“A Case Study about Chronic Gastritis”
Table of Contents
I.
Introduction
II.
History and Physical Examination
III.
Gordon’s Need Assessment
IV.
Pathophysiology
V.
Laboratory Procedures/ Findings/ Implementation
VI.
Drug Study
VII.
Nursing Care Plan
VIII.
Recommendation
INTRODUCTION The human stomach, especially in this country, is almost always overburdened by overeating and by eating in such a manner and under such conditions that digestion is retarded. Too frequent eating is as great source of gastric irritation as the habit of overfilling the stomach at each meal. While, perhaps overeating and eating food combinations that impede normal digestion may be regarded as the chief causes of chronic irritation of the stomach, the habits of eating in a hurry, failure to properly masticate the food, eating hot and cold foods, eating when fatigued, when emotionally stressed, when cold, and the practice of eating a hearty meal and returning immediately to work, impede the digestive process. All such abuses help to lay the ground work for disease of the stomach. While taking such stimulants as tea, coffee, and cocoa, and such narcotics as tobacco and alcohol contribute towards the causation of gastric impairment, the habit of using condiments is often worse. It should be understood that any act, habit, or indulgence that lowers functioning power, this is to say, anything that causes enervation, will lessen digestive function and pave the way for the evolution of chronic gastritis. Overwork, loss of sleep, lack of rest, stimulation, food deficiencies, emotional stresses, etc., by lowering the power of the nerves to maintain normal function, produce indigestion. Above statements are such reasons why I choose this topic because it seems as common as we look at it but I may say that this must not be discarded or misunderstood because any moment we might have it if we won’t understand it better. It may not seem so interesting but I tell you having an idea of it might catch your attention. To start I will discuss to you gastritis. It is a condition in which the stomach lining known as the mucosa is inflamed. The stomach lining contains special cells that produce acid and enzymes, which help break down food for digestion, and mucus, which protects the stomach lining from acid. When the stomach lining is inflamed, it produces less acid, enzymes, and mucus. Gastritis may be acute or chronic. Sudden, severe inflammation of the stomach lining is cal led acute gastritis. Inflammation that lasts for a long time is called chronic gastritis. If chronic gastritis is not treated, it may last for years or even a lifetime. Acute gastritis is more common in the young; chronic gastritis is more often found in adults. Chronic gastritis is brought on from overeating, improper eating, hasty eating, or improper mastication; gum chewing; the use of tobacco--chewing or smoking. It can also be caused by irritation due to excessive alcohol use, chronic vomiting, stress, or the use of certain medications such as aspirin or other antiinflammatory drugs. It may also be caused by Helicobacter pylori (H. pylori), a bacteria that lives in the mucous lining of the stomach. Without treatment the infection can lead to ulcers, and in some people, stomach. Pernicious anemia: A form of anemia that occurs when the stomach lacks a naturally occurring substance needed to properly absorb and digest vitamin B12. Bile reflux: A backflow of bile into the stomach from the bile tract (that connects to the liver and gallbladder). Infections caused by bacteria and viruses.
In people who have gastritis symptoms, pain or discomfort in the upper abdomen is the most common. The pain is usually in the upper central portion of the abdomen (the "pit" of the stomach). Gastritis pain occurs in the left upper portion of the abdomen and in the back. The pain seems to "go right straight through" a person as it travels from the belly to the back. People often use the terms burning, aching, gnawing, or sore to describe the pain. Usually, a vague sense of discomfort is present, but the pain may be sharp, stabbing, or cutting. Other symptoms of gastritis include: Belching, Nausea and vomiting, Bloating, Feeling of fullness or burning in the upper part of the belly, in more severe gastritis, bleeding may occur inside the stomach.
History and Physical Examination Clinical History
General Data: This is a case of 22/female, Filipino, Roman Catholic, Admitted on March 5, 2013 Chief Complaint: Vomiting History of Present Illness:
The Patient is known case of chronic gastritis since December 2012 s/p EGD (2012) with recurrent admissions since December 2012. 1 day PTA- The patient experienced vomiting of previously ingested food (20 times) associated with epigastric pain characterized as colicky, non radiating, graded as 7/10 in pain severity, aggravated by food intake. There was no fever or melena noted. Persistence of symptoms prompted consult and subsequent admission at the hospital.
Review of Systems General: (+) weight loss, no anorexia, (-) fever, no malaise HEENT: no headache, no dizziness, no blurred vision, no hearing loss, no ear pain, no tinnitus, no dysphagia, no sore throat, no epistaxis, no hoarseness Respiratory: no cough, no dyspnea CVS: no chest pain, no orthopnea, no PND, no palpitations, no easy fatigability Gastrointestinal: no abdominal pain, no changes in bowel movement, (+) nausea and vomiting, no hematemesis, no melena, no hematochezia Genitourinary: no oliguria, no dysuria, no increased frequency, no hesitancy, no tea colored urine
Musculoskeletal: no muscle or joint pain, no limitations of movement Endocrine: no polyuria, no polydipsia, no polyphagia, no heat or cold intolerance Hematologic: no easy bruising, no bleeding tendencies, no pallor Neurologic: No seizures, no weakness, no paralysis, no tremors, no memory loss
Past Medical History
(-) Hypertension (-) Diabetes Mellitus (-) Bronchial Asthma (-) Cancer (-) PTB Allergies: denies any allergies to food and drugs
Family Medical History
(-) Hypertension (+) Diabetes Mellitus – father (-) Bronchial asthma (-) Cancer
Personal and Social History
Occupation: Call center Agent Smoking History: nonsmoker Alcohol intake: nonalcoholic drinker
PHYSICAL EXAMINATION
General Survey
Conscious, coherent, not in cardio-respiratory distress
Vital Signs
BP: 110/80
Skin and Integumentary
Good skin turgor, no pallor
HEENT
anicteric sclera, pink palpebral conjunctivae, no watery nasal discharge,
HR: 86
RR: 20
Temp: 37.1
no cervical lymphadenopathy, no tonsillolaryngeal congestion, no neck vein engorgement Symmetrical chest expansion, no retractions, no chest lagging, (+) equal
Chest and Lungs
local and tactile fremiti, clear breath sounds adynamic precordium, irregular rate regular rhythm, apex beat at 5 th ICS
Cardiovascular
MCL, no murmurs, no heaves, no thrills Abdomen
flabby, soft, (+) epigastric tenderness, normoactive bowel sound
Extremities
no gross deformities, full and equal pulses, no cyanosis, no edema
Neurologic Examination Mental Status Exam
conscious, coherent, oriented in 3 spheres
Sensorium
GCS 15
Cranial Nerves
I
No anosmia
II
2-3 mm pupils equally reactive to light
III,IV,V V1,V2,V3
intact EOM’s (+) corneal reflex
VII
No facial asymmetry
VIII
Intact gross hearing
IX,X
uvula midline, (+) gag reflex
XI
Good shoulder shrug
XII
Tongue in midline
Motor Examination
RUE 5/5 RLE 5/5
Cerebellar Examination
LUE 5/5 LLE 5/5
Finger-to-nose, alternate pronation-supination, heel-to-shin, ataxia, tandem walk
Muscle stretch reflexes
Babinski reflex
Sensory Examination
Sensory deficit, Romberg’s test (-)
Meningeal Examination
Kernig’s test, Brudzinsky’s tesrt (-)
GORDON’S NEED ASSESSMENT
A. Health Perception and management Rarely visits a doctor to have a check-up and seek for medical assistance Buys and takes over the counter drugs such as Solmux, Neozep, Biogesic, Mefenamic Acid, Diatabs and Loperamide. Doesn’t take any multivitamins No vices since young except for drinking alcohol occasionally After experiencing epigastric pain, she decided to see a physician B. Nutrition and metabolism Prior: Eats her meal 3x a day Can drink up to 1.5L per day Drinks coffee and softdrinks
During
Weight: 41 kgs. (+) weight loss Height: 4’11’’ Underweight (BMI: 18.89kg/m2) On NPO to Liquid Diet
Hooked D5NSS 1Lx8Hours Elimination She voids 4-5 times a day She has irregular bowel movement She always experienced vomiting and heart burn Activity and Exercise The patient ambulate within the house She does household chores Able to bathe herself Doesn’t take too much exercise Prolong on sitting Sexuality/Reproductive Single No history of STD or any disease of genitals Cognitive/Perceptual Oriented to people, time and place Responds to stimuli verbally and physically Epigastric pain felt characterized as colicky, non-radiating Roles and Relationships Single Well supported and loved by her family with closed relationship Self Perception/Self Concept Though weak, she still manages to appear calm and relaxed Value/Belief Roman Catholic Have strong faith in God Coping/Stress Able to accept situation by cooperating with the medical advices and procedures Sleep/Rest Can sleep/rest well Medication History Metoclopromide 10mg TIV q8 Omeprazole 40 mg TIV q12 PNSS 90cc + KCL 10 meqs to run for 1 hour x 2 cycles Tramadol 50mg IV PRN Gavicson 1 sachet after meal BID Domperidone 10mg 1tab BID premeals
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Laboratory Procedures/ Findings/ Implementation
Complete Blood Count
Increased WBC
Creatinine
Normal
Sodium
Normal
Potassium
Deficit
Urinalysis
Normal
Pregnancy Test
Negative
EGD
Hypokalemia secondary to GI Loss
DRUG STUDY I. Generic Name:Metoclopramide Brand Name:Clopra, Emex , Maxeran , Maxolon, Reglan Classifications :gastrointestinal agent; prokinetic agent (gi stimulant); autonomic nervous system agent; direct-acting cholinergic (parasympathomimetic); antiemetic Availability : 5 mg, 10 mg tablets; 5 mg/5 mL solution; 5 mg/mL injection Actions Potent central dopamine receptor antagonist. Structurally related to procainamide but has little antiarrhythmic or anesthetic activity. Exact mechanism of action not clear but appears to sensitize GI smooth muscle to effects of acetylcholine by direct action. Therapeutic effects 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, biliary, or pancreatic secretions. Antiemetic action results from drug-induced elevation of CTZ threshold and enhanced gastric emptying. In diabetic gastroparesis, indicated by relief of anorexia, nausea, vomiting, persistent fullness after meals. Uses Management of diabetic gastric stasis (gastroparesis); to prevent nausea and vomiting associated with emetogenic cancer chemotherapy (e.g., cisplatin, dacarbazine); to facilitate intubation of small bowel; symptomatic treatment of gastroesophageal reflux. Contraindicatons Sensitivity or intolerance to metoclopramide; allergy to sulfiting agents; history of seizure disorders; concurrent use of drugs that can cause extrapyramidal symptoms; pheochromocytoma; mechanical GI obstruction or perforation; history of breast cancer. Safety during pregnancy (category B) or lactation is not established. Nursing Implications Assessment & Drug Effects Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or tremors. Extrapyramidal symptoms are most likely to occur in children, young adults, and the older adult and with high-dose treatment of vomiting associated with cancer chemotherapy. Symptoms can take months to regress. Be aware that during early treatment period, serum aldosterone may be elevated; after prolonged administration periods, it returns to pretreatment level. Lab tests: Periodic serum electrolyte. Monitor for possible hypernatremia and hypokalemia, especially if patient has CHF or cirrhosis. Adverse reactions associated with increased serum prolactin concentration (galactorrhea, menstrual disorders, gynecomastia) usually disappear within a few weeks or months after drug treatment is stopped.
II. Generic Name:Omeprazole(o-me´pra-zole) Brand Name:Losec,Prilosec Classifications :gastrointestinal agent; proton pumpinhibitor Availability: 10 mg, 20 mg, 40 mg capsules Actions An antisecretory compound that is a gastric acid pumpinhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+-ATPase enzyme system [the acid (proton H+) pump] in the parietal cells. Therapeutic effects Suppresses gastric acid secretion relieving gastrointestinal distress and promoting ulcer healing. Uses Duodenal and gastric ulcer. Gastroesophageal reflux disease including severe erosive esophagitis (4 to 8 wk treatment). Long-term treatment of pathologic hypersecretory conditions such as Zollinger-Ellison syndrome, multiple endocrine adenomas, and systemic mastocytosis. In combination with clarithromycin to treatduodenal ulcers associated with Helicobacter pylori. Contraindications Long-term use for gastroesophageal reflux disease, duodenal ulcers; lactation. Adverse effects CNS:Headache, dizziness, fatigue. GI:Diarrhea, abdominal pain, nausea, mild transient increases in liver function tests. Urogenital:Hematuria, proteinuria. Skin:Rash. Nursing implications Assessment & Drug Effects Lab tests: Monitor urinalysis for hematuria and proteinuria. Periodic liver function tests with prolonged use. Patient & Family Education Report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in urine. Report severe diarrhea; drug may need to be discontinued. Do not breast feed while taking this drug. III. Generic Name: Aluminum/ Magnisium Trisillicat Brand Name: Gaviscon Action: anti ulcer Indication and Dosage: 5ml TID after meal Heartburn Contraindication: Contraindicated in patients hypersensitive to drug Adverse Reaction: Constipation; diarrhea Severe allergic reactions (rash; itching; difficulty breathing;; swelling of the mouth, face, lips, or tongue) Nursing Responsibility: Take the medicine after dolan
IV.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Generic Name: Domperidone Brand Names: Motilium Classification: Antidopaminergics. anti-emetic Mode of Action: facilitates gastric emptying and decreases small bowel transit time by increasing esophageal and gastric peristalsis and by lowering esophageal sphincter pressure. Indications: The relief of nausea and vomiting, epigastric sense of fullness, upper abdominal discomfort and regurgitation of gastric contents Contraindications: Known hypersensitivity to domperidone or any of the excipients. Prolactin-releasing pituitary tumour (prolactinoma.) Domperidone should not be used when stimulation of gastric motility could be harmful: gastro-intestinal haemorrhage, mechanical obstruction or perforation. Adverse/Side Effects Immune System Disorder: Very rare; Allergic reaction Endocrine disorder: Rare; increased prolactin levels Nervous system disorders: Very rare; extrapyramidal side effects. Gastro-intestinal disorders: Rare gastro-intestinal disorders including very rare transient intestinal cramps Skin and subcutaneous tissue disorders: Very rare; urticaria Reproductive system and breast disorders: Rare; galactorrhoea, gynaecomastia, amenorrhoea Drug Interactions: anticholinergic drugs may compromise the beneficial effects of domperidone. it may accelerate absorption of drugs from the small bowel while slowing absorption of drugs taken up from the stomach, particularly those with sustained-release or enteric-coated formulations. Care should be exercised when domperidone is administered in combination with MAO inhibitors. The concomitant administration ofdomperidone maleate with antacids or H2-receptor blockers does not decrease the absorption ofdomperidone. Nursing Responsibilities Take this medication by mouth as prescribed usually 30 minutes before meals and at bedtime Monitor for persistence of nausea and vomiting to evaluate the effectiveness of the drug. Monitor for signs of abdominal discomfort such as epigastric pain or abdominal fullness. Monitor vital signs to determine signs of dehydration Perform oral care Do not increase your dose or take this more often than directed. Tell client to limit intake of alcoholic beverages. Tell patient that she may get dizzy or drowsy with this drug, tell her not to sit or stand quickly. Tell patient to keep away from the sun because this can make her more sensitive to the sun Tell patient to avoid taking the drug together with anti-cholinergic drugs in order not to alter its effect.
V. Brand Name: TRAMADOL Therapeutic: Analgesics (centrally acting) ACTIONS Physiologic Mechanism: Decreased pain. Pharmacologic Mechanism • Binds to mu-opioid receptors. • Inhibits reuptake of serotonin and norepinephrine in the CNS. INDICATION: Moderate to moderately severe pain NURSING CONSIDERATIONS • Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. • Assess BP & RR before and periodically during administration. Respiratory depression has not occurred with recommended doses. • Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects. • Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously received opioids for more than 1 wk; may cause opioid withdrawal symptoms. • Prolonged use may lead to physical and psychological dependence and tolerance, although these may be milder than with opioids. This should not prevent patient from receiving adequate analgesia. Most patients who receivetramadol for pain d not develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve pain. • Tramadol is considered to provide more analgesia than codeine 60 mg but less than combined aspirin 650mg/codeine 60 mg for acute postoperative pain. • Monitor patient for seizures. May occur within recommended dose range. Risk increased with higher doses and inpatients taking antidepressants (SSRIs, tricyclics, or Mao inhibitors), opioid analgesics, or other durgs that decrese the seizure threshold. • Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse some, but not all, of the symptoms of overdose. Treatment should be symptomatic and supportive. Maintain adequate respiratory exchange. • Encourage patient to cough and breathe deeply every 2 hr to prevent atelactasis and pneumonia.
NURSING CARE PLAN 1. ASSESSMENT: Patient is vomiting more often DIAGNOSIS: Risk for Fluid Volume Deficit related to inadequate intake and excessive fluid output (nausea and vomiting) PLANNING: After nursing actions, adequate fluid intake. INTERVENTION: Fill your individual needs. Encourage clients to drink. Provide additional IV fluids as indicated. Monitor vital signs, evaluation of skin turgor, capillary refill and mucous membranes. Collaboration: the provision of drugs. EVALUATION: The mucosa of the lips moist Good skin turgor Good capillary refill Input and output balanced 2. ASSESSMENT: Abdominal Guarding, Pain Scale: 7/10 DIAGNOSIS: Acute pain related to irritation of the gastric mucosa secondary to psychological stress. PLANNING: After the act of nursing, pain can be reduced, patients can rest and generally good condition. INTERVENTION: Investigate complaints of pain, note the location, intensity of pain, and pain scale. Instruct patient to report pain as soon as it began. Monitor vital signs. Explain the causes and effects of pain on the client and his family. Encourage rest during the acute phase. Encourage relaxation techniques. Provide an environment conducive situation. Collaboration with the medical team in the delivery of the action. EVALUATION: Clients express the pain diminished or disappeared. The client does not grimace in pain. Vital signs are within normal limits. The pain intensity was reduced (reduced pain scale 1-10). Demonstrate relax, rest, sleep, increased activity quickly. 3. ASSESSMENT: (+)Weight Loss, Nothing per orem DIAGNOSIS: Imbalanced Nutrition: Less Than Body Requirements related to the lack of food intake. PLANNING: After the patient's nutritional needs of nursing actions are met. INTERVENTIONS: Instruct patient to eat small meals but frequently. Give soft foods. Perform oral hygiene.
Measure weight basis. Texture observation, the patient's skin turgor. Observations of nutritional intake and output. EVALUATIONS: General condition is quite Good skin turgor Increased weight Difficulty swallowing is reduced
4. ASSESSMENT: “ano ba dapat kainin ko?’’ as patient verbalized DIAGNOSIS: Knowledge Deficit related to the conditions and lack of coping skills PLANNING: After health teachings to the patient, she will gain more knowledge and can cope more skills to care for herself. IMPLEMENTATION: Guidelines emphasize nutrition and how to cope with a diet when away from home. Discuss with the client the importance of reviewing the needs of calories every 2 to 4 weeks. Encourage the use of stress management techniques. Increase program regular practice. Encourage follow-up care visits with physicians and counselors. EVALUATION: Clients expressed the importance of lifestyle changes to maintain a normal weight. Clients seeking counseling resources to help make changes. Clients trying to maintain weight.
RECOMMENDATION The eating habits should be corrected. If you experience frequent indigestion, eat smaller, more frequent meals to buffer stomach acid secretion. Avoid any spicy, acidic, fried or fatty food. Practice good eating habits. Avoid alcohol, it irritates and erodes the mucous lining of the stomach, causing inflammation and bleeding. Don't smoke. Smoking interferes with the protective lining of the stomach, making the stomach more susceptible to gastritis as well as ulcers. Smoking also increases stomach acid; delays stomach healing and are a leading risk factor for stomach cancer. Still, quitting isn't easy, especially if you've smoked for years. Talk to your doctor about methods that may help you stop smoking. Switch pain relievers. Some may cause stomach inflammation or make existing irritation worse.
Follow doctor's advice. Your doctor may recommend that you take an over-the-counter antacid or acid blocker to help prevent recurring gastritis. Call your health care provider if symptoms of gastritis do not improve with treatment. Maintain a healthy weight. Heartburn, bloating and constipation tend to be more common in obese people. Maintaining a healthy weight can often help prevent or reduce these symptoms. Exercise regularly. Aerobic exercise that increases your breathing and heart rate also stimulates the activities of intestinal muscles, helping to move food wastes through your intestines more quickly. Manage stress. Stress increases risk of heart attack and stroke, increases stomach acid production and slows digestion. For relaxation, practice yoga. Make a habit of regular exercise, morning walk, eat healthy, nutritious food, it boosts your immune system & makes you calm.
