CASESTUDY IN GASTRIC ULCER
SUMITTED BY:
DEVIE MARIE AGUSTIN SHERYL CABELIZA MABEL DEL ROSARIO REGINA MARIE GRANDE RIA LUCY QUERAL BLENDINA TEMPORAL
SUBMITTED TO: MR. JAKE B. CANAPI
CLIENTS PROFILE
Name:
C.Z
Age:
71 y/o
Gender:
Female
Address:
Maluyo, Allacapan Cagayan
Birthday:
October 25, 1939
Religion:
Iglesia Ni Cristo
Occupation:
Housekeeping
Admission date:
September 30, 2011
Time:
1: 25 a.m.
Chief complaints:
abdominal pain
Admitting Diagnosis:
Gastric Cancer
Admitting Physician:
Dr. Tiangco
NURSING HEALTH HISTORY Present health history One day PTA, the patient complain abdominal Pain of her RUQ, hence admitted to CVMC. Past health history 6 months PTa,patient complain of severe abdominal pain at the RUQ,patient was noted to tondo hospital and one medical intervention done was bloob transfusion,1 day PTA, patient with the recurrence of the condition patient was brought to CVMC.She also have no vaccination at all. Social health history According to the patient she is a housewife and a smoker.she has a 11siblings but 9 are still alive,5 boys and 4 girls ,their house is made of wood with 2 rooms and 3 windows,they have an animals like chicken,pig and duck.they poultry is near their house and for their drinking water is purified. Family history According to t he patient ,she has a history of brain cancer with her father side
ANATOMY AND PHYSIOLOGY
INTRODUCTION Gastric cancer was once the second most common cancer in the world. In most developed countries, however, rates of stomach cancer have declined dramatically over the past half century. In the United States, stomach malignancy is currently the 14th most common cancer. Decreases in gastric cancer have been attributed in part to widespread use of refrigeration, which has had several beneficial effects: increased consumption of fresh fruits and vegetables; decreased intake of salt, which had been used as a food preservative; and decreased contamination of food by carcinogenic compounds arising from the decay of unrefrigerated meat products. Salt and salted foods may damage the gastric mucosa, leading to inflammation and an associated increase in DNA synthesis and cell proliferation. Other factors likely contributing to the decline in stomach cancer rates include lower rates of chronic Helicobacter pylori infection, thanks to improved sanitation and use of antibiotics, and increased screening in some countries. Nevertheless, gastric cancer is still the second most common cause of cancer-related death in the world, and it remains difficult to cure in Western countries, primarily because most patients present with advanced disease. Even patients who present in the most favorable condition and who undergo curative surgical resection often die of recurrent disease. However, 2 studies have demonstrated improved survival with adjuvant therapy: a US study using postoperative chemoradiation and a European study using preoperative and postoperative chemotherapy. Anatomy The molecular biology responsible for carcinogenesis, tumor biology, and response to therapy in stomach cancer are active areas of investigation but are not addressed in this review. Instead, this article focuses on clinical management, which first requires a thorough understanding of gastric anatomy. An image depicting stomach anatomy can be seen below.
Stomach and duodenum, coronal section. The stomach begins at the gastroesophageal junction and ends at the duodenum. The stomach has 3 parts: the uppermost part is the cardia; the middle and largest part is the body, or fundus; and the distal portion, the pylorus, connects to the duodenum. These anatomic zones have distinct histologic features. The cardia contains predominantly mucin-secreting cells. The fundus contains mucoid cells, chief cells, and parietal cells. The pylorus is composed of mucusproducing cells and endocrine cells. The stomach wall is made up of 5 layers. From the lumen out, the layers include the mucosa, the submucosa, the muscularis layer, the subserosal layer, and the serosal layer. The peritoneum of the greater sac covers the anterior surface of the stomach. A portion of the lesser sac drapes posteriorly over the stomach. The gastroesophageal junction has limited or no serosal covering. The right portion of the anterior gastric surface is adjacent to the left lobe of the liver and the anterior abdominal wall. The left portion of the stomach is adjacent to the spleen, the left adrenal gland, the superior portion of the left kidney, the ventral portion of the pancreas, and the transverse colon. The site of stomach cancer is classified on the basis of its relationship to the long axis of the stomach. Approximately 40% of cancers develop in the lower part, 40% in the middle part, and 15% in the upper part; 10% involve more than one part of the organ. Most of the decrease in gastric cancer incidence and mortality in the United States has involved cancer in the lower part
of the stomach; the incidence of adenocarcinoma in the cardia has actually shown a gradual increase. Pathophysiology There are 3 oncogenic pathways that are deregulated in the majority (>70%) of gastric cancers: the proliferation/stem cell, NF-kappa β, and Wnt/beta-catenin pathways. Their study suggests that interactions between these pathways may play an important role in influencing disease behavior and patient survival. Understanding the vascular supply of the stomach allows understanding of the routes of hematogenous spread. The vascular supply of the stomach is derived from the celiac artery. The left gastric artery, a branch of the celiac artery, supplies the upper right portion of the stomach. The common hepatic artery branches into the right gastric artery, which supplies the lower portion of the stomach, and the right gastroepiploic branch, which supplies the lower portion of the greater curvature. Understanding the lymphatic drainage can clarify the areas at risk for nodal involvement by cancer. The lymphatic drainage of the stomach is complex. Primary lymphatic drainage is along the celiac axis. Minor drainage occurs along the splenic hilum, suprapancreatic nodal groups, porta hepatis, and gastroduodenal areas.
GORDON’S 11 FUNCTIONAL HEALTH PATTERN
HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN Before hospitalization: The patient views health as an important matter. She said that absence of disease means wellness which is contributive to her satisfying performance of ADL’ s. She believes in doctors and nurses but takes OTC meds except ibuprofen because according to her she has allergy on it. During Hospitalization The patient and her SO’s acquired help from the hospital when she experience pain on her abdomen. She was admitted because they believed that her condition is a serious matter.
NUTRITIONAL METABOLIC PATTERN Before hospitalization The patient has no allergy on food. She usually eats 3x a day but sometimes losses her appetite. Her usual meals is composed of coffee, rice, while her lunch and dinner composed of rice, vegetables , meat or fish. She drink 5-6 glasses a day. During Hospitalization The patient is NPO for 2 days prior to her operation. ELIMINATION PATTERN Before Hospitalization The patient has irregular bowel function. she sometimes defecate once or twice a week and sometimes she defecates everyday with a dark brown stool. She urinates 5-6 times a day with a yellow ambered urine. During Hospitalization The patient was on IFC intact and draining well. She had a dark yellow orange urine. She did not yet defecate. SLEEP REST PATTERN Before Hospitalization According to the patient, she has trouble in sleeping. She sleeps 10 in the evening and wakes up 1 in the morning. Then if she feels sleepy in the morning even if she was doing her household chores she goes to bed and sleeps. She doesn’t take naps in the afternoon .She only sits and stays at home and sometimes she watch TV.
During Hospitalization . According to her, she cannot sleep well due to the pain she feels. She usually get her sleep at 8 in the evening but wakes at 10 then she gets her sleep at 1 and wakes up at 5 am. ACTIVITY EXERCISE PATTERN Before Hospitalization The patient considers he daily household chores to be a form of her exercisers. She cleans the house, washed the clothes, and washed the dishes. During Hospitalization
The patient almost stays on her bed lying flat. According to her she cannot do bathing alone. She needs assistance of her grandson and his husband in going to the C.R
COGNITIVE PERCEPTUAL PATTERN Before Hospitalization The client is in good mental status. She just finish grade 2. She knows a little in reading and writing .She can understand tagalog, ilokano and itawis. She knows how to compute. During hospitalization The client has a good communication skills. She interacts with us actively and happily .She answers our question immediately and comprehensively. But she is not aware of her disease she only that she has a serious disease and needs a prompt treatment.
ROLE-RELATIONSHIP PATTERN Before hospitalization According to the patient, she lives with her husband and stays their daughter at Allacapan Cagayan. She has 2 children but only one are alive. She has 17 grandsons and granddaughters. They have a good relationship with each other. They sometimes have misunderstanding but they settle it immediately. During hospitalization Her husband and her grandson are there to care for her. They are very supportive and they provide all her needs in her hospitalization SELF PERCEPTION-SELF CONCEPT PATTERN Before Hospitalization She considers herself as a strong person and she do her best to provide the needs of their family. She considers herself as helpful especially in doing their household chores. She often socialized with her neighbors but she was friendly and accommodating when neighbors came to their house .She was a loving parent as well as being a grandmother to her grandsons and granddaughters. During Hospitalization She considers herself as a burden to her family due to her condition. But she still believes that she can still help her family by helping herself to recover from her illness. COPING-STRESS TOLERANCE PATTERN Before Hospitalization According to the patient, dirty house, quarrels and noisy environment predispose her mostly to stress. When she encounters problems she solve it herself. As much as possible, she doesn’t want to tell it to her family. But if he can no longer bear it, she tells it to her husband, and her children. During Hospitalization She feels stress all the time because of her condition. But she was able to manage it by talking to her husband and taking rest.
SEXUALITY-REPRODUCTIVE PATTERN
Before Hospitalization According to the patient, she had her menarche when she was 12 years old and menopause at the age of 40. She was married when she was 17 years old. She has 11 children, 5 boys and 6 girls, 2 are now dead due to rabies and unknown disease. Her children were all married and she had also 17 grandchildren. During hospitalization According to the patient, she can no longer engage in sexual activity because they are too old enough to do it. VALUES- BELIEF PATTERN Before Hospitalization She was an active member as well as a deaconess of the Iglesia ni cristo since 1982 . she attends mass every Thursday and Saturday . She has a strong faith in God and she considers as a powerful instrument on her daily life. During Hospitalization The clients faith was still very strong even if she has illness. She hopes that through the help of God, she will get soon. She always pray and trust God that He will be there for her. She entrusted her life to God.
PHYSICAL ASSESSMENT AREA ASSESSED SKIN Color
Temperature
Mobility and turgor HAIR Color Texture Distribution
METHOD USED NORMAL FINDINGS
ACTUAL FINDINGS
REMARKS
Inspection
Varies from light to deep brown, from ruddy pink to light pink, from yellow overtone to olive.
With pallor
Slightly Normal
Palpation
Uniformity of warmth and within the normal range Varies with environmental temp. And humidity, body temp. And activity.
37.1
Normal
Varies with environmental temp. and humidity, body temp. and activity.
Normal
Palpation
Springs back to normal when pinched.
Thin legs and feet.
Normal
Inspection Palpation inspection
Black Fine, straight, silky and resilient Evenly distributed hair
Black Fine but dry Evenly distributed hair
Normal Normal Normal
Nail surface is slightly curved or flat Nail edges are smooth, rounded and clean Pink, highly vascularized Prompt return of usual color(1sec.)
Surface is slightly curved Edges are rough and dirty Yellowish-whitish Prompt return of usual color
Normal Due to poor hygiene Normal Normal
Normocephalic and symmetrical facial movement
Normocephalic and symmetrical facial movement
Normal
NAIL Shape and contour inspection Color Inspection Blanch test palpation
Head Size and shape
Inspection
Facial structures
Inspection
No abnormalities in structure, no involuntary muscle movement in facial muscles
No abnormalities in structure, no involuntary muscle movement in facial muscles
Normal
EYES Eyebrows
Inspection
Inspection
Hair evenly distributed, skin intact Symmetrically aligned, equal movement Equally distributed, curved slightly outward Clear, no discharge
Normal
Eyelashes
Hair evenly distributed, skin intact Symmetrically aligned, equal movement Equally distributed, curved slightly outward Clear, no discharge
Eyelids
Inspection
PERRLA
PERRLA
Normal
Conjunctiva
Inspection
Clear and unicteric
Clear and unicteric
Normal
Pupil
Inspection
Normal
inspection
Normal
Sclera NOSE Size, shape and color Discharge Nares Septum MOUTH Lips
Inspection Inspection Inspection
Normal
Symmetric and straight, color brown same as facial color No discharge No nasal flaring Intact and in midline
Symmetric and straight, color red No discharge No nasal flaring Intact and in midline
Pink color, soft, moist, smooth
Dry lips
Due to possible dehydration
Teeth
Inspection and palpation Inspection
Smooth, white, shiny tooth enamel
Normal
Gums
Inspection
Pink gums, moist, firm in texture
Smooth, yellowish enamel, incomplete teeth Pink gums, moist, firm in texture
Inspection
Normal Normal Normal Normal
Normal
NECK Head movement TH0RAX AND LUNGS Posterior and anterior thorax Lungs ABDOMEN symmetry umbilicus tenderness EXTREMITIES upper
lower
Inspection
Coordinated smooth movements without discomfort
Coordinated smooth movements without discomfort
Normal
Inspection
Chess wall intact, no tenderness
Elevated chest wall
Due to abnormalities in lungs
Auscultation
Chest symmetric
Chest symmetric
Normal
Inspection
Symmetrical bilaterally midline and inverted, no sign of discoloration, inflammation
Symmetrical bilaterally midline, with discoloration and inflammation
Normal
Palpation
No tenderness
Rigid and tender
Associated with gastroinstestinal abnormalities
Inspection and palpation
No edema No lesions
No edema No lesions
Normal
Inspection and palpation
No edema No lesions
No edema on her feet and legs nor lesions on legs
Normal
LABORATORY ANALYSIS HEMATOLOGY RESULT -
129 0.37 3.82 175 98.2 37. 7 343 15.2
(120 – 160 g/L) (0.38 – 0.47) (4.5 to 6.0 x 109 /L) (150 – 400 x 109 /L) (80 – 100 fL) (26 – 32 pg) (320 – 360 g/L) (4.5 – 11 x 109 /L)
-
96.9 2.6 0.5
(35 – 65) (20 – 40) (2 – 8)
Physical Test: Color Transparency pH Specific Gravity
-
amber turbid 5.0 1.030
Chemical Test Albumin Sugar Ketone Blood Bilirubin Nitrite Leukocytes
-
Trace Negative Positive Positive Negative Negative Negative
Hemoglobin in mass concentration Erythrocyte Volume Fraction Erythrocyte Number Concentration Thrombocyte Number Concentration Mean Corpuscular Volume (MCV) Mean Corpuscular Hemoglobin (MCH) Mean Corpuscular Hemoglobin Content Leukocyte Number Concentration WBC Differential Count: Neutrophils Lymphocytes Monocytes URINALYSIS RESULT
DRUG STUDY D5LRS + BIOMIX CELEMIN ½ x 12⁰ OD KETOROLAC 30 mg IV q 8⁰ GENERIC NAME: Ketorolac BRAND NAME: Toradol CLASSIFICATION: Nonsteroidal anti-inflammatory agents, nonopioid analagesics DOSAGE: 30mg/amp1 amp IM MECHANISM OF ACTION: - Inhibits prostaglandin synthesis, producing peripherally mediated analgesia - Also has antipyretic and anti-inflammatory properties. - Therapeutic effect:Decreased pain INDICATION: Short term management of pain (not to exceed 5 days total for all routes combined)
CONTRAINDICATIONS: - Hypersensitivity - Cross-sensitivity with other NSAIDs may exist¨Pre- or perioperative use - Known alcohol intoleranceUse cautiously in: 1) History of GI bleeding 2) Renal impair-ment (dosage reduction may be required) 3) Cardiovascular disease SIDE EFFECTS/ ADVERSE EFFECTS: - CNS: 1) drowsiness 2) abnormal thinking 3) dizziness 4) euphoria 5) headache- RESP: 1) asthma 2) dyspnea - CV: 1) edema 2) pallor 3) vasodilation - GI: 1) GI Bleeding 2) abnormal taste 3) diarrhea 4) dry mouth 5) dyspepsia 6) GI pain 7) nausea - GU: 1) oliguria 2) renal toxicity 3) urinary frequency - DERM: 1) pruritis 2) purpura 3) sweating 4) urticaria - HEMAT: 1) prolonged bleeding time - LOCAL: 1) injection site pain - NEURO: 1) paresthesia - MISC: 1) allergic reaction, anaphylaxis NURSING IMPLICATIONS/RESPONSIBILITIES: - Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria. - Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. - Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy.
- Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. - Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur. - Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another. HYDROCORTISONE 100 g IV q 8⁰ x 1 dose more HYDROCORTISONE ACETATE Anusol HC, CaldeCort, Carmol HC, Colifoam, Cortaid, Cortamed, Cort-Dome, Cortef Acetate, Corticaine, Cortifoam, Cortiment , Epifoam, Hydrocortone Acetate HYDROCORTISONE CYPIONATE Cortef Fluid HYDROCORTISONE SODIUM PHOSPHATE Hydrocortone Phosphate HYDROCORTISONE SODIUM SUCCINATE A-Hydrocort, Solu-Cortef HYDROCORTISONE VALERATE Westcort Classifications: skin and mucous membrane agent; antiinflammatory; synthetic hormone;adrenal corticosteroids; glucocorticoid; mineralocorticoid Pregnancy Category: C NURSING IMPLICATIONS Assessment & Drug Effects Establish baseline and continuing data on BP, weight, fluid and electrolyte balance, and blood glucose. Lab tests: Periodic serum electrolytes blood glucose, Hct and Hgb, platelet count, and WBC with differential. Monitor for adverse effects. Older adults and patients with low serum albumin are especially susceptible to adverse effects. Be alert to signs of hypocalcemia (see Appendix F). Ophthalmoscopic examinations are recommended every 2–3 mo, especially if patient is receiving ophthalmic steroid therapy. Monitor for persistent backache or chest pain; compression and spontaneous fractures of long bones and vertebrae present hazards. Monitor for and report changes in mood and behavior, emotional instability, or psychomotor activity, especially with long-term therapy. Be alert to possibility of masked infection and delayed healing (antiinflammatory and immunosuppressive actions). Note: Dose adjustment may be required if patient is subjected to severe stress (serious infection, surgery, or injury). Note: Single doses of corticosteroids or use for a short period (<1 wk) do not produce withdrawal symptoms when discontinued, even with moderately large doses. Patient & Family Education Expect a slight weight gain with improved appetite. After dosage is stabilized, notify physician of a sudden slow but steady weight increase [2 kg (5 lb)/wk]. Avoid alcohol and caffeine; may contribute to steroid-ulcer development in long-term therapy. Do not ignore dyspepsia with hyperacidity. Report symptoms to physician and do NOT selfmedicate to find relief. Do NOT use aspirin or other OTC drugs unless prescribed specifically by the physician. Note: A high protein, calcium, and vitamin D diet is advisable to reduce risk of corticosteroidinduced osteoporosis. Notify physician of slow healing, any vague feeling of being sick, or return to pretreatment symptoms. Do not abruptly discontinue drug; doses are gradually reduced to prevent withdrawal symptoms. Report exacerbation of disease during drug withdrawal.
Carry medical identification at all times. It needs to indicate medical diagnosis, drug therapy, and name of physician. Apply topical preparations sparingly in small children. The hazard of systemic toxicity is higher because of the greater ratio of skin surface area to body weight. Check shelf-life date on topical corticosterone during long-term use. Do not breast feed while taking/using this drug without consulting physician.
FUROSEMIDE 40 mg IV q 8⁰ with BP precaution GENERIC NAME: furosemide BRAND NAME: Lasix DRUG CLASS AND MECHANISM: Furosemide is a potent diuretic (water pill) that is used to eliminate water and salt from the body. In the kidneys, salt (composed of sodium and chloride), water, and other small molecules normally are filtered out of the blood and into the tubules of the kidney. The filtered fluid ultimately becomes urine. Most of the sodium, chloride and water that is filtered out of the blood is reabsorbed into the blood before the filtered fluid becomes urine and is eliminated from the body. Furosemide works by blocking the absorption of sodium, chloride, and water from the filtered fluid in the kidney tubules, causing a profound increase in the output of urine (diuresis). The onset of action after oral administration is within one hour, and the diuresis lasts about 6-8 hours. The onset of action after injection is five minutes and the duration of diuresis is two hours. The diuretic effect of furosemide can cause depletion of sodium, chloride, body water and other minerals. Therefore, careful medical supervision is necessary during treatment. The FDA approved furosemide in July 1982. PRESCRIPTION: Yes GENERIC AVAILABLE: Yes PREPARATIONS: Tablets: 20, 40, and 80mg. Oral solution: 10 mg/ml, 40 mg/5 ml. Injection: 10 mg/ml STORAGE: Furosemide should be stored at room temperature in a light resistant container. PRESCRIBED FOR: Furosemide is a powerful diuretic that is used to treat excessive accumulation of fluid and/or swelling (edema) of the body caused by heart failure, cirrhosis, chronic kidney failure, and the nephrotic syndrome. It is sometimes used alone or in conjunction with other blood pressure pills to treat high blood pressure. DOSING: The usual starting oral dose for treatment of edema in adults is 20-80 mg as a single dose. The same dose or an increased dose may be administered 6-8 hours later. Doses may be increased 20-40 mg every 6-8 hours until the desired effect occurs. The effective dose may be administered once or twice daily. Some patients may require 600 mg daily. The starting oral dose for children is 2 mg/kg. The starting dose may be increased by 1-2 mg/kg every 6 hours until the desired effect is achieved. Doses greater than 6 mg/kg are not recommended. The recommended dose for treating hypertension is 40 mg twice daily. DRUG INTERACTIONS: Administration of furosemide with aminoglycoside antibiotics (for example, gentamicin) or [ethacrynic acid (Edecrin) - another diuretic] may cause hearing damage. Furosemide competes with aspirin for elimination in the urine by the kidneys. Concomitant use of furosemide and aspirin may, therefore, lead to high blood levels of aspirin and aspirin toxicity. Furosemide also may reduce excretion of lithium (Eskalith, Lithobid) by the kidneys, causing increased blood levels of lithium and possible side effects from lithium. Sucralfate (Carafate) reduces the action of furosemide by binding furosemide in the intestine and preventing its absorption into the body. Ingestion of furosemide and sucralfate should be separated by two hours. PREGNANCY: There are no adequate studies of furosemide in pregnant women. NURSING MOTHERS: Furosemide is secreted in breast milk. Nursing mothers should avoid breastfeeding while taking furosemide.
SIDE EFFECTS: Common side effects of furosemide include low blood pressure, dehydration and electrolyte depletion (for example, sodium, potassium). Less common side effects include jaundice, ringing in the ears (tinnitus), sensitivity to light (photophobia), rash, pancreatitis, nausea,diarrhea, abdominal pain, and dizziness. Increased blood sugar and uric acid levels also may occur. IPATROPINE + SALBUTAMOL q 6⁰ CEFTRIAXONE 1g IV q 12⁰ cephalosporin. It preferentially binds to one or more of the penicillin-binding proteins (PBP) located on cell walls of susceptible organisms. This inhibits third and final stage of bacterial cell wall synthesis, promoting osmotic instability, thus killing the bacterium. Dosage: 1 g IM, 7 gms IVTT every 24 hours This drug is indicated in patients with neurologic complications, carditis and arthritis. It is also effective in Gram negative infections; Meningitis, Gonorrhea. It is also for Bone and joint infections, Lower respiratory tract infections, middle ear infection, PID, Septicemia and Urinary Tract infections. Contraindications: Patients hypersensitive to cephalosporins, penicillins and related antibiotics. Pregnancy (Category B). Breastfeeding women. Side effects:
CNS: fever, dizziness CV: phlebitis GI: diarrhea, abdominal cramps, pseudomembranous colitis, biliary sludge URO: Genital pruritus; moniliasis HEM: eosinophilia, thrombocytosis, leukopenia SKIN: pain, indurations, tenderness, rash other: hypersensity reactions
Drug Interactions:
Probenecid decreases renal elimination of ceftriaxone Aminoglycosides may cause synergistic effects Alcohol use causes disulfiram like reactions
Nursing Responsibilities:
determine hypersensitivity reactions periodic coagulation studies (PT and INR) should be done. inject in large muscles, such as gluteus maximus or lateral aspect of thigh and rotate sites. report signs such as petechiae, ecchymotic areas, epistaxis or other forms of unexplained bleeding. avoid alcohol use
OMEPRAZOLE 40mg @V q 8⁰
GENERIC NAME: omeprazole, omeprazole/sodium bicarbonate BRAND NAME: Prilosec, Zegerid DRUG CLASS AND MECHANISM: Omeprazole is in a class of drugs called proton pump inhibitors (PPI) that block the production of acid by the stomach. Other drugs in the class include lansoprazole (Prevacid),rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium). Proton pump inhibitors are used for the treatment of conditions such as ulcers, gastroesophageal reflux disease (GERD) and the Zollinger-Ellison syndrome, which are all caused by stomach acid. Omeprazole, like otherproton-pump inhibitors, blocks the enzyme in the wall of the stomach that produces acid. By blocking the enzyme, the production of acid is decreased, and this allows the stomach and esophagus to heal. Zegerid contains omeprazole and an antacid (sodium bicarbonate). The FDA approved omeprazole in September 1989. GENERIC AVAILABLE: Yes (Prilosec) PRESCRIPTION: Yes; No (Prilosec OTC, Zegerid OTC) PREPARATIONS: Capsules: 10, 20 and 40 mg. Tablets: 20 mg (Prilosec OTC). Powder for oral suspension: 20 and 40 mg STORAGE: Capsules should be stored at 15 to 30 C (59 to 86 F) and tablets at 20 to 25 C (68 to 77 F). They should be kept away from moisture and light. PRESCRIBED FOR: Omeprazole is used for treating acid-induced inflammation and ulcers of the stomach and duodenum; gastroesophageal reflux disease (GERD); erosive esophagitis, heartburn; prevention of upper gastrointestinal bleeding in critically ill patients; and ZollingerEllison Syndrome. It also is used in combination with antibiotics for eradicating H. pylori infection of the stomach. DOSING: For ulcers, GERD, erosive esophagitis and eradication of H. pylorithe recommended dose for adults is 20-40 mg daily. Ulcer healing usually occurs within 4-8 weeks. H. pylori infections are treated for 10-28 days. The usual dose for prevention of upper gastrointestinal bleeding in critically ill patients is 40 mg daily for 14 days. Prilosec OTC is used for treating heartburn for up to two weeks, and the usual dose is 20 mg daily. For the management of Zollinger-Ellison Syndrome the starting dose for adults is 60 mg daily, and the dose is adjusted based on either the response of symptoms or the actual measurement of acid production. Doses greater than 80 mg should be divided. Doses up to 120 mg three times a day have been used in the treatment of Zollinger-Ellison Syndrome. For maximal efficacy, omeprazole tablets should be taken before meals, swallowed whole and should not be crushed, chewed or opened. DRUG INTERACTIONS: Omeprazole potentially can increase the concentrations in blood of diazepam (Valium), warfarin (Coumadin), andphenytoin (Dilantin) by decreasing the elimination of these drugs by the liver. The absorption of certain drugs may be affected by stomach acidity. Therefore, omeprazole as well as other PPIs reduce the absorption and concentration in blood of ketoconazole (Nizoral) and increase the absorption and concentration in blood of digoxin (Lanoxin). This may reduce the effectiveness of ketoconazole or increase digoxin toxicity. Through unknown mechanisms, omeprazole may increase blood levels of saquinavir and reduce blood levels of nelfinavir and atazanavir, drugs that are used for treating patients with infection caused by the human immunodeficiency virus (HIV). Accordingly, the dose of saquinavir may need to be reduced to avoid toxicity, and the doses of nelfinavir and atazanavir may need to be increased to maintain efficacy.
ASSESSMENT
NURSING DIAGNOSIS
PLANNING
Subjective: “Nasakit unay toy sugat ko.” As verbalized by the patient.
Altered comfort: -pain r/t presence of surgical incision
At the end of the shift as evidence by pain scale of 5/10, the client will be able to verbalized relief from pain
Objective: - facial grimacing - guarded movement -moaning -irritability -pain scale 9/10
Objective: Surgical incision
NURSING INTERVENTION Assessed pain, note location, character, severity
RATIONALE
EVALUATION
Use in monitoring effectiveness of care
Kept at rest in semi fowler’s position
Gravity localized inflammatory exudates into lower abdomen/pelvis
The goal was partially met because client wasn’t able to have relief pain as evidenced by client’s pain scale of 7/10
Encouraged early ambulation Provided diversional activities
Risk for infection r/t surgical incision
At the end of the shift, the client will achieved timely wound belching and be afebrile
Observed for localized signs at insertion of invasive lines, sutures, surgical incision wounds Proper handwashing techniques by all caregiver between therapies. Encouraged early ambulation, deep breathing, couging, position change and emphasize necessity taking antibiotics as
Promote normalization of organ function Refocuses attention, promote relaxation and may enhance coping abilities Relief of pain facilitates cooperation with therapeutic intervention To assess causative / contributing infection A first-line defense against nosocomial infection/cross contamination Prevent exposure of client to reduce / correct existing risk for infection For mobilization of respiratory secretions
Goal met, the pt. achieve timely wound with febrile
directed
Subjective: “Nanghihina talaga ako.” Objective: Always in bed Drowsy listless
Fatigue r/t poor physical condition
After 2 days of rendering interventions, the client will improve sense of energy as evidence by good physical condition, unlistless, undrowsy and can move out of bed.
Measure physiological response to activity
Premature discontinuation of treatment when client begins to feel well may result in return of infection To determine degree of fatigue
Establish realistic activity goals with client
Enhance commitment to promote optimal outcomes
Provide environment conducive to relief of fatigue
Temperature and level of humidity all known to affect exhaustion
Assist client to identify appropriate coping behavior
Promote sense of control and improves self-esteem
Goal unmet due to pain and old age.
