I.
Personal Data
Name: Patient F
16 years old Age: Male Sex: Nationality: Filipino Ward: Male Medical Ward Bed No: G12 II.
Diagnosis
Acute Gastritis Gastritis with with some signs signs of dehydratio dehydration n III.
III.A
History tory of Pres resent ent Illness ess Signs & Symptoms • • • • •
III.$
omiting A!dominal A!dominal Pain "ausea Indigestion #eadache
Allergies
"one as claimed !y the patient
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Past Illness
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IV.
Anatomy & Ph Physiology
'he gastrointestinal (I! tract is a passageway that !egins at the lips and ends at the anus (Figure 1). Its purpose is to transport and digest food. Along the way* the passageway changes character !ecause different functions are re+uired at different points. In the uppermost portion* the teeth !egin the process of digestion !y grinding food into small fragments. 'he esophagus deli,ers the food to the stomach where strong acid further !rea-s up and degrades the swallowed material.
mall amounts of the li+uified food called chyme are then deli,ered in spurts from the stomach into the duodenum where they are mi/ed with !ile from the li,er (,ia the !ile ducts) and pancreatic 0uice (,ia the pancreatic duct). $ile aids in the !rea-down and digestion of fat* while the pancreatic enyme amylase fragments starches into smaller molecules. 'he pancreas also releases a fluid into the duodenum* which neutralies the acidic stomach contents. 'his neutral !ileamylasefragmented food su!stance passes to the upper small intestine for the ne/t phase of digestion. It is mo,ed along !y peristalsis* worm3li-e contractions of the intestine. 'he small intestine is so named !ecause its cali!re is small* a!out one inch in diameter. 'he term small creates some confusion !ecause* in terms of length* it is not small at all. In fact* it normally measures nearly 24 feet in length5 'he small intestines 0o! is a!sorption of food. 'he !ody gains access to the food that we consume !y means of a!sorption of microscopic particles of food through the wall of the small intestine. itamins and minerals and large amounts of fluid are also a!sor!ed !y the small intestine and pass into the !loodstream for distri!ution to the rest of the !ody. $y the time the intestinal contents reach the large intestine* most of its nutritional ,alue has !een e/tracted* lea,ing a watery waste product. 'he role of the large intestine is fluid a!sorption from the remaining waste and compaction and storage of what is left. 7/pulsion of the waste (feces* stool) is generally under ,oluntary control and is underta-en when socially con,enient. 'he large intestine is so named !ecause it is wider than the small intestine* not !ecause it is longer. It is much shorter than the small intestine* measuring a!out 8 feet. Another name for the large intestine is the colon. It !egins in the lower portion of the right side of the a!domen and tra,els up the right side to turn across the midline and !ac- down the left side much li-e a s+uare picture frame (Figure 2). As stool mo,es from the cecum to ascending colon* trans,erse colon* descending colon* sigmoid colon* and finally rectum* it !ecomes less watery and more compacted. 'he rectum is the last foot or so of the large intestine and it lies surrounded !y the !ones of the pel,is. At the ,ery !ottom of the rectum is the anus* where lie the sphincter muscles that control the opening of the !owel. V.
Patho"hysiology of A#$te astritis
Acute gastritis can !e caused !y stress* chemical su!stances such as drugs and alcohol* spicy foods* hot and sour. In e/periencing the stress will occur sympathetic ner,e stimulation " (,agus ner,e)* which will increase the production of hydrochloric acid (#%l) in the stomach. 'he presence of #%l that is in the stomach will cause nausea* ,omiting and anore/ia. %hemicals or stimulating foods will cause columnar epithelial cells* whose function is to produce mucus* reducing production. While it is the function of mucus to protect gastric mucosa that did not participate undigested. 'he response of the gastric mucosa due to decreased ,asodilation* mucous secretion ,aries among gastric mucosal cells. 'here gastric mucosal lining cells produce #%l (especially the fundus) and !lood ,essels. asodilatation gastric mucosa will cause increased production of #%l. Anore/ia can also cause pain. 'he pain inflicted !y #%l contact with the gastric mucosa. 9esponse due to decreased gastric mucosal mucus secretion may !e e-sfeliasi (e/foliation). Gastric mucosal cell e/foliation will lead to erosion of the mucosal cells. Mucosal cell loss due to erosion lead to !leeding. $leeding happens to people with life3threatening* !ut it can also stop yourself !ecause the process of regeneration* so that erosion disappear within 2:3:; hours after hemorrhage. Additional Information astritis is an inflammation* irritation* or erosion of the lining of the stomach. It can occur suddenly (acute) or gradually (chronic).
%hemicals or stimulating foods will cause columnar epithelial cells* whose function is to produce mucus* reducing production. While it is the function of mucus to protect gastric mucosa that did not participate undigested. 'he response of the gastric mucosa due to decreased ,asodilation* mucous secretion ,aries among gastric mucosal cells. 'here gastric mucosal lining cells produce #%l (especially the fundus) and !lood ,essels. asodilatation gastric mucosa will cause increased production of #%l. Anore/ia can also cause pain. 'he pain inflicted !y #%l contact with the gastric mucosa. 9esponse due to decreased gastric mucosal mucus secretion may !e e-sfeliasi (e/foliation). Gastric mucosal cell e/foliation will lead to erosion of the mucosal cells. Mucosal cell loss due to erosion lead to !leeding. $leeding happens to people with life3threatening* !ut it can also stop yourself !ecause the process of regeneration* so that erosion disappear within 2:3:; hours after hemorrhage. %a$ses of astritis
Gastritis can !e caused !y irritation due to e/cessi,e alcohol use* chronic ,omiting* stress* or the use of certain medications such as aspirin or other anti3inflammatory drugs. It may also !e caused !y any of the following<
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Heli#oa#ter "ylori (H. "ylori!: A !acteria that li,es in the mucous lining of the stomach= without treatment* the infection can lead to ulcers* and in some people* stomach cancer. Perni#io$s anemia: A form of anemia that occurs when the stomach lac-s naturally occurring su!stance needed to properly a!sor! and digest ,itamin $12 Bile refl$x: A !ac-flow of !ile into the stomach from the !ile tract (that connects to the li,er and gall!ladder) Infe#tions caused !y !acteria and ,iruses If gastritis is left untreated* it can lead to a se,ere loss of !lood and may increase the ris- of de,eloping stomach cancer.
Diagnosti# Pro#ed$re •
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'""er endos#o"y. An endoscope* a thin tu!e containing a tiny camera* is inserted through your mouth and down into your stomach to loo- at the stomach lining. 'he doctor will chec- for inflammation and may perform a !iopsy* a procedure in which a tiny sample of tissue is remo,ed and then sent to a la!oratory for analysis. Blood tests. chec-ing your red !lood cell count to determine whether you ha,e anemia* which means that you do not ha,e enough red !lood cells. It can also screen for #. pylori infection and pernicious anemia with !lood tests. e#al o##$lt lood test (stool test!. 'his test chec-s for the presence of !lood in your stool* a possi!le sign of gastritis. )reatment for astritis
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'a-ing antacids and other drugs (such as proton pump inhi!itors or #32 !loc-ers) to reduce stomach acid
A,oiding hot and spicy foods
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If the gastritis is caused !y pernicious anemia* $12 ,itamin shots will !e gi,en. 7liminating irritating foods from your diet such as lactose from dairy or gluten from wheat
VI.
Diagnosti# st$dies %$%3 determine le,els of red to white !lood cells and to chec- if anaemia is a cause. •
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7G>3 to image and determine the health of oesophagus3to3stomach3 to3duodenum function.
VII. *edi#al *anagement Medication
?mepraole :@mg e,ery 12 hours I
eneri# Nameuodenal and gastric ulcer. Gastroesophageal reflu/ disease including se,ere erosi,e esophagitis (: to ; w- treatment). &ong3term treatment of pathologic hypersecretory conditions such as ollinger37llison syndrome* multiple endocrine adenomas* and systemic mastocytosis. In com!ination with clarithromycin to treat duodenal ulcers associated with #elico!acter pylori. %ontraindi#ations :&ong3term use for gastroesophageal reflu/ disease* duodenal ulcers= lactation. Ad+erse effe#ts %NS:#eadache* diiness* fatigue. I:Diarrhea* a!dominal pain* nausea* mild transient increases in li,er function tests. 'rogenital:#ematuria* proteinuria. S,in:9ash. N$rsing im"li#ations Assessment & Dr$g -ffe#ts a tests< Monitor urinalysis for hematuria and proteinuria. Periodic li,er function tests with prolonged use. Patient & amily -d$#ation 9eport any changes in urinary elimination such as pain or discomfort associated with urination* or !lood in urine. 9eport se,ere diarrhea= drug may need to !e discontinued. >o not !reast feed while ta-ing this drug.
'rane/amic Acid 8@@mg e,ery 6 hours
eneri# Name:'rane/amic Acid
%lassifi#ation )hera"e$ti# < hemostatic agents Pharma#ologi#: fi!rinolysis inhi!itors Indi#ations and 'sage Patients with hemophilia for short3term use (two to eight days) 'o reduce or pre,ent hemorrhage during and following tooth e/traction. 'reatment of se,ere localied !leeding secondary to hyperfi!rinolysis* including epista/is* hyphema* or hypermenorrhea (menorrhagia) and hemorrhage following certain surgical procedures 'reatment of hereditary angioedema Side -ffe#ts • • •
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"ausea omiting >iarrhea #ypotension 'hrom!oem!olic* e.g.* arterial* ,enous* em!olic= "eurologic* e.g.* ,isual impairment* con,ulsions* headache* mental status changes= myoclonus= 9ash %ontraindi#ations 'rane/amic acid is contraindicated in patients with<
hypersensiti,ity to trane/amic acid or any of the ingredients ac+uired defecti,e color ,ision* since this prohi!its measuring one endpoint that should !e followed as a measure of to/icity su!arachnoid hemorrhage acti,e intra,ascular clotting Precautions Pregnan#y 'rane/amic acid crosses the placenta. $reast3feeding 'rane/amic acid is distri!uted into !reast mil-= concentrations reach appro/imately 1 of the maternal plasma concentration "ursing 9esponsi!ilities Before:
Monitor !lood pressure* pulse* and respiratory status as indicated !y se,erity of !leeding. Monitor for o,ert !leeding e,ery 18H4@ min. Monitor neurologic status (pupils* le,el of consciousness* motor acti,ity) in patients with su!arachnoid hemorrhage.
Assess for throm!oem!olic complications.(especially in patients with history). "otify physician of positi,e #omans sign* leg pain hemorrhage* edema* hemoptysis* dyspnea* or chest pain. Monitor platelet count and clotting factors prior to and periodically throughout therapy in patients with systemic fi!rinolysis. D$ring: ta!ilie I catheter to minimie throm!ophle!itis. Monitor site closely.
After:
Instruct patient to notify the nurse immediately if !leeding recurs or if throm!oem!olic symptoms de,elop. %aution patient to ma-e position changes slowly to a,oid orthostatic hypotension.
>iphenhydramine 8@g 1 cap $I> P?
%ASSII%A)I/N: Antipar-insonian drug A%)I/N: Antagonies the effect of histamine at #1 receptor sites= does not !ind or inacti,ate histamine INDI%A)I/N 0 'S-S: par-insonism or drug3induced e/trapyramidal effects %/**/N ADV-1S- --%)S: %NS: headache* fatigue* an/iety* tremors* ,ertigo* confusion* depression* seiures* hallucinations %V: tachycardia* palpitations* orthostaic hypotension* heart failure --N)< !lurred ,ision I: dry mouth* nausea* ,omiting* constipation* flatulence '< urinary hesitancy or fre+uency* urine retention Hematologi#< leu-openia S,in: photosensiti,ity* dermatitis %/N)1A2INDI%A)I/NS: cardiac disease or hypertension glaucoma gastric or duodenal ulcers N'1SIN %/NSID-1A)I/NS: %aution the client that the medication may cause drowsiness* creating difficulties or haards or other acti,ities that re+uire alertness. 'ell the client to ta-e the medication with food to decrease GI upset. •
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7/plain to the client that arising +uic-ly form a lying or sitting position may cause orthostatic hypotension. When ta-ing these medications* the client needs to ha,e !lood cells counts* renal function* hepatic function* and !lood pressure monitored. Ad,erse effects of these drugs occur more commonly in elderly clients. 7/plain to the client that use of these drugs in warm weather may increase the li-elihood of heatstro-e.
ucralfate 1gta! B J glass of #2@ 'I> P?
eneri# Name : sucralfate %lassifi#ation< Antiulcer drug
Pregnancy %ategory $ )hera"e$ti# a#tions ucralfate protects GI lining against peptic acid* pepsin and !ile salts !y !inding with positi,ely3charged proteins in e/udates forming a ,iscous paste3li-e adhesi,e su!stance thus forming a protecti,e coating. Indi#ations hort3term treatment of duodenal ulcers* up to ; wMaintenance therapy for duodenal ulcer at reduced dosage after healing ?rphan drug use< 'reatment of oral and esophageal ulcers due to radiation* chemotherapy* and sclerotherapy Knla!eled uses< Accelerates healing of gastric ulcers* long3term treatment of gastric ulcers* treatment of reflu/ and peptic esophagitis* treatment of "AI> or aspirin3induced GI symptoms and GI damage* pre,ention of stress ulcers in critically ill patients • • •
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N$rsing #onsiderations Assessment History: Allergy to sucralfate= chronic renal failure or dialysis= pregnancy* lactation Physi#al: -in color* lesions= refle/es* orientation= mucous mem!ranes* normal output Inter+entions Gi,e drug on an empty stomach* 1 hr !efore or 2 hr after meals and at !edtime. Monitor pain= use antacids to relie,e pain. Administer antacids !etween doses of sucralfate* not within 4@ min !efore or after sucralfate doses. Measure and record regular weight to monitor mo!iliation of edema fluid. A,oid gi,ing food rich in potassium. • • •
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Arrange for regular e,aluation of serum electrolytes* $K".
)ea#hing "oints 'a-e the drug on an empty stomach* 1 hour !efore or 2 hours after meals and at !edtime. If you are also ta-ing antacids for pain relief* do not ta-e antacids 4@ minutes !efore or after ta-ing sucralfate. Lou may e/perience these side effects< >iiness* ,ertigo (a,oid dri,ing or operating dangerous machinery)= indigestion* nausea (eat fre+uent small meals)= dry mouth (use fre+uent mouth care* suc- on sugarless loenges)= constipation (re+uest aid). 9eport se,ere gastric pain. •
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Metoclopramide 1@g e,ery ;hours P9" for nausea ,omiting
%lassifi#ations:gastrointestinal agent= pro-inetic agent (gi stimulant)= autonomic ner,ous system agent= direct3acting cholinergic (parasympathomimetic)= antiemetic Pregnan#y %ategory:B A#tions < Potent central dopamine receptor antagonist. tructurally related to procainamide !ut has little antiarrhythmic or anesthetic acti,ity. 7/act mechanism of action not clear !ut appears to sensitie GI smooth muscle to effects of acetylcholine !y direct action. )hera"e$ti# effe#ts Increases resting tone of esophageal sphincter* and tone and amplitude of upper GI contractions. As a result* gastric emptying and intestinal transit are accelerated with little effect* if any* on gastric* !iliary* or pancreatic secretions. Antiemetic action results from drug3induced ele,ation of %' threshold and enhanced gastric emptying. In dia!etic gastroparesis* indicated !y relief of anore/ia* nausea* ,omiting* persistent fullness after meals. 'ses Management of dia!etic gastric stasis (gastroparesis)= to pre,ent nausea and ,omiting associated with emetogenic cancer chemotherapy (e.g.* cisplatin* dacar!aine)= to facilitate intu!ation of small !owel= symptomatic treatment of gastroesophageal reflu/. %ontraindi#atons ensiti,ity or intolerance to metoclopramide= allergy to sulfiting agents= history of seiure disorders= concurrent use of drugs that can cause e/trapyramidal symptoms= pheochromocytoma= mechanical GI o!struction or perforation= history of !reast cancer. afety during pregnancy (category $) or lactation is not esta!lished. %a$tio$s 'se %#F= hypo-alemia= -idney dysfunction= GI hemorrhage= history of intermittent porphyria.
N$rsing Im"li#ations Assessment & Dr$g -ffe#ts 9eport immediately the onset of restlessness* in,oluntary mo,ements* facial grimacing* rigidity* or tremors. 7/trapyramidal symptoms are most li-ely to occur in children* young adults* and the older adult and with high3dose treatment of ,omiting associated with cancer chemotherapy. ymptoms can ta-e months to regress. $e aware that during early treatment period* serum aldosterone may !e ele,ated= after prolonged administration periods* it returns to pretreatment le,el. &a! tests< Periodic serum electrolyte. Monitor for possi!le hypernatremia and hypo-alemia* especially if patient has %#F or cirrhosis. Ad,erse reactions associated with increased serum prolactin concentration (galactorrhea* menstrual disorders* gynecomastia) usually disappear within a few wee-s or months after drug treatment is stopped. •
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N$rsing %are Plan:
Assessment< S$3e#ti+e: NMasa-it tiyan -o at nagsusu-a a-o pag-atapos -umainO as ,er!alie !y the patient /3e#ti+e: a!dominal pain scale up to out of 1@* whitish gastic output
"ursing >iagnosis Acute Pain related to irritation of mucous Impaired nutritional needs less than body requirements related to inadequate intake, anorexia. Interference volume of fluid and electrolyte balance is less than body requirements related to inadequate intake, vomiting.
Planning : Pain can !e reducedlost "utritional deficiencies resol,ed. Patients can increase the input of nutrients is ade+uate and to a,oid irritating foods. >isorders of fluid !alance did not occur. Nursing interventions Instruct to a,oid foods and !e,erages that may !e irritate the gastric mucosa 9e,iew pain scale and location of pain* o!ser,ation of ,ital signs* pro,ide a +uiet and comforta!le en,ironment* encourage rela/ation techni+ues with !reath in* do the colla!oration in the pro,ision of drugs in accordance with the indication to reduce the pain. •
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Assess food inta-e* !ody weight !alanced on a regular !asis* gi,e oral care on a regular !asis* encourage clients to eat little !ut often* gi,e food in warm* auscultation !owel sounds* assess food preferences* super,ised la!oratory tests such as< #!* #t* Al!umin A,oid caffeine drin-s A,oid alcohol and nicotine. Pro,ide physical and emotional support A,oid foods and li+uids !y mouth until acute symptoms of decreases Assess signs and symptoms of dehydration* ,ital sign o!ser,ation* measuring inta-e and encourage clients to drin- out Q 18@@328@@ml* o!ser,ation of s-in and mucous mem!ranes* in colla!oration with the medical pro,ision of intra,enous fluids. $eware of the indicator gastritis hemorragis (#ematemesis* tachycardia* hypotension).
!valuation •
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Pain gone controlled* loo-ed rela/ed and a!le to sleep rest* pain scale shows the num!er @. ta!le weight* normal la!oratory ,alues al!umin* no nausea and ,omiting weight within normal limits* normal !owel sounds. Moist mucous mem!ranes* good s-in turgor* electrolytes returned to normal* capillary filling pin-* sta!le ,ital signs* input and output !alance.
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