A GRAND CASE PRESENTATIONPresented to the Faculty of

Tarlac State UniversityCollege of Nursing

Tarlac City

In Partial FulfilmentOf 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 LiahonaMangubat, 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 high-

dose 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

patient’s 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 patient’s

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 patient’s 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. PERSONAL DATA

A. Demographic Data

Name of the Patient: Mr. E.B.S

Age: 57 y/o

Sex: Male

Civil Status: Single

Occupation: Unemployed

Religious affiliation: Roman Catholic

Role Position in the Family: Father

Address: Brgy. Buhilit, Tarlac City

Date of Birth: July 25, 1951

Place of Birth: Caloocan, Manila

Nationality: Filipino

Health Care Financing: None

Admitting diagnosis: UGIB probably secondary to BPUD

Date admitted: 09/17/08 10:08:49 a.m.

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.

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 MOTHER SIDE

80 y/o 72 y/o 79y/o HPN 73 y/o

No known No known No known

65 y/o 55 y/o Stroke pneumonia

A/W A/W HPN HPN/HD UGIB SLE SLE stabbed HD

Legend:

Living female- HPN- hypertension

Living male- SLE- systemic lupus erythematosus

Patient- HD- heart disease Deceased male - A/W- alive and well

Deceased female – In the third degree of the patient’s family tree shows that his grandfather on the

mother side had hypertension and did because of it. Towards to the father side, patient’s

grandfather and grandmother died of no known cause. The patient’s father had stroke and

61 60 X

59 58 30 X

25 X

40 63

X X

X

X X

X

65A/W

40X

X

X

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

family’s 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 self- perception.

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 year’s 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 (Mosby’s 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

patient’s 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 patient’s conjunctiva were pale.

Hearing

The Voice – Whisper Test was used for the auditory assessment. Two feet behind

the patient’s 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 patient’s 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 patient’s 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 patient’s data with the standard stated above, it denotes that the

patient’s 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 skin’s 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 patient’s 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 September 24, 2008

8 am - 36.6 °C 6 am - 36.5 °C

10 am - 36.1 °C 10 am - 36.7 °C

11 am - 37 °C 2 pm - 37 °C

11:15 am - 37.5°C

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:

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 Time Respiratory RateSeptember 23, 2008

11 am 19 cycle per minute11:15am 21 cycle per minute11:30 am 28 cycle per minute11:45 am 22 cycle per minute12:00 pm 20 cycle per minute

4 pm 19 cycle per minute6 pm 20 cycle per minute10 pm 17 cycle per minute

September 24, 2008

6 am 18 cycle per minute10 am 20 cycle per minute2 pm 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. Patient’s

blood pressure during assessment was 130/ 70 mmHg. The patient has pulse rate of

88bpm. The patient’s 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 patient’s 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 Time Pulse rate Blood pressureSeptember 23, 2008

11 am 70 bpm 110/80 mm Hg11:15am 73 bpm 130/90 mm Hg11:30 am 108 bpm 140/80 mm Hg11:45 am 88 bpm 120/90 mm Hg12:00 pm 78 bpm 110/70 mmHg

4 pm 88 bpm 130/70 mm Hg6 pm 90 bpm 120/70 mm Hg10 pm 85 bpm 110/80 mm Hg

September 24, 2008

6 am 91 bpm 130/70 mm Hg10 am 82 bpm 120/80 mm Hg2 pm 80 bpm 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

patient’s 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 The patient is 5’ 6 1/2” tall (1.6891 meters).

Weight The patient is 60 kilograms (132.28 pounds) on a medium frame.

Body Mass Index BMI=kg/m2

=60kg/2.85

=21

The patient’s 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 1 cup of rice with meat and vegetables for lunch as served by the

hospital

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 Denies use of vitamin and food supplements but claims to use

NSAIDS regularly particularly aspirin.

Food Preferences Prefers fish for viand rather than poultry and meat products.

Food Prohibitions Claims to have a diet low in fat as advised by his physician.

Allergy/intolerances Denies any food allergies or food intolerances.

Mastication/

Swallowing problems Had difficulty masticating hard, solid foods due to incomplete

number of permanent teeth. Did not use any dentures.

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

and abdomen.

IVF An intravenous infusion of PNSS was given during the hospital

admission to maintain fluid and electrolyte imbalance.

Skin Turgor Upon pinching skin at the sternal area, at 1 second the skin went

back to its original state.

Mucous Membrane Moist and no lesions noted.

Condition of Teeth

and Gums Has brownish stained to yellowish teeth; without central incisors

on the lower portion of the gums; with brownish pink gums.

Tongue Has whitish center and pinkish on its tongue borders.

Bowel Sounds Has 18 high-pitched bowel sounds per minute; present on all four

quadrants

Percussion Tympanitic over the bowels and dullness over the liver area at the

right upper quadrant.

Palpation 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 physician’s 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 non-tender 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 Suddarth’s 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 Suddarth’s 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 patient’s 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 client’s 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

Date Ordered and Date Result/s

Indication or Purpose/s

Results Normal Values( units used in the

hospital)

Analysis and Interpretation of

ResultsBlood Chemistry Date Ordered

September 17, 2008

ResultSeptember 17, 2008

September 20, 2008

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.

FBS 10.6mmol/L

Creatinine 88.3

FBS 3.9-6.6 mmol/L

Creatinine 53-106mmol/L

Elevated

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/ patient’s 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 Date Ordered and Indication or Results Normal Values Analysis and

and Laboratory Procedures

Date Result/s in Purpose/s ( units used in the hospital) Interpretation of Results

Serum Electrolytes

Date OrderedSeptember 17, 2008

ResultSeptember17, 2008

These measures ions reflect the acid-base balance

Sodium 136.4 mmol/LPotassium 4.18 mmol/LChloride 110.2 mEq/l

Sodium 136-142 mmol/LPotassium 3.8-5.0 mmol/L

Chloride 95-103 mEq/L

NormalNormal

Elevated

NURSING RESPONSIBILITIES

BEFORE:

Explain the procedure and purpose of the test to the patient/ patient’s 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 Date Ordered and Indication or Results Normal Values Analysis and

Laboratory Procedures

Date Result/s in Purpose/s Interpretation of Results

Urinalysis Date OrderedSeptember 17, 2008

ResultSeptember17, 2008

To determine existing infection in the genitourinary tract and to identify existence of blood if there is any.

Physical Examination

Color: Yellow

Appearance: Slightly turbidReaction: 5.0Specific gravity: 1.015

Chemical Exam

Albumin- negativeGlucose – negative

Microscopic ExamPus cells: 10-15/HPFRBC: 0-1/HPFEpithelial: occasionalMucus Threads: occasionalA.urates/ phosphates: fewBacteria: few

Color: Straw – dark yellowAppearance:ClearReaction: 4.6 – 6.5Specific Gravity:1.016 – 1.022

Albumin – negativeGlucose – negative

Pus cells: 0 – 2/HPF

RBC: 0/HPF

Normal

Normal

Decreased

NormalNormal

Elevated

Normal

NURSING RESPONSIBILITIES

BEFORE:

Explain the procedure and purpose of the test to the patient/ patient’s immediate relative present and assess level of

knowledge regarding the test.

DURING:

Adhere to standard precaution.

AFTER:

Monitor for signs of infection.

Follow up results from laboratory.

Diagnostic and

Laboratory Procedures

Date Ordered and Date Result/s

in

Indication or Purpose/s

Results Normal Values( units used in the hospital)

Analysis and Interpretation of

Results

Complete Blood Count

Date Ordered

September 17, 2008

ResultSeptember 18, 2008

September 19, 2008

CBC is used as a broad screening test to check for such disorders as Anemia or Infection.

RBC 2.81 T/LWBC 9.5G/LLympho 1.9 20.5%LMid 0.5 4.8%MGran 7.1 74.7%GHgb 92 g/LHct 244L/LMCV 86.8fLMCH 37.2 pgMCHc 377g/LPLT 231G/L

WBC 8.3 G/LRBC 2.65T/LLYM 2.1 25.4%LMID 0.6 6.7%MGRAN 5.6 67.9%GHgb 80g/LHCT 231 L/LMCV 87.0 fLMCH 30.2pgMCHc 346 g/LPLT 272.6 G/L

RBC 4.2-6.3T/LWBC 4.1-10.9G/LLympho 0.6-4.1 10.0-58.5%LMid 0.0-1.8 0.1-24.0%MGran 2.0-7.8 37.0-92.0%GHgb 120-180 g/LHct 370-510L/LMCV 80.0-97.0fLMCH 26.0-32.0 pgMCHc 310-360g/LPLT 140-440G/L

RBC 4.2-6.3T/LWBC 4.1-10.9G/LLympho 0.6-4.1 0.0-58.5%LMid 0.0-1.8 0.1-24.0%MGran 2.0-7.8 37.0-92.0%GHgb 120-180 g/LHct 370-510L/LMCV 80.0-97.0fLMCH 26.0-32.0 pgMCHc 310-360g/LPLT 140-440G/L

DecreasedNormalNormalNormalNormalDecreasedDecreasedNormalElevatedElevatedNormal

NormalDecreasedNormalNormalNormalDecreasedDecreasedNormalNormalNormalNormal

NURSING RESPONSIBILITIES

BEFORE:

Explain the procedure and purpose of the test to the patient/ patient’s immediate relative present and assess level of

knowledge regarding the test.

Prepare materials to be used.

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

Date Ordered and Date Result/s in

Indication or Purpose/s

Results Normal Values( units used in the

hospital)

Analysis and Interpretation of

ResultsHematology Date Ordered

September 17, 2008

ResultSeptember 17, 2008

Hematology is used as a broad screening test to check for such disorders as Anemia or Infection.

Hemoglobin: 133g/LHematocrit: 6.38%

RBC: 4.3312/LWBC: 11.48/L

Hgb: 140-170g/L

Hct: 0.415-0.504 vol%RBC: 3.5-4.712/LWBC: 4.5-118/L

Decreased

Elevated

Normal Elevated

NURSING RESPONSIBILITIES

BEFORE:

Explain the procedure and purpose of the test to the patient/ patient’s 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;

.

DURING:

Adhere to standard precaution.

AFTER:

Follow up results from laboratory.

Diagnostic/ Date Ordered and Indication or Results Normal Values Analysis and

Laboratory Procedure

Date Result/s in Purpose/s Interpretation of Results

Fecalysis Result September 17,2008

To identify the presence of parasites in the gastrointestinal tract and determine presence of occult blood.

Color: reddish blackConsistency: softMicroscopic findings: no ova or parasite seenPus cell: 0.1Red cell: plenty

Color: brownConsistency: formed

Pus cell: NegativeRed cell: Negative

Not NormalNot Normal

Not NormalNot 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 liquid—this 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

stomach—the 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 movements—the 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 juice—bile, 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 body’s 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.

Non-modifiable: Advanced age Family history of PUD Blood type O

Modifiable risk factors

PATHOPHYSIOLOGY

Book Based

Smoking Alcohol Chronic cirrhosis

Habitual use of NSAID Infection of H. pylori

Altered mucosal blood flow

Cytotoxic effect

Inhibits prostaglandin

secretion

Decreased bicarbonate

secretion

Increased gastrin level

Increased gastric output

Inflammatory response

Affection of mucous production

Impaired mucosal defense to acid

Tissue damage(Mucosal defects)

Allow back diffusion of

hydrogen ions

Diffusion of acid and pepsin into

the cell

Ulceration of mucosal barrier

Gastric outlet Epigastric painVomiting (hematemesis)

Further damage blood vessels

BLEEDING PEPTIC ULCER DISEASE

UPPER GASTROINTESTINAL BLEEDING

Blood volume depletion Accumulation of blood in GI tract

Increased peristalsis

diarrhea hematochezia melena

Digestion of blood proteins

Increased BUN

Decreased cardiac output

Decreased systolic BP<100mmHg Increased pulse rate >100

Compensatory constriction of peripheral arteries

Metabolic Acidosis Decreased blood flow to kidneys

Decreased blood flow to skin

Compensatory failure

Death Lactic acidosis

Anoxia

Decreased urine output

Tubular necrosis

Renal failure

Death oliguria

Decreased blood flow to brain

-anxiety-confusion-stupor-coma

Decreased coronary blood flow

Myocardial Infarction

Heart failure

Angina Pulmonary edema dysrhythmias

Client Based

Mucosal damage

CC: HematocheziaEpigastric pain

Bleeding peptic ulcer disease

Tobacco (9packs/year) Alcohol (minimum of 2 bottles/day since 13y/o

Use of NSAIDs aspirin once a day since 2003)

Upper gastrointestinal bleeding

Accumulation of blood in GI tract

Blood volume depletion

-hematemesis(1 cup vomitus)

-melena (3x a day)

Compensatory constriction of peripheral arteries

-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 PLANSNURSING CARE PLANS

Table 5.Ineffective Tissue PerfusionTable 5.Ineffective Tissue Perfusion

Assessment Planning Nursing Interventions Desired OutcomeS> θ

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

Scientific ExplanationDecrease in oxygen resulting in failure to nourish tissues at capillary level

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

Independent Position to Semi – Fowler’sR: 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 activitieso Increase fluid intakeo Continue performing exercises

Dependent Hook 1 unit of PRBC Type B, properly

cross - matchedR: To increase the red blood cell level and hemoglobin Monitor for signs of Blood transfusion

reactionsR: To prevent occurrence of anaphylactic shock

After the shift, the patient will be able to demonstrate adequate tissue perfusion as evidenced by:a. Warm and dry

skin b. Improved

capillary refillc. Non – pale

nailbedsd. Non – pale

palpebral conjunctiva

Table 6.Ineffective Airway Clearance (During Blood Transfusion)Assessment Planning Intervention Expected Outcome

S> “Nahihirapan akong huminga habang sinasalinan ako ng dugo, parang may bumabara.” As verbalized.O> restlessness noted >blotchy skin with 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.

After 1 hour of appropriate nursing interventions, the patient will have a patent airway and will be able to breathe comfortably.

Discontinue blood transfusion.R: therapy have induced an untoward reaction in the patient’s system

Assume comfortable position (upright or fowler’s)R: upright position facilitates lung expansion

Keep environment well-ventilatedR: movement of air helps relieve dyspnea

Support and demonstrate client in using pursed-lip and controlled breathing techniquesR: decreases respiratory rate and improves oxygenation

Monitor respiratory rate, depth and ease of respiration closelyR: determines progression of the condition

Impart health teachings>avoid allergens>signs of respiratory insufficiency

After 1 hour of appropriate nursing interventions, the patient will have a patent airway and will be able to breathe comfortably as evidenced by: Decreased respiratory rate Regular breathing rhythm Absence of nasal flaring Verbalization of ease in

breathing

Table 7Table 7.Risk for deficient fluid volumeAssessment Planning Nursing Interventions Desired

OutcomeS> θ

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

Scientific ExplanationAt risk for experiencing vascular, cellular, or intracellular dehydration

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.

Independent Provide fresh water and oral fluids preferred by the client

unless contraindicatedR: To replace the fluid losses of the patient’s body Maintain patent IV access, set an appropriate IV infusion

flow rate and administer at a constant flow rate as ordered.R: To maintain normal intracellular and extracellular fluid volume Watch for early signs of hypovolemia, including restlessness,

weakness, muscle cramps and postural hypotension.R: To detect and prevent occurrence of hypovolemia Monitor daily weight for sudden decreases, especially in the

presence of decreasing urine output or active fluid lossR: Body weight changes reflect changes in body fluid volume Monitor total fluid intake and output every 8 hours.R: To determine if there is an existing deficiency in fluid volume Render health teachings:o Avoid humid places to reduce insensible fluid losseso Replenish lost fluids after daily activities through intake of

water and other liquid products.Collaborative

Refer the patient’s 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

Table 8.Disturbed Sleep PatternTable 8.Disturbed Sleep Pattern

Assessment Planning Intervention Expected OutcomeS> “Hindi ako makatulog ng 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 of sleep, amount and quality.

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

Position as preferredR: assuming a comfortable position induces rest

Render bedside careR: facilitates comfort

Provide sponge bath and change clothingR: improves well-being and 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 sleepR: use of back massages has been shown effective for promoting relaxation which likely leads to improved sleep

Keep environment quietR: 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

After 1 hour of appropriate nursing interventions, the patient will be able to gain rest and sleep as evidenced by: Less irritable mood Ability to sleep without

interruptions at the end of the shift

Table 9.FatigueTable 9.Fatigue

Assessment Planning Intervention Expected OutcomeS> “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 to decreased ability to transport oxygen

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

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

Assist with ADLs as necessary; encourage independence and activity without causing exhaustionR: eases completion of patient’s activity while promoting self-reliance

Encourage walking exercises and gradually increasing activities as toleratedR: expands endurance towards self-activities

Provide rest periodsR: conserves energy and minimizes feelings of fatigue

Perform active-assistive ranges-of-motionR: prevents contractures during periods of inactivity

Help in identifying essential and non-essential tasks and determine which can be delegatedR: 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 MANAGEMENTTable 10.IVF

Medical Management Date General description Indication Client’s reaction

IVF (PNSS) Date Ordered:September 17, 2008

Date Started:September 17, 2008

Date Ended:Ongoing

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.

o Isotonic solution

o Rehydration of both in and outside cell.

Consumed with no adverse reactions.

NURSING RESPONSIBILITIES:

BEFORE:

Recheck doctor’s order, and compute for the flow rate. Observe the 7 R’s. Explain the procedure to the patient. Wash hands.

DURING:

Monitor and regulate the IV and its patency. Monitor for signs of phlebitis or infiltration.

AFTER:

Proper disposal of IVF. Assess if condition is improving. Wash hands.

Table 11.Blood Transfusion

Medical Management Date General description Indication Client’s reaction

Blood Transfusion1 unit Packed RBC Type B+, Properly

cross-matched

Date Ordered:September 20, 2008

Date Started:September 23, 2008

Date Ended:September 23, 2008

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

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.

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

NURSING RESPONSIBILITIES:

BEFORE:

Check physician’s order, including blood type, product and number of units and period of time blood must be transfused.

Obtain consent from patient’s family.

Prepare the needed materials.

Transfusion must be started 30 minutes after blood is taken from the refrigerated storage.

Check the patient’s 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

Client’s 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 client’s 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)

AFTER

Chart the procedure including the time, name and dosage of the drug and the client’s response to the administration. Assess patient’s infection

Name of drug Date ordered/ Route/ General Indication/ Client’s response

Date started/Date changed

Dosage/Frequency of

administration

action/mechanism of action

Purpose to medicine with actual s/e

Generic name:

Rebamipide

Brand name:

Mucosta

Date Ordered:September 17, 2008

Date Started:September 17, 2008

Date Ended:September 24, 2008

Route of Administration: Oral

Dosage and Frequency:100 mg/cap, 1 cap TID/NGT

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

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

Had given and reaction occurred.

NURSING RESPONSIBILITIES:

BEFORE:

Assess client’s condition before starting the therapy.

Be alert for adverse reactions and interactions

Orient client on some possible side effects of drug.

AFTER

Chart the procedure including the time, name and dosage of the drug and the client’s response to the administration. Assess patient’s infection

Name of drug Date ordered/Date started/Date changed

Route/Dosage/

Frequency of administration

General action/mechanism of

action

Indication/Purpose

Client’s response to medicine with

actual s/e

Generic name:

Tranexamic acid

Brand name:

Cyklokapron

Classification:

Antifibrinolytic

Date Ordered:September 17, 2008

Date Started:September 17, 2008

Date Ended:September 20, 2008

Route of Administration: IVP

Dosage and Frequency:500 mg now then q 6 hours

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.

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.

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

Client’s 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.

AFTER:

Stay with the client for at least 15-30 minutes after giving the drug

Be alert for adverse reaction and drug interaction.

Monitor patient’s hydration.

Name of drug Date ordered/Date started/Date changed

Route/Dosage/

Frequency of administration

General action/mechanism of

action

Indication/Purpose

Client’s response to medicine with

actual s/e

Generic name:

Diphenhydramine

Brand name:

Allerdryl

Classification:

Antihistamine, sleep aid, antitussive

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 h1-receptor sites on effector cells.

Therapeutic Effect: Relieves allergy

symptoms

Given to relieve allergy symptoms and promotes sleep and calmness.

Had given and reaction occurred.

NURSING RESPONSIBILITIES:

BEFORE:

Assess patient’s underlying condition before therapy.

Be alert for adverse reaction.

DURING:

Administered with meal to reduce GI distress.

Warm patient to avoid alcohol consumption.

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

Client’s response to medicine with

actual s/e

Generic name:

Hydrocortisone

Brand name:

Ala-cort

Classification:

Glucocorticoid

Date Ordered:September 23, 2008

Date Started:September 23, 2008

Date Ended:September 23, 2008

Route of Administration: IVP

Dosage and Frequency:500mg stat

Chemical Effect: May stabilize

leukocyte lysosomal membranes, suppress immune response, stimulate bone marrow and influence nutrient metabolism

Therapeutic Effect: Reduces inflammation

Given to reduce inflammation.

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.

DURING

Inject for over at least 30 seconds. Monitor’s 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.

Table 13.Type of Diet

Type of diet Date Prescribed General description Indications Specific foods

taken

Client’s

response

NPO September 17, 2008 NO solid foods or either

liquids to be ingested

For patients prior to

operation.

Able to comply

Soft diet September 20, 2008 Foods that are mashed or

pureed, placed in soups,

stews, chili, curries, or

made into sauces.

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

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.

AFTER:

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.

Table 14.Exercise

Type of exercise Date started General description Indication/ purpose Client’s 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)

To maintain or increase muscle strength and endurance and health to retain cardiorespiratoryFunction.

To prevent deterioration of joint capsules. ankylosis, and contractures.

The patient was able to move freely.

NURSING RESPONSIBILITIES:BEFORE:

Assess patient’s 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 Subjective

Objective Assessment Planning Interventions Evaluation

September 23, 2008

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

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

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.

Positioned to Semi – Fowler’s 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

Monitored for signs of Blood transfusion

After 2 hours of appropriate nursing interventions, the patient demonstrated adequate tissue perfusion as evidenced by:a. Warm and dry

skin b. Improved

capillary refillc. Non – pale

nailbedsd. Non – pale

palpebral conjunctiva

reactionsDate Subjective Objective Assessment Planning Interventions Evaluation

September 23, 2008

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

> restlessness noted>blotchy skin with erythematous wheals on the head and neck>nasal flaring>use of accessory muscles>rapid, shallow breathing>dyspneic; RR= 28 breaths/minute

Ineffective Airway Clearance related to bronchospasm secondary to hypersensitivity reaction secondary to blood transfusion

After 1 hour of appropriate nursing interventions, the patient will have a patent airway and will be able to breathe comfortably.

>Discontinue blood transfusion>Assume comfortable position (upright or fowler’s)>Keep environment well-ventilated>Support and demonstrate client in using pursed-lip and controlled breathing techniques>Monitor respiratory rate, depth and ease of respiration closely>Impart health teachings avoid

allergens signs of

respiratory insufficiency

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

Date Subjective

Objective Assessment Planning Interventions Evaluation

September 23, 2008

θ > 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

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

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.

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 patient’s frequent passing of stool and vomiting to the attending physician.

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

Date Subjective Objective Assessment Planning Interventions EvaluationSeptember 23, 2008

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

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

Fatigue related to decreased ability to transport oxygen

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

> 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 discharged follow energy conservation strategies

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

such as sitting instead of standing during showering and storing items at waist level

Date Subjective Objective Assessment Planning Interventions EvaluationSeptember 24, 2008

“Hindi ako makatulog ng maayos dito.” As verbalized.

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

Disturbed Sleeping pattern related to environmental condition

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

>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

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.Patient’s Daily Program in the Hospital

Nursing Problems: 1st day: 09-23-08 2nd day: 09-24-08Ineffective Tissue

PerfusionCapillary refill within 4 seconds; Tissue perfusion within 4

seconds

* After appropriate nursing interventions, the patient demonstrated adequate tissue perfusion

Capillary refill within 2-3 seconds; Tissue perfusion within 2-3 seconds

* Continuity of the nursing care plan was imposed

Ineffective Airway Clearance

Nasal flaring; Dyspneic; RR= 28 breaths/minute

* After appropriate nursing interventions, the patient had a patent airway and was able to breathe comfortably

Absent

Risk for Deficient Fluid Volume

Dryness of lips observed; with cold clammy extremities

* After appropriate nursing interventions, the patient maintained normal fluid volume

Dryness of lips still observed

*Continuity of nursing interventions was implemented

Fatigue Weak-looking; mostly confined in bed

* After appropriate nursing interventions, the patient will gain energy and improved well-being

Minimal

*Continuity of the nursing care plan was implemented

Disturbed Sleep Pattern Weak-looking Irritable at times; yawns during conversation

* After appropriate nursing interventions, the patient was able to gain rest and sleep

2.Vital signsRR

4 pm19 cpm

6 am18 cpm

PRTemp.

Blood Pressure

88 bpm36.5 oC

130/70 mmHg

91 bpm36.5oC

130/70 mmHg

6 pm20 cpm90 bpm36.6 oC

120/70 mmHg

10 am20 cpm82 bpm36.7 oC

120/80 mmHg10 pm17 cpm85 bpm36.8 oC

110/80 mmHg

2pm20 cpm80 bpm37 oC

110/70 mmhg3. Diagnostics and Lab.

Procedures- -

4. Medical and Surgical Management

- -

5. Drugs PNSS + 1 amp Lysmix; Diphenhydramine; Hydrocortisone - 6. Diet Soft Diet Soft Diet

7. Activity and Exercise Daily activity (active ROM) Daily activity (active ROM)

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 physician’s 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:

Patient’s 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 patient’s 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 it’s 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

Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professionals

Nurse’s Handbook of Health Assessment by Janet R. Weber

Brunner and Suddarth’s 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