articulation, rate and rhythm. Comprehension is intact. Upon cognitive status assessment, patient was able to correctly repeat series of numbers as to examine attention. Memory is intact as reflective of the ability to correctly respond to questions and to identify all the objects as requested. When given a practical situation, the patient evaluated and gave an action suited to the exampled scenario requiring judgment. Patient had also demonstrated an awareness and understanding towards self. Thought Process was based on reality, logical and coherent. No suicidal ideations can be inferred. Analysis/Interpretation: Mental Status is the degree of competence shown by a person in intellectual, emotional, psychological, and personality functioning (Mosbys Pocket Dictionary of Medicine, Nursing, and Health Professions 5th Edition). The patient responded accordingly to the situation and can be considered as mentally healthy. 3. Emotional Status

During the interview Mr. E.B.S. was calm and relaxed. He was cooperative and able to answer all the questions asked appropriately. He usually uttered jokes and always smiles. According to him, he is not depressed, and stated he was happy with his family. And most of the time, he complains of boredom, and desire to go home. Analysis/Interpretation: It is normal for an individual to react on the stimuli he perceives and feels. The patients mood and affect then was influenced by his present condition and the environment. 4. Sensory Perception In the assessment of sensory perception, examination of vision, hearing, smell, taste and touch were included. Vision In the examination of the eyes, extraocular muscle movements of both eyes were examined first, the Six Fields of Gaze was used as the assessment method. Standing two feet in front of the patient, a pen was used for the patient to follow from superior, inferior, left and right oblique angles. The patient was able to follow the pen to all the directions. Pupillary constriction was also tested using a penlight wherein the light was introduced from the front to the lateral side of one eye and then repeated the same procedure to the other eye. Both pupils constricted as light was directed to them. Typewritten words of about the font size of 10 can not be read by the patient at a distance of approximately 14 inches. The patient also verbalized that the gauge of his vision 300/300. It was also noted that the patients conjunctiva were pale. Hearing The Voice Whisper Test was used for the auditory assessment. Two feet behind the patients other ear, words and phrases were whispered and the patient was instructed to

repeat the words and phrases that were whispered. The procedure was then repeated to the other. The patient was able to repeat all the words that have been whispered to him.

Smell In assessing the sense of smell of the patient, he was instructed to close his eyes and let him smell things like alcohol and perfume. He was then instructed to recognize and name the different materials which he had done with positive remarks. Taste In assessing the sense of taste, the patient was again instructed to close his eyes and was allowed to taste things sugar and salt. The patient named all the things that he tasted. Tactile In the examination of the touch sensation of the patient, he was again instructed to close his eyes and was instructed to locate and name the part of his body that was gently being pricked by a pen. We then gently pricked him on both the upper and lower extremities and he was able to verbalize the location. Analysis/Interpretation: For the test of the Cardinal Fields of Gaze, the extraocular muscle movements are being assessed. Normally, both eyes of the patient should move smoothly and symmetrically in each of the six fields of gaze. Pupils should constrict briskly to direct and consensual light and to accommodation. Reading is generally possible at a distance of 14 inches for the assessment of near vision. (Health Assessment and Physical Examination, Estes 2006).

With this given data, the patients pupillary response and extraocular muscle movements are still within normal but his visual acuity is deviated as evidenced by his verbalization of his own gauge of vision. For the auditory accuracy, the patient should be able to repeat words whispered from a distance of two feet. (Health Assessment and Physical Examination, Estes 206). Based on this data, the patients auditory accuracy is within the normal limit. Olfactory receptor cells are located in the upper parts of the nasal cavity, the superior nasal conchae, and on parts of the nasal septum and are covered by hairlike cilia that project into the cavity. The chemical component of odors binds with the receptors, causing nerve impulses to be transmitted to the olfactory cortex located in the base of the frontal lobe. (Health Assessment and Physical Examination, Estes 2006). Comparing the patients data with the standard stated above, it denotes that the patients olfactory function transmits impulses to the frontal lobe properly. Four qualities of taste are found in the taste buds distributed over the surface of the tongue: bitter is located at the base, sour along the sides, and salty and sweet near the tip. (Health Assessment and Physical Examination, Estes 2006). With this data, we can compare the data from the client and conclude that his taste buds that help transmit taste sensations are functioning well. The skin contains receptors for pain, touch, pressure and temperature. These receptors originate in the dermis and terminate as either free nerve endings throughout the skins surface or as special touch receptors that are encapsulated and found predominantly in the fingertips and lips. Sensory signals that help determine precise locations on the skin are transmitted along rapid sensory pathways, and less distinct signals such as pressure or

poorly localized touch are sent via slower sensory pathways. (Health Assessment and Physical examination, Estes 2006) The patients sensory transmission functions well as manifested by the data presented above. 5. Motor Stability Upon interview the patient verbalized that he experienced easy fatigability and made him collapse 3 times during his hospitalization days. He was not able to sit, stand and walk without assistance due to fatigability. And he answers the questions while he was on lying position. On the second day of interview the patient is able to ambulate from his bed to comfort room. He remains erect and balanced during all stages of gait. Height and length of his steps are symmetrical from each foot. The arms swing freely at the side of the torso but in opposite direction to the movement of the legs. The lower limbs are able to bear full body weight during standing and ambulation. The head and neck turn toward the intended direction, followed by the rest of the body. He is able to transfer easily from various positions. Assessment for the Range of Motion of the patient was done through instructions assistance which includes the ability of the patient to bend his shoulder farther apart. He can also move his shoulder medially (toward the midline of the body), and laterally (away the midline of the body), as well as rotating his shoulder medially and laterally. He can bend his elbows closer and farther apart or rotate it laterally to face upward and medially to face downward. Extension and flexion of his wrist can be done, and extending it beyond the neutral position. The patient can also flex and extend his knees and do dorsiflexion (flexing the foot at the ankle so that the toes moves toward the chest) or plantar flexion (moving the foot at

the ankle so that the toes move away from the chest) of his ankles and feet, or tilting his foot inward and outward and moving it toward and away the midline of the body. Neck muscles are symmetrical with head in central position. Movement through full range of motion can be done without complaints of discomfort or limitation.

Analysis/Interpretation: Normal muscle strength allows for complete voluntary range of joint motion against both gravity and moderate to full resistance. Muscle strength is equal bilaterally. There are no observed involuntary muscle movements. Range of Motion standards are as follows: Walking is limited in one smooth, rhythmic fashion as the heel strikes the floor, body weight is then shifted to the ball of the foot, and then elevates off the floor before the next step forward. The normal ROM for the shoulder is forward flexion 1800, abduction 1800, adduction 500, internal and external rotation, 900. The normal ROM for the elbows is extension of 600, supination of 900, pronation of 900 and flexion of 1800. The normal ROM for the wrist is extension, hyperextension 700, flexion 900. The normal ROM for the knees is flexion 1300, extension in some cases, hyperextension is possible up to 150. The normal ROM for the ankles and feet is dorsiflexion of 200, plantar flexion of 450, eversion of 200, inversion of 200, abduction of 300 and adduction of 100. (Health Assessment and Physical Examination, Estes 2006).

Our patient had a problem with his motor stability during on his hospitalization, he experienced fatigability that results him to collapse. But few days past the patient gained strength with frequent rest. He was then discharge because he regained from fatigue.

6. Body Temperature
Table 1.Body Temperature

September 23, 2008 8 am - 36.6 C 10 am - 36.1 C 11 am - 37 C 11:15 am - 37.5C 11:30 am - 37.9 C 11:45 am - 37.6 C 12 pm - 36.8 C 1 pm - 37 C 2 pm - 37 C 3 pm - 36.5 6 pm - 36.6 C 10 pm - 36.8 C Analysis/Interpretation:

September 24, 2008 6 am - 36.5 C 10 am - 36.7 C 2 pm - 37 C

Normal body temperature per axilla is 36.40C to 37.40C. (Health Assessment, Janet R. Weber, 2006). During the two day monitoring period, Mr. E.B.S.s body temperature taken per axilla is within normal limits. There is uniformity in temperature of her body upon palpation. 7. Respiratory Status On the assessment of the respiratory status of the patient, there is no presence of difficulty of breathing and chest pain. Upon inspection, it reveals a normal breathing pattern which is regular and even in rhythm, respiratory rate were under normal range.

Thorax rises and falls in unison in the respiratory cycle as observed. Tactile fremitus(posterior equal vibration on both lungs that is decreased over periphery of lungs and increased over major areas). Depth of respiration is not exaggerated and effortless and patient inhale and exhale through the nose. The following listed below were the recorded respiratory rates during the shift:
Table 2.Respiratory Rate

Date September 23, 2008

September 24, 2008

Time 11 am 11:15am 11:30 am 11:45 am 12:00 pm 4 pm 6 pm 10 pm 6 am 10 am 2 pm

Respiratory Rate 19 cycle per minute 21 cycle per minute 28 cycle per minute 22 cycle per minute 20 cycle per minute 19 cycle per minute 20 cycle per minute 17 cycle per minute 18 cycle per minute 20 cycle per minute 20 cycle per minute

Analysis/Interpretation: Based on the Physical Assessment and Physical Examination Third Edition (Marry Ellen Zator Estes) the normal respiratory rate is 12- 20 breaths per minute, normal respirations are regular and even in rhythm, depth of inspiration is not exaggerated and effortless with the thorax rises and falls in unison in the respiratory cycle. As to compare the data observed to the above standard, it shows that there is no problem in the respiratory status of the patient, since all findings fall on the normal range as per standard. 8. Circulatory status Upon inspection, patient was pale in appearance and moderate weakness was observed. Patient was mostly confined to bed. Cold clammy extremities were noted as well as pale palpebral conjunctiva. Capillary refill of 4 seconds was assessed. Patients blood

pressure during assessment was 130/ 70 mmHg. The patient has pulse rate of 88bpm. The patients skin turgor after pinching turns to its normal position. As the figure shows that the pulse rates are within the normal range, in terms of rhythm it was even in tempo. The elasticity of patients pulse was considered artery feels springy, straight, and resilient. The force of the arterial pulse can be classified as in three point scale: 3+-----------full, bounding 2+-----------normal 1+-----------weak, thready 0 ------------absent

Table 3.Pulse Rate and Blood Pressure

Date September 23, 2008

September 24, 2008

Time 11 am 11:15am 11:30 am 11:45 am 12:00 pm 4 pm 6 pm 10 pm 6 am 10 am 2 pm

Pulse rate 70 bpm 73 bpm 108 bpm 88 bpm 78 bpm 88 bpm 90 bpm 85 bpm 91 bpm 82 bpm 80 bpm

Blood pressure 110/80 mm Hg 130/90 mm Hg 140/80 mm Hg 120/90 mm Hg 110/70 mmHg 130/70 mm Hg 120/70 mm Hg 110/80 mm Hg 130/70 mm Hg 120/80 mm Hg 110/70 mm Hg

Analysis/Interpretation: The normal pulse rate ranges from 60-100 beats per minute and the rhythm is normal due to it is regular with equal bilateral strength upon bounding, as to compare the force of the pulse from the scale above it falls under to the 2+ which is normal. The normal blood pressure is within the 120 to 140 systolic pressure and 80-90 diastolic pressure. Normally, the skin is a uniform whitish pink or brown color, depending on the patients race. 2-3 seconds is the normal time for capillary refill.

Based on the findings, the patient has poor capillary refill as evidenced by pale nail beds and prolonged time if perfusion which is 4 seconds. Due to poor perfusion, patient appeared pale and body weakness has been observed. 9. Nutritional Status Height Weight Body Mass Index The patient is 5 6 1/2 tall (1.6891 meters). The patient is 60 kilograms (132.28 pounds) on a medium frame. BMI=kg/m2 =60kg/2.85 =21 The patients BMI is 21. Usual Diet Rice and Fish; the physician ordered NPO temporarily but also ordered to have general liquids after gastric lavage was done and then soft diet was ordered lastly. Last meal taken Number of Meals Daily Prior to admission, patient claims that he eats twice a day during lunch and dinner. Breakfast consists of a cup of coffee without any food intake. Vitamin/Food Supplement use Food Preferences Food Prohibitions Mastication/ Swallowing problems Had difficulty masticating hard, solid foods due to incomplete number of permanent teeth. Did not use any dentures. Denies use of vitamin and food supplements but claims to use NSAIDS regularly particularly aspirin. Prefers fish for viand rather than poultry and meat products. Claims to have a diet low in fat as advised by his physician. 1 cup of rice with meat and vegetables for lunch as served by the hospital

Allergy/intolerances Denies any food allergies or food intolerances.

Usual weight

His usual weight before the age of 30 was 55 kilograms; he felt that he gained weight at the age of 30 years old along with increasing age.

Muscle Mass

Muscles over the temporal areas, dorsum of the hands and spine area are firm and developed, has bilateral strength upon initiating voluntary movement.

Body fat IVF

Equal in distribution and had a slightly increased fat over the waist and abdomen.

An intravenous infusion of PNSS was given during the hospital admission to maintain fluid and electrolyte imbalance. Upon pinching skin at the sternal area, at 1 second the skin went back to its original state. Moist and no lesions noted. Has brownish stained to yellowish teeth; without central incisors on the lower portion of the gums; with brownish pink gums.

Skin Turgor Mucous Membrane Condition of Teeth and Gums

TongueHas whitish center and pinkish on its tongue borders. Bowel Sounds Percussion Palpation Has 18 high-pitched bowel sounds per minute; present on all four quadrants Tympanitic over the bowels and dullness over the liver area at the right upper quadrant. Nontender on all the four quadrants; no masses noted and no pain upon palpation. Analysis/Interpretation: The normal BMI is between 20 and 25. More than 25 is considered overweight or obese and less than 20 is considered undernourished. According to the Healthy Asian Diet Pyramid there should be a DAILY intake of rice, grains, bread, fruits and vegetables; OPTIONAL DAILY for fish, shellfish and dairy products; WEEKLY for sweets, eggs and poultry and MONTHLY for meat. The regular number of meals should be three times daily such as breakfast, lunch and dinner. Allergies should be absent, if present it should be well

tolerated and managed. Mastication must be supported by a complete number of teeth. Muscle mass should be firm and developed with equal bilateral strength. Body fat should be equally distributed. Patient must be energetic. IVFs are according to physicians prescription. Skin turgor must be normal by a 1-2 seconds return of pinched skin. Teeth must be complete, straight and without cavities. Bowel sounds must be high-pitched with irregular gurgles 5-35 times per minute and must be present in all four quadrants. Upon percussion, there should be a generalized tympany over bowels and dullness on the RUQ. Upon palpation, there should be no masses and pain elicited or noted and abdomen is nontender in all four quadrants (Weber.2006).

Patient has a normal body mass index. Prior to admission, there is an irregularity on the number of meals taken. Stimulants such as caffeine included in a cup of coffee increase acid production on the stomach and could be one of the factors contributing to peptic ulcer disease. Regular use of NSAIDs (aspirin) could increase risk for bleeding tendencies on the gastrointestinal system. Patient had difficulty on mastication, therefore, foods that are soft are the ones tolerated for eating. There is a gradual increase in weight starting age 30. A difference of 5kg was gained. Muscle mass, body fat, skin turgor and mucous membranes are normal. The condition of the teeth is not normal due to missing numbers of teeth that interferes with normal food intake. The condition of the abdomen on auscultation, percussion and palpation are within normal limits.

10. Elimination Pattern Upon assessment, the patient verbalized that before admission, his normal bowel movement is once a day every morning. He described that before he was brought to the hospital, he had experienced three bowel movements wherein for the first one, was a semi formed stool and brownish in color but for the next two defecation, the stool is characterized as black and soft in consistency. Upon admission, he verbalized that he had still passed bloody stool for approximately ten times. The attending physician ordered for an NGT insertion and gastric lavage. After that, the patient said that his bowel movement returned to normal which was once a day but still the color is black and soft in consistency.

But during the day of the assessment, the patient has defecated for three times characterized as black and soft and measures for about 3 cups. The patient described his bladder habits before admission as being able to void for approximately three to four times a day depending on the amount of fluids he had taken. During his hospitalization period, he verbalized that his micturition period increased to approximately six times a day. He described his urine as yellowish in color and he claimed that he never experienced any dysuria. Analysis/Interpretation: The characteristics of the stool can vary greatly. Stool is normally light to dark brown; however, specific disease processes and ingestion of certain foods and medications may change the appearance of the stool. Blood in the stool can present in various ways and must be investigated. If blood is shed in sufficient quantities into the upper GI tract, it produces a tarry-black (melena), whereas blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. (Brunner and Suddarths Textbook of Medical Surgical Nursing, Eleventh Edition) Under normal circumstances with average fluid intake of approximately 500 to 2000 ml/day, the bladder should be able to store urine for periods of two to four hours at a time during the day. At night, the release of vasopressin in response to decreases fluid intake causes decrease in the production of urine and makes it more concentrated. This phenomenon usually allows the bladder to continue filling for periods of six to eight hours in adolescents and adults. (Brunner and Suddarths Textbook of Medical Surgical Nursing, Eleventh Edition) With this, it is highly evident that the patient is experiencing deviations from his elimination pattern, focusing on the bowel movements. The characteristics of his stool signify that he is suffering form upper gastrointestinal bleeding. No deviations on his micturition status are noted.

11. Reproductive Status The patient did agree for the assessment of his genitalia but has verbalized that he does not feel any pain in that area and no discharges were observed. He also claimed that he was circumcised at the age of 13 years old. Analysis/Interpretation: The normal characteristics of the male reproductive area are as follows: Penis Urinary meatus must be located at tip of glans penis, there must be no discharges, should wrinkled. The glans are varies in size; rounded, broad or pointed; free of lesions. Upon palpation there should be no masses, slightly tender, foreskin may not be present; should retract and return easily with clean, smooth skin underneath. Scrotum The left should be lower than right, pink or normal skin color, many skin folds. As to compare the gathered data to the above standards, the patient has a normal reproductive status. Testis The location should be entirely in sack, left slightly lower that right, oval in shape and symmetrical, smooth and firm and very tender. Comparison to the actual genitalia of the patient to the standards mentioned above is not possible due to the patients refusal for the assessment of his reproductive organ. 12. State of Physical Rest and Sleep Before hospitalization, he usually sleeps at 9:00pm and wakes up between 5:30 to 6:00 in the morning. According to the patient his sleep pattern was disturbed during his stay in the hospital he fell asleep at around 10:30 and it is being disturbed because of the hospital routines and sometimes because of the urge of defecating as claimed and after

giving the his medication he had difficulty to fell asleep again, he now usually woke up at around 5:00am as stated by the patient. During day time he cannot sleep because of the ambience and poor ventilation of the room as verbalized during our interview. Analysis/Interpretation: A normal sleeping hour of an adult per day is 8 hrs without being disturbed. (Fundamentals of Nursing 5th edition by Kozier, Erb, et.al) Due to the hospital routines and the urge of defecating his sleep and rest disturbed. As compared to the normal sleep hours stated above his sleep time is below normal. Because of the disturbed sleep pattern it may cause fatigue, body malaise and irritability to the patient.

13. State of Skin Appendages: Upon inspection, the clients skin color is light brown with milder colored palms, soles. Dryness of his lips is noted. Upon palpation, the skin is described as cold and clammy, the texture is described as dry and skin turgor returns promptly after pinching. Nails are intact with no swelling on and are pink in color. His nail beds are pale upon examination. There are no lesions found and no marked of jaundice observed. The patient also has dry lips. On his right arm there is an intravenous catheter inserted and connected to 0.9 % NaCl fluids and slight swelling noted on the site of insertion. Skin integrity is maintained in major parts of the body except for the insertion area.

Analysis/Interpretation: The normal generalized color for dark-skinned individuals is light to dark brown to olive with milder colored palms, soles, nailbeds and lips. Texture is described as smooth, soft, warm and dry to touch. Pinched skin to test for turgor should return immediately after. There should also be no swelling, pitting or edema present when pressed firmly for 5-10 seconds over tibia or ankle. Nails are present per distal phalanx, are pink in color, round

and with a 160-degree nail base. It is also hard, immobile and firm in texture. (Weber, Janet R. Nurses Handbook of Health Assessment p.252-267) Nail beds of the patient are pale in appearance and his lips are dry as compared to the standards stated above these findings are not normal. But for the other part of examination to his skin are in normal state except for the insertion area of his IV line to his right arm. Nail beds are indication of decrease circulation or hypoxia maybe due to decrease cardiac output.

Table 4.Diagnostic and Laboratory Procedures

Diagnostic and Laboratory Procedures Blood Chemistry

Date Ordered and Date Result/s Date Ordered September 17, 2008 Result September 17, 2008 September 20, 2008

Indication or Purpose/s Blood Chemistry is used to assess a wide range of conditions and the function of organs. To assess blood sugar, blood tests measure other substances. To assess kidney function.

Results FBS 10.6mmol/L Creatinine 88.3

Normal Values Analysis and ( units used in the Interpretation of hospital) Results FBS 3.9-6.6 mmol/L Elevated Creatinine 53106mmol/L Normal

NURSING RESPONSIBILITIES BEFORE: Instruct patient not to take any food or fluids per orem (NPO) 12 hours before blood extraction. Explain the procedure and purpose of the test to the patient/ patients immediate relative present and assess level of knowledge regarding the test. DURING: Adhere to standard precaution.

AFTER: Make sure blood sample reaches the laboratory immediately. Apply pressure on the venipuncture site and explain that some bruising, discomfort and swelling may appear at the site and that moist compress can alleviate this. Monitor for signs of infection. Follow up results from laboratory.

Diagnostic and Laboratory Procedures Serum Electrolytes

Date Ordered and Date Result/s in Date Ordered September 17, 2008 Result September17, 2008

Indication or Purpose/s These measures ions reflect the acid-base balance

Results

Normal Values ( units used in the hospital) Sodium 136-142 mmol/L Potassium 3.8-5.0 mmol/L Chloride 95-103 mEq/L

Analysis and Interpretation of Results Normal Normal Elevated

Sodium 136.4 mmol/L Potassium 4.18 mmol/L Chloride 110.2 mEq/l

NURSING RESPONSIBILITIES BEFORE: Explain the procedure and purpose of the test to the patient/ patients immediate relative present and assess level of knowledge regarding the test. DURING: Adhere to standard precaution.

AFTER: Make sure blood sample reaches the laboratory immediately. Apply pressure on the venipuncture site and explain that some bruising, discomfort and swelling may appear at the site and that moist compress can alleviate this. Monitor for signs of infection.

Follow up results from laboratory. Date Ordered and Date Result/s in Date Ordered September 17, 2008 Result September17, 2008 Indication or Purpose/s To determine existing infection in the genitourinary tract and to identify existence of blood if there is any. Results Physical Examination Color: Yellow Appearance: Slightly turbid Reaction: 5.0 Specific gravity: 1.015 Chemical Exam Albumin- negative Glucose negative Microscopic Exam Pus cells: 1015/HPF RBC: 0-1/HPF Epithelial: occasional Mucus Threads: occasional A.urates/ phosphates: few Albumin negative Glucose negative Pus cells: 0 2/HPF RBC: 0/HPF Normal Normal Elevated Normal Color: Straw dark yellow Appearance: Clear Reaction: 4.6 6.5 Specific Gravity: 1.016 1.022 Normal Normal Values Analysis and Interpretation of Results

Diagnostic and Laboratory Procedures Urinalysis

Normal Decreased

Bacteria: few NURSING RESPONSIBILITIES BEFORE: Explain the procedure and purpose of the test to the patient/ patients immediate relative present and assess level of knowledge regarding the test. DURING: Adhere to standard precaution. Monitor for signs of infection. Follow up results from laboratory. AFTER:

Diagnostic and Laboratory Procedures Complete Blood Count

Date Ordered and Date Result/s in Date Ordered September 17, 2008

Indication or Purpose/s

Results

Normal Values ( units used in the hospital)

Analysis and Interpretation of Results Decreased Normal Normal Normal Normal Decreased Decreased Normal Elevated Elevated Normal Normal Decreased Normal Normal Normal Decreased Decreased Normal Normal Normal Normal

CBC is used as a broad screening test to check for such disorders as Result Anemia or September Infection. 18, 2008

RBC 2.81 T/L WBC 9.5G/L Lympho 1.9 20.5%L Mid 0.5 4.8%M Gran 7.1 74.7%G Hgb 92 g/L Hct 244L/L MCV 86.8fL MCH 37.2 pg MCHc 377g/L PLT 231G/L WBC 8.3 G/L RBC 2.65T/L LYM 2.1 25.4%L MID 0.6 6.7%M GRAN 5.6 67.9%G Hgb 80g/L HCT 231 L/L MCV 87.0 fL MCH 30.2pg MCHc 346 g/L PLT 272.6 G/L

RBC 4.2-6.3T/L WBC 4.1-10.9G/L Lympho 0.6-4.1 10.0-58.5%L Mid 0.0-1.8 0.1-24.0%M Gran 2.0-7.8 37.0-92.0%G Hgb 120-180 g/L Hct 370-510L/L MCV 80.0-97.0fL MCH 26.0-32.0 pg MCHc 310-360g/L PLT 140-440G/L RBC 4.2-6.3T/L WBC 4.1-10.9G/L Lympho 0.6-4.1 0.0-58.5%L Mid 0.0-1.8 0.1-24.0%M Gran 2.0-7.8 37.0-92.0%G Hgb 120-180 g/L Hct 370-510L/L MCV 80.0-97.0fL MCH 26.0-32.0 pg MCHc 310-360g/L PLT 140-440G/L

September 19, 2008

NURSING RESPONSIBILITIES BEFORE: Explain the procedure and purpose of the test to the patient/ patients immediate relative present and assess level of knowledge regarding the test. Prepare materials to be used. Adhere to standard precaution. Make sure blood sample reaches the laboratory immediately. Apply pressure on the venipuncture site and explain that some bruising, discomfort and swelling may appear at the site and that moist compress can alleviate this. Monitor for signs of infection. Follow up results from laboratory. DURING: AFTER:

Diagnostic and Laboratory Procedures Hematology

Date Ordered and Date Result/s in Date Ordered September 17, 2008 Result September 17, 2008

Normal Values ( units used in the hospital) Hematology is used Hemoglobin: 133g/L Hgb: 140-170g/L as a broad screening Hematocrit: 6.38% test to check for Hct: 0.415-0.504 vol such disorders as RBC: 4.3312/L % 8 Anemia or Infection. WBC: 11.4 /L RBC: 3.5-4.712/L WBC: 4.5-118/L

Indication or Purpose/s

Results

Analysis and Interpretation of Results Decreased Elevated Normal Elevated

NURSING RESPONSIBILITIES BEFORE: . DURING: Adhere to standard precaution. Follow up results from laboratory. AFTER: Explain the procedure and purpose of the test to the patient/ patients immediate relative present and assess level of knowledge regarding the test. Instruct client that it may be uncomfortable to remain still in necessary position/s but it is important to do so. ask the patient to remove or assist in removing some or all of his/her clothes and to wear a gown during the exam;

Diagnostic/ Date Ordered and Laboratory Date Result/s in Procedure Fecalysis Result September 17,2008

Indication or Purpose/s To identify the presence of parasites in the gastrointestinal tract and determine presence of occult blood.

Results Color: reddish black Consistency: soft Microscopic findings: no ova or parasite seen Pus cell: 0.1 Red cell: plenty

Normal Values Color: brown Consistency: formed Pus cell: Negative Red cell: Negative

Analysis and Interpretation of Results Not Normal Not Normal Not Normal Not Normal

NURSING RESPONSIBILITIES BEFORE: Explain the procedure of the fecalysis to the patient and obtain her consent. Discuss the post procedure self-care activities that the client should follow. DURING: Adhere to standard precaution. AFTER: Observe for proper infection control.

ANATOMY AND PHYSIOLOGY

Your digestive system is a series of hollow organs joined in a long, twisting tube from the mouth to the anus. Inside this tube is a lining called the "mucosa." In your mouth, stomach, and small intestine, the mucosa contains tiny glands that produce juices to help you digest food. The digestive tract of a typical adult is about 30 feet long. Two solid organs, the liver and the pancreas, produce digestive juices that reach the intestine through small tubes. In addition, parts of other organ systems (such as nerves and blood) play a major role in the digestive system. ANATOMY Oral cavity In humans, digestion begins in the oral cavity where food is chewed. Saliva is secreted in large amounts (1-1.5 litre/day) by three pairs of exocrine salivary glands (parotid, submandibular, and sublingual) in the oral cavity, and is mixed with the chewed food by the tongue. There are two types of saliva. One is a thin, watery secretion, and its purpose is to wet the food. The other is a thick, mucous secretion, and it acts as a lubricant and causes food particles to stick together and form a bolus. The saliva serves to clean the

oral cavity and moisten the food, and contains digestive enzymes such as salivary amylase, which aids in the chemical breakdown of polysaccharides such as starch into disaccharides such as maltose. It also contains mucin, a glycoprotein which helps soften the food into a bolus. Swallowing transports the chewed food into the esophagus, passing through the oropharynx and hypopharynx. The mechanism for swallowing is coordinated by the swallowing center in the medulla oblongata and pons. The reflex is initiated by touch receptors in the pharynx as the bolus of food is pushed to the back of the mouth. Esophagus The esophagus, a narrow, muscular tube about 25 centimeters long, starts at the pharynx, passes through the larynx and diaphragm, and ends at the cardiac orifice of the stomach. The wall of the esophagus is made up of two layers of smooth muscles, which form a continuous layer from the esophagus to the oten and contract slowly, over long periods of time. The inner layer of muscles is arranged circularly in a series of descending rings, while the outer layer is arranged longitudinally. At the top of the esophagus, is a flap of tissue called the epiglottis that closes during swallowing to prevent food from entering the trachea (windpipe). The chewed food is pushed down the esophagus to the stomach through peristaltic contraction of these muscles. It takes only seconds for food to pass through the esophagus. Stomach The stomach is a pear shaped pouch and it is also described as a thick walled elastic bag. The food enters the stomach after passing through the cardiac orifice. In the stomach, food is further broken apart, and thoroughly mixed with gastric acid and digestive enzymes that break down proteins. The acid itself does not break down food molecules; rather, the acid provides an optimum pH for the reaction of the enzyme pepsin. The parietal cells of the stomach also secrete a glycoprotein called intrinsic factor which enables the absorption of vitamin B-12. Other small molecules such as alcohol are absorbed in the stomach,

passing through the membrane of the stomach and entering the circulatory system directly. Food in the stomach is in semi-liquid form. The transverse section of the alimentary canal reveals four distinct and well developed layers called serosa, muscular coat, submucosa and mucosa. Serosa: It is the outermost thin layer of single cells called mesothelial cells. Muscular coat: It is very well developed for churning of food. It has outer longitudinal, middle smooth and inner oblique muscles. Submucosa: It has connective tissue containing lymph vessels, blood vessels and nerves. Mucosa: It contains large folds filled with connective tissue. The gastric glands have a packing of lamina propria. Gastric glands may be simple or branched tubular secreting mucus, hydrochloric acid, pepsinogen and renin. Small intestine After being processed in the stomach, food is passed to the small intestine via the Pyloric sphincter. The majority of digestion and absorption occurs here as chyme enters the duodenum. Here it is further mixed with three different liquids: 1. bile, which emulsifies fats to allow absorption, neutralizes the chyme, and is used to excrete waste products such as bilin and bile acids (which has other uses as well). It is not an enzyme, however. The bile juice is stored in a small organ called the gall bladder. 2. pancreatic juice made by the pancreas. 3. intestinal enzymes of the alkaline mucosal membranes. The enzymes include: maltase, lactase and sucrase, to process sugars; trypsin and chymotrypsin are also added in the small intestine. Most nutrient absorption takes place in the small intestine. As the acid level changes in the small intestines, more enzymes are activated to split apart the molecular structure of the various nutrients so they may be absorbed into the circulatory or lymphatic systems. Nutrients pass through the small intestine's wall, which contains small, finger-like structures called villi, each of which is covered with even smaller hair-like structures called microvilli. The blood, which has absorbed nutrients, is carried away from the small

intestine via the hepatic portal vein and goes to the liver for filtering, removal of toxins, and nutrient processing. The small intestine and remainder of the digestive tract undergoes peristalsis to transport food from the stomach to the rectum and allow food to be mixed with the digestive juices and absorbed. The circular muscles and longitudinal muscles are antagonistic muscles, with one contracting as the other relaxes. When the circular muscles contract, the lumen becomes narrower and longer and the food is squeezed and pushed forward. When the longitudinal muscles contract, the circular muscles relax and the gut dilates to become wider and shorter to allow food to enter. In the stomach there is another phase that is called Mucus which promotes easy movement of food by wetting the food. It also nullifies the effect of HCl on the stomach by wetting the walls of the stomach as HCl has the capacity to digest the stomach.If the form of food in the stomach is semi-liquid form,the form of food in the small intestine is liquid form.It is in the small intestine where the digestion of food is completed. Large intestine After the food has been passed through the small intestine, the food enters the large intestine. The large intestine is roughly 1.5 meters long, with three parts: the cecum at the junction with the small intestine, the colon, and the rectum. The colon itself has four parts: the ascending colon, the transverse colon, the descending colon, and the sigmoid colon. The large intestine absorbs water from the bolus and stores feces until it can be egested. Food products that cannot go through the villi, such as cellulose (dietary fiber), are mixed with other waste products from the body and become hard and concentrated feces. The feces is stored in the rectum for a certain period and then the stored feces is egested due to the contraction and relaxation through the anus. The exit of this waste material is regulated by the anal sphincter. PHYSIOLOGY Movement of Food Through the System

The large, hollow organs of your digestive system contain muscles that enable their walls to move. This movement of the organ walls propels food and liquid and also mixes the contents within each organ. The movement of your esophagus, stomach, and intestine is called peristalsis. The action of peristalsis looks like an ocean wave moving through the muscle. The muscle of the organ produces a narrowing and then propels the narrowed portion slowly down the length of the organ. These waves of narrowing push the food and fluid in front of them through each hollow organ. The first important muscle movement occurs when you swallow food or liquid. Although you are able to start swallowing by choice, once the swallow begins, it becomes involuntary and proceeds under the control of the nerves. When you start to eat, the salivary glands in your mouth pump out digestive juices (saliva, or spit), which begin to break down your food chemically. The brain triggers this flow of saliva whenever you sense food or even think about eating. Together your salivary glands, which are located under the tongue and near the lower jaw, produce 1 to 3 pints of saliva a day. Your tongue and teeth help to get the digestive process started by chewing and chopping the food so it's small enough to be swallowed. Swallowing is very complicated when you are ready to swallow, your tongue pushes a small bit of mushed-up food (known as a bolus) toward the back of your throat and into the opening of your esophagus. The journey from the back of your throat through the esophagus to the stomach typically takes eight seconds. Your esophagus is the organ into which the swallowed food is pushed. It connects the throat above with the stomach below. At the junction of the esophagus and stomach, there is a ringlike valve, which keeps the opening between the two organs closed. However, as food approaches the closed ring, the surrounding muscles relax and allow the food to pass.

The food then enters your stomach, which has three mechanical tasks to do:

First, your stomach must store the swallowed food and liquidthis requires the muscle of the upper part of the stomach to relax and accept large volumes of swallowed material.

The second job is to mix up the food, liquid, and digestive juice produced by the stomachthe lower part of your stomach mixes these materials by its muscle action.

The third task of the stomach is to empty its contents slowly into your small intestine.

Several factors affect emptying of your stomach, including the type of food you have eaten (mainly its fat and protein content) and the degree of muscle action of the emptying stomach and the next organ to receive the contents (the small intestine). As the food passes along your small intestine, which is over twenty feet long, the nutrients are absorbed through the wall of the small intestine and passed into the bloodstream. By the time the food has reached the large intestine (colon), the nutrients have been removed and waste materials remain. In the colon, the waste material, which includes undigested parts of food (mostly fiber) and older cells that have been shed from the mucosa, is passed along by the muscle contractions (peristalsis). Eventually the waste reaches the end of the digestive tract, the rectum. Your colon absorbs water from the waste material, which causes the material (stool) to become firmer. Stool usually remains in the colon and rectum for a day or two, until it is expelled by a bowel movement. There is a wide variation in normal bowel movementsthe average person has a bowel movement anywhere from 3 times a day to 3 times a week.

Production of Digestive Juices The glands that act first are in your mouth--the salivary glands. Saliva produced by these glands contains an enzyme that begins to digest the starch from food into smaller molecules. The next set of digestive glands is in the lining of your stomach. They produce stomach acid and an enzyme that digests protein. One of the unsolved puzzles of the digestive system is why the acid juice of the stomach does not dissolve the tissue of the stomach itself. In most people, the stomach mucosa is able to resist the juice, although food and other tissues of the body cannot. After your stomach empties the food and juice mixture into the small intestine, the juices of two other digestive organs mix with the food to continue the process of digestion. One of these organs is the pancreas. It produces a juice that contains a wide array of enzymes to break down the carbohydrate, fat, and protein in food. Other enzymes that are active in the process come from glands in the wall of the small intestine. The liver produces yet another digestive juicebile, which, between meals, is stored in the gallbladder. At mealtime, bile is squeezed out of the gallbladder into the bile ducts to reach the intestine and mix with the fat in your food. The acids in the bile dissolve the fat into a watery mixture, much like detergents that dissolve grease from a frying pan. After the fat is dissolved, it is further broken down by enzymes from the pancreas and the lining of the intestine. Absorption and Transport of Nutrients Digested molecules of food (including carbohydrates, fats, proteins, and vitamins), as well as water and minerals from your diet, are absorbed from the cavity of the upper small intestine. Most of these absorbed materials cross the mucosa into your blood and are

carried off in the bloodstream to other parts of the body for storage or use by the bodys cells for energy and nourishment. How the digestive process is controlled Hormone Regulators A fascinating feature of the digestive system is that it contains its own regulators. Hormones that control the functions of the digestive system are produced and released by cells in the mucosa of the stomach and small intestine. These hormones are released into the blood of the digestive tract, travel back to the heart and through the arteries, and return to the digestive system, where they stimulate digestive juices and cause organ movement. The hormones that control digestion are:

Gastrin, which causes the stomach to produce an acid for dissolving and digesting some foods. It is also necessary for the normal growth of the lining of the stomach, small intestine, and colon.

Secretin, which causes the pancreas to send out a digestive juice. It stimulates the stomach to produce pepsin, an enzyme that digests protein, and stimulates the liver to produce bile.

Cholecystokinin (CCK), which causes the pancreas to grow and produce the enzymes of pancreatic juice. It also causes the gallbladder to empty.

Additional hormones in the digestive system regulate appetite:

Ghrelin, which is produced in the stomach and upper intestine in the absence of food in the digestive system and stimulates appetite. Peptide YY, which is produced in the digestive system in response to a meal in the system and inhibits appetite.

Both of these hormones work on the brain to help regulate the intake of food for energy.

Nerve Regulators Two types of nerves help to control the action of the digestive system. Extrinsic (outside) nerves come to the digestive organs from the unconscious part of the brain or from the spinal cord. They release a chemical called acetylcholine and another called adrenaline.

Acetylcholine causes the muscle of the digestive organs to squeeze with more force and increase the "push" of food and juice through the digestive tract. Acetylcholine also causes the stomach and pancreas to produce more digestive juice. Adrenaline relaxes the muscle of the stomach and intestine and decreases the flow of blood to these organs.

Even more important, though, are the intrinsic (inside) nerves, which make up a very dense network embedded in the walls of the esophagus, stomach, small intestine, and colon. The intrinsic nerves are triggered to act when the walls of the hollow organs are stretched by food. They release many different substances that speed up or delay the movement of food and the production of juices by the digestive organs.

PATHOPHYSIOLOGY Book Based


Non-modifiable: Modifiable risk factors

Advanced age Family history of PUD

Altered mucosal blood flow

Smoking Alcohol Chronic cirrhosis

Habitual use of NSAID

Infection of H. pylori

Cytotoxic effect

Inhibits prostaglandin secretion

Increased gastrin level

Increased gastric output

Decreased bicarbonate secretion

Impaired mucosal defense to acid

Inflammatory response

Affection of mucous production

Tissue damage (Mucosal defects)

Allow back diffusion of hydrogen ions

Diffusion of acid and pepsin into the cell

Vomiting (hematemesis)

Gastric outlet

Ulceration of mucosal barrier BLEEDING PEPTIC ULCER DISEASE Further damage blood vessels

Epigastric pain

UPPER GASTROINTESTINAL BLEEDING

Blood volume depletion Decreased cardiac output

Accumulation of blood in GI tract

Increased peristalsis Decreased systolic BP<100mmHg Increased pulse rate >100 diarrhea hematochezia melena Digestion of blood proteins Increased BUN

Compensatory constriction of peripheral arteries

Metabolic Acidosis

Compensatory failure

Decreased blood flow to skin

Decreased blood flow to kidneys

Death

Lactic acidosis Decreased urine output Anoxia Renal failure Tubular necrosis

Death Decreased blood flow to brain Decreased coronary blood flow Myocardial Infarction Heart failure

oliguria

Angina -anxiety -confusion -stupor -coma

Pulmonary edema

dysrhythmias

Client Based

Tobacco (9packs/year)

Alcohol (minimum of 2 bottles/day since 13y/o

Use of NSAIDs aspirin once a day since 2003)

Mucosal damage

Epigastric pain

CC: Hematochezia

Bleeding peptic ulcer disease

Upper gastrointestinal bleeding

Blood volume depletion

Accumulation of blood in GI tract

Compensatory constriction of peripheral arteries

-hematemesis (1 cup vomitus) -melena (3x a day)

-delayed capillary refill (4sec) Decreased Hgb count (80 g/L) -delayed tissue perfusion (4sec) -pale nail beds -pale palpebral conjunctiva -dry lips -cold clammy extremities

NURSING CARE PLANS


Table 5.Ineffective Tissue Perfusion

Assessment S> O> weak in appearance > with pale nailbeds > with cold clammy extremities > capillary refill within 4 seconds > tissue perfusion within 4 seconds > pale palpebral conjunctiva noted >Hgb= 80 g/L >Hct= .231 L/L Nursing Diagnosis Ineffective tissue perfusion related to decreased hemoglobin concentration in blood secondary to upper gastrointestinal bleeding Scientific Explanation Decrease in oxygen resulting in failure to nourish tissues at capillary level

Planning Within the shift, the patient will demonstrate adequate tissue perfusion as evidenced by warm and dry skin and improved capillary refill.

Nursing Interventions Independent Position to Semi Fowlers R: To facilitate lung expansion and promote oxygenation Perform active assistive Range of motion exercises and provide simple massage therapy. R: To enhance circulation of blood to the blood vessels especially those in the periphery Allow for periods of rest before and after planned exertion periods such as meals and physical activity R: Physical and emotional rest help lower arterial pressure and reduce the workload of the myocardium Health teachings: o Avoid strenuous activities o Increase fluid intake o Continue performing exercises Dependent Hook 1 unit of PRBC Type B, properly cross - matched R: To increase the red blood cell level and hemoglobin Monitor for signs of Blood transfusion reactions

Desired Outcome After the shift, the patient will be able to demonstrate adequate tissue perfusion as evidenced by: a. Warm and dry skin b. Improved capillary refill c. Non pale nailbeds d. Non pale palpebral conjunctiva

R: To prevent occurrence of anaphylactic shock

Table 6.Ineffective Airway Clearance (During Blood Transfusion)

Assessment S> Nahihirapan akong huminga habang sinasalinan ako ng dugo, parang may bumabara. As verbalized. O> restlessness noted

Planning After 1 hour of appropriate nursing interventions, the patient will have a patent airway and will be able

Intervention Discontinue blood transfusion. R: therapy have induced an untoward reaction in the patients system Assume comfortable position

Expected Outcome After 1 hour of appropriate nursing interventions, the patient will have a patent airway and will be able to breathe comfortably as evidenced by:

>blotchy skin with to breathe comfortably. erythematous wheals on the head and neck >nasal flaring >use of accessory muscles >rapid, shallow breathing >dyspneic; RR= 28 breaths/minute Nursing Diagnosis: Ineffective Airway Clearance related to bronchospasm secondary to hypersensitivity reaction secondary to blood transfusion Scientific Explanation: Inability to clear obstruction characterized by bronchospasm of the respiratory tract to maintain a clear airway.

(upright or fowlers) R: upright position facilitates lung expansion Keep environment well-ventilated R: movement of air helps relieve dyspnea Support and demonstrate client in using pursed-lip and controlled breathing techniques R: decreases respiratory rate and improves oxygenation Monitor respiratory rate, depth and ease of respiration closely R: determines progression of the condition Impart health teachings >avoid allergens >signs of respiratory insufficiency

Decreased respiratory rate Regular breathing rhythm Absence of nasal flaring Verbalization of ease in breathing

Table 7.Risk for deficient fluid volume

Assessment

Planning

Nursing Interventions

Desired Outcome

S> O> weak looking > dryness of lips observed > with cold clammy extremities > capillary refill within 4 seconds > tissue perfusion within 4 seconds > frequent passing of black colored stool (approximately 3 times) > with vomitus of approximately 2 cups characterized as bloody Nursing Diagnosis Risk for deficient fluid volume related to excessive losses of fluids through normal routes Scientific Explanation At risk for experiencing vascular, cellular, or intracellular dehydration
Table 8.Disturbed Sleep Pattern

Within 2 Independent hours of Provide fresh water and oral fluids preferred by the client appropriate unless contraindicated nursing R: To replace the fluid losses of the patients body interventions, Maintain patent IV access, set an appropriate IV infusion flow the patient rate and administer at a constant flow rate as ordered. will be able to R: To maintain normal intracellular and extracellular fluid maintain volume normal fluid Watch for early signs of hypovolemia, including restlessness, volume as weakness, muscle cramps and postural hypotension. evidenced by R: To detect and prevent occurrence of hypovolemia maintenance Monitor daily weight for sudden decreases, especially in the of urine output presence of decreasing urine output or active fluid loss of 4-5 times a R: Body weight changes reflect changes in body fluid volume day, normal Monitor total fluid intake and output every 8 hours. blood R: To determine if there is an existing deficiency in fluid volume pressure, pulse Render health teachings: and body o Avoid humid places to reduce insensible fluid losses temperature. o Replenish lost fluids after daily activities through intake of water and other liquid products. Collaborative Refer the patients frequent passing of stool and vomiting to the attending physician. R: To inform physician of the present condition of the patient and be able to carry out any immediate orders to prevent any complications

After 2 hours of appropriate nursing interventions, the patient will be able to maintain normal fluid volume as evidenced by: a. Maintenance of urine output of 4-5 times a day b. Maintenance of normal blood pressure, pulse and body temperature

Assessment Planning S> Hindi ako makatulog ng After 1 hour

of

Intervention Position as preferred

Expected Outcome After 1 hour of appropriate

maayos dito. As verbalized. O>weak-looking >pale to look at >irritable at times >mostly confined in bed >yawns during conversation >untended beddings and bedside >environment characterized as humid Nursing Diagnosis: Disturbed Sleeping pattern related to environmental condition Scientific Explanation: Time-limited disruption sleep, amount and quality. of

appropriate nursing interventions, the patient will be able to gain rest and sleep.

R: assuming a comfortable nursing interventions, the position induces rest patient will be able to gain rest and sleep as evidenced by: Render bedside care R: facilitates comfort Less irritable mood Provide sponge bath and change Ability to sleep without clothing interruptions at the end of R: improves well-being and the shift comfort Provide measures to take before bedtime to assist with sleep (carbohydrates such as crackers) R: simple measures can increase quality of sleep Provide a back massage before sleep R: use of back massages has been shown effective for promoting relaxation which likely leads to improved sleep Keep environment quiet R: excessive noise disrupts sleep Health teachings: >warm bath before going to bed >quiet activities before sleeping such as reading a book >reduce daytime napping in the late afternoon Intervention Expected Outcome

Table 9.Fatigue

Assessment

Planning

S> Nanghihina ako, hindi ko nagagawa lahat ng pangsariling gawain nang mag-isa. Madali ako mapagod. As verbalized. O>weak-looking >pale in appearance >mostly confined in bed >slightly drowsed >limited ADLs >Hgb= 80 g/L >Hct= .231 L/L Nursing Diagnosis: Fatigue related decreased ability transport oxygen to to

After 1 hour of appropriate nursing interventions, the patient will gain energy and improved wellbeing.

Scientific Explanation: An overwhelming sense of exhaustion and decreased capacity for physical and mental work at usual level.

Assist with ADLs as necessary; encourage independence and activity without causing exhaustion R: eases completion of patients activity while promoting self-reliance Encourage walking exercises and gradually increasing activities as tolerated R: expands endurance towards self-activities Provide rest periods R: conserves energy and minimizes feelings of fatigue Perform active-assistive ranges-of-motion R: prevents contractures during periods of inactivity Help in identifying essential and non-essential tasks and determine which can be delegated R: aids in balancing available energy and energy demands Impart health teachings >follow a healthy lifestyle with adequate nutrition, fluids and rest, pain relief and appropriate exercise >maintain regular family routines once discharged >follow energy conservation strategies such as sitting instead of standing during showering and storing items at waist level

After 1 hour of appropriate nursing interventions, the patient will gain energy and improved well-being as evidenced by: Increase in ability to perform ADL without easy exhaustion Less weak in appearance Verbalization of increased energy

MEDICAL MANAGEMENT
Table 10.IVF

Medical Management IVF (PNSS)

Date Date Ordered: September 17, 2008 Date Started: September 17, 2008 Date Ended: Ongoing

General description Plain Normal Saline Solution is typically the first fluid used when dehydration is severe enough to threaten the adequacy of blood circulation and is the safest fluid to give quickly in large volumes.

Indication o Isotonic solution o Rehydrati on of both in and outside cell.

Clients reaction Consumed with no adverse reactions.

NURSING RESPONSIBILITIES: BEFORE: Recheck doctors order, and compute for the flow rate. Observe the 7 Rs. Explain the procedure to the patient. Wash hands. Monitor and regulate the IV and its patency. Monitor for signs of phlebitis or infiltration. Proper disposal of IVF. Assess if condition is improving. Wash hands. DURING: AFTER:

Table 11.Blood Transfusion

Medical Management Blood Transfusion 1 unit Packed RBC Type B+, Properly crossmatched

Date Date Ordered: September 20, 2008 Date Started: September 23, 2008 Date Ended: September 23, 2008

General description The transfer of blood or blood components from one person (the donor) into the bloodstream of another person (the recipient).

Indication Transfusions are given to restore lost blood, to improve clotting time, and to improve the ability of the blood to deliver oxygen to the body's tissues.

Clients reaction The patient had developed reactions such as having erythematous skin inflammation on the face and difficulty of breathing

NURSING RESPONSIBILITIES: BEFORE: Check physicians order, including blood type, product and number of units and period of time blood must be transfused. Obtain consent from patients family. Prepare the needed materials. Transfusion must be started 30 minutes after blood is taken from the refrigerated storage. Check the patients vital signs. Warm blood by wrapping it in a towel and store at room

DURING:

Stay with the patient with at least 15 mins. or the first 50ml of transfusion in order to observe reactions and complications. Blood should not be allowed to hang at 4-6 hours at room temperature because of the danger of proliferation and RBC hemolysis. Monitor vital signs. Monitor patient for side effects and adverse reactions.

AFTER: After completion of transfusion, flush remaining blood on tubing with PNSS. Check the vital signs. Document the procedure, time, vital signs, and reactions.

Table 12.Drugs

Name of drug

Date ordered/ Date started/ Date changed

Route/ Dosage/ Frequency of administration

General action/mechanism of action

Indication/ Purpose

Clients response to medicine with actual s/e

Generic name: Pantoprazole Brand name: Protonix Classification: Gastric acid suppressant

Date Ordered: September 17, 2008 Date Started: September 17, 2008 Date Ended: September 18, 2008

Route of Administration: Via IV Dosage and Frequency: Pantoprazole 80 mg +100 cc of PNSS in soluset to run for 12 hrs.

Chemical Effect: Inhibits the activity of the proton pump by binding to hydrogen-potassium adenosine triphosphatase, located at secretory surface of the gastric parietal cells. Therapeutic Effect: Suppresses gastric secretion.

-patient with GERD -short-term therapy for erosive esophagitis

Had given and reaction occurred.

NURSING RESPONSIBILITIES: BEFORE: Assess clients condition before starting the therapy. Be alert for adverse reactions and interactions Orient client on some possible side effects of drug. Tell patient to report abdominal pain or bleeding.

DURING:

Assess patient for complaint of epigastric or abdominal pain Assess for bleeding (blood in the stool or emesis) Chart the procedure including the time, name and dosage of the drug and the clients response to the administration. Assess patients infection

AFTER

Name of drug

Date ordered/ Date started/ Date changed Date Ordered: September 17, 2008 Date Started: September 17, 2008 Date Ended: September 24, 2008

Generic name: Rebamipide Brand name: Mucosta

Route/ Dosage/ Frequency of administration Route of Administration: Oral Dosage and Frequency: 100 mg/cap, 1 cap TID/NGT

General action/mechanism of action

Indication/ Purpose For gastric mucosal lesions in acute gastritis and acute exacerbation of chronic gastritis.

Clients response to medicine with actual s/e Had given and reaction occurred.

it works by enhancing mucosal defense, scavenging free radicals, and temporarily activating genes encoding cyclooxygenase-2.

NURSING RESPONSIBILITIES: BEFORE: Assess clients condition before starting the therapy. Be alert for adverse reactions and interactions Orient client on some possible side effects of drug. Chart the procedure including the time, name and dosage of the drug and the clients response to the administration. Assess patients infection

AFTER

Name of drug

Date ordered/ Date started/ Date changed

Route/ Dosage/ Frequency of administration

General action/mechanism of action

Indication/ Purpose

Clients response to medicine with actual s/e

Generic name: Tranexamic acid Brand name: Cyklokapron Classification:

Date Ordered: September 17, 2008 Date Started: September 17, 2008

Route of Administration: IVP Dosage and Frequency: 500 mg now then q 6 hours

Date Ended: September 20, Antifibrinolytic 2008 NURSING RESPONSIBILITIES: BEFORE: Explain the importance and action of the drugs. Tell the possible reaction or side effects of the drugs. Monitor patient for any adverse reaction.

Forms a reversible complex that displaces plasminogen from fibrin resulting in inhibition of fibrinolysis; it also inhibits the proteolytic activity of plasmin

-treatment of excessive bleeding -prophylaxis in patients with coagulopathy undergoing surgical procedures

Had given and reaction occurred.

AFTER: Stay with the client for at least 15-30 minutes after giving the drug Be alert for adverse reaction and drug interaction.

Name of drug

Date ordered/ Date started/ Date changed

Route/ Dosage/ Frequency of administration

General action/mechanism of action

Indication/ Purpose

Clients response to medicine with actual s/e

Generic name: Omeprazole Brand name: Losec Classification: Proton pump inhibitor

Date Ordered: September 18, 2008 Date Started: September 18, 2008 Date Ended: September 24, 2008

Route of Administration: Via IV Dosage and Frequency: PNSS 100 cc + Omeprazole 80 mg TRF 12 hrs.

Chemical Effect: inhibits acid pump and binds to hydrogen-potassium adenosine triphosphate on secretory surface of gastric parietal cells to block formation of gastric acid. Therapeutic Effect: Relieves symptoms caused by excessive gastric acid.

Given to reduce gastric acid.

Had given and reaction occurred.

NURSING RESPONSIBILITIES: BEFORE: Explain the importance and action of the drugs. Tell the possible reaction or side effects of the drugs. Monitor patient for any adverse reaction. Stay with the client for at least 15-30 minutes after giving the drug Be alert for adverse reaction and drug interaction.

AFTER:

Monitor patients hydration.


Date ordered/ Date started/ Date changed Route/ Dosage/ Frequency of administration General action/mechanism of action Indication/ Purpose Clients response to medicine with actual s/e

Name of drug

Generic name: Diphenhydramine Brand name: Allerdryl Classification:

Date Ordered: September 23, 2008 Date Started: September 23, 2008 Date Ended: September 23, 2008

Route of Administration: IVP Dosage and Frequency: 1 amp stat

Chemical Effect: Competes with histamine for h1receptor sites on effector cells. Therapeutic Effect: Relieves allergy symptoms

Given to relieve allergy symptoms and promotes sleep and calmness.

Had given and reaction occurred.

Antihistamine, sleep aid, antitussive NURSING RESPONSIBILITIES: BEFORE:

Assess patients underlying condition before therapy. Be alert for adverse reaction. Administered with meal to reduce GI distress. Warm patient to avoid alcohol consumption. Stay with the client for at least 15-30 minutes after giving the drug

DURING:

AFTER:

Be alert for adverse reaction and drug interaction.


Name of drug Date ordered/ Date started/ Date changed Route/ Dosage/ Frequency of administration General action/mechanism of action Indication/ Purpose Clients response to medicine with actual s/e

Generic name: Hydrocortisone Brand name: Ala-cort Classification:

Date Ordered: September 23, 2008 Date Started: September 23, 2008

Route of Administration: IVP Dosage and Frequency: 500mg stat

Date Ended: September 23, Glucocorticoid 2008 NURSING RESPONSIBILITIES: BEFORE: Explain the importance and action of the drugs. Tell the possible reaction or side effects of the drugs. Monitor patient for any adverse reaction.

Chemical Effect: Given to reduce May stabilize leukocyte inflammation. lysosomal membranes, suppress immune response, stimulate bone marrow and influence nutrient metabolism Therapeutic Effect: Reduces inflammation

Had given and reaction occurred.

DURING Inject for over at least 30 seconds. Monitors patients weight, blood pressure and electrolyte levels. monitor patient for stress

AFTER:

Stay with the client for at least 15-30 minutes after giving the drug Be alert for adverse reaction and drug interaction. Date Prescribed September 17, 2008 General description NO solid foods or either liquids to be ingested Soft diet September 20, 2008 Foods that are mashed or pureed, placed in soups, stews, chili, curries, or made into sauces. Indications For patients prior to operation. For patient who has difficulty swallowing, surgery involving the mouth or gastrointestinal tract, and pain from newly adjusted braces. -oatmeal -porridge -mashed potatoes Able to comply Specific foods taken NPO Clients response Able to comply

Table 13.Type of Diet

Type of diet

NURSING RESPONSIBILITIES: BEFORE: Relieve illness symptoms that depress appetite prior to meal time (e.g. give an analgesic for pain) Provide familiar food that the person likes. Avoid unpleasant or uncomfortable treatments immediately before meals. Provide a tidy, clean environment that is free of unpleasant sights and odors.

Wash hands and other appropriate infection control.

DURING: Warn the patient if the food is hot or cold. Allow ample time for the client to chew and swallow the food before offering more. Provide fluid as requested and needed. Use a straw or special drinking cup to avoid spills. Assist the client to clean the mouth and hands. Have the client rest for 30 minutes to one hour to prevent aspiration. Reposition the client.

AFTER:

Table 14.Exercise

Type of exercise

Date started

General description

Indication/ purpose

Clients response to activity/ exercise

Active ROM

September 23, 2008

Isotonic exercise in which the patient independently movers each joint in the body through its complete range of movement, maximally stretching all muscle groups within each plane over the joint. (Active ROM of upper extremities may include combing of hair, bathing and dressing)

The patient was able to To maintain or increase move freely. muscle strength and endurance and health to retain cardiorespiratory Function. To prevent deterioration of joint capsules. ankylosis, and contractures.

NURSING RESPONSIBILITIES: BEFORE: Assess patients ability to move Raise side rails Cloth patient with loose gown Teach/demonstrate the exercise

DURING: Perform each ROM to point of slight resistance, but not beyond never to point discomfort Assist the patient during exercise

AFTER: Let the patient take enough rest after the exercise RECORD NURSING MANAGEMENT (SOAPIE/R)
Table 15.SOAPIE/R

Date September 23, 2008

Subjective

Objective > weak in appearance > with pale nailbeds > with cold clammy extremities > capillary refill within 4 seconds > tissue perfusion within 4 seconds > pale palpebral conjunctiva noted

Assessment Ineffective tissue perfusion related to decreased hemoglobin concentration in blood secondary to upper gastrointestinal bleeding

Planning Within 2 hours of appropriate nursing interventions, the patient will demonstrate adequate tissue perfusion as evidenced by warm and dry skin and improved capillary refill.

Interventions Positioned to Semi Fowlers position Performed active assistive Range of motion exercises. Allowed for periods of rest before and after planned exertion periods such as meals and physical activity Hooked 1 unit of PRBC Type B, properly cross - matched

Evaluation After 2 hours of appropriate nursing interventions, the patient demonstrated adequate tissue perfusion as evidenced by: a. Warm and dry skin b. Improved capillary refill c. Non pale nailbeds d. Non pale palpebral conjunctiva

Date September 23, 2008

Subjective Nahihirapan akong huminga pagkatapos kong masalinan ng dugo, parang may bumabara. As verbalized

Monitored for signs of Blood transfusion reactions Objective Assessment Planning Interventions > restlessness Ineffective After 1 hour of >Discontinue noted Airway appropriate blood transfusion >blotchy skin with Clearance nursing >Assume erythematous related to interventions, comfortable wheals on the head bronchospasm the patient will position (upright or and neck secondary to have a patent fowlers) >nasal flaring hypersensitivity airway and will >Keep >use of accessory reaction be able to environment wellmuscles secondary to breathe ventilated >rapid, shallow blood comfortably. >Support and breathing transfusion demonstrate client >dyspneic; RR= in using pursed-lip 28 breaths/minute and controlled breathing techniques >Monitor respiratory rate, depth and ease of respiration closely >Impart health teachings avoid allergens signs of respiratory

Evaluation After 1 hour of appropriate nursing interventions, the patient had a patent airway and was able to breathe comfortably as evidenced by: Decreased respiratory rate; RR= 20 breaths/minute Regular breathing rhythm Absence of nasal flaring Verbalization of ease in breathing

insufficiency

Date September 23, 2008

Subjective

Objective > weak looking > dryness of lips observed > with cold clammy extremities > capillary refill within 4 seconds > tissue perfusion within 4 seconds > frequent passing of black colored stool (approximately 3 times) > with vomitus of approximately 2 cups

Assessment Risk for deficient fluid volume related to excessive losses of fluids through normal routes

Planning Within 2 hours of appropriate nursing interventions, the patient will be able to maintain normal fluid volume as evidenced by maintenance of urine output of 4-5 times a day, normal blood pressure, pulse and body temperature.

Interventions Provided fresh water and oral fluids preferred by the client unless contraindicated Maintained patent IV access, set an appropriate IV infusion flow rate and administer at a constant flow rate as ordered. Watched for earl signs of hypovolemia, including restlessness, weakness, muscle cramps and postural hypotension. Monitored daily weight for sudden decreases, especially in the presence of decreasing urine output or active fluid loss Monitored total fluid intake and output every 8 hours. Referred the patients frequent passing of stool and vomiting to the attending physician.

Evaluation After 2 hours of appropriate nursing interventions, the patient maintained normal fluid volume as evidenced by: a. Maintenance oof urine output of 4-5 times a day b. Maintenance of normal blood pressure, pulse and body temperature

characterized as bloody

Date September 23, 2008

Subjective Nanghihina ako, hindi ko nagagawa lahat ng pangsariling gawain nang mag-isa. Madali ako mapagod. As verbalized.

Objective >weak-looking >pale in appearance >mostly confined in bed >slightly drowsed >limited ADLs >Hgb= 80 g/L >Hct= .231 L/L

Assessment Fatigue related to decreased ability to transport oxygen

Planning After 1 hour of appropriate nursing interventions, the patient will gain energy and improved well-being.

Interventions > Assist with ADLs as necessary; encourage independence and activity without causing exhaustion >Encourage walking exercises and gradually increasing activities as tolerated >Provide rest periods >Perform active-assistive ranges-of-motion >Help in identifying essential and non-essential tasks and determine which can be delegated >Impart health teachings: follow a healthy lifestyle with adequate nutrition, fluids and rest, pain relief and appropriate exercise maintain regular family routines once

Evaluation After 1 hour of appropriate nursing interventions, the patient was able to gain energy and improved well-being as evidenced by: Increase in ability to perform ADL without easy exhaustion Less weak in appearance Verbalization of increased energy

Date September 24, 2008

Subjective Hindi ako makatulog ng maayos dito. As verbalized.

Objective >weak-looking >pale to look at >irritable at times >mostly confined in bed >yawns during conversation >untended beddings and bedside >environment characterized as humid

Assessment Disturbed Sleeping pattern related to environmental condition

Planning After 1 hour of appropriate nursing interventions, the patient will be able to gain rest and sleep.

discharged follow energy conservation strategies such as sitting instead of standing during showering and storing items at waist level Interventions >Position as preferred >Render bedside care >Provide sponge bath and change clothing >Provide measures to take before bedtime to assist with sleep (carbohydrates such as crackers) >Provide a back massage before sleep >Keep environment quiet >Health teachings: warm bath before going to bed quiet activities before sleeping such as reading a book reduce daytime napping in the late afternoon

Evaluation After 1 hour of appropriate nursing interventions, the patient was able to gain rest and sleep as evidenced by: Less irritable mood Ability to sleep without interruptions at the end of the shift

EVALUATION
Table 16.Patients Daily Program in the Hospital

Nursing Problems: Ineffective Tissue Perfusion

1st day: 09-23-08 Capillary refill within 4 seconds; Tissue perfusion within 4 seconds * After appropriate nursing interventions, the patient demonstrated adequate tissue perfusion Nasal flaring; Dyspneic; RR= 28 breaths/minute * After appropriate nursing interventions, the patient had a patent airway and was able to breathe comfortably Dryness of lips observed; with cold clammy extremities * After appropriate nursing interventions, the patient maintained normal fluid volume Weak-looking; mostly confined in bed * After appropriate nursing interventions, the patient will gain energy and improved well-being Weak-looking

2nd day: 09-24-08 Capillary refill within 2-3 seconds; Tissue perfusion within 2-3 seconds * Continuity of the nursing care plan was imposed Absent

Ineffective Airway Clearance Risk for Deficient Fluid Volume Fatigue

Dryness of lips still observed *Continuity of nursing interventions was implemented Minimal *Continuity of the nursing care plan was implemented Irritable at times; yawns during conversation

Disturbed Sleep Pattern

2.Vital signs RR PR Temp. Blood Pressure

4 pm 19 cpm 88 bpm 36.5 oC 130/70 mmHg 6 pm 20 cpm 90 bpm 36.6 oC 120/70 mmHg 10 pm 17 cpm 85 bpm 36.8 oC 110/80 mmHg PNSS + 1 amp Lysmix; Diphenhydramine; Hydrocortisone Soft Diet Daily activity (active ROM)

* After appropriate nursing interventions, the patient was able to gain rest and sleep 6 am 18 cpm 91 bpm 36.5oC 130/70 mmHg 10 am 20 cpm 82 bpm 36.7 oC 120/80 mmHg 2pm 20 cpm 80 bpm 37 oC 110/70 mmhg Soft Diet Daily activity (active ROM)

3. Diagnostics and Lab. Procedures 4. Medical and Surgical Management 5. Drugs 6. Diet 7. Activity and Exercise

EVALUATION I. General Condition of the Patient upon Discharge The patient has no subjective complaint and was discharged in the afternoon of September 24, 2008. With that of discharging condition, patient has shown remarkable progress. The over-all health state can be described as well, functioning and without present complications. Ambulatory abilities are restored and the emotional-psychological state is stabilized. II. Discharge Planning Medication Medications should be taken at right dose, right time, right route and report any untoward side effects of drugs as prescribed. Exercise Exercise everyday for at least 30 minutes per day. Take enough rest and sleep. Treatment As per physicians order and appropriateness Health Teachings Stay away from factors that contribute to the occurrence of further harm to his condition Quit smoking Avoid drinking alcohol too frequently Eat whenever you feel like eating. OPD follow-up To have a follow up check up in the OPD as scheduled

Diet Diet as tolerated.

Eat variety of nutritious foods. Avoid alcoholic beverages Avoid spicy foods

CONCLUSIONS Having series of research about the disease, its management and after completing the case study, the group had come out with the following conclusions: Patients condition was explored well enough as proven by adequate data gathered. Proper analysis was made so that nursing problems were formulated Evaluation of the improvement of the patients health situation through monitoring of vital signs, nursing procedures, diet, drugs, activity and exercise was done. Health teachings, before the discharge was accomplished.

RECOMMENDATIONS

After dealing with the patient and studying his condition we recommend her the following: Should comply to avoid spicy foods, alcohol, and smoking. Should know the signs and symptoms of bleeding Have his regular check up. Should undergo breast biopsy to make definitive diagnosis and assess if its risk for the development of breast cancer. Stay away from any contributing factors in the aggravation of his condition.

BIBLIOGRAPHY

7th Edition Nursing Diagnosis Handbook: A Guide to Planning Care by Betty J Auckley and Gail B. Ladwig Health Assessment and Physical Examination, Third Edition by Mary Ellen Zator Estes Mosbys Pocket Dictionary of Medicine, Nursing and Health Professionals Nurses Handbook of Health Assessment by Janet R. Weber Brunner and Suddarths Textbook of Medical Surgical Nursing 11th Edition by Suzanne Smeltzer, Brenda G. Barc, Janice L. Hinkle, Kerry H. Cheever, volume 1 G and A notes, Clinical Pocketguide for Medical Interns, Clerks, Nurses, Nursing Students, and other Allied Health Professionals by Gregory N. Palma and Adrian D. Oseda Understanding Pathophysiology, 3rd Edition by Sue, Huether E. McCance, Kathryn C. www.emedicine.com www.wikipedia.com