LICEO DE CAGAYAN UNIVERSITY

R.N.P. Blvd., Carmen, Cagayan de Oro City

C OLLE GE OF NURSING
   
  

A family Care Study

With

PEPTIC ULCER
DISEASE

Submitted to:

Clinical Instructor

As Partial Requirement for NCM501202

Submitted by:

NCM501202 Student

January 18, 2007

 Table of Contents

I. INTRODUCTION ----------------------------------------------------1 – 2

II. HEALTH HISTORY -------------------------------------------------3 – 4

III. DEVELOPMENTAL DATA ---------------------------------------5 - 6

IV. MEDICAL MANAGEMANT ---------------------------------------7 - 17

V. ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY----------18 - 22

VI. NURSING ASSESSMENT ----------------------------------------23 -25

VII. NUSING MANAGEMENT -----------------------------------------26 -35

VIII. REFERRALS AND FOLLOW-UP--------------------------------36

IX. EVALUATION AND IMPLICATIONS---------------------------37

X. BIBLIOGRAPHY -----------------------------------------------------38
I. INTRODUCTION

Overview of the Case

Too much stress, too much spicy food, and you may be headed for an ulcer or
so the thinking used to go.

A peptic ulcer is an ulcer of one of those areas of the gastrointestinal tract that
are usually acidic. A more general term, peptic ulcer disease (PUD), is also in use.
Most ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that
lives in the acidic environment of the stomach. Ulcers can also be caused or
worsened by drugs such as Aspirin and other NSAIDs. Contrary to general belief,
more peptic ulcers arise in the duodenum (first part of the small intestine, just after
the stomach) than in the stomach. About 4 % of stomach ulcers are caused by a
malignant tumour, so multiple biopsies are needed to make sure. Duodenal ulcers
are generally benign.

The common belief was that peptic ulcers were a result of lifestyle. Doctors
now know that a bacterial infection or medications — not stress or diet — cause most
ulcers of the stomach and upper part of the small intestine (duodenum). Esophageal
ulcers may also occur and are typically associated with the reflux of stomach acid.

Although stress and spicy foods were once thought to be the main causes of
peptic ulcers, doctors now know that many ulcers are caused by the corkscrew-
shaped bacterium Helicobacter pylori (H. pylori).

H. pylori lives and multiplies within the mucous layer that covers and protects
tissues that line the stomach and small intestine. Often, H. pylori causes no
problems. But sometimes it can disrupt the mucous layer and inflame and erode
digestive tissues, producing an ulcer. One reason may be that people who develop
peptic ulcers already have damage to the lining of the stomach or small intestine,
making it easier for bacteria to invade and inflame tissues.

1
 The most common ulcer symptom is gnawing or burning pain in the abdomen
between the breastbone and the belly button. The pain often occurs when the
stomach is empty, between meals and in the early morning hours, but it can occur at
any other time. It may last from minutes to hours and may be relieved by eating food
or taking antacids. Less common symptoms include nausea, vomiting, or loss of
appetite. Sometimes ulcers bleed. If bleeding continues for a long time, it may lead to
anemia with weakness and fatigue. If bleeding is heavy, blood may appear in vomit or
bowel movements, which may appear dark red or black.

Objective of the Study

The objectives of this care study aims to:

1. Develop knowledge, which would make us or the readers aware on what are
the possible causative agents and the signs & symptoms manifested by the
patient on having this specific condition
2. Know the possible actions that would help alleviate or even prevent a certain
problem related to the condition of the patient for the prevention of possible
complications
3. Even give some interventions to those problems that were observed to the
patient, but are not related to its diagnosis.
4. Have a correct nursing care rendered to the patient on the entire therapy
5. Identify what are the uses of the drugs being prescribed by the patients
physician during the entire hospitalization

Scope and limitation of the Study

This study focuses mainly on the patient’s specific condition, which is bleeding
peptic ulcer and even focused more on the condition of the patient before and upon
admission to further evaluate what are the possible nursing and medical interventions
would be applied to the patient on the entire course of therapies.

2
II. HEALTH HISTORY
Patients Profile
The name of the patient was, male; 74 years old; a Roman Catholic; and a
Filipino citizen. He is married to Mrs. and have three siblings namely; and presently
residing at.
He was born on the. He is five feet four inches in height and 100 pounds in
weight
He is negative on food and drug allergies. His chief complains were
Hematochezia and Hemoptysis. He was diagnosed by his physician Dr. Bacal, with
T/C bleeding peptic ulcer disease.
Personal Health History
My patient has not received any blood from the past. He has no known food
and medicine allergies. He had experienced having a cough when the time he
stopped smoking and it gone out to be more severe on the following days. As his
watcher said that he was hospitalized for several times because of his condition. , is
susceptible to many diseases since the patient was to old and have vices that
precipitates lots of diseases and complications. The patient also told me that when
there were times that there is pain on his stomach, he sometimes skip his meals. As
we all know, that, skipping a meal will lessen our body’s nutrients/strength and would
become prone to diseases when the nutritive status of our body is altered. And due to
tiredness and inadequate nutrients on his body, the patient would become weak and
alters his daily activities. The above factors made my patient a susceptible individual
to a certain disease.

History of Present Illness and Chief Complains

, presently residing in was admitted at Cagayan de Oro Polymedic General
Hospital due to Hematochezia ( cause: bleeding in colon/rectum and results to loss of
blood higher in the digestive tract or through defecation of bloody stools (melena);
and also hemoptysis ( coughing up of blood from respiratory tract. Bloodsteaked
sputum often is presented in minor upper respiratory infection or bronchitis). The
patient was experiencing severe pain on his abdominal area when he does not eat
his meals. Since the cause the discomforts felt by the patient on his abdomen, as
3
1
well as the bloody stools during defecation, and with laboratory examination taken by
(e.g. CBC), the patient is then positive with a peptic ulcer disease. He was also noted
with acute bronchitis; the patient was not able to talk clearly because of his
productive cough or retained secretions/bronchospasm that obstructs the airway of
the patient, that’s why he has dyspnea and some manifestations of hyperventilation
and tachypnea, these was the cause why the patient has ineffective airway clearance
during his hospitalization. Few minute prior to admission the patient encountered
dizziness and brought patient to his room on a stretcher (condition upn admission)
The result of his physical assessment was that he is febrile and is in
respiratory distress. His vital signs during the first day of assessment were,
temperature: 36.3oc; pulse rate: 88bpm; respiration rate: 28 cpm; and blood pressure:
140/70 mmHg. There was no skin lesions observed upon admission. Dr. Bacal’s
admitting diagnosis to was Bleeding Peptic Ulcer Disease

III. DEVELOPMENTAL DATA

 The stage of older adulthood is considered to begin at 65 years of age. Many
physical, psychological, and social changes occur during later adulthood. The critical
transition comes at the time of retirement for both the husband and the wife. In old
age persons are moving toward completion of their life cycles. Old age can be a
time when a person can enjoy his/her time with his/her grandchildren and leisure
time activities, and forget about things caused him/her a great deal of stress and
anxiety in the past three or four decades . During this stage a person must adapt to
changing physical abilities. This stage is characterized by increased wisdom although
many other things are lost such as health, friends, family and independence. The
aging process of people in this stage of development varies greatly. Ego integrity Vs
despair represents this stage in the psychosocial theory. The developmental tasks of
the older adult are: adjusting to decreases physical strength and loss of health,
adjusting to retirement and reduced income, coping with death of a husband or wife
and preparing for one's own deatheating periods.

According to Erik Erickson’s Psychosocial Development Theory lies on the

stage 8 (integrity vs. Despair), wherein, ego integrity is the ego's accumulated
assurance of its capacity for order and meaning. And despair is signified by a fear of
one's own death, as well as the loss of self-sufficiency, and of loved partners and
friends.
This stage is focused on reflecting back on the person’s life, that is, those who
are unsuccessful during this phase will feel that their life has been wasted and will
experience many regrets. The individual will be left with feelings of bitterness and
despair.
Those who feel proud of their accomplishments will feel a sense of integrity.
Successfully completing this phase means looking back with few regrets and a
general feeling of satisfaction. These individuals will attain wisdom, even when
confronting death.
In general, this is the patients time for reflecting on and reviewing how he met
previous challenges and lived his life. Adjusting to decreasing physical strength and
health; Adjusting to retirement and reduced income; Establishing an explicit affiliation

5
with one's age group; and Meeting social and civil obligations are the right ways on
how to establish a satisfactory physical living arrangements on his kind of stage.

6
IV. MEDICAL MANAGEMANT

December 3, 2006
12:10 AM

 Please admit to Medical Ward  For further medical management

and monitoring

 TPR every four hours  For baseline data of

interventions and close
monitoring of patients vital signs

 For – CBC and Chest PA  CBC- includes absolute number

of percentages of erythrocytes,
leukocytes,platelets, hemoglobin
and hematocrit in blood sample.
Used to evaluate blood if it is
potential for infection or other
disorders/abnormalities.

 (#1 IVF therapy)  This medication is an

intravenous (IV) solution used to
supply water, calories, and
electrolytes

 Combivent 1 neb every 6 hours  Relaxes bronchial uterine and

vascular smooth muscle by
stimulating beta2 receptors that
helps to prevent or treat
broncho-spasm in patient with
severe obstructive airway
disease

 Esomemeprazole (Nexium)  Proton Pump Inhibitor that

20mg 1 tab BID, PO reduces gastric acid secretion
and decreases gastric acidity
that helps eradicate Helicobac-
ter Pylori.

 Sucralfate (Iselpin) 1g/10ml BID,  Short term treatment of ulcer

PO (duodenal).Maintenance therapy
for duodenal ulcer

 Isoptin 240 mg 1 tab OD, PO  Inhibits the transport of calcium

7
into myocardial and vascular
 smooth muscle cells, resulting in
inhibition of excitation-
contraction coupling and
subsequent contraction. For
management of hypertension

 Administer O2  For oxygen therapy of the

patient since the patient cannot
breath normally during
admission.

December 4,2006

 Lactulose (Dupholac), 20cc BID  Produces an osmotic effect in

colon, resulting distention
promotes peristalsis. For or to
treat constipation

 Cefixime (Tergeof) 200mg BID,  Stable in the presence of beta-

PO lactamase enzyme. Used for
acute bronchitis and acute
exacerbations of chronic
bronchitis

December 5,2006

 IVF TF with D5NSS at 20 gtts /  This medication is an

min intravenous (IV) solution used to
supply water, calories, and
electrolytes (e.g., sodium,
chloride) to the body.

8
December 6, 2006

 On going IVF # 5 D5NSS @ 20  This medication is an

gtts / min. intravenous (IV) solution used to
supply water, calories, and
electrolytes (e.g., sodium,
chloride) to the body.

 Terminate when consume (IVF to  The Patient is done with the

consume) Intravenous therapy and should
continue his therapy with his
medications.

December 7, 2006

 Discontinue Nebulization  This indicates that patient has

alleviated his respiratory
conditions and has change its
conditions unlike before

 May Go Home Tomorrow  This indicate that the patient is in

good condition and return to its
functional level.

 Discontinue Isoptin  The blood pressure of the

patient was back on its normal
ranges on a couple of days of
admission. So the specific drug
was discontinued.

 Resume spiriva 1 cap OD  For the total wellness of his

inhalation bronchospasm.

9
 LABORATORY RESULTS

RADIOGRAPHIC REPORT

(CHEST PA)

December 4, 2006

The lungs are clear. The heart is enlarged (CTR:067) exhibiting inferolateral

displacement of the cardiac apex. There are crescentic calcifications in the aortic

knob.

The midline structures are not displaced. The costophrenic sulci and

hemidiaphragms are intact. The rest of the included structures are unremarkable.

• CU cardiomegaly is considered. ECG correlation suggested

• Atheromatous aorta

?
DPBR, Radiologist

10
HEMATOLOGY REPORT
Lab no. : 600066002
Date Received: 12-04-06 (5:58)
Date Reported: 14-04-06 (7:18)

TEST RESULT UNIT REFERENCE

WHITE BLOOD CELLS 23.31 10^3/uL 5.0 - 10.0

RED BLOOD CELLS 4.40 10^6/uL 4.2 - 5.4

HEMOGLOBIN 13.2 g/dL 12.0 – 16.0

HEMATOCRIT 39.7 % 37.0 – 47.0

MCV 94.7 fL 82.0 – 98.0

MCH 30.1 pg 27.0 – 31.0

MCHC 32.0 g/dL 31.5 – 35.0

DIFFERENTIAL COUNT
Lymphocyte 7.5 % 17.4 – 48.2

Neutrophil 89.2 % 43.4 – 76.2

Monocyte 7.4 % 4.5 – 10.5

Eosinophils .9 % 1.0 – 3.0

Basophils .2 % 0.0 – 2.0

PLATELET 189 10^3/uL 150 - 400

11
 DRUG STUDY

Generic Brand Date

Name Name ordered Classification Dose/ Mechanism Indication Contraindication Side Effects Nursing
Frequency/ of Action Precaution
Route

Verapami Isoptin December Anti- 240mg/ Inhibits the Managemen Hypersensitivity, Anxiety, Use
3, 2006 hypertensiv 1tab od/ transport of t of sick sinus confusion, cautiously in
e PO calcium hypertension syndrome Dizziness, severe
into headache, hepatic
myocardial BP less than 90 nervousness, impairement-
and mmHg blurred geriatric
vascular vision, patient.
smooth CHF, severe polyuria,
muscle ventricular vomiting History of
cells, dysfunction serious
resulting in ventricular
inhibition of arrhythmias.
excitation-
contraction
coupling
and
subsequent
contraction.

12
 Generic Brand Date
Name Name ordered Classification Dose/ Mechanism Specific Contraindication Side Effects Nursing
Frequency/ of Action Indication Precaution
Route

Sucralfate Iselpin December Antiulcer 1 gram Unknown. Short term Use cautiously Dizziness, Drug is
3, 2006 drugs qid/ PO Probably treatment of to patient with headache, minimally
(befire adheres ulcer chronic renal vertigo, absorbed
meals at to and (duodenal) failure constipation, and causes
HS) protects nausea, few adverse
surface of Maintenance gastric effect
ulcer by therapy for discomfort,
forming a duodenal diarrhea, dry Drug
barrier. ulcer mouth contains
Aluminum
but isn’t
classified as
Antacid.
Monitor
patients
renal
insufficiency
for
aluminum
toxicity

13
Generic Name Brand Name Date
ordered Classification Dose/ Mechanism Specific Contraindication Side Effects Nursing
Frequency/ of Action Indication Precaution
Route

Esomepra- Nexium Decembe Antiulcer 20mg/ 1 Proton Helicoba Hypertensive to Headache, Give at
zole r 3, 2006 drugs tab bid/ Pump cter drug or some dry mouth, least one
PO Inhibitor Pylori components of diarrhea, hour
that eradicati esomeprazole nausea, before
reduces on or omeprazole abdominal meals
gastric pain,
acid vomiting, Monitor
secretion and GI
and constipatio symptom
decreases n s for
gastric improve
acidity ment or
worsenin
g.

14
 Generic Brand Name Date
Name ordered Classification Dose/ Mechanism Specific Contraindication Side Effects Nursing
Frequency of Action Indication Precaution
/ Route

Combivent Salbutamol December Broncho- 1 neb q Relaxes To prevent or Hypertensive Dizziness, Drug may
Sulfate 3, 2006 dilators 6o bronchial treat broncho- to drug or headache, decrease
uterine and spasm in ingredients heartburn, sensitivity
vascular patient with nausea, of
smooth severe Use vomiting, spirometr
muscle by obstructive extended cough, y used
stimulating airway release increase for dx of
beta2 disease tablets sputum, asthma
receptors. cautiously in tachycardi
patient with a Patient
GI narrowing may use
tablet
and
aerosol
together
monitor
for signs
of toxicity.

15
Generic Name Brand Name Date
ordered Classification Dose/ Mechanism Specific Contraindication Side Nursing
Frequenc of Action Indication Effects Precaution
y/ Route

Lactulose Dupholac December Laxatives 20cc/ Produces For or treat Patient with a Abdomin Minimize
4, 2006 bid/ PO an constipation low galactose al sweet taste
osmotic diet cramps, dilute with
effect in belching, water or
colon, Use diarrhea, give with
resulting cautiously in gaseous food.
distention patient with distention
promotes diabetes , Monitor
peristalsis. mellitus. flatulence sodium
, nausea, level for
vomiting hypernatre
mia,
especially
when
giving in
higher
doses to
treat
hepatic
encephalo
pathy.

16
Generic Brand Date
Name Name ordered Classification Dose/ Mechanism Specific Contraindication Side Effects Nursing
Frequency/ of Action Indication Precaution
Route

Cefixime Tergeof December Cephalospori 200mg/ Stable in Used for Hypertensive Flatulence, Once
4, 2006 n / antibiotic bid/ PO the acute to drugs or elevated reconstituted,
presence bronchitis and other alkaline keep
of beta- acute cephalosporin phosphatase suspension
lactamas exacerbations drugs. level. at room
e enzyme of chronic temperature
bronchitis. where it
maintains
potency for
14 days.

17
V. ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY

Digestive System, organs for changing food chemically into simple soluble
substances absorbable by tissues. This process involves catalytic reactions between
ingested food and enzymes secreted into the intestinal tract (see Intestine). Digestion of
fatty substances appears to involve the assembly of bile salts, phospholipids, fatty
acids, and monoglycerides that can pass through intestinal cells. Other nutrients such
as iron and vitamin B12 are absorbed by specific “carrier proteins” that make them
transferable by the intestinal cells. The process described here is typical of all
vertebrates except ruminants.
Digestion includes both mechanical and chemical processes. The mechanical
processes include chewing to reduce food to small particles, the churning action of the
stomach, and intestinal peristaltic action. These forces move the food through the
digestive tract and mix it with various secretions. Three chemical reactions take place:
conversion of carbohydrates into such simple sugars as glucose (see Sugar
Metabolism), breaking down of protein into such amino acids as alanine, and
conversion of fats into fatty acids and glycerol (see Fats and Oils). These processes are
accomplished by specific enzymes.
When food is eaten, the six salivary glands produce secretions that are mixed
with the food. The saliva breaks down starches into dextrin and maltose, dissolves solid
food to make it susceptible to the action of later intestinal secretions, stimulates

18
secretion of digestive enzymes, and lubricates the mouth and oesophagus for the
passage of solids.

Stomach and Intestinal Action

Gastric juice in the stomach contains agents such as hydrochloric acid and some
enzymes, including pepsin, rennin, and traces of lipase. (The surface of the stomach
itself is thought to be protected from acid and pepsin by its mucous coating.) Pepsin
breaks proteins into peptones and proteoses. Rennin separates milk into liquid and solid
portions; lipase acts on fat. Another function of stomach digestion is gradually to release
materials into the upper small intestine, where digestion is completed. Some
constituents of gastric juice become active only when exposed to the alkalinity of the
small intestine; secretion is stimulated by chewing and swallowing and even by seeing
or thinking of food (see Reflex). The presence of food in the stomach also stimulates
production of gastric secretions; these in turn stimulate the production of digestive
substances in the small intestine.
The most extensive part of digestion occurs in the small intestine; here most food
products are further hydrolysed and absorbed. Predigested material supplied by the
stomach is subjected to the action of three powerful digestive fluids: pancreatic fluid,
intestinal juice, and bile. These fluids neutralize the gastric acid, ending the gastric
phase of digestion.
Intestinal juice is secreted by the small intestine. It contains a number of
enzymes; its function is to complete the process begun by the pancreatic juice. The flow
19
of intestinal juice is stimulated by the mechanical pressure of food partly digested in the
intestine.
The water-soluble substances, including minerals, amino acids, and
carbohydrates, are transferred into the venous drainage of the intestine and through the
portal blood channels directly to the liver. Many of the fats, however, are resynthesized
in the wall of the intestine and are picked up by the lymphatic system (see Lymph),
which carries them into the systemic blood flow as it returns through the vena caval
system (see Heart), bypassing an original passage through the liver (see Circulatory
System).

Excretion

Undigested material is formed into a solid mass in the colon by reabsorption of

water into the body. If colonic muscles propel the excretory mass through the colon too
quickly, it remains semi-liquid. The result is diarrhoea. Insufficient activity of the colonic
musculature, on the other hand, produces constipation. The stool is held in the rectum
until excreted through the anus.
Many disorders of absorption are collectively called malabsorptive states, the
most profound and difficult being a condition known as spruce.

20
 PATHOPHYSIOLOGY

Definition:
Peptic Ulcer
 A circumscribed breaks or ulcerations of the gastrointestinal mucosa and
underlying tissues caused by gastric secretions that have low pH(acid)
Predisposing Factors
 Blood Type (tends to strike with type “A” blood; duodenal ulcers tends to afflict
type “O” Blood.
 Genetic Predisposition/ Factors
 Normal Aging
 Exposure to irritants (alcohol use and tobacco smoking)
 Physical trauma
 Emotional stress or psychosomatic factors (e.g. chronic anxiety)

Precipitating Factors
 Epigastric Pain which is burning
 Piercing and periodic
 Hyperacidity
 Nausea or vomiting

21
 Schematic Diagram

HCl = Pepsin Irritants

(Alcohol and tobacco)

Increase or excessive mucous or gastric acid

secretions (caused by secretions
stress or stimulants)

Damage of mucous
membrane

PEPTIC ULCER DISEASE

S/s: Pain (burning,

Aching, or gowning)
Epigastric Tenderness

Bleeding at the site (GIT)

Passage of tarry stools (melena)
May occur

Complications:
pyloric or duodenal obstruction,
hemorrhage and perforation
22
VI. NURSINS ASSESSMENT
EENT:
Impaired vision blind pain
reddened drainage gums hard
of hearing deaf burning edema
lesions teeth
assess eyes ears nose throat for
abnormalities no problem
RESP:
Asymmetric tachypnea apnea
rales cough barrel chest
bradypnea shallow rhonchi
sputum diminished dyspnea
orthopnea labored wheezing
pain cyanotic
asses resp. rate, rhythm, depth,
pattern, breath sounds, comfort no
problem
CARDIO VASCULAR
Arrhythmia tachycardia
numbness diminished pulse
edema fatigue irregular
bradycardia murmur tingling
absent pulses pain
assess heart sounds, rate rhythm,
pulse, blood pressure, circ., fluid
retention, comfort no problem
GASTRO INTESTINAL TRACT
Obese distention mass
dysphagia rigidly pain
assass abdomen, bowel habits,
swallowing, bowel sounds, comfort
no problem
GENITO-URINARY
Pain urine color vaginal
bleeding hematuria discaharge
noctoria
Assess urine freq., control, color,
odor, comfort/gyn-bleeding,
discharge no problem
NEURO
Paralysis stuporous unsteady
seizures lethartic comatose
vertigo tremors confused
vision grip
assess motor function, sensation,
LOC, strength, grip, gait,
coordination, orientation,speech,
no problem
MUSCULOSKELETAL and SKIN
Appliance stiffness itching
petechiae hot drainage
prosthesis swelling lesion
poor turgor cool deformity
wound rash skin color flushed
atrophy pain ecchymosis
diaphoretic moist
assess mobility, motion, gait,
alignment, joint function/skin color,
texture, turgor, integrity no
problem
Place an (x) in the area of
abnormality. Comment at the space
provided indicate the location of the
problem in the figure if appropriate,
using (x)
Pain at OD
_________________________
_________________________
_________________________
_________________________
O2 administration
_________________________
(nasal Cannula)
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Tachypnea (RR 28cpm)
_________________________
Hyperventilation
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Abdominal Pain
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
IVF D5NSS 1l infusing at
Right hand @ 20gtts/min
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Pain @ Right Knee / Leg
(Arthritis)
_________________________
_________________________
_________________________
_________________________
_________________________
Body is Weak
23
 SUBJECTIVE “maayo raman OBJECTIVE

COMMUNICATION:akong paminaw, sakit

Hearing loss lang usahay akong tuo
Comments___________ Glasses languages
Visual changes nga mata”
____________________ Contact lens hearing aide
Denied ____________________ R L
____________________ Pupil Size ___3.0mm__ γ speech difficulties
____________________ Reaction ____PERRLA_____
“gahanga- kon
OXYGENATION: ko tungod sa akong ubo
Dyspnea Comments___________ Resp. γ regular γ irregular
na grabe ang plema Describe: __Patient exhibits hyperventilation a
Smoking history ___________________
panalagsa”
_____________ __________________ manifestation of tachypnea on patient_______

cough __________________ R _side is symmetrical during inhalation/exhalation

sputum __________________ L _side is symmetrical during inhalation/exhalation
denied “gapaminhod
___________________
CIRCULATION: usahay and akong tiil ug
usahay pud musakit Heart rhythm γ regular γ irregular
Chest pain Comments___________
Ankle edema ___________________________
tungod aning arthritis
____________________
Pulse Car. Rad. DP Fem.*
Leg pain na____________________
hinungdan nganu R _+______+_______+______+_____+______
____________________
galisod kog lakaw L _+______+_______+______+_____+______
Numbness of ____________________
usahay” Comments:_all pulses are palpable or noted during
Extremities ____________________
the assessment (positive)
____________________
* if applicable
Denied ____________________

NUTRITION: “Dili nagyud

Diet___________________________________ γ Dentures γ none
kau ko g,a kaun wala
N V Comments__________
man gyud koy gana Full Partial With Patient
Character ____________________
Diet as bisag
Tolerated
unsa nga pagkaun Upper γ γ γ
γ Recent change in ____________________
na ihatag sa akoa”
wieght,appetite ____________________
γ Swallowing ____________________
Lower γγγ
difficulty _____________________
γ Denied _____________________ “sige ko ug
kalibang ug tae na basa
ELIMINATION: asComments
verbalizad by the
Usual bowel pattern γ urinary frequency __________ Bowel sound________
patient. Still his stool is
___________________ ______Audible______
____2 x per day___ ____Every Hour______
black, tarry/bloody
__________________ Abdominal Distension
Constipation γ urgency
(melena), and wet
___________________ Present yes no
Remedy γ dysuria
(characteristics)
___________________ Urine* (color.,
_December 5, 2006_ γ hematuria ___________________ consistency, odor)
Date of last BM γ incontinence ___________________ __________________
________________ γ polyuria ___________________ __________________
Diarrhea γ foly in place ___________________ __________________
Character γ denied ___________________ *if they are in place?
________________
MGT. OF HEALTH & ILLNESS: Briefly describe the patient's ability to follow
Alcohol denied treatments (diet, meds, etc.) for chronic health
(amount, frequency) problems (if present).
____as patient verbalized that he doesn’t Medications ordered by the doctor are always
24
drink alcoholic beverages any more __ available and given at the right time but not
SBE Last Pap Smear _____N/A__________ similar to his diet. He seldom eat food because
LMP: _________N/A_____________________ of his condition, as the patient stated
 SUBJECTIVE
SKIN INTEGRITY: “wala man koy
γ Dry Comments ___________
katol-katol sa akong
____________________
panit, wla pud koy
γ Itching ____________________
problema anang mga
____________________
samad samad sa akong
γ Other ____________________
panit”
____________________
γ Denied ____________________
ACTIVITY/ SAFETY: “gabatiun kog
γ Convulsion kalipong
Commentsdili napud ko
___________
γ Dizziness tanto maka lakaw lakaw.
____________________
γ Limited motion Kung magkaun ko
____________________
Of joints taman rako lingkod sa
____________________
____________________
akong bed o sa akong
Limitation in ____________________
higdaanan mukaun ug
Ability to ____________________
ga diapers na gali ko
γ Ambulate ____________________
kay lisod na kau
γ Bathe self ____________________
maglakaw-lakw ”
γ Other ____________________
γ Denied ____________________
COMFORT/SLEEP/AWAKE:
γ Pain Comments“sigi ko ug ihi-
__________
(location) ihi___________________
sa gabie, dili pud ko
Frequency ____________________
katulog ug tarong kay
Remedies) ____________________
gaubuha ko ug mau”
γ Nocturia ____________________
γ Sleep difficulties ____________________
COPING:
Occupation _________None _____________
Members of household ___Melsa, Rebbeca Fe,
Lenthi Ann____________________________
Most supportive person ____ Rebbeca Fe ____
______________________________________
SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)
______100 lbs ___ Daily Weight
___140/70 mmHg__ BP q Shift
_____N/A________ Neuro vs.
_____N/A________ CVP/SG. Reading
Diagnostic/ laboratory
Date Date done
Exams
ordered
Complete Blood Count
12-04-06 12-04-06
12-04-06 Chest X-Ray 12-04-06
VII. NURSING MANAGEMENT
OBJECTIVE
γ Dry γ cold γ pale
γ Flushed γ warm
γ Moist γ cyanotic
*ashes, ulcers, decubitus (describe size, location, drainage)
__tenderness/ ulcerations or rashes are not noted
during the assessment
γ LOC and orientation _The patient is still aware of the
time, date and place______________________________
Gait: γ walker γ cane other
γ Steady γ unsteady____________________
γ Sensory and motor losses in face or extremities
_______________________________
γ ROM limitations __cannot extremely move his
right leg or even his lower extremities because of his
arthritis____________________________________
__________________________________________
__________________________________________
__________________________________________
γ Facial grimaces
γ Guarding
Other signs of pain __there were no other signs of
pains felted by the patient during my assessment_
____________________________________________
Side rail release form signed ( 60 + years)
_________________________________________
Observed non- verbal behavior Always touching his jaw
during my assessment when he speaks and even
after coughing.
The person and his phone number that can be reached any
time __________________________
_________________________________________
_____N/A_______PT/OT _____N/A_______
_____N/A____ Irradiation
_____N/A____ Urine Test _____N/A_______
_____N/A____ 24 hour Urine collection
I.V. Fluids/Blood
Date Date disc.
ordered
12-05-06 D5NSS 1L @20 (Still Infused)
gtts/min
25
 IDEAL NURSING MANGEMENT

ACTIONS/INTERVENTIONS
NURSING DIAGNOSIS: Diarrhea RATIONALE
Diarrhea Management
May be related to (NIC)
Independent
Inflammation, irritation, or malabsorption of the bowel
Observe and record
Presence stool frequency,
of toxins Helps differentiate individual disease and
characteristics,
Segmental narrowing of the lumen assesses
amount,
Possiblyand precipitating
evidenced by factors. severity of episode.
Increased bowel sounds/peristalsis
Promote bedrest,and
Frequent, provide
oftenbedside Rest(acute
severe, watery stools decreases intestinal motility and
phase)
commode.
Changes in stool color reduces the
Abdominal pain; urgency (sudden painful metabolic
need torate when infection
defecate), cramping or
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT hemorrhage is a WILL:
Bowel Elimination (NOC) complication. Urge to defecate may occur
Report reduction in frequency of stools,without
return to more normal stool consistency.
Identify/avoid contributing factors warning and be uncontrollable, increasing
Remove stool promptly. Provide room risk of
deodorizers. incontinence/falls if facilities are not close
at hand.

Identify foods and fluids that precipitate Reduces noxious odors to avoid undue
diarrhea, e.g., patient
raw vegetables and fruits, whole-grain embarrassment.
cereals,
condiments, carbonated drinks, milk Avoiding intestinal irritants promotes
products. intestinal rest.

Restart oral fluid intake gradually. Offer

clear liquids
hourly; avoid cold fluids.
Administer medications as indicated:
Antidiarrheals, e.g., diphenoxylate
(Lomotil),
Loperamide (Imodium), anodyne
suppositories;
Provides colon rest by omitting or
decreasing the stimulus 26
of foods/fluids. Gradual resumption of
liquids may
prevent cramping and recurrence of
diarrhea; however,
cold fluids can increase intestinal motility.
Decreases GI motility/propulsion
(peristalsis) and
diminishes digestive secretions to relieve
cramping and
diarrhea. Note: Use with caution in UC
because they may
precipitate toxic megacolon.
NURSING DIAGNOSIS: Fluid Volume, risk for deficient
Risk factors may include
Excessive losses through normal routes (severe frequent diarrhea, vomiting)
Hypermetabolic state (inflammation, fever)
Restricted intake (nausea/anorexia)
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual
diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Hydration (NOC)
Maintain adequate fluid volume as evidenced by moist mucous membranes,
good skin turgor, and capillary
refill; stable vital signs; balanced I&O with urine of normal concentration/amount.

ACTIONS/INTERVENTIONS RATIONALE
Fluid/Electrolyte Management (NIC)
Independent

Monitor I&O. Note number, character, and Provides information about overall fluid
amount of balance, renal
stools; estimate insensible fluid losses, function, and bowel disease control, as
e.g., diaphoresis. well as guidelines
Measure urine specific gravity; observe for for fluid replacement.
oliguria.
Hypotension (including postural),
Assess vital signs (BP, pulse, tachycardia, fever can
temperature). indicate response to and/or effect of fluid
loss.

Observe for excessively dry skin and Indicates excessive fluid loss/resultant 27
mucous membranes, dehydration.
decreased skin turgor, slowed capillary
refill.
Indicator of overall fluid and nutritional
Weigh daily. status.

Maintain oral restrictions, bedrest; avoid Colon is placed at rest for healing and to
exertion. decrease
intestinal fluid losses.

Observe for overt bleeding and test stool Inadequate diet and decreased absorption
daily for occult may lead to
blood. vitamin K deficiency and defects in
coagulation,
potentiating risk of hemorrhage.
Note generalized muscle weakness or
cardiac Excessive intestinal loss may lead to
dysrhythmias. electrolyte
Collaborative imbalance, e.g., potassium, which is
Administer parenteral fluids, blood necessary for proper
transfusions as
indicated. skeletal and cardiac muscle function.
Minor alterations in
serum levels can result in profound and/or
Administer medications as indicated: life-threatening
Antidiarrheal (Refer to ND: Diarrhea); symptoms.

Reduces fluid losses from intestines.

NURSING DIAGNOSIS: Pain, acute

May be related to
the effect of gastric acid secretion on damaged tissue
Possibly evidenced by
Reports of colicky/cramping abdominal pain/referred pain
Guarding/distraction behaviors, restlessness
Facial mask of pain; self-focusing
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Pain Level (NOC)
Report pain is relieved/controlled.
Appear relaxed and able to sleep/rest appropriately.

ACTIONS/INTERVENTIONS RATIONALE 28
Pain Management (NIC)
Independent
Encourage patient to report pain. May try to tolerate pain rather than request
Assess reports of abdominal cramping or analgesics.
pain, noting Colicky intermittent pain occurs with
location, duration, intensity (0–10 scale). Crohn’s disease
Investigate and Predefecation pain frequently occurs in UC
report changes in pain characteristics. with urgency,
which may be severe and continuous.
Changes in pain
characteristics may indicate spread of
disease/developing
complications, e.g., bladder fistula,
Note nonverbal cues, e.g., restlessness, perforation, toxic
reluctance to megacolon.
move, abdominal guarding, withdrawal,
and depression.
Investigate discrepancies between verbal Body language/nonverbal cues may be
and nonverbal both physiological
cues. and psychological and may be used in
conjunction with
Review factors that aggravate or alleviate verbal cues to determine extent/severity of
pain. the problem.

May pinpoint precipitating or aggravating

Encourage patient to assume position of factors (such as
comfort, e.g., stressful events, food intolerance) or
knees flexed. identify developing
complications.

Provide comfort measures (e.g., back rub, Reduces abdominal tension and promotes
reposition) and sense of
diversional activities. control.

Observe/record abdominal distension, Promotes relaxation, refocuses attention,

increased and may
temperature, decreased BP. enhance coping abilities.
Collaborative
Implement prescribed dietary May indicate developing intestinal
modifications, e.g., obstruction from
commence with liquids and increase to inflammation, edema, and scarring.
solid foods as
tolerated.
Complete bowel rest can reduce pain, 29
cramping.
Pain varies from mild to severe and
Administer medications as indicated, e.g.: necessitates
Analgesics; management to facilitate adequate rest
Anti-ulscer drugs; and recovery.
Note: Opiates should be used with caution
because they
may precipitate toxic megacolon.

Relieve spasms of GI tract and resultant

colicky pain.
 ACTUAL NURSING MANAGEMENT 30

“Subjective”
• The patient complained of difficulty of breathing because of his cough and
even verbalized that his throat was very painful when he will swallow food
“Objective”
• The patient manifests tachypnea or hyperventilation during the assessment.
With a respiration Rate of 28 cpm, with a productive cough noted and shows
facial grimace upon respiration or coughing.
“Assessment”
 • Ineffective airway clearance related to increased production of secretions,
retained secretions and bronchospasm.
“Planning”
• At the end the interventions given to the patient, he would somehow perform
with himself the skills or techniques on how to lessen, ease, or prevent
dyspnea, cough or hyperventilation. The patient will also learn about the
reason of the condition, how it occurs and how it would be prevented and
what are the uses of the medications given by his physician.
“Implementation”
• Assist patient to assume position of comfort (e.g. elevate the head part of the
bed).- Elevation of head facilitates respiratory function by use of gravity;
however patients in severe distress will seek the position that most eases
breathing.
• Keep environment to a minimum (e.g. dust, smoke, and feather pillow)-
Precipitator of allergic reaction of respiratory reaction that can trigger or
exacerbate onset of acute episode
• Encourage or assist with abdominal or pursed lips breathing exercise.-
provide patient with some means to cope with control dyspnea and reduces
air trapping
• Increase fluid intake to 3000mL/day within cardiac tolerance. Provide
warm/tepid liquids recommended intake of fluid between, instead of during
31
meals.- hydration helps reduces the viscosity of secretions, facilitating
expectoration using warm liquids may decrease bronchospasm . Fluids
during meals can increase gastric distention and pressure on the diaphragm.
• Administer medications as prescribed by his doctor such as bronchodilator
(e.g. ventolin, combivent)- this medication relaxes smooth muscles and
reduce local congestion, reducing airway spasm, wheezing, and mucus
production.

“Evaluation”
 • At the end of a couple of interventions done to the patient, he reports reduced
difficulty in breathing that is, retained secretions are somehow lessened and
coughing was also reduced. And he will be able to prevent bronchospasm if
he continue using or performing the interventions for the wellness of his
health

“Subjective”
• The patient has a complaint of bloody and dark colored stool (melena). Also
verbalized that he coughs or cough-up blood with sputum on it. And also
experiences burning epigastric pain or discomfort on his abdominal part or
area.
“Objective”
• Was diagnosed with bleeding peptic ulcer disease; on his complete blood
count results found out that his hemoglobin was deceased and this is a sign
for blood loss. And regarding his discomforts felt on his abdomen, wherein
he show facial grimace when pains is felt.
“Assessment”
• Increase risk of anemia due to acute GI bleeding related to ulcer 32

• Acute pain related to pyloric obstructions complication of peptic ulcer

“Planning”
• At the end of the interventions done to the patient, he will be able to perform
specific interventions with him self on how to lessen or prevent the
discomforts felt by the patient and how to manage of having a regular or
normal characteristics of stools upon defecation. By teaching patient the
methods to minimize symptoms while maintaining adequate nutrition and also
teaching patient about necessary life style changes aimed at decreasing
stress and minimizing effectiveness of coping mechanism.
“Implementation”
 • Provide small and frequent meals- Food prevents distenson and release of
gastrins and has an acid neutralizing effect. Patient should eat meals on a
regular basis.
• Institute measures to neutralize or buffer hydrochloric acid, inhibit acid
secretion and decreases the activity of pepsin
• Administer antacids as prescribed by the physician to reduce acidity and
even anti ulcer drugs (e.g. esomeprazole)- to treat peptic ulcer or eradicate
helicobacter pylori.
• Diet regulation through the use of bland foods and restriction of irritating
substances such as nicotine, caffeine, alcohol, spices, and gassy foods.
• To have some bed rest to reduce physical activity and promote comfort to the
patient.
• Encourage hydration to reduce anticholinergic side effects and dilute the
hydrochloric acid in the stomach
“Evaluation”
• At the end of a several interventions, the patient somehow reports reduced
pain; the patient verbalizes appropriate diet modification and even
demonstrates compliance with the prescribed medication regimen in order to
reach the total health and wellness.

33

“Subjective”
• The patient complained of pain on his right leg and even numbness, and
wasn’t able to walk with him self because of the pains and even because of
his condition, as he verbalized.
“Objective”
• Has limitation on his range of motion: right leg, when tenderness is felt.
There is facial grimace when patient wants to move his leg or when pain
occurs. He was not able to ambulate by himself.
“Assessment”
• Acute Pain related to joint tenderness due to arthritis on right leg
“Planning”
• The patient would somehow perform the techniques on how to exercise or
practice moving his affected area with himself and even would tolerate the
pain for a short period of time. And even the patient would be aware on what
are the significance of the said interventions and how it affects his total
condition or how it can help him on the entire course of health teachings.
“Implementation”
• Elevate the affected portion or the foot of the patient with pillows under it. So
hat it would promote blood circulation.
• To practice exercising his leg joints by extension or flexion of knees(range of
motion exercise)
• Apply heat and colds to or on the affected area to provide relief or comfort to
the area by constriction / dilation of blood vessels
• Promote rest and position of comfort to ease joint pains and encourage diet
rich in nutrients – dense food such as fruit, vegetables or legumes
• Administer medications as prescribed by his doctor such as analgesics - this
drug reduces pains felt by the patient.

34

“Evaluation”
• At the end of a couple of interventions done to the patient, he reports reduced
difficulty in breathing that is, retained secretions are somehow lessened and
coughing was also reduced. And he will be able to prevent bronchospasm if
he continue using or performing the interventions for the wellness of his
health
 35

VIII. REFERRALS AND FOLLOW-UP

It is important to comply regularly its medication as prescribed by his attending

physician and to continue and finish its entire therapeutic regimen. And explain to the
patient the use and side effects of the medications so that he will be aware of its effects
such as bronchodilators for the treatment of his cough that helps alleviate or prevent
bronchospasm (e.g. ventolin for Nebulization) and even anti-ulcer drugs to prevent
reoccurrence of the disease (e.g. Sucralfate).
He should practice moving his lower extremities to promote blood circulation and even
to improve the range of motion of his foot or feet so that he could somehow, able to
ambulate with him self in later times. To perform bed exercise such as leg exercise,
since patient is always on bed and have limitations on his physical activity because his
still weak.
The patient was instructed to avoid over work for the following days and must
have adequate bed rest to regain energy or strength. By means of anticipating the
needs on the course of healing and curing process the patient must then focused to
himself by not always depending on the interventions that are not highly needed just to
ease or prevent any health problem regarding his condition . But he should focus
entirely on how to prevent the problem on his actions by himself.
Environmental sanitation is needed to provide a healthy and therapeutic way of
curing himself. Smoking and alcohol consumption must be prevented totally by the
patient so that his problem would not be worse again..
Upon discharged, he must come back to the hospital one week after, for the
follow-up check-up to confirm if the patients condition is really restored. Also to know if
there are complications sited during the check up to know if patients condition have
worsen or not.
And lastly, he should take note of the foods that are irritating to his GI tract to
prevent reoccurrence of abdominal pain and even should eat adequate amount of foods
every meals. Eating nutritious food would somehow help the patient on regaining some
strengths or energy to his body, such as green leafy vegetables, fruits, and foods rich in
36
protein.

IX. EVALUATION AND IMPLICATIONS

At the end of my hospital duty, I as a student nurse was able to render care to my
patient to help him resolve his problem regarding health. Through observing the
patient’s status, I was able to identify some problems during my assessment. Because
of a couple of interventions or health teachings applied and imparted to the patient, I
was able to lessen its respiratory pattern on the patients problem of breathing
(ineffective Airway Clearance); alleviated pains felt by the patient due to the effects of
the peptic ulcer or to the arthritis; and even have defecated a normal characteristics of
stool.
Patient was willing to pursue his medical therapy just to promote health and
wellness for the betterment of his condition. During the treatment, the patient was able
to develop or enhance health awareness on his disease and with this knowledge
instilled to his mind, he was then aware on how the disease was transmitted and what
are the proper ways or interventions done just to minimize or prevent this disease from
getting worst.
I have also made the patient realize the importance of completing the course of
therapy by taking the medicines prescribed or ordered to him by his physician. In
addition, eating healthy or nutritious foods that were prescribed to him by the health
providers was further been explained to him especially the benefits he will gain in eating
these nutritious foods.
In general, the patient was very cooperative to what health measures
administered to him by the health providers.
Moreover, these several interventions given to the patient made his body
functions different than as before

37

X. BIBLIOGRAPHY
• Lippincott Williams and Wilkins, Nursing 2006 Drug Handbook, 26th Edition,
• Barbara Kozier et al, Fundamentals of Nursing, 7th Edition,
• Lippincott Williams and Wilkins, Nursing 2004 Drug Handbook, 24rd Edition,
• Mosby’s Pocket Dictionary of Medicine, Nursing Allied Health, 4th Edition,
Published in Elsevier Science (Singapore) PTE LTD
• Microsoft ® Encarta ® Premium Suite 2005. © 1993-2004 Microsoft
Corporation. All rights reserved.
• Mosby’s Comprehensive Review of Nursing, 13th Edition by:
Saxton,Nugent,Pelikan
• http://www.cnn.com/HEALTH/library/DS/00583.html
• Smeltzer & Bare, medical Surgical Nursing, 10th ed. Vol. 1, Lippincott Williams
& Wilkins, Philadelphia, USA pp.1015-1051
• Mosby’s MEDICAL ENCYCLOPEDIA, the definitive health reference
• http://www.wrongdiagnosis.com/p/peptic_ulcer/symptoms.htm
• http://en.wikipedia.org/wiki/Peptic_ulcer
• http://www.emedicine.com/med/topic1776.htm
• http://www.gicare.com/pated/ecdgs09.htm
• http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=8

38
LICEO DE CAGAYAN UNIVERSITY
R.N.P. Blvd., Carmen, Cagayan de Oro City
C OLLE GE OF NURSING
   
  
 A Care Study
Moesis L. Labuntog

Submitted to:

Ms. Asterie Revelo, RN

Clinical Instructor

As Partial Requirement for NCM501202

Submitted by:

Librea, Celso R.
NCM501202 Student

January 18, 2007