A2A Round3

April 2012
A case of Multiple Gastrointestinal problems: Gastric Ulcer, Gastritis Submitted by: Erosive GERD grade A and FecalTeam leader: Retention
Members:
Competency Enhancement Training Program for Nurses (CETN) batch 24
Submitted to:
A brief introduction
Professional Development and Training Department
MAKATI MEDICAL CENTER NURSING SERVICE DIVISION

April 2012
CASE STUDY:
[Title of the case ]
[ DATE] Page 2 of 51
TABLE OF CONTENTS
INTRODUCTION Background of the Study Statement of the Problem Scope & Limitation CLINICAL FRAME WORK Course in the ward outline Pathophysiological framework DISCUSSION AND ANALYSIS Demographic Profile Pertinent Histories Hollistic Assessment Diagnostic Study Pharmacological Study Nursing Care Plans SUMMARY OF FINDINGS CONCLUSIONS RECOMMENDATIONS BIBLIOGRAPHY APPENDICES: (if any)
1 1 3 6 6 15 16 17 18 19 20 21 22 22 22 23 23
INTRODUCTION
CASE STUDY:
This study is a partial requirement in the Competency Enhancement Training Program (CETN) of Nursing Services Division. The study was done during the clinical exposure as trainee nurses on the 7th Floor Circular area of Makati Medical Center. Gastritis is a condition in which the stomach liningknown as the mucosais inflamed. The stomach lining contains special cells that produce acid and enzymes, which help break down food for digestion, and mucus, which protects the stomach lining from acid. When the stomach lining is inflamed, it produces less acid, enzymes, and mucus. Erosive gastritis is a type of gastritis that often does not cause significant inflammation but can wear away the stomach lining. Erosive gastritis can cause bleeding, erosions, or ulcers. Erosive gastritis may be acute or chronic. Gastroesophageal reflux is a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal. Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis). GERD is a chronic disorder that is largely treated on the basis of symptoms, especially in primary-care practice, irrespective of possible underlying mucosal damage or complications. Grade A GERD is defined as one (or more) mucosal break no longer than 5 mm that does not extend between the tops of two mucosal folds. Gastric Ulcer is a round or oval sore where the lining of the stomach has been eaten away by stomach acid and digestive juices. Ulcers penetrate into the lining of the stomach. Gastritis may develop into Gastric Ulcers. Gastric ulcers usually occur along the upper curve of the stomach. Fecal Retention or Constipation refers to a decrease in the frequency of bowel movements or difficulty in passing stools. The stool of a constipated person is typically hard because it contains less water than normal. Constipation is a symptom, not a disease. Pyloric stenosis is defined as an obstruction to gastric emptying due to any cause situated above the biliary ampulla. In 80% the ulcer was situated at or near the pylorus, but in 6% there was a remote gastric ulcer with surrounding inflammatory and fibrous tissue which shortened the lesser curve and extended to envelop the pylorus. Earlier surgical treatment has reduced the number of peptic ulcers that progress to pyloric stenosis. In approximately half the patients in whom pyloric stenosis is diagnosed there are no abnormal physical signs. A gastric succussion splash, only significant if at least three hours have elapsed since the last meal, is the commonest abnormal finding. Visible waves of gastric peristalsis coursing across the
CASE STUDY:
abdomen from left to right are of great diagnostic value, and occasionally it is possible to see the outline of a grossly distended stomach.
Background of the Study

This study was conducted at the 7th Floor Circular Area. Makati Medical Center. 7 Circular is a general Nursing unit with total bed capacity of 22 large private rooms. The room starts from room 742-763. Unit accepts adult patients of any category of the patient with medical cases according to the implemented zoning. But if there are no available rooms in the units, it can accept patient out of zoning but refuses pediatric and maternity cases patients.
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Statement of the Problem

This paper seeks to present an analysis of the given case encountered on Fecal Retention, Gastric Ulcer Modified, Gastritis Diffuse erosive GERD Grade A. Specifically, it attempts to answer the following questions: 1. What is Demographic profile of the case? 2. What are the significant histories of patient that may have contributed to the patient current condition? 3. What is the status of patient in terms of physical and psychological aspects? 4. What are the significant diagnostics required for the patient? What is the significance of performing the test in relation to patient diagnosis? 5. What are the prescribed medication / treatment regimen applied to the patient? What are the classification, action, indication, contraindication, rationale, and adverse reaction of this drugs/ agents? 6. What are the priority nursing problems identified? 7. How should the nurse intervene to answer the identified problems?
CASE STUDY:
Scope and Limitation

This study explores the condition of an adult female client who has Fecal Retention, Gastric Ulcer, Modified Gastritis, diffuse erosive GERD grade A. This study is a retrospective A since the patient was handled by the researcher from March 14 16 2012. This includes the exploration of the disease, medical management and comprehensive nursing management as well as various nursing diagnoses identified and plan of action for each. The case was conducted at Makati Medical Center specifically at the 7th floor Circular area of the hospital. The researchers were able to handle the patient from March 14-16. During the 6 2 am shift and 2 10 pm shift. The patient was handled for a total of twenty four hours divided in two shifts. The aspects that were looked into were the demographic profile of the client, patients verbalizations, researchers observation of the client, patients chart, and the interventions done for the patient. The researcher was able to recall significant verbalizations that lead to the development of the nursing problems. Data collection was done through the patients chart, verbalizations of the client and the researchers observation. Psychological assessment and history was done by the researcher. Pertinent laboratory results were not obtained because the copies were not filed???? in the chart.
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CLINICAL FRAMEWORK
COURSE IN THE WARD OUTLINE
Day 1 MARCH 13, 2012 (2258H) ER admission (+) stabbing abdominal pain of 9/10 on the right upper quadrant (+)right upper quadrant direct tenderness (-) right lower quadrant pain (+) murphys sign
(-) Rovsings sign (-) pregnancy test Rectal examination not done Nothing by mouth For Complete Blood Count Therapeutics: Hyoscine-N-Butyl Bromide, 20mg via IV Tramadol 50mg via IV
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Day 2 MARCH 14, 2012 (0007H) stabbing abdominal pain of 9/10 on the right upper quadrant (+)right upper quadrant direct tenderness (+) murphys sign (+) nausea (-) vomiting IVF D5LR 1L to run at 100ml/hour Serum lipase
TEST. OKS LNG?) (dKO NA TINANGGAL KHT WLNG RESULT PRA MLMN NA MAY GNITO SYANG
Result: unavailable Ultrasound of whole abdomen Nalbuphine, 5mg via IV for pain Metoclopramide, 10mg via IV for nausea and vomiting every 8 hours
(0017H) Discontinue Metoclopramide Hold Nalbuphine
(0025H) Hold ultrasound of the abdomen Schedule for Esophago-Gastroduodenoscopy with cleansing enema For plain film of the abdomen o Result: Fecal retention
Pantoprazole, 40mg via IV once a day
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Complete Blood Count results o o o o o (No time) PROBLEM LIST: 1. Gastric ulcer, modified 2. Gastritis, diffuse GERD, fecal retention Pre-procedural diagnosis: Gastric ulcer Pre-procedure assessment o Vital signs: Temperature: 36.2C Pulse rate: 82 Respiratory rate: 19 BP: 100/60 O2 saturation: 100% Hematocrit: 44.90% (35.9-44.6) White Blood Cells: 12.00 (4.4-11) Segmenters: 73.00% (40-70) Lymphocytes: 18.00% (22-43) Mean corpuscular hemoglobin concentration (MCHC): 31.8% (33.4-35.5)
Intra-procedure assessment o o o Sedation start: 0803H Procedure start: 0808H Positioning: left lateral position
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Post-operative assessment o BP every 30 minutes: 87/53
Post-operative order: For cleansing enema now Sedation medicines: o o o Diphenhydramine, 25mg via IV Fentanyl, 25mg via IV Midazolam, 5mg via IV
Low fat diet; no coffee, no milk, no softdrinks Repeat CBC Liver function test Give Pantoprazole, 40mg via IV every 12 hours Resume Metoclopromide
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Day 3 MARCH 15, 2012 (No time indicated) Discontinue all IV fluids and IV medications then shift to heplock Start Lanzoprazole for 30mg/tablet, 1 tablet now then 2 times a day before meals Domperidone, 10mg/tablet, three times a day before meals Repeat CBC results o o o Red Blood Cells: 4.17 (4.5-5.1) Monocytes: 8% (0-7) Mean corpuscular hemoglobin concentration (MCHC): 31.9% (33.4-35.5)
Day 4 MARCH 16, 2012
May go home anytime
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PATHOPHYSIOLOGICAL FRAMEWORK
DISCUSSION AND ANALYSIS Date 1. Admission: March 14 2012 at 0013H case? of What is Demographic profile of the Name of patient: V.K.R.V Gender: Female Civil Status : Single Address: Cavite Age: 22years old DOB: January 3 1990 Nationality: Filipino Religion: Roman Catholic Educational attainment: College undergraduate Admitting Impression: Acute Cholecystitis Final Diagnosis: Fecal retention; Gastric Ulcer, Gastritis, Erosive GERD grade A
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2. What are the significant histories of patient that may have contributed to his current condition? Chief complaint Summarized Current Illness Episodes History of Present Illness Right upper quadrant pain Hours prior to admission patient had a sudden onset of severe abdominal pain caused by spasm on the right upper quadrant of the abdomen minutes after intake of bananacue; no medications were taken. Pain was said to be about 4/10 in severity. One hour prior to admission, right upper quadrant pain persisted, non-radiating with associated nausea, no vomiting. Pain was 9/10 in severity thus prompting emergency department consultation. Temp: 36.2 C PR: 82 bpm RR: 19 cpm BP: 100/70 mmHg Pain: 9/10 None Other Patient History Female Family history of constipation Poor eating habit (Skipping meals) Stress (admitted to be severely stressed out with a scale of 10/10) Excessive alcohol drinking (6-7 bottles a day 2 weeks prior to admission Jan 5,2012) Coffee drinking (3-4 cups a day) Sedentary lifestyle Fecal Retention, Gastric Ulcer, Modified gastritis,diffuse + erosive GERD grade A Duodenitis, pyloric stenosis, gastric ulcer, Pylorotomy (January 2012) Prior to admission: consumes 3-4 cups of coffee a day; consumes 4-5 glasses of water a day; skipping meals due to academic schedule (with maximum 2 meals per day during days with classes; occasional drinker (history revealed that the patient has been drinking 6-7 bottles of alcoholic beverage for 2 weeks straight prior to January 5, 2012 admission)
Initial Vital signs
Current contraptions Risk factors noted
Concurrent Disorder Past medical History Diet and nutrition
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Height: 150cm Weight:41.20kg BMI is 18.30 which is interpreted as underweight Psychosocial history While admitted: low fat, no milk, no coffee, no softdrinks With significant other Occupation: Law student Support system: Family Copes up with stress by going out with friends Both parents: with hypertension and diabetes Distant relatives: asthma Grandmother and mother: constipation
Family History
3. What is the status of patient in terms of physical and psychological aspects? Norm Neurological Assessment Alert and oriented to person place and time. GCS=15 Behavior appropriate to situation. Pupils equal and reactive to light. Active ROM of all extremities and symmetry of strength. Cranial Nerves are Intact Etc. Cardiovascular Assessment Regular radial pulse. Capillary refill time < 4 sec. peripheral pulses palpable. No edema. No calf tenderness or clubbing positive Allens Test Etc. Respiratory Assessment Regular, non labored breath sounds clear and equal on all lobes. Respirations 12-20 per minute Sputum clear, nail beds and mucus membrane are pink Etc. Gastrointestinal Assessment Variance Rationale relating to patient case
No deficit
No deficit
No deficit
Abdomen flat,
Pain is due to presence
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Abdomen is soft, non-distended, non tender. Bowel sounds present in 4 quadrants. Bowel movements within own normal patterns and consistency. Etc
normoactive bowel sounds, no mass noted, Right upper quadrant pain 9/10 in severity, positive Murphys sign
of ulceration in the gastrointestinal wall due to exposure to increased concentration of acidpepsin secretions. This frequently occurs when the stomach is empty or between meals. A positive Murphys sign was assessed during the patient stay in the Emergency Department, that led to an initial clinical impression of Acute Cholecystitis
Integumentary Assessment Skin color uniform within patients norm. Smooth, soft, warm dry and intact. Turgor skin lifts easily and snaps back immediately when release. Mucus membrane moist, intact pink. Hygiene good Etc. Musculoskeletal Assessment Absence of joint swelling and tenderness. Normal ROM of all joints. No muscle weakness. Surrounding tissues show evidence of inflammation, nodules, nail changes, ulceration or rashes. No deformity Etc. Genitourinary Assessment Able to empty bladder without dysuria bladder not distended after voiding. Urine clear and yellow to amber content of urine. No contraptions attached . Genitourinary Assessment If female, no vaginal bleeding, discharges or lesions. Normal menstrual periods. If male, no prostrate problems, penile
No deficit
No deficit
No deficit
LMP: March 9, 2012
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bleeding, lesions or discharges. No complaints of sexual dysfunction Psycho/Social Assessment Behavior appropriate to situation. Cooperative congruent affect. Responds appropriately to all questions
No deficit
Activities of Daily Living Assessment ADL needs ( for the whole time duration of care rendered ) a. Hygiene and Grooming: done independently b. Activity: as tolerated c. Nutrition: low fat, no milk, no coffee, no soft drinks (March 15-16) d. Toileting: done independently, voiding freely, continent e. Sleep: able to sleep and rest Sensory Deficits ( state if any ) not applicable a. Vision: ___________________________________________________________________ b. Hearing: __________________________________________________________________ c. Speech: __________________________________________________________________ d. Others: ___________________________________________________________________ Assistive Device use: not applicable
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Cultural Spiritual Assessment A. Are there any spiritual, traditional, ethnic or cultural practices that need to be part of your patient care? NONE B. Is there any way the nurse can assist you with your religious/ spiritual practices? NONE Would you like to be visited by the hospital chaplain? NO 4. What are the significant diagnostics required for the patient? What is the significance of performing the test in relation to patient diagnosis? Hematology March 14, 2012 Hematocrit Red Blood Cells White blood Cells Segmenters Lymphocytes Monocytes MCHC (Mean corpuscular Hemoglobin Concentrate) Results 44.9% (high) normal 12.0% (high) 73% (high) 18% (low) Normal 31.8% (low) Normal Value 35.9- 44.6 % 4.5-5.1 4.4- 11% 40- 70% 22-43% 0-7% 33.5- 35.5%
March 15, 2012 Results Normal 4.17(low) Normal Normal Normal 8% (high) 31.9% (low)
Laboratory test were done to differentiate the main cause of the upper quadrant abdominal pain felt by the patient. The CBC is a very common test, this will help to determine patients general health status. An elevated hematocrit is most often associated with dehydration, which is a decreased amount of water in the tissues. This may be due to prolonged symptoms of nausea that led to decrease in appetite. Critically high or low levels should be immediately called to the attention of the patient's nurse or doctor; transfusion decisions are based on the results of laboratory tests. Findings of increased white blood cells suggest presence of infection. Low Lymphocytes are caused by immunity problems (weak immune systems) or infections. (Dito nlng siguro isingit ung increased ung segmenters kasi due to infection din un dba?) Hypochromic anemia indicated by low MCHC, indicates a decrease in concentration of hemoglobin in a given volume of blood, which can be caused by bleeding. This was also suggested by a slightly low level of RBC. Bout sa increased monocytes... may nasearch ako na associated sya with recovery from an acute infection... since sa march 15 tumaas ung monocytes eh dba
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after na ng procedure nya un.. possible natreat na tlga ung infection.. yan lang ung nkkta kong correlation nila.. hahaha
Diagnostic Procedures Pregnancy Test Abdominal Xray Esophagogastroduoden oscopy
Date March 14, 2012 March 14, 2012 March 14, 2012
Results Negative Fecal Retention Healing Modified Gastric ulcer, Gastritis, Diffused Gastroesophageal reflux disease
Pregnancy test is done mandatory in all female patients in the reproductive stage for preventing any drug interactions and contraindicated procedures for pregnant patients. Abdominal x-ray was done to somehow visualize the abdominal area in a noninvasive manner and provide a general baseline data regarding the patients condition. Esophagogastroduodenoscopy was done to visualize the gastrointestinal tract to find presence of any ulcerated area. This was also done to obtain biopsy specimens to test for Helicobacter pylori and exclude malignant disease.
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5. What are the prescribed medication / treatment regimen applied to the patient? What are the classification, action, indication, contraindication, rationale, and adverse reaction of this drugs/ agents?
Generic Name Metoclopramide Drug Action
Brand Name Cloprimed Uses
Major Drug category Antiemetic Occurred Side Effects/ Adverse Reactions None noted
An antiemetic that acts as Nausea and vomiting dopamine antagonist. It inhibits dopamine receptors that are part of the pathway to the vomiting center Significant Drug Common Drug Dose Contraindication Interaction Antagonistic with 10mg/2ml 1 ampule every 8 History of seizures antimuscarinic agents and hours for nausea and Peptic ulcer disease P opioid analgesics. May affect vomiting IV push heochromocytoma absorption of other drugs given concomitantly Nursing Medication management 1) Assessment 2) Intervention For prevention of nausea and vomiting. 1. Monitored for presence of nausea and vomiting.
3) Education Informed patient of the drugs purpose is to alleviate nausea and vomiting Informed patient of untoward side effects to report once administered: extrapyramidal symptoms such as acute dystonic reactions.
4) Evaluation No nausea and vomiting noted
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Generic Name Duphalac syrup Drug Action Lactulose is a colonic acidifier that works by increasing stool water content and softening the stool. It is a man-made sugar solution. Significant Drug Interaction antacids containing aluminum and/or magnesium, Other laxatives.
Brand Name Lactulose Uses This medication is a laxative used to treat constipation. It may help to increase the number of bowel movements per day and the number of days you have a bowel movement. Common Drug Dose
Major Drug category Laxative Occurred Side Effects/ Adverse Reactions Soft bowel consistency
Contraindication Galactosemia Bowel obstruction Hypersensitivity.
15-45 ml/day
Nursing Medication management 1) Assessment 2) Intervention 1. Assessed the patients bowel movement, March 14, 2012: Fecal retention was consistency and frequency identified 2. Monitored intake and output. 3. Auscultated bowel sounds. 4. Checked the latest electrolyte results for early indication of electrolyte imbalance. 5. Instructed significant others to report if there is no bowel movement or if theres diarrhea. 6. Administered medication once daily after feeding via NGT. 3) Education 4) Evaluation Instruct that the patient will obtain March 14, 2012: bowel movement of 4 times soft feces (a laxative that could help) March 15, 2012: bowel movement of 3 times Maybe taken after meals
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Generic Name
Domperidone
Drug Action increase the duration of antral and duodenal contractions to increase gastric emptying. Significant Drug Interaction anti-cholinergic drugs Anti-muscarinic agents and opioid analgesics dopaminergic agonists.
Brand Name Motilium Uses generally to suppress nausea and vomiting, or as a prokinetic agent or gastric emptying. Common Drug Dose
Major Drug category Anti-emetic; anti-vertigo preparations. Occurred Side Effects/ Adverse Reactions None
Contraindication presence of gastro-intestinal haemorrhage, obstruction or perforation. hypersensitivity to domperidone. prolactinreleasing pituitary tumour (prolactinoma).
10 mg
Nursing Medication management 1) Assessment 2) Intervention 1. Monitor intake and output. March 14, 2012: Fecal retention was 2. Provided and monitored NGT feeding as identified prescribed. 3. Provided calm and comfortable environment 4. Kept hydrated with intravenous fluid. 3) Education 4) Evaluation Explained that this medication is No episodes of nausea and vomiting given for the patient to move bowel March 14, 2012: bowel movement of 4 times Instructed patient and significant March 15, 2012: bowel movement of 3 times others to report drowsiness, disorientation and extrapyramidal reactions.
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Generic Name Lanzoprazole Drug Action blocks the production of acid by the stomach
Brand Name Prevacid Uses used for treating ulcers of the stomach and duodenum, gastroesophageal reflux disease (GERD) and Zollinger-Ellison Syndrome.
Major Drug category proton pump inhibitors Occurred Side Effects/ Adverse Reactions stomach pain, irregularity, diarrhea, headache, nausea and dizziness. none noted yata to kasi na relieve yung pain after magbigay (I think tama ung yellow highlight) Contraindication known hypersensitivity to lansoprazole or other substituted benzimidazoles such as omeprazole or esomeprazole
Significant Drug Interaction Boodthinners Ampicillin Atazanavir Iron Theophyline Clopidogrel Digoxin Ketoconazole
Common Drug Dose
15 mg
Nursing Medication management 1) Assessment 2) Intervention 1. monitored for adverse effects such as Patient is diagnosed to have Gastritis, headache, rashes Gastric ulcer and GERD 2. monitored for gastric discomforts. 3. Auscultated bowel sounds
3) Education -Instructed that medication will be given before meals for better absorption -Instructed to report if there is stomachache, flatulence, nausea and vomiting.
4) Evaluation March 15, 2012 0800H, Pain scale of 7/10 but relieved after medication. March 16, 2012 1200H: Pain scale of 0/10
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Generic Name Midazolam Drug Action Brand Name Dormicum Uses
Major Drug category Anti-anxiety agents, sedative/hypnotics, benzodiazepines Occurred Side Effects/ Adverse Reactions None noted
increase the activity of GABA, used for treatment of acute thereby producing a calming seizures, moderate to severe effect, relaxing skeletal insomnia, and for inducing (NONE NOTED) muscles, and inducing sleep. sedation and anesthesia Benzodiazepines bind to the before medical procedures benzodiazepine site on GABAA receptors, which potentiates the effects of GABA by increasing the frequency of chloride channel opening. Significant Drug Common Drug Dose Contraindication Interaction Acute narrow-angle 5mg alcohol, opioids, glaucoma; coma or patients barbiturates, other in shock; acute alcohol sedatives and intoxication; intrathecal and anaesthetics. epidural admin. Acute opiates, pulmonary insufficiency or phenobarbital, other marked neuromuscular benzodiazepines. respiratory weakness Plasma concentrations including unstable increased by CYP3A4 myasthenia gravis; severe inhibitors respiratory depression. antiretroviral agents. Midazolam concentration decreased by phenytoin, carbamazepine, phenobarbital, rifampicin. Halothane, thiopental requirements may be reduced during concurrent use. Nursing Medication management 1) Assessment 2) Intervention Assess level of sedation and level of Pre-procedure medcation for consciousness throughout and for 2-6 hr esophagogastroduodenoscopy following administration. Monitor BP, pulse and respiration continuously during IV administration. Oxygen and resuscitative equipment should be immediately available. 3) Education -instructed that the medication makes the patient feel drowsy -instructed significant others regarding patient safety like keeping the siderails raised and keeping sharp objects away from the patient 4) Evaluation Esophagogastroduodenoscopy tolerated well
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Generic Name Cefuroxime Drug Action
Brand Name Zegen Uses Used to treat certain infections caused by bacteria
Major Drug category Cephalosporin Occurred Side Effects/ Adverse Reactions diarrhea,nausea, vomiting,headache, or migraines, dizziness and abdominal pain. None noted
Second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Significant Drug Common Drug Dose Contraindication Interaction 500mg Probenecid Contraindicated in (Benemid);A blood patients thinner such as hypersensitive to warfarin (Coumadin); drug. Cimetidine (Tagamet), famotidine (Pepcid), Use cautiously in omeprazole (Prilosec), patients ranitidine hypersensitive to (Zantac).Diuretics penicillin because of such as bumetanide possibility of cross(Bumex), furosemide sensitivity with other (Lasix), indapamide beta-lactam (Lozol), antibiotics.. hydrochlorothiazide (HCTZ, HydroDiuril, Hyzaar, Lopressor, Vasoretic, Zestoretic), metolazone (Mykrox, Zarxolyn), spironolactone (Aldactazide, Aldactone), torsemide (Demadex), and others. Nursing Medication management 1) Assessment 2) Intervention Assess if patient is allergic to penicillins March 14, 2012: Patient had high WBC or cephalosporins. count 12% (Normal Value: 4.4-11%) Assisted in administering with food to prevent any stomach upset.
3) Education Informed patient of untoward side effects to report once administered: severe skin rash, itching, hives, difficulty breathing or swallowing, wheezing, painful sores in the mouth or throat
4) Evaluation March 15, 2012: 8.76% (Normal Value: 4.411%)
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Generic Name Tramadol Drug Action Brand Name Uses Used to treat moderate to severe pain Used to treat moderate to severe chronic pain when treatment is needed around the clock.
Major Drug category Analgesics (Opioid) Occurred Side Effects/ Adverse Reactions Hives, DOB; swelling of your face, lips, tongue, or throat. agitation, hallucinations, fever, tachypnea, nausea, vomiting, diarrhea, loss of coordination, fainting;seizure, peeling skin rash; or shallow breathing, weak pulse. None noted Contraindication
inhibits reuptake of norepinephrine, serotonin and enhances serotonin release. It alters perception and response to pain by binding to muopiate receptors in the CNS.
Significant Drug Common Drug Dose Interaction Suicidal patients, acute 50mg Warfarin. Increased alcoholism; head injuries; risk of seizures with raised intracranial pressure; SSRI, TCA. Increased severe renal impairment; risk of serotonin lactation syndrome with mirtazapine, venlafaxine, SSRI and MAOI; MAOIs Reduced analgesic efficacy of tramadol with carbamazepine, 5-HT3-receptor antagonist. Increased respiratory and CNS depression with CNS depressants Nursing Medication management 1) Assessment 2) Intervention Monitored patient for seizures. May March 13, 2012 at emergency room: Pain occur within recommended dose scale is 9/10 range. Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration 3) Education 4) Evaluation Instructed patient that medication March 15, 2012 0800H, Pain scale of 7/10 can cause side effects that may but relieved after medication. impair thinking or reactions. Instructed patient not to stop using March 16, 2012 1200H: Pain scale of 0/10 tramadol suddenly to avoid unpleasant withdrawal symptoms such as anxiety, sweating, nausea, diarrhea, tremors, chills, hallucinations, trouble sleeping, or breathing problems. Instructed patient that tramadol can cause respiratory depression and seizures.
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CASE STUDY: Generic Name

Fentanyl Drug Action Acts at specific opioid receptors, causing analgesia, respiratory depression, physical depression, euphoria
[ DATE]
Brand Name Duragesic Uses Analgesic action of short duration during anesthesia and immediate postop period
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Major Drug category Narcotic agonist analgesic
Occurred Side Effects/ Adverse Reactions Sedation, clamminess, sweating, headache, vertigo, floating feeling, dizziness, lethargy, confusion, lightheadedness, nervousness, unusual dreams, agitation, euphoria, hallucinations, delirium, insomnia, anxiety, fear, disorientation, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, convulsions Palpitation, increase or decrease in BP, circulatory depression, cardiac arrest, shock, tachycardia, bradycardia, arrhythmia, palpitations -sedation, weakness, decrease in bp lang nakita ko, pakicheck na lang ulit sa data kung meron pa (SAME decrease in BP lng, conscious sedation)
Significant Drug Interaction Potentiation of effects when given with other CNS acting drugs or barbiturate anesthetics; decrease dose of fentanyl when coadministering
Common Drug Dose
Contraindication Contraindicated with hypersensitivity to narcotics, diarrhea caused by poisoning, acute bronchial asthma, upper airway obstruction, pregnancy.
25mcg
Nursing Medication management 1) Assessment 2) Intervention Assessed for level of consciousness Pre-procedure Medication for Observed for signs of side effects or esophagogastroduodenoscopy adverse effects Monitored for adverse reactions and if pain increases
3) Education Educate the patient about the possible side effects of the drug and monitor closely.
4) Evaluation Esophagogastroduodenoscopy procedure was tolerated well.
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Generic Name Hyoscine-n-butylbromide Drug Action Hyoscine-n-butylbromide acts by interfering with the transmission of nerve impulses by acetylcholine in the parasympathetic nervous system (specifically the vomiting center) Significant Drug Interaction Medications such as antidepressants (tricyclic type) MAO inhibitors (e.g., phenelzine, linezolid, tranylcypromine, isocarboxazid, selegiline, furazolidone), quinidine, amantadine, antihistamines (e.g.,diphenhydramine), anticholinergics, potassium chloride supplements, antacids, absorbent-type antidiarrhea medicines (e.g.,kaolin-pectin).
Brand Name Buscopan Uses Paroxysmal pain in diseases of the stomach or intestine, spastic pain & functional disorders in the biliary & urinary tracts & female uterine organs Common Drug Dose
Major Drug category Antispasmodics Occurred Side Effects/ Adverse Reactions Buscopan can cause tachycardia, urinary retention and xerostomia. When administered IV, Visual accommodation disturbances and dizziness none noted Contraindication Contraindicated to patient with myasthenia gravis, glaucoma, hypertrophy of the prostatew/ urinary retention,mechanical stenosis of GIT and tachycardia.
Nursing Medication management 1) Assessment 2) Intervention Monitor heart rate March 13, 2012 at emergency room: Pain scale Take note for any reactions of the is 9/10 patient to the drug or therapy. Prevent any side effects that may arise. Be aware of the drug contraindications and drug interactions that may affect the action of the drug. Be alert for drug adverse reactions and interactions.
3) Education Educate patient to possible side effects of the drug.
4) Evaluation March 15, 2012 0800H, Pain scale of 7/10 but relieved after medication. March 16, 2012 1200H: Pain scale of 0/10
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6. What are the priority nursing problems identified? What should the nurse plan to render a quality health care in terms of identified problems?
Nursing Diagnosis #1: Acute pain related to irritation/disruption of gastric tissue as evidenced by pain scale of 7/10.
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Goal: To alleviate pain.
Rationale: In patients with gastric ulcer, pain is primarily the cause of the patients discomfort. Therefore, this is the first problem which healthcare providers tend to. This is caused by the irritation and erosion of the gastric mucosa by the excessive secretion of HCl (Smeltzer, 2009). This in turn causes a gnawing or burning pain in the epigastric region of the abdomen (Marieb, 2006).
Expected Outcomes: At the end of 8 hours of nursing intervention, the patient will: Report that pain is relieved/controlled Follow prescribed pharmacological regimen Demonstrate use of relaxation skills and diversional activities as indicated.
Interventions
Independent: 1. Assessed characteristics of pain: location, severity, type, frequency, precipitating and relieving factors. 2. Encouraged verbalization of feelings. 3. Monitored for changes in vital signs. 4. Observed for nonverbal cues of pain. 5. Note response to medications and report to physician if pain is not being relieved. 6. Promoted bed rest, allowing her to assume position of comfort. 7. Provided with calm and safe environment and provided with adequate periods conducive for rest. 8. Encouraged to do deep breathing exercises and suggested diversional activities such as watching TV. 9. Reinforced use of call light as needed. 10.All needs were attended to.
Evaluation
At the end of the nurse-patient relationship, the patient denies recurrence of abdominal pain. She was able to rest well and verbalizes a pain scale of 0/10.
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Dependent: 1. Assisted in administration of pain medication (Tramadol and Buscopan). kla pakicheck sa data natin kung nagbigay ba nito nung time of care natin, nde ko ma verify sa patients data eh
GOAL MET
Nursing Diagnosis #2: Ineffective gastrointestinal tissue perfusion related to decreased levels of RBC as evidenced by abdominal pain and tenderness Goal: To promote effective tissue perfusion
CASE STUDY:
Rationale: Ineffective tissue perfusion is defined as the failure to nourish the tissues in the capillary level (Doenges, 2008). The lack of oxygen supplied to the tissues causes the production of lactic acid in the area thus causing pain. It is important to promote good perfusion to the affected areas to promote better circulation and to prevent the chances of development of further problems.
Expected Outcomes: At the end of 8 hours of nursing intervention, the patient will: Demonstrate increased perfusion as individually appropriate (vital signs within normal limits, balanced intake/output, free of pain/discomfort)
Interventions
Independent: 1. Assessed general health condition. 2. Monitored for changes in vital signs and level of consciousness. 3. Evaluated for signs of infection. 4. Noted for reports of nausea/vomiting. 5. Assessed location, severity, and quality of abdominal pain. 6. Auscultated bowel sounds. 7. Noted for changes in characteristics and frequency of stool and abdominal distention. 8. Reviewed laboratory studies (CBC). 9. Encouraged small frequent feedings.
Evaluation
At the end of the nurse-patient relationship, the patients vital signs were within her normal limits and was afebrile. She verbalized that she does not feel pain. Bowel movements seem to be regular with 2-3 bowel movements per day. There were no reports of nausea and vomiting.
Dependent: 2. Assisted in administration of pain medication (Tramadol and Buscopan). kla pakicheck sa data natin kung nagbigay ba nito nung time of care natin, nde ko ma verify sa patients data
CASE STUDY:
eh 1.
GOAL MET
Nursing Diagnosis # 3: Imbalanced nutrition: less than body requirements related to inability to digest food properly as evidenced by BMI of 18.3 (underweight) Goal: To promote balanced nutrition CASE STUDY: [Title of the case ] [ DATE]
Page 38 of 51 Rationale: The risk of being underweight is that the body has fewer energy reserves, in cases of illness this can worsen the condition and delay the recovery time.
Expected Outcomes: At the end of 8 hours of nursing intervention, the patient will: Experience no aspiration as evidence by: noiseless respirations, and clear breath sounds. Verbalize understanding of risk factors and appropriate interventions. Demonstrate behaviors/lifestyle changes to prevent developing potential problem.
Interventions
Independent: 1. Weighed as indicated. 2. Consulted with patient about likes/dislikes, foods that cause distress, and preferred meal schedule. 3. Provided a pleasant environment at mealtime, remove noxious stimuli. 4. Provided oral hygiene before meals. 5. Assessed for abdominal distention, frequent belching, guarding behavior, and reluctance to move. 6. Assisted in ambulation as the patient tolerates.
Evaluation
Interdependent: 1. Coordinated with the Dietary Department to plan the patients diet based on her dietary needs.
At the end of the nurse-patient relationship, the patients current weight is at 41.20 kg and the same BMI (18.3 underweight). The patient was able to verbalize that she dislikes fatty foods and eats a lot of fruits and vegetables. The patient also admits to drink only 4-5 glasses of water a day and she also drinks alcohol and a lot of coffee (about 3-4 times a day). She also admits to skipping meals or having them at a later time. There is no abdominal distention or other discomforts noted, and patient was able to tolerate food well.
GOAL PARTIALLY MET
CASE STUDY:
Nursing Diagnosis # 4: Mild anxiety related to upcoming diagnostic procedure. Goal: To ease anxiety
Rationale: Anxiety can be defined as a vague uneasy feeling of discomfort or dread accompanied by an autonomic response and a feeling of apprehension caused by anticipation of danger (Doenges, 2008). More often, anxiety in hospitalized patients is caused by lack of information about diagnostic procedures and about their health plan. Anxiety can trigger the bodys parasympathetic response and produce symptoms such as abdominal pain (Doenges, 2008) which in turn can aggravate the patients condition who is already suffering from abdominal discomfort.
CASE STUDY:
Expected Outcomes: At the end of 8 hours of nursing intervention, the patient will: Appear relaxed and report that anxiety is reduced to a manageable level Verbalize awareness of feelings of anxiety Use resources/support systems effectively
Interventions
Independent: 1. Assessed general health condition and level of anxiety. 2. Established a therapeutic relationship with the patient conveying empathy. 3. Monitored for changes in vital signs. 4. Observed for behavior which can point to the patients level of anxiety. 5. Observed for defense mechanisms being used. 6. Encouraged patient to verbalize feelings. 7. Provided calm environment conducive for rest. 8. Promptly addressed the patients concerns by answering their questions honestly and referring them to the proper individuals if the need arises.
Evaluation
At the end of the nurse-patient relationship, the patient is free from anxiety and was able to verbalize her feelings.
CASE STUDY:
Nursing Diagnosis #5: Risk for aspiration related to incompetent cardiac sphincter secondary to GERD Goal: To prevent aspiration
Rationale: It is important to watch out for signs of aspiration especially in persons with GERD. If the refluxed fluids enter the pharynx and the larynx, it can result in coughing and choking. It can also cause pneumonia when the fluid causes inflammation within the lungs.
Expected Outcomes: At the end of 8 hours of nursing intervention, the patient will: Maintain usual pattern of bowel functioning. Verbalize understanding of risk factors and appropriate interventions Demonstrate behaviors/lifestyle changes to prevent developing potential problem.
Interventions
Independent: 1. Assessed general health condition and noted risk factors for aspiration. 2. Noted level of consciousness. 3. Elevated head of bed to highest possible position during mealtimes and encouraged the patient to sit up in bed when eating or drinking. 4. Advised to sit up in bed for at least 2 hours after eating to prevent reflux. 5. Encouraged to eat small frequent feedings.
Evaluation
At the end of the nurse-patient relationship, there was no incidence of aspiration noted. There was also no episode of vomiting noted. The patient was also able to tolerate her food well.
GOAL MET
CASE STUDY:
CASE STUDY:
Nursing Diagnosis #6: Risk for constipation related to fecal impaction secondary to pyloric stenosis Goal: To promote functional bowel elimination.
Rationale: Having a risk for constipation means that the patient is at risk for a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool (Doenges, 2008). Constipation can also be brought about by not eating enough foods containing fibers and not drinking enough water. The longer the stool is contained in the colon, the greater are the chances of it causing infection.
Expected Outcomes: At the end of 8 hours of nursing intervention, the patient will: Maintain usual pattern of bowel functioning. Verbalize understanding of risk factors and appropriate interventions Demonstrate behaviors/lifestyle changes to prevent developing potential problem.
Interventions
Independent: 1. Assessed general health condition. 2. Auscultated abdomen for presence, locations, and characteristics of bowel sounds reflecting bowel activity. 3. Encouraged to increased oral fluid intake. 4. Encouraged early ambulation as tolerated. 5. Assessed frequency, color, consistency, and amount of stools.
Evaluation
At the end of the nurse-patient relationship, the patient shows a low risk for constipation, as evidenced by (+) bowel movement of 2-3 times a day. Stool is soft and brown.
GOAL MET Dependent: 1. Assisted in administration of stool softeners (Lactulose)
CASE STUDY:
Nursing Diagnosis #7: Readiness for enhanced comfort as evidenced by appearance of being relaxed and active cooperation in plan of care Goal: To promote enhanced comfort
Rationale: Readiness for enhanced comfort is defined as a pattern of ease and relief in a persons different biopsychosocial dimensions (Doenges, 2008). It is important to recognize this pattern in the patient so that health teachings can readily be taught with the cooperation of the patient herself.
Expected Outcomes: At the end of 8 hours of nursing intervention, the patient will: Verbalize sense of comfort Demonstrate behaviors of optimal level of ease Participate in desirable and health-seeking behaviors.
Interventions
Independent: 1. Verified on how the client is managing pain and pain components effectively. 2. Assisted patient in discovering nonphramacological methods for pain management like guided imagery, and breathing exercises. 3. Provided with comfort measures. Interdependent: 1. Collaborated with other members of the health team in treating/managing medical conditions involving oxygenation, elimination, mobility, electrolyte balance, and hydration to promote stability.
Evaluation
At the end of the nurse-patient relationship, the patient was able to verbalize that she was feeling fine and denies any further discomforts. She was able to rest and sleep well.
GOAL MET
CASE STUDY:
CASE STUDY:
Nursing Diagnosis #8: Readiness for enhanced therapeutic regimen management Goal: To promote enhanced therapeutic regimen management
Rationale: Readiness for enhanced therapeutic regimen management is defined in NANDA as a pattern of regulating an integrating into daily living a program for treatment of illness and it sequelae that is sufficient for meeting health-related goals and can be strengthened.
Expected Outcomes: At the end of the nurse-patient relationship, the patient will: Assume responsibility for managing treatment regimen Demonstrate proactive management by anticipating and planning for the likelihood of potential complications Identify and use available resources Remain free of preventable complications/progression of disease.
Interventions
Independent: 1. Verify clients knowledge of the therapeutic regimen. 2. Involved patient and he significant others in the plan of care. Dependent 1. Reviewed take-home medications with the patient, taking note of dosage and frequency of intake. 2. Instructed as to when the patient is to return for her check-up.
Evaluation
At the end of the nurse-patient relationship, the patient was able to verbalize that she understood the discharge instructions that were given to her.
GOAL MET
CASE STUDY:
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS Summary of Findings:

I. Factors that led to the development of the problem:
Predisposing factors: Female Family history of Constipation (grandmother and mother) Precipitating factors: Sedentary lifestyle Caffeine and excessive alcohol intake Poor eating habits (skipping meals and binge eating) Perpetuating Stress II. Interrelationship of factors identified that led to the development of multiple gastrointestinal problems such as Fecal retention, Gastritis, Gastric Ulcer, GERD-A: According to studies, women are more likely to have digestive diseases than men since women are more sensitive to irritants in the digestive system. Moreover, women are more reportedly to have higher stress level than men which can aggravate digestive diseases. In relation to the case, the patient is a female and a law student. The patient admitted that she was experiencing severe stress rating of 10/10 because of heavy load of school works. With this, the patient experienced poor eating habits (eating a large bulk of meal not on time and only twice a day). To cope up with stress, the patient drinks coffee about 3-4 cups per day and have tried drinking alcoholic beverage 6-7 bottles a day for 2 weeks straight. With the factors mentioned that led to inflammation of gastric lining because of increase in gastric acid production, patient was diagnosed with gastritis. Furthermore, excessive gastric acid production led to gastric lining ulcerations. From this, formed scars from healing ulcers can lead to the thickening of the mucosal lining and most probably the pylorus of the stomach, thus leading to pyloric stenosis. To relieve such condition the patient underwent pylorotomy last January 2012. In addition, scarring or swelling of tissues from stomach to small intestine delays gastric emptying which caused increased pressure in lower esophageal sphincter making it incompetent, thus, patient was diagnosed with GERD.
CASE STUDY:
Conclusions
Based on the analysis of the different factors identified, the researcher therefore concluded that the factors that led to the development of multiple gastrointestinal problems such as Fecal retention, Gastric Ulcer, Gastritis and Erosive GERD grade A are multi-factorial in nature.
Recommendations
Based on the summary of findings and conclusion, the following are being recommended:
1. To the patient, that strict obedience will be implemented to the prescribed therapeutic regimen after discharge. 2. To the family, to be able to provide a positive environment and support to help the patient in recovering from her condition. The researchers also recommend that they read materials regarding the prevention and treatment to promote knowledge within the family regarding this condition. 3. To the healthcare team, that they thoroughly assess future patients with the same manifestations to easily diagnose patients and provide healthcare immediately and prevent further complications. Also, we recommend that they would continue to update recent studies regarding this kind of condition in order to provide optimum health care service to future patients.
CASE STUDY:
4. To the Training Department, that they provide trainings and seminars for the enhancement of nurses knowledge, skills and attitude in handling patients with such conditions upon admission to discharge. 5. To the Nursing Services Division, that holistic care will be provided by nurses effectively and efficiently to patients who have multiple gastrointestinal problems. Programs may also be given to nurses to develop the competence in caring for patients with similar condition. Moreover, follow-ups may be conducted to guarantee the compliance of the patient with the discharge instructions given and the progress in the patients health condition.
CASE STUDY:
REFERENCES
BOOKS
Porth, C (2005) Pathophysiology: Concepts of Altered Health Status. Quezon City Phippines. Lipincott William&Wilkins and C&E Publishing Inc. Spratto, G. and Woods, A. (2008). 2008 Edition PDR Nurses Drug Handbook. Thomson Delmar Learning
JOURNALS / ARTICLES
C. T. HOWE, B.M., B.CH. Pyloric Stenosis in Adults Retrieved April 5, 2012 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2482055/pdf/postmedj00481-0045.pdf
INTERNET SOURCES
Best, M. (n.d.) Hematocrit. Retrieved April 5, 2012 from http://www.surgeryencyclopedia.com/Fi-La/Hematocrit.html#b#ixzz1rAcsWLIW
Zieve, D et al (2010). CBC. ADAM Inc. Retrieved April 5, 2012 from http://www.nlm.nih.gov/
medlineplus/ency/article/003642.htm Best, M. (n.d.) Hematocrit. Retrieved April 5, 2012 from http://www.surgeryencyclopedia.com/Fi-La/Hematocrit.html#b#ixzz1rAcsWLIW Patti, M.G. (2012). Gastroesophageal reflux disease. Retrieved from http://emedicine.medscape.com/article/176595-overview#a0104
OTHERS
CASE STUDY:
APPENDICES

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April 2012

Professional Development and Training Department

MAKATI MEDICAL CENTER NURSING SERVICE DIVISION

Background of the Study

Statement of the Problem

Scope and Limitation

(0017H) Discontinue Metoclopramide Hold Nalbuphine

Pantoprazole, 40mg via IV once a day

Post-operative assessment o BP every 30 minutes: 87/53

Day 4 MARCH 16, 2012

May go home anytime

Initial Vital signs

Current contraptions Risk factors noted

Concurrent Disorder Past medical History Diet and nutrition

Pain is due to presence

LMP: March 9, 2012

Diagnostic Procedures Pregnancy Test Abdominal Xray Esophagogastroduoden oscopy

Generic Name Metoclopramide Drug Action

Brand Name Cloprimed Uses

4) Evaluation No nausea and vomiting noted

Contraindication Galactosemia Bowel obstruction Hypersensitivity.

Common Drug Dose

Generic Name Cefuroxime Drug Action

4) Evaluation March 15, 2012: 8.76% (Normal Value: 4.411%)

[Title of the case ]

CASE STUDY: Generic Name

Major Drug category Narcotic agonist analgesic

Common Drug Dose

4) Evaluation Esophagogastroduodenoscopy procedure was tolerated well.

3) Education Educate patient to possible side effects of the drug.

Goal: To alleviate pain.

GOAL PARTIALLY MET

GOAL MET Dependent: 1. Assisted in administration of stool softeners (Lactulose)

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS Summary of Findings:

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