TABLE OF CONTENTS I.
Introduction a. Overview of the case b. Objective of the study c. Scope and Limitation Limitation of the study
II.
Health History
III.
Developmental Data
IV.
Medical Management a. Medical orders with rationale b. Drug Study c. Laboratory results
V.
Anatomy and Physiology with Pathophysiology
VI.
Nursing Assessment
VII.
Nursing Management a. Ideal Nursing Management b. Actual Nursing Management (SOAPIE)
VIII. Referrals and Follow-up IX.
Evaluation and Implications
X.
Bibliography
I.
INTRODUCTION a. Overview of the Case
is inflammation of the lining of the stomach and has many possible Gastritis is inflammation causes. Common causes of gastritis are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin as aspirin or ibuprofen. ibuprofen. Gastritis may also develop after major surgery, traumatic injury, burns, or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in the banding or reconstruction of the digestive tract. Chronic causes are infection with bacteria, primarily Helicobacter chronicbile reflux, reflux, and stress; certain autoimmune disorders can cause pylori , chronicbile gastritis as well. The most common symptom is abdominal upset or pain. Other symptoms
are
indigestion,
abdominal
bloating,
nausea,
and
vomiting
and and pernicious anemia. anemia. Some may have a feeling of fullness or burning in the upper abdomen. An esophagogastroduodenoscopy, An esophagogastroduodenoscopy, blood test, complete blood count test, or a stool test may be used to diagnose gastritis. Treatment includes taking antacids or other medicines, such as proton pump inhibitors or antibiotics, and avoiding hot or spicy foods. For those with pernicious anemia, B12 injections are given, but more often oral B12 supplements are recommended. Many people with gastritis experience no symptoms at all. However, upper central abdominal central abdominal pain is the most common symptom; the pain may be dull, vague, burning, aching, gnawing, sore, or sharp. Pain is usually located in the upper central portion of the abdomen, the abdomen, but but it may occur anywhere from the upper left portion of the abdomen around to the back. Other signs and symptoms may include :Nausea,Vomiting :Nausea,Vomiting (if present, may be clear, green or yellow, blood-streaked, or completely bloody, depending on the severity of the stomach inflammation) inflammation),belching ,belching (if present, usually does not relieve the pain much)Bloating. much)Bloating.Early Early signs are loss appetite,unexplained weight loss. Acute gastritis is a gastric gastric mucosal mucosal erosion erosion caused caused by damage damage to mucosal mucosal defenses. Alcohol consumption does not cause chronic gastritis. It does, however, erode the mucosal lining of the stomach; low doses of alcohol
stimulate hydrochloric stimulate hydrochloric acid secretion. High doses of alcohol do not stimulate secretion of acid. NSAIDs inhibit cyclooxygenase-1, or cyclooxygenase-1, or COX-1, an enzyme responsible for the biosynthesis of eicosanoids of eicosanoids in the stomach, which increases the possibility of peptic of peptic ulcers forming. Also, NSAIDs, such as aspirin, reduce a substance that protects the stomach called prostaglandin. These prostaglandin. These drugs used in a short period are not typically dangerous. However, regular use can lead to gastritis.
b.General Objective
The objective of making this case study is to identify the problem of our patient and to determine the factors that contribute to this kind of disease so that specific actions should be done and rendered to our patient. I have selected this patient having this kind of disease because the primary concept that should fit our study is all about abnormalities pertaining a child with physiologic disorders. Having this kind of case study is a privilege for me because it would be a good learning process by adding new knowledge and concept about different kinds of diseases that may be present in some patients. By making this case study I can identify the disease step by step, its nature on how this disease occur, and nursing actions that would be appropriate for the patient. This study aims to convey familiarity and to provide an effective nursing care to a patient diagnosed with Acute Gastritis through understanding the patient history, disease process and management. c.Specific Objectives
At the end of this study, study, we will be able able to: 1. Define Acute Gastritis 2. Identify the development theory of the patient 3. Discuss the health history of the patient 4. Identify the history of the patient 5. Discuss the medical management of the disease 6. Show the physical assessment of the patient
7. Discuss the pathophysiology of the disease 8. Enumerate and discuss the nursing management 9. Identify the drugs administered to the patient 10. Discuss the health teachings which includes the referral and follow-up
d.
Scope and Limitations The scope of this study covers from the patient’s health history, developmental
data, and as well as with her medical and nursing management. Based upon the assessment done, appropriate interventions were implemented to have a proper care for the client’s health.
The study is limited from the information being collected from the patient. The data gathering through objective and subjective assessment was limited based upon my interview to Ms.RFE and nursing assessment. The patient was being assessed for 1 day from the time we had our ward duty exposure.
II.
HEALTH HISTORY a. Profile of Patient Patient’s Name
: Ms. RFE
Address
: Yacapin Burgos CDOC
Age
: 28 y.o
Sex
: Male
Birth Date
: 10-11-86
Religion
: Roman Catholic
Nationality
: Filipino
Civil Status
: Single
Family Income
: 10,000/month
Occupation
: Nurse
Date of Admission
: 2-714 – 3:25 PM
Admitting Diagnosis
: T/C Acute Gastrtis
Attending Physician
: Dr. Tan
b. Personal Health History
According to Ms. RFE, they don’t had history of acute gastrtis in her mother side and DM in her father side. She also admits drinking of alcoholic beverage for socialization purposes. She even claims to have known the negative effect of these products but would always associate it with enjoying life and some sort of relaxation. Patient has no allergy to foods. She loves to eat fatty and acidic foods and on her teenage days she mentioned that she had stop drinking.
c. History of Present Illness
One day prior to admission patient had onset of abdominal pain radiating to right epigastric region. Four days prior to admission pain at the epigastric region is frequently occuring.
d. Chief Complaint
10/10 pain scale of abdomen.
III.
DEVELOPMENTAL DATA
As part of understanding our client’s totality, we as nurses should understand their developmental aspects and compare them with that of the well-known theories formulated by Erikson, Freud, and Havighurst. A. Erikson's Stages of Psychosocial Development
Psychosocial
development
as
articulated
by
Erikson
describes
eight
developmental stages through which a healthy developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Young Adulthood (19-40 yrs) Intimacy vs. Isolation: According to Erikson, this stage is characterized by increasing importance of human closeness and sexual fulfillment: gradually, the acquisition of love. Implication: Based on our assessment the patient was able to participate easily and able to build trust with others and accepts the chosen lifestyle and might do changes relating to health.
B.Sigmund Freud's Psychosexual Development
The concept of psychosexual development as envisioned by Freud at the end of the nineteenth and the beginning of the twentieth century is a central element in the theory of psychology. It consists of five separate phases' oral, anal, phallic, latency, and genital. In the development of his theories, Freud's main concern was with sexual desire, defined in terms of formative drives, instinct and appetites that result in the formation of an adult personality. Genital (Puberty and after) Energy is directed toward full sexual maturity and function and development of skills, needed to cope with the environment. Implication: Based on our assessment, patient was able to have her own income as evidenced of being independent for her self from her parents and do his own decision making. C.JEAN PIAGET ’S COGNITIVE THEORY
Piaget refers to the adulthood stage as the formal operational stage.The formal operational stage is the fourth and final of the stages of cognitive development of Piaget's theory. This stage, which follows the Concrete Operational stage, commences at around 11 years of age (puberty) and continues into adulthood. It is characterized by acquisition of the ability to think abstractly and draw conclusions from the information available. During this stage the young adult functions in a cognitively normal manner and therefore is able to understand such things as love, "shades of gray", and values. Lucidly, biological factors may be traced to this stage as it occurs during puberty and marking the entry to adulthood in Physiology, cognition, moral judgments (Kohlberg), Psychosexual development (Freud), and social development (Erikson). Some two-thirds of people do not successfully complete this stage, and "fixate" at the concrete operational stage.
In case of Ms. RFE, she is on this stage since she has social groups and he has sound judgments on problems that she may encounter.
PHASE AND STAGE
AGE
SIGNIFICANT BEHAVIOR
Formal Operational
11-adulthood
Uses rational thinking
Phase
Reasoning is deductive and futuristic
D.ROBERT HAVIGHURST ’S DEVELOPMENTAL TASK THEORY
Robert Havighurst believes that learning is basic to life and that people continue to learn throughout life. He describe growth and development as occurring during six stages each associated with from six to ten tasks to be learned. In the middle years, from about thirty to about fifty-five, men and women reach the peak of their influence upon society, and at the same time the society makes its maximum demands upon them for social and civic responsibility. It is the period of life to which they have looked forward during their adolescence and early adulthood. And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it. The biological changes of ageing, which commence unseen and unfelt during the twenties, make themselves known during the middle years. Especially for the woman, the latter years of middle age are full of profound physiologically-based psychological change.
The developmental tasks of the middle years arise from changes within the organism, from environmental pressure, and above all from demands or obligations laid upon the individual by his own values and aspirations. Since most middle-aged people are members of families, with teen-age children, it is useful to look at the tasks of husband, wife, and children as these people live and grow in relation to one another. Each family member has several functions or roles.
The Man of the Family
The Woman of the Family
a man
a woman
a husband
a wife
a father
a mother
a provider
a homemaker &
a homemaker
family manager
The Teenager a person a family member
Unless the man performs well as a provider, it will be difficult for the woman to perform well as a homemaker. Unless the woman performs well as a mother, it will be difficult for the teen-age child to meet the tasks of adolescence. The developmental tasks of family members then, are reciprocal; they react upon one another.
IV.
MEDICAL MANAGEMENT A. Doctor’s Order
Date
Order
Rationale
2/7//2014 4:35PM
Pls. Admit to ROC under Dr. Tan
-For constant monitoring by hospital staff and for prompt rendering of nursing care
Secure consent to care and -For legal purposes which provides and protects mgt. patients with his due right
DAT diet
-To maintain nutritional supplementation
IVF: PNSS iiL @ 25gtts
-To provide a quick route to supply body with fluids and electrolytes.
Monitor V/S q4, O2 sat q4
-For constant monitoring of cardinal measurements, especially patient’s RR
Labs: CBC, U/A,
-CBC is ordered to determine blood component levels including platelet, the clotting factor of the blood. U/A is ordered To
evaluate renal function
Meds: Omeprazol 40mg IV now then OD Iin AM
-Symptomatic gastroesophageal reflux disease (GERD) without esophageal lesions
2/8/14
I and O q shift
-Measure fluid intake and loss
Pls. Inform AP
-For medical mgt.
Refer accordingly
-For referral unusualities.
Give Tramadol 50mg IV now
For UTZ of upper abdomen
For CXL
-
10AM
concerning
To relieve severe pain
acute/
-to evaluate the condition of the digestive system
- To evaluate lung
condition
Tramadol 50mg q8h (6am2pm-10pm)
- To relieve acute/
severe pain
D/C Omeprazol IVF TF: D5NM IL @20gtts/min x 3 bottles
-
To provide glucose electrolytes
fluids and
Cefuroxime ( Kefox ) 75mg IVTT ANST then q8h
- Skin and skin structure infections, infections of the urinary and lower respiratory tract
D/C Tramadol
Ketorolac 15mg IVTT ANST then q8h
IVF TF: 20gtts/min
D5NM
IL
@
- Short term management of moderately severe acute pain for single dose treatment
- - To provide fluids glucose and electrolytes
B
Classification
Dose/ frequen cy
Mechanism of Actions
Specific Contraindica Side Indication tion effects
GIT drugs (Anti-ulcer drugs) & (Proton Pump Inhibitors)
40mg IV now then OD Iin AM
Inhibits activity of acid (proton) pump and binds to hydrogenpotassium adenosine triuphosphat e at secretory surface of gastric parietal cells to block formation of gastric acid
Symptom atic gastroeso phageal reflux disease (GERD) without esophage al lesions
.
Nsg Precautions
D r u Omep g razole S t u d y
Tram adol
Contraindicat ed in patients with known hypersensitivi ty to drug or its components Use cautiously in pregnant or lactating women
CNS: 1. Administer headache, drug before dizziness, meals. asthenia 2. Provide GI: appropriate diarrhea, safety and abdominal comfort pain, measures if CNS nausea, effects occur to vomiting, prevent injury. constipati on, 3. Make sure flatulence patient swallow the tablets or Musculosk capsules whole eletal: and not to open, back pain chew or crush.
Classification
Dose/ frequen cy
Mechanism of Actions
Specific Contraindica Side Indication tion effects
Nsg Precautions
GIT drugs (Anti-ulcer drugs) & (Proton Pump Inhibitors)
50mg q8h (6am2pm10pm)
Centrally acting analgesic not chemically related to opioids but binds to muopioid receptors and inhibits reuptake of norepinep hrine and serotonin
Used for
Assess patientpain( location
moderate to severe pain
Hypersensitiv
Vasodila tion, ity, acute dizzines intoxication with s/vertigo, headache alcohol, , stimulatio hypnotics n, ,centrally anxiety ,confusio acting n and analgesics sleep disorder
andtypes) - Assess for hypersensitivity reaction: rash and pruritus -Monitor for possible drug induced adverse reaction CNS; stimulation dizziness, vertigo, headache, CV: vasodilation GI: nausea
Tram adol
Classification
Dose/ frequen cy
Mechanism of Actions
Specific Contraindica Side Indication tion effects
Nsg Precautions
GIT drugs (Anti-ulcer drugs) & (Proton Pump Inhibitors)
50mg q8h (6am2pm10pm)
Centrally acting analgesic not chemically related to opioids but binds to muopioid receptors and inhibits reuptake of norepinep hrine and serotonin
Used for
Assess patientpain( location
Dose/ frequen cy
Mechanism of Actions
Specific Contraindica Side effects Indication tion
Nsg Precautions
15mg IVTT ANST then q8h
Unknown. May inhibit prostaglandi n synthesis, to produce anti inflammatory , analgesic, and antipyretic effects
Short term managem ent of moderatel y severe acute pain for single dose treatment
Correct hypovolemia before giving ketorolac
Classification
Ketor Analgesic olac
moderate to severe pain
Hypersensitiv
Vasodila tion, ity, acute dizzines intoxication with s/vertigo, headache alcohol, , stimulatio hypnotics n, ,centrally anxiety ,confusio acting n and analgesics sleep disorder
andtypes) - Assess for hypersensitivity reaction: rash and pruritus -Monitor for possible drug induced adverse reaction CNS; stimulation dizziness, vertigo, headache, CV: vasodilation GI: nausea
Short term management of moderately severe acute pain for single dose treatment
CNS: drowsiness CV: edema, Hypertension GI: nausea, dyspepsia Hematologic: decreased platelet absorption Skin: pruritus Other: pain at the injection site
Carefully observe patient’s with coagulopathies and those taking coagulants drug inhibit platelet aggregation and can prolong bleeding time
Classification
Ketor Analgesic olac
Cefur oxime
Dose/ frequen cy
Mechanism of Actions
Specific Contraindica Side effects Indication tion
Nsg Precautions
15mg IVTT ANST then q8h
Unknown. May inhibit prostaglandi n synthesis, to produce anti inflammatory , analgesic, and antipyretic effects
Short term managem ent of moderatel y severe acute pain for single dose treatment
Correct hypovolemia before giving ketorolac
Classification
Dose/ frequen cy
Mechanism of Actions
Specific Contrain Indication dication
Side effects
Nsg Precautions
Cephalosporin s
75mg IVTT now then q8h
Second generation cephalospori ns that inhibits cell wall synthesis, osmotic instability, usually bactericidal
Skin and skin structure infections, infections of the urinary and lower respiratory tract
CNS: Fever, headache CV: Diarrhea GI: genital pruritus Hematologi c: thrombocyto penia Skin: pain in Duration Other: hypersensiti vity reaction
Before administration, ask the patient if he is allergic to penicillins or cephalosporins
Short term management of moderately severe acute pain for single dose treatment
CNS: drowsiness CV: edema, Hypertension GI: nausea, dyspepsia Hematologic: decreased platelet absorption Skin: pruritus Other: pain at the injection site
Contraindi cated in patient’s hypersens itive to drug or other cephalosp orin
Carefully observe patient’s with coagulopathies and those taking coagulants drug inhibit platelet aggregation and can prolong bleeding time
Monitor PT and INR in patient with impaired vitamin K synthesis or low vitamin k store. Vitamin K may be
Cefur oxime
Classification
Dose/ frequen cy
Mechanism of Actions
Specific Contrain Indication dication
Side effects
Nsg Precautions
Cephalosporin s
75mg IVTT now then q8h
Second generation cephalospori ns that inhibits cell wall synthesis, osmotic instability, usually bactericidal
Skin and skin structure infections, infections of the urinary and lower respiratory tract
CNS: Fever, headache CV: Diarrhea GI: genital pruritus Hematologi c: thrombocyto penia Skin: pain in Duration Other: hypersensiti vity reaction
Before administration, ask the patient if he is allergic to penicillins or cephalosporins
Contraindi cated in patient’s hypersens itive to drug or other cephalosp orin
Monitor PT and INR in patient with impaired vitamin K synthesis or low vitamin k store. Vitamin K may be needed
B. Laboratory Results X-RAY REPORT
Name:Ms. RFE Age/Sex: 28/F Requested by: Dr. Tan
Chest X-ray PA:
Date: Febuary 8, 2014 Examination: CXR PA
B. Laboratory Results X-RAY REPORT
Name:Ms. RFE Age/Sex: 28/F Requested by: Dr. Tan
Date: Febuary 8, 2014 Examination: CXR PA
Chest X-ray PA: The lungs are clear Heart is not enlarged Aorta is not dilated Diaphragm and both cotosphrenic sulci are intact The rest of the visualized chest structures are unremarkable
Impression: No significant chest findings
Test
Result
Total WBC Total RBC Hemoglobin
10.0 x 10 ^9/L 3.3 x 10 ^12/L 9.0 g/dL
Hematocrit MCV MCH MCHC Platelet Count Differential Count
29.9 % 89.5 fL 29.3 pg 32.0 g/dL 400 x 10^9/L
HEMATOLOGY References Ranges 5.0 – 10.0 3.69 – 5.90 13.70 – 16.70
40.00 – 49.70 70.00 – 97.00 26.10 – 33.30 32.0 – 35.0 150.0 – 390.0
Implications
Normal *Low Hgb suggests anemia * Normal Normal Normal Normal
Neutrophils
77.50 %
54.0 - 62.0
Lymphocytes
19.20 %
20.0 - 40.0
Monocytes Eosinophils Basophils RDW - CV
7.10 % 2.10 % 0.10 % 11.6 %
4.0 – 10.0 1.0 – 6.0 0.00 – 1.00 11.5 – 14.5
Name: Ms. RFE Age: 28/F
* Increased due to infection and stress response – PTB and emotional stress * Decreased due to advanced tuberculosis cp Normal Normal Normal Normal
Date done: 2/8/14 Clinician: Dr. Tan
URINALYSIS Test
Result
Color Appearance Glucose Protein Reaction Specific Gravity
Yellow Clear Negative Negative 6.0 pH 1.020
WBC RBC Epithelial Cells Mucous Threads Urates Bacteria
0-1 0-2 Few Rare None Seen Few
Macroscopic
Microscopic
Name: Ms. RFE Age: 28/F
Date done: 2/8/14 Clinician: Dr. Tan
Ultrasound report Ultrasound of the Upper Abdomen
MEASUREMENTS R Liver Lobe =14.73cm
R Kidney =10.51 x 4.12 x 4.19 cm C-T = 0.97cm
L Liver Lobe= 12.82cm
L Kidney=11.7 x 5.13 x 5.44 cm C-T =1.39cm
Gallbladder= 6.25 x 2.26 x 1.69cm
Spleen = 9.40cm
The liver is normal in size and parenchymal echogenecity. No focal mass lesion seen. The intrahepatic ducts and extrahepatic ducts are not dilated. The gallbladder is normal in size and configuration with smooth and not thickened wall. No intraluminal intense echo seen. Pancreas and spleen are unremarkable. Both kidneys are normal in size and echopattern. No pelvocallectasia nor lithiasis seen. Impression: NEGATIVE ULTRASOUND OF THE LIVER , INTRAHEPATIC DUCTS, EXTRAHEPATIC DUCTS, GALLBLADDER, PANCREAS, SPLEEN AND BOTH KIDNEYS.
V.
ANATOMY & PHYSIOLOGY with PATHOPHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and small intestine. Its characteristic shape is shown, along with terms used to describe the major regions of the stomach. The right side of
the
stomach is called the greater curvature and the
left
the lesser curvature. The most distal and narrow section of the stomach is termed the pylorus - as food is liquefied in the stomach it passes through the pyloric canal into the small intestine. The wall of the stomach is structurally similar to other parts of the digestive tube, with the exception that the stomach has an extra oblique layer of smooth muscle inside the circular layer, which aids in performance of complex grinding motions. In the empty state, the stomach is contracted and its mucosa and submucosa are thrown up into distinct folds called rugae; when distended with food, the rugae are "ironed out" and flat. The image below shows rugae on the surface of a dog's stomach.
Within the stomach there is an abrupt transition
from
stratified
squamous
epithelium extending from the esophagus to a columnar epithelium dedicated to
secretion. In most species, this transition is very close to the esophageal orifice, but in some, particular horses and rodents, stratified squamous cells line much of the fundus and part of the body. The image below is of the mucosal surface of an equine stomach showing esophageal epithelium (top) and glandular epithelium (bottom). The creatures attached to the surface are bots, larval forms of Gasterophilus.
If the lining of the stomach is examined with a hand lens, one can see that it is covered with numerous small holes. These are the openings of gastric pits which extend into the mucosa as straight and branched tubules, forming gastric glands. Types of Secretory Epithelial Cells
Four major types of secretory epithelial cells cover the surface of the stomach and extend down into gastric pits and glands: Mucous cells: secrete an alkaline mucus that protects the
epithelium against shear stress and acid Parietal cells: secrete hydrochloric acid! Chief cells: secrete pepsin, a proteolytic enzyme
G cells: secrete the hormone gastrin
There are differences in the distribution of these cell types among regions of the stomach - for example, parietal cells are abundant in the glands of the body, but virtually absent in pyloric glands. The micrograph to the right shows a gastric pit invaginating into the mucosa (fundic region of a raccoon stomach). Notice that all the surface cells and the cells in the neck of the pit are foamy in appearance - these are the mucous cells. The other cell types are farther down in the pit and, in this image, difficult to distinguish. Mouth
Is the first portion of the alimentary canal that receives food and begins digestion by mechanically breaking up the solid food particles into smaller pieces and mixing them with saliva. The oral mucosa is the mucous membrane epithelium lining the inside of the mouth. Pharynx
The section of the alimentary canal that extends from the mouth and nasal cavities to the larynx, where it becomes continuous with the esophagus. Esophagus
The esophagus is a tube that carries swallowed foods to the stomach. Stomach
Is a muscular organ of the digestive tract. It is located between the esophagus and the small intestine. The stomach is hollow and sac-shaped. It is involved in the second phase of digestion, following mastication (chewing).The stomach produces protease enzymes and hydrochloric acid which kills bacteria and gives the right pH for the protease enzyme to work.
Small Intestine
The part of the gastrointestinal tract (GI tract) that extends from the pyloric sphincter to the ileocecal valve, where it empties into the large intestine. The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive system that are closely associated with the small intestine.
Large Intestine
The part of the gastrointestinal tract (GI tract) that extends from the pyloric sphincter to the ileocecal valve, where it empties into the large intestine. The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive system
that
are
closely
associated
with
the
small
intestine
VI.
NURSING ASSESSMENT TOOL
Name of Patient: Ms. RFE
Temp: 36˚C
PR: 90bpm
VII. NURSING SYSTEM REVIEW CHART RR: 22cpm BP: Height: Weight: 110/70mmHg 5’2’ 60kg
EENT []impaired []blind []pain vision []reddened []drainage []gums []hard []deaf []burning hearing []edema []lesion []teeth Assess eyes, ears, nose, throat for any abnormalities [ x]no problem RESPIRATORY []asymmetric []tachypnea []apnea []rales [ x]cough []barrel chest
[]bradypnea
[]shallow
[]rhonchi
[]sputum []diminished []dyspnea []orthopnea []labored []wheezing []pain []cyanotic Assess respiration, rate, rhythm, depth, pattern, breath sounds, comfort [ x]no problem CARDIOVASCULAR []arrhythmia []tachycardia []numbness []diminished []edema []fatigue pulses []irregular []bradycardia []murmur []tingling []absent []pain pulses Assess heart sound, rate, rhythm, pulse, blood pressure, circulation, fluid retention, comfort [x]no problem GASTROINTESTINAL TRACT []obese []distention []mass []dysphagia []rigidity [x]pain Assess abdomen, bowel habits, swallowing, bowel sound, comfort []no problem
Date: 2/9/14
sunken eyeballs Cough Vomiting Moderate diarrhea Cough Vomiting Abdominal 5/10 Abdominal 3/10
Pain Pain
GENITO-URINARY & GYNE []pain []urine color []vaginal bleeding []hematuria []discharges []nocturia Assess urine frequency, control, color, odor, comfort, gyne bleeding, discharges [x]no problem NEURO []paralysis []stuporous []unsteady []seizures []lethargic []comatose []vertigo []tremors []confused []vision []grip Assess motor function, sensation, Loc, strength, grip, gait, coordination, orientation, speech [ x]no problem MUSCULOSKELETAL & SKIN []appliance []stiffness []itching []petechiae []hot []drainage []prosthesis []swelling []lesion []poor turgor []cool []deformity []wound []rash []skin color []flushed []atrophy []pain (back) []ecchymosis []diaphoretic []moist Assess mobility, motion, gait, alignment, joint, function, skin color, texture, turgor, integrity [ x]no problem
NURSING ASSESSMENT II SUBJECTIVE DATA OBJECTIVE DATA []Languages COMMUNICATIO Comments: Maayo []Glasses man ako panan.aw N og pandungog as []Contact Lens []Hearing Loss []Hearing Aide verbalized. []Visual Changes Pupil L3mm R3m []Speech difficulties size m [x]Denied Reaction PERRLA Comments: giubo Respiration []Regular [ x]Irregular OXYGENATION ko pero wla man Describe: Respiration is regular in rate []Dyspnea []Smoking History noon plema as verbalized. [x]Cough []Sputum R full chest expansion, symmetric to Left lung []Denied L full chest expansion, symmetric to right lung Comments: dili Heart Rhythm [x]Regular []Irregular CIRCULATION man sakit ako Ankle Edema: No ankle edema noted. []Chest Pain dughan og wala Pulse Car Rad AP Fem* man sad naminhod R []Numbness of + 90bpm + Refuse ako kalawasan as extremities d verbalized. L + 90bpm + Refuse d [x]Denied Comments Comments: Maayo []Dentures [ x]None NUTRITION man ako ako Diet: DAT diet pagkaon . Complete Incomplete []Recent change Upper [] [] in weight and Lower [] [] appetite []Swallowing Difficulty [x]Denied Urinary frequency Bowel Sounds ELIMINATION Comments: Bowel NORMOACTIVE Usual bowel 4-6 times a day sounds are hard as pattern gargles, prominent on Once daily []Urgency Abdominal Distention RLQ of abdomen. Constipation []Dysuria []Yes [ x]No Remedy Eats Papaya []Hematuria Urine color, consistency, odor Date of last BM []Incontinence 2/9/14 []Polyuria Pale yellow, Diarrhea []Foley in place moderate, aromatic Character []Denied
MANAGEMENT OF HEALTH AND ILLNESS
Briefly describe patient’s ability to follow treatments (diets, medications, etc.) Patient is able to comply with prescribed diet, medications and treatment.
[x]Alcohol []Denied “ gainom ko usahay pag nay mga okasyon []SBE Last Pap Smear LMP 2/1/14
SUBJECTIVE DATA
Comments: ok raman ako pamanit wala man sad katol2x og dili pud dry as verbalized..
SKIN INTEGRITY
[]Dry []Itching [x]Denied
ACTIVITY & SLEEP
[]Convulsion []Dizziness []Limited Motion of Joints
Comments: makalakaw man noon ko og makaligo na ako ra as verbalized.
Limitation in ability to []Ambulate []Bathe self
OBJECTIVE DATA
[]Dry
[]Cold
Pale
[]Flushed
[]Warm
[]Moist
[]Cyanotic
Rashes, ulcers, decubitus (describe size, location, drainage, color, odor No rashes noted LOC & Orientation Patient is conscious and is oriented to time, place, and date Gait:
[]Walker
[x]Steady
[]Cane
[]Unsteady
[]Sensory & motor losses in face and extremities No sensory and motor losses in face and extremities ROM Limitations: No ROM limitations
[x]Denied COMFORT/SLEEP/AWAKE
[x]Pain(location, frequency remedy abdomen,pain reliever
[]Nocturia []Sleep Difficulty [x]Denied
[]Facial Grimace
Comments: Magsakit []Guarding & lang ako ako tiyan []Other signs of pain: no other signs of pain usahay mao dili kayu noted ko makatulog as verbalized.
COPING
Occupation: Nurse Members of household: 5 members Most supportive person: mother
Observed non-verbal behaviour: Patient is typically quiet but very responsive when asked Person and phone number that can be reached at any time: 09067302815
VIII. NURSING MANAGEMENT A. IDEAL NURSING MANAGEMENT NURSING DIAGNOSIS: Airway Clearance, ineffective May be related to Thick, viscous, or bloody secretions
Fatigue, poor cough effort
Tracheal/pharyngeal edema
Possibly evidenced by Abnormal respiratory rate, rhythm, depth
Abnormal breath sounds (rhonchi, wheezes), stridor Dyspnea
Desired Outcomes Maintain patent airway.
Expectorate secretions without assistance.
Demonstrate behaviors to improve/maintain airway clearance.
Participate in treatment regimen, within the level of ability/situation.
Identify potential complications and initiate appropriate actions.
Nursing Interventions
Rationale
Assess respiratory function, e.g., breath sounds, rate, rhythm, and depth, and use of accessory muscles.
Diminished breath sounds may reflect atelectasis. Rhonchi, wheezes indicate accumulation of secretions/inability to clear airways that may lead to use of accessory muscles and increased work of breathing
Note ability to expectorate mucus/cough effectively; document character, amount of sputum, presence of hemoptysis.
Expectoration may be difficult when secretions are very thick as a result of infection and/or inadequate hydration. Blood-tinged or frankly bloody sputum results from tissue breakdown (cavitation) in the lungs or from bronchial ulceration and may require further evaluation/ intervention.
Place patient in semi- or high- Fowler’s position. Assist patient with coughing and deep-breathing exercises.
Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open atelectatic areas and promote movement
of secretions into larger airways for expectoration. Clear secretions from mouth and trachea; suction as necessary.
Prevents obstruction/aspiration. Suctioning may be necessary if patient is unable to expectorate secretions.
Maintain fluid intake of at least 2500 mL/day unless contraindicated.
High fluid intake helps thin secretions, making them easier to expectorate.
Humidify inspired air/oxygen.
Prevents drying of mucous membranes; helps thin secretions.
Administer medications as indicated:Mucolytic agents, e.g., acetylcysteine (Mucomyst);Bronchodilators, e.g., oxtriphylline (Choledyl), theophylline (Theo-Dur);
Corticosteroids (prednisone).
Be prepared for/assist with emergency intubation.
Reduces the thickness and stickiness of pulmonary secretions to facilitate clearance.Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery.May be useful in presence of extensive involvement with profound hypoxemia and when inflammatory response is life-threatening. Intubation may be necessary in rare cases of bronchogenic TB accompanied by laryngeal edema or acute pulmonary bleeding.
NURSING DIAGNOSIS: Altered Sleep Pattern Risk factors may include
Ambient temperature, humidity, lighting , noise
Caregiving responsibilities
Lack of sleep privacy
Interruptions
Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Desired Outcomes
Report improve sleep
Report increased sense of well-being and feeling rested
Identify individually appopriate interventions to promote sleep
Nursing Interventions
Rationale
Identify presence of factors known to interefere with sleep, including current illness, hospitalization
Sleep problems can arise form internal and external factors, and may require assessment over time to differentiate specific causes
Ascertain presence of short term alteration in sleep patterns, suach as can occur with travel, sharing bed with new sleep partner, crisis at work
Hepls identify circumstances thatare known to interrupt sleep acutely, but not necessary long term
Note environmental factors, such as unfamiliar or uncomfortable room; excessive noise and light; frequent medical and monitoring interventions
These factors can reduce client’s ability to rest and sleep at a time when more rest is needed
Listen to report of sleep quality
Helps clarify client’s perception of sleep quantity and quality response to inadequate sleep
Turn on soft music, calm TV program, or quite environment
To enhance relaxation
Minimize sleep-disrupting factors
To promote readiness of sleep, improve sleep duration and quality
Nursing Diagnosis Fluid
volume
excessive
deficient
losses
Intervention
related
through
to
normal
Rationale
Monitor intake and output,
Provide
information
about
note number, character and
over all fluid balance, renal
amount of stools.
function and bowel diseases
Assess vital signs changes.
control as well as guidelines
Observe for excessively dry
for fluid replacement.
routes
skin
and
mucous
Hypotension, tachycardia and
membrane, dry skin turgor.
fever can indicate response of
Weigh daily.
fluid loss.
Administer
parenteral
as
indicated.
Indicates dehydration.
Indicator of overall fluid and nutritional status.
Maintenance of bowel rest that will require alternate fluid replacement to correct losses.
Nursing Diagnosis
Intervention
Acute pain related to hyper peristalsis prolonged
diarrhea,
skin/tissue
Rationale
Note non-verbal cues.
Permit
irritation, peri rectal fissures, fistulas
patient
to
assume
in conjunction with verbal cues
position of comfort.
to
Cleans rectal area with mild
problem.
soap and water wipes after
defecating.
Record
distention
temperature
and
Reduce
extent
of
abdominal
the
tension
prescribe
modifications,
Protect skin from undigested bowel
decrease blood pressure. Implement
identify
and sense of control.
abdominal
increase
Non-verbal cues may be used
contents
preventing
excoriation. dietary
administer
May
indicate
intestinal
medication as indicated.
developing
obstruction
from
inflammation.
Complete
bowel
rest
reduce pain and cramping.
can
Nursing Diagnosis
Intervention
Acute pain related to hyper peristalsis prolonged
diarrhea,
skin/tissue
Rationale
Note non-verbal cues.
Permit
irritation, peri rectal fissures, fistulas
patient
to
assume
in conjunction with verbal cues
position of comfort.
to
Cleans rectal area with mild
problem.
soap and water wipes after
defecating.
Record
distention
temperature
and
Reduce
extent
of
abdominal
the
tension
prescribe
modifications,
Protect skin from undigested bowel
decrease blood pressure. Implement
identify
and sense of control.
abdominal
increase
Non-verbal cues may be used
contents
preventing
excoriation. dietary
administer
May
indicate
intestinal
medication as indicated.
developing
obstruction
from
inflammation.
Complete
bowel
rest
reduce pain and cramping.
b. Actual Nursing Management (SOAPIE)
S
O
A
“giubo ko pero wala man noon plema ” as verbalized by the patient.
Non-productive cough
Use of accessory muscles for breathing
RR: 22 cpm
Ineffective Airway Clearance related to excessive mucous production Short Term: At the end of 1hr, I will be able to maintain patent airway
P
can
b. Actual Nursing Management (SOAPIE)
S
O
A
“giubo ko pero wala man noon plema ” as verbalized by the patient.
Non-productive cough
Use of accessory muscles for breathing
RR: 22 cpm
Ineffective Airway Clearance related to excessive mucous production Short Term: At the end of 1hr, I will be able to maintain patent airway
P
I
Independent
Placed patient in a semi-fowlers position to facilitate full lung expansion.
Assisted patient with coughing and deep-breathing exercises.
Maintained
fluid
intake
of
at
least
2500
mL/day
unless
contraindicated.
Encoraged patient to eat foods rich in vit.c like orange, lemon
Objectives met. At the end of nursing exposure, patient was able to maintain E
patent airway and cough out secretions w/out assistance.
S
O
“sakit ako tiyan ” as verbalized.
Abdominal pain (5/10)
Facial grimace
PR= 90bpm
Acute pain r/t inflammation of gastric mucosa A
P
I
At the end of 30mins patient will be able to reduce pain in a tolerable level
Independent
Placed client in a comfortable position.
Encouraged patient in a diversional activities lik watching TV, reading magazines
Encouraged deep breathing exercise and relaxation technique
Provide quite environment free from distractions
Collaborative
E
Administer pain reliever as ordered by the physician
Objectives met. At the end of 30mins patient was be able to reduced pain in a tolerable level
S
“basa akong tae usahay ” as verbalized.
O
A
sleepy
moderate diarrhea
:sunken eyeballs
Risk for fluid volume deficient r/t excessive loss though vomiting and diarrhea At the end of 15- 30 min of nursing interventions, patient’s will be able to
P
verbalize a normal pattern of bowel functioning.
I
>Monitor intake and output and compare to the normal variation, to assess the level of dehydration >Increase fluid intake to regain the fluid lose in the body. >Monitor the vital signs every hour, to detect any alteration or to identify any variation from normal values >Monitor laboratory values, reflects hydration and identifies NA return and protein deficient Provide IVF Fluids and electrolytes for maintain hydration and electrolytes balance.
E
At the end of the 30 minutes the patient verbalized effectiveness of the intervention given and would able to maintain normal bowel pattern.
S
“baspermi ko ga-mata kay gasakit ako tiyan” as verbalized.
O
A
>Irritable
>Restless
>Weak
>Crying
Sleep pattern disturbance related to abdominal discomfort
At the end of 8 hour the patient will able to have an adequate sleep.
P
I
>Organized nursing care. (to promote minimal interruption in sleep.)
>Instructed the mother of the patient to limit the fluid of the patient before bedtime. ( to reduce voiding during sleeping hours.)
>Back rub, comfortable position done to the patient. ( to promote rest)
E
>Maintained environment conducive to sleep. ( to promote sleep)
At the end of 8 hours patient achieved optimal amount of sleep as evidence by rested appearance
Health Teachings
MEDICATION
Before the patient is discharge, She was instructed to comply all of her medication regimen as prescribe by the attending physician,(Dr.Tan)..
Encouraged to engage in light exercises or exercises he can tolerate EXERCISE
like brisk walking, jogging, or slow running. However, patient is instructed to observe rest periods and consume oral fluids to replace water lost through perspiration. Patient is also instructed to maintain adequate rest period. Instructed to
TREATMENT
increase fluid intake to 3 liters per day. Taught preventive measures including: role of nutrition and fluids; avoiding respiratory iiritants, vand balance between activity and rest.
OUTPATIENT (FOLLOW-UP)
Instructed patient to return one week after discharge at CPGH for evaluation of overall physical condition.
Instructed to eat small frequent feedings – DAT diet. Patient is also DIET
encouraged to maintain adequate fluid intake and to consume fruits and vegetable to supply necessary vitamins and minerals.
VIII. REFERRALS AND FOLLOW-UP
To allow continuous monitoring of the patient’s condition, she should visit the
doctor a week after discharge for follow-up checkup for OPD as scheduled. This will ensure through follow up of his condition and prevention of potential complications. Always apply the universal precaution which is the hand washing and improve environmental sanitation. She was also advised to have proper personal hygiene. With regard to his medications, she is advised to maintain a compliant behaviour as well as to stick to his diet modification and lifestyle changes. And for any unusualities that the patient may encounter always consult to the doctor for further assessment, test and etc.
IX. EVALUATION and IMPLICATION
My assessment for two successive days showed that the patie nt’s status has slightly been stable and had improved the patient’s view towards promoting health. I
had established rapport and harmonious communication during the whole course of the study, reviewed patient’s chart and had carried out doctor’s orders.
Moreover, I had understood the Anatomy, Physiology and Pathophysiology of the disease condition of the patient which is Acute Gatritis . I had identified Patient’s Clinical Manifestations as basis for the Actual and Ideal Nursing Care Plans and had intervened identified problems through patient-based nursing care. As a nursing student, the knowledge that I had gained during the 2 days assessing and caring of the patient had enhanced my understanding about the patient’s
condition. This exposure had helped me improved and developed my interpersonal relationship to people whom I worked with.
