ST. ANTHONY COLLEGE CALAPAN CITY
A case study Presented to Maritess Dela Vega RN, MAN in Fulfilment of the Requirements in Related Learning Experience 101 for the Degree Bachelor of Science in Nursing
Acute Gastritis
Presented by: Joeben Jarencio
LEVEL II PEDIA WARD
March 5, 2013
I.
INTRODUCTION
Gastritis (inflammation of the gastric or stomach mucosa) is a common GI problem. Gastritis maybe acute, lasting several hours to a few days, or chronic, resulting from repeated exposure to irritating agents or recurring episodes of acute gastritis. Acute Gastritis is often caused by dietary indiscretion – person eats food that is irritating, too highly seasoned, or contaminated with disease causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is cause by ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis or obstruction. Acute gastritis also may develop in acute illness, especially when the patient has had major traumatic injuries; burns; severe infection; hepatic, renal, or respiratory failure; or major surgery. Gastritis maybe the first sign of an acute systemic infection.
1.
RATIONALE
I chose this study out of curiosity as it was my first time to encounter such case and because of that, I was interested in it. I am willing to undergo new experiences which would bring new learning for me as I have not been exposed yet to the Pediatric ward. Another reason was that it was one of the suggestions of our clinical instructor to be used in making case study
LEARNING OBJECTIVES
II.
To have further learning and comprehension about acute gastritis. To define its meaning. To identify the risk factors that has been linked to this problem, the signs and symptoms, and its clinical manifestations. To learn the treatment and other related management regarding the case.
CLINICAL SUMMARY
A. GENERAL DATA Name:
J. A.
Case No. :
081538
Address:
Poblacion, Baco
Unit assignment:
Pediatric Ward
Age:
5 years old
Birthdate:
December 18, 2004
Gender:
Male
Religion:
Roman Catholic
Name of Father:
Luisito Aceveda
Name of Mother:
Clarita Aceveda
Date of Admission:
August 17, 2010
Time of Admission:
5:27 PM
Admitting Physician:
Jonathan C Jumig, MD
Admitting diagnosis:
Systemic viral infection; upper respiratory tract infection
B. CHIEF COMPLAINT Fever, cough PATHOPHYSIOLOGY
A. DRUG STUDY Generic
Brand
Action
Classifica tion
Indication
Contraindica tion
Side Effects/Adverse Effects
Nursing Responsibiliti es
aluminum hydroxide
Dissolves Antacid in acidic gastric secretions , releasing anions that partially neutralize gastric hydrochlor ic acid. Also elevates gastric pH, inhibiting the action of pepsin
>Duodenal ulcer >Dyspepsia >Gastric Ulcer >Gastroesop hageal reflux disease (GERD)
>Signs or symptoms of appendicitis or inflamed bowel; >Ulcerative colitis; patients with colostomy, diverticulitis, or ileostomy >Children <6 years, CHF, edema, preeclampsi a
> constipation, diarrhea, edema
>Monitor long-term use of high doses >hypermagnesemi if patient is on a, sodiumhypophosphatemia restricted , osteomalacia, diet. (Drug osteoporosis contains sodium.) >Assess for GI bleeding >Watch for constipation >With longterm use, monitor blood phosphate level and assess for signs and symptoms of hypophospha temia (anorexia, malaise, muscle weakness). Also monitor bone density >Tell patient to take drug 1 hour after meals and at bedtime. >Caution patient not to take drug within 1 to 2 hours of antiinfectives, H2 blockers, iron, corticosteroid s, or entericcoated drugs. >Advise patient to take drug with water or fruit juice. >Instruct patient to report signs and symptoms of GI bleeding and hypophospha temia (appetite loss, malaise, muscle
weakness). >Recommen d increased fiber and fluid intake and regular physical activity to help ease constipation. >inform patient that drug contains sodium, so he should discuss drug therapy with health care providers if he's later told to consume a low-sodium diet >A dvise patient that he'll need to undergo periodic blood testing and bone mineral density tests if he's receiving long-term therapy. >As appropriate, review all other significant and lifethreatening adverse reactions and interactions, especially those related to the drugs, tests, and foods mentioned above
Amoxicillin
Inhibits cell-wall synthesis during bacterial multiplicati on, leading to cell death. Shows enhanced activity toward gramnegative bacteria compared to natural and penicillina seresistant penicillins.
Antiinfective
It is prescribed in the treatment of infections caused by a susceptible gramnegative or grampositive bacteria.
Known hypersensiti vity to any penicillin prohibits its use.
Among the most serious adverse reactions are anaphylaxis, nausea, and diarrhea. Allergic reactions and rashes are common
> Monitor for signs and symptoms of hypersensitivi ty reaction. >Monitor patient's temperature and watch for other signs and symptoms of superinfectio n (especially oral or rectal candidiasis). >Instruct patient to immediately report signs and symptoms of hypersensitivi ty reactions, such as rash, fever, or chills. >Tell patient he may take drug with or without food. >Tell patient not to chew or swallow tablets for suspension, because they're not meant to be dissolved in mouth. >Advise patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of fluids. >Tell patient taking hormonal contraceptive s that drug may reduce contraceptive efficacy. Suggest she use
alternative birth control method. >Inform patient that drug lowers resistance to other types of infections. Instruct him to report new signs and symptoms of infection, especially in mouth or rectum. >Tell parents they may give liquid form of drug directly to child or may mix it with foods or beverages. >As appropriate, review all other significant and lifethreatening adverse reactions and interactions, especially those related to the drugs, tests, foods, and herbs mentioned above.
III.
NURSING PROCESS A. PROBLEM LISTS
Date of onset
Nursing Problem
Date identified
Date resolved
Aug. 24, 2010
Risk for Injury related to dizziness
Aug. 26, 2010
Aug. 26, 2010
Aug. 26, 2010
Self-care deficit: Oral hygiene related to pain
Aug. 26, 2010
Aug. 26, 2010
B. Nursing Care Plan
Assessment S> >”Simula nung pumunta kami ditto hindi ko pa sya natoothbrushan dahil masakit ang ngipin nya at bibig” as verbalized by the mother
Nursing Diagnosis
Planning
Intervention
Rationale
Self-care deficit: Oral hygiene related to pain as manifested by:
Goal: Within 8 hours of continuous nursing care the client will be able to perform oral hygiene
>Determined age and developmental issues
> It affects client’s ability comprehend to instruction >Pain affects the performance of selfcare
>Dental carries >Yellowish Teeth >Halitosis >Vital signs as taken: Temp: 36.2°C PR: 61 bpm RR: 28 cpm
O>
>Dental carries >Yellowish Teeth >Halitosis >Vital signs as taken: Temp: 36.2°C PR: 61 bpm RR: 28 cpm
Outcomes: The client will: >verbalize understanding of healthcare practices >demonstrate techniques to meet self-care needs >perform self-care activities within level of own ability >identify personal resources who can provide assistance
Assessment
Nursing Diagnosis
Planning
S> >”Kapag tumatayo sya, nahihilo sya saka natutumba kaya palagi ko sya inaalalayan” as verbalized by the mother
Risk for Injury related to dizziness as manifested by: >weakness >irregular pulse rate >irregular breathing >vital signs as taken: Temp: 36.2°C PR: 61 bpm RR: 28 cpm
Goal: Within 8 hours of continuous nursing care the client will be free from injury
O> >weakness >irregular pulse rate >irregular breathing >vital signs as taken: Temp: 36.2°C PR: 61 bpm RR: 28 cpm
Outcomes: The client will: >identify factors that contribute to possibility of injury >demonstrate behaviours to reduce risk factors >identify help from support people to reduce risk for injury
>Noted concomitant existing conditions that may be factors for care such as pain >Promoted family’s participation in problem identification and desired goals and decision making >Provided for communication among those who are involved in assisting the client >Demonstrated the proper oral hygiene >Instructed the client to return demonstration and assisted during demonstration >Instructed family to provide equipment within easy reach during personal care activities
Intervention >Noted client’s age and developmental stage >Assessed muscle strength, gross, and fine motor coordination >Ensured side rails up of bed >Instructed client to request assistance as needed especially during ambulation >Monitored environment for potentially unsafe conditions >Instructed the mother to assist the client during
>It enhances commitment to plan, optimizing outcomes, and supporting health promotion >It enhances coordination and continuity of care
Evaluation Goal Met. The client: >verbalized understanding of healthcare practices >demonstrated techniques to meet self-care needs >performed self-care activities within level of own ability >identified personal resources who can provide assistance
>To promote better understanding >To ensure that the client correctly understand >To prevent selfhumiliation
Rationale >It affects client’s ability comprehend to instruction >To identify risk for falls
>To prevent client fall >To promote safety behaviours
>To reduce contributing factors of injury >To lessen the dizziness effort of the patient that can
Evaluation Goal Met. The client: >identified factors that contribute to possibility of injury >demonstrated behaviours to reduce risk factors >identified help from support people to reduce risk for injury
Assessment
Nursing Diagnosis
Planning
S> >”Kapag tumatayo sya, nahihilo sya saka natutumba kaya palagi ko sya inaalalayan” as verbalized by the mother
Risk for Injury related to dizziness as manifested by: >weakness >irregular pulse rate >irregular breathing >vital signs as taken: Temp: 36.2°C PR: 61 bpm RR: 28 cpm
Goal: Within 8 hours of continuous nursing care the client will be free from injury
O> >weakness >irregular pulse rate >irregular breathing >vital signs as taken: Temp: 36.2°C PR: 61 bpm RR: 28 cpm
Outcomes: The client will: >identify factors that contribute to possibility of injury >demonstrate behaviours to reduce risk factors >identify help from support people to reduce risk for injury
Intervention >Noted client’s age and developmental stage >Assessed muscle strength, gross, and fine motor coordination >Ensured side rails up of bed >Instructed client to request assistance as needed especially during ambulation >Monitored environment for potentially unsafe conditions >Instructed the mother to assist the client during ambulation and sitting >Taught the client to rise up slowly from lying and stand up slowly
Rationale >It affects client’s ability comprehend to instruction >To identify risk for falls
>To prevent client fall >To promote safety behaviours
Evaluation Goal Met. The client: >identified factors that contribute to possibility of injury >demonstrated behaviours to reduce risk factors >identified help from support people to reduce risk for injury
>To reduce contributing factors of injury >To lessen the dizziness effort of the patient that can reduce risk for injury >To allow proper blood circulation
C. DISCHARGE PLANNING Medication
Instructed the client to take home medication as ordered by the physician
Exercise Advise client to have non-strenuous and non jarring exercise such as walking. Tell client to initiate exercise through repetitive low intensity exercises first. As time and experiences increases the client can move to higher intensity exercises. Advice client and her family to try to have or maintain safe , clean, comfortable and calm environment . Advise significant others to be supportive
Treatment:
Ensure follow up and self-care Advise client or significant others to take in time prescribed medicines Ensures dietary restriction on salt, fluid proteins, and other substances may be recommended
C. DISCHARGE PLANNING Medication
Instructed the client to take home medication as ordered by the physician
Exercise Advise client to have non-strenuous and non jarring exercise such as walking. Tell client to initiate exercise through repetitive low intensity exercises first. As time and experiences increases the client can move to higher intensity exercises. Advice client and her family to try to have or maintain safe , clean, comfortable and calm environment . Advise significant others to be supportive
Treatment:
Ensure follow up and self-care Advise client or significant others to take in time prescribed medicines Ensures dietary restriction on salt, fluid proteins, and other substances may be recommended Tell significant others to closely watch and monitor for signs of developing kidney failure
Health Teaching:
Describe to the client the signs and symptoms to be reported immediately (Blood in the urine, foamy urine, swelling on the face, legs and abdomen. Clearly and specifically explain the nature of the disease, its coarse and eventual prognosis of the condition to the child (if old enough to understand ) and parents or caregivers, they need to understand the while complete resolutions expected a small possibility exists for persistent disease and that an even smaller possibility exists for progression . This info. Is necessary for some pt. to ensure that compliance with the follow up program occurs.
OPD
Advise significant others to immediately consult his physician if signs and symptoms of the diseases occurs or persist
Remind client of her check-up schedules and appointments. Tell him to attend them as diligently as he can. This is to rule out the recurrence or progression of the problem.
Out-patient follow-up:
Advise to have a regular check-up for his condition
Diet
Assure a low sodium, low protein diet Limitation of fluid and salt intake to minimize vascular overload
Spiritual
Tell the client to pray without ceasing and don’t stop counting on God. Advise family to provide moral support and widen their understanding Tell the relatives to pray for the client to help with the recovery.
ACKNOWLEDGEMENTS First and foremost, I would like to thank my clinical instructor, Ms. Ma. Olivia Andria O. Andres for the valuable guidance and advice. She inspired me greatly to work in this case study. Her willingness to motivate me contributed tremendously to my study. Besides, I would like to thank the authority of our school, St. Anthony College for providing us, students, a good environment and facilities to complete our designated projects. Also, I would like to thank this opportunity to give my warmest gratitude to Mr. Daren Linatoc, Dr. Avelino Isles, and Mrs. Luzviminda Cardiño for giving me the pattern and checking my drafts. In addition, I would also like to thanks all the staff of Pediaric Ward of Oriental Mindoro Provincial Hospital for guiding me. Finally, an honourable mention goes to my family and friends for their understanding and support to me in completing this project. Without the help of the particular that mentioned above, I would not be able to accomplish this case study.
Table of Contents Acknowledgement
Chapter I: Introduction A. Rationale for Choosing the Case B. Learning Objectives
Chapter II: Clinical Summary A. B. C. D. E. F. G. H. I. J. K.
General Data Chief Complaint History of Present Illness Past Medical History Familial History Physical Assessment Review of System Patterns of Functioning Activities of Daily Living Patient’s Concept of Health, Illness, and Hospitalization Laboratory and Diagnostic Examination
Chapter III: Clinical Discussion of the Disease A. Anatomy and Physiology B. Pathophysiology C. Drug Study
Chapter IV: Nursing Process A. Problem List B. Nursing Care Plan C. Discharge Plan
