Académique Documents
Professionnel Documents
Culture Documents
Angeles City
College of Nursing
Submitted by:
Enriquez, Rachelle
Pangilinan, Raidis
Sunga, Chrisha
Tapnio, Eleazar
Tuvera, James
BSN III-B GROUP 6
Submitted to:
Jasleen S. Yumang, RN. MN.
Date
October 05, 2016
1
Introduction
Take care of your body. Its the only place you have to live in.
-Anonymous
Our body is the place we live in and if you try to destruct it, it is possible that you
dont
have anywhere to go. It is like a house, if not maintained properly, it will slowly wear
out. It is like our health if not maintained properly it will result to different kind of
Illnesses and diseases that will put our lives at risk. It is a game between living or
dying.
early as possible.
Duodenal peptic ulcer disease is a ulcerative disorders that occur in areas of the
upper gastrointestinal tract that are exposed to acid-pepsin secretions. The most common
forms of peptic ulcer are duodenal and gastric ulcers. Peptic ulcer disease, with its
remissions and exacerbations, represents a chronic health problem. Duodenal ulcers
occur five times more commonly than gastric ulcers. Ulcers in the duodenum occur at any
age and frequently are seen in early group, with a peak incidence between 55 and 70
years of age. Both types of ulcers affect men three to four times more frequently than
women. (Carol Mattson Porth, 2011)
2
Anemia is clinical condition that results from an insufficient supply of healthy red
blood cells (RBCs), the volume of packed RBCs, and/or the quantity of hemoglobin.
Hypoxia results because the bodys tissues are not adequately oxygenated. Not a disease
in itself, anemia reflects a number of underlying pathologic processes leading to an
abnormality in RBC number, structure, or function. When anemia is identified, further
testing must be done to determine its cause. (JOYCE M. BLACK, 2010)
Gathering data for the statistics about Upper Gastrointestinal Bleeding in the
Philippines, the incidence of UGIB is approximately 100 cases per 100,000 population
per year. Bleeding from the upper GI tract is approximately 4 times more common than
bleeding from the lower GI tract and is a major cause of morbidity and mortality. Mortality
rates from UGIB are 6-10% overall.(www.doh.com)
3
Gathering data for the statistics about Upper gastrointestinal bleeding done in Wales,
United Kingdom the overall incidence of hospitalization for UGIB was 134 per 100,000
population; incidence was higher among men than women (153 vs. 117 per 100,000).
Incidence was two times higher in areas with the lowest and highest socioeconomic
status. Overall case fatality rates at 30 days after hospital admission was 10.0%; fatality
rates rose with age and were higher for men than women and for those with comorbid
illnesses. Adjusted fatality rates were 13% higher for patients admitted on weekends than
on weekdays and 41% higher for patients admitted on holidays than on weekdays.
Fatality rates decreased from 11.4% to 8.6% during the study period.The authors
concluded that UGIB incidence, but not mortality, was associated with socioeconomic
deprivation. They also concluded that patients who were admitted on weekends or
holidays suffered higher mortality than those admitted on weekdays. They speculate that
this difference in mortality could be attributed to reduced staffing and lack of availability
of endoscopy on weekends and holidays in some hospitals.
Objectives
4
A. Nurse-centered
Short Term:
After the completion of the clinical case study, the student nurses shall have:
Long term:
At the end of the clinical case study, the student nurses shall have:
Collated and analyzed gathered laboratory values and diagnostic work ups;
interpret the findings accurately to serve as a basis in identifying and formulating
appropriate health problems;
Identified diagnostics tests, laboratory results, pathophysiology, medical and
nursing management applicable to manage the condition of the patient;
5
Identified and prioritized actual and potential nursing care plans and document
patients progress through SOAPIEs;
Reiterated the importance of health teachings given regarding compliance to
treatment regimen to the patient and significant others before discharge to
hospital.
B. Patient-Centered
Short Term:
After the completion of the clinical case study, the patient shall have:
Long Term:
At the end of the clinical case study, the patient shall have:
6
Demonstrated compliance to medical and nursing management and treatment
and;
Demonstrated lifestyle changes for the promotion of health and prevention of
further complications.
A. Assessment
1. PERSONAL HISTORY
A. Demographic data
Mrs. Bleed a single mother who is 69 years old female, born on March 02,
1947 in Pampanga. She has 7 children, 2 males and 5 Females. She is a Filipino citizen
and is affiliated to the Roman Catholic Church. Mrs. Bleed and her family currently
resides in Minalin, Pampanga.
During the interview with Mrs. Bleed daughter, who is the primary source of
information, last September 16, 2016. She disclosed that her mother on September 13,
2016, from tuesday afternoon until early morning of Wednesday has been suffering from
fever,productive cough, no appetite and body malaise. The same day of September 14,
2016,Wednesday at 2 am, her mother started vomiting blood for 5 times (Approximately
2 cups of blood) and also blood was present in her mothers urine. And at 6 am she was
sent to tertiary hospital and was admitted to Jose B. Lingad Memorial Hospital in San
Fernando,Pampanga on September 14, 2016 at 6:50 AM with a chief complaint of
7
Hematemesis and hematuria. Her final diagnosis in the tertiary hospital was Upper
Gastrointestinal Bleeding Secondary to Duodenal peptic ulcer disease.
The family is an Extended type composed of Mrs. Bleed together with her 3
childrens (including her second daughter 50 y/o, third daughter 49 y/o and her 4th son 48
y/o) and her grand childrens and the wife and husbands of her children. Mrs. bleed has 7
children (5 females and 2 males) 3 of them lives together with her. Mrs.Bleed a single
parent who is 10 years separated with his husband (from year 2006) who works as a
construction worker in Saudi Arabia. Mrs. Bleed is a senior citizen, who used to be a
factory worker for 10 years, from year 1986 to 1996, and a dressmaker for another 10
years, from year 1996 to 2006, she used to make kurtina and sofa clothing. Despite of
her old age she still try to sew or repair clothes to add with their daily expenses.
The one providing her needs is her 3 children who lives together with her. The 3
children of Mrs. bleed who provides her needs is her Second daughter who sells kakanin
every morning, who earns more or less than 200-400 pesos a day ,her third daughter who
takes care of them and her son who is 4th among the 7 children, who works as a
construction worker earning 300-400 pesos a day, it depends if their is an available work
to do .
8
Below that amount, the family is considered poor and since the monthly income of the
family is more or less 7k-10k a month which is used for their daily expenses.
Mrs. Bleed usually wakes up early, at about 6:00 in the morning. She usually just
walk around the house and does simple exercise like stretching, walking then she will
have her coffee and breakfast with her family. She usually pass the time socializing with
neighbors,playing tong-its,mahjong and also by watching TV and sometimes she sew or
repair clothes and curtains where she earns a little. Mrs.Bleed has a poor personal habits
she does smoke usually 10 to 15 sticks a day for 10 years already, and drinks alcohol.
She usually retires at about 12:00 pm and when having difficulty in sleeping she
usually drink beer to be able to sleep. Mrs. Bleed loves to eat filipino dishes. They eat or
have their meals 4 times a day. For breakfast they have usually have rice,tuyo,itlog na
maalat and coffee which she drinks it 3 times a day. For lunch, rice,sinigang, adobo and
other filipino dishes and also softdrinks everyday. Dinner rice and ulam and for the
midnight snack, bread and pancit canton. Mrs. Bleed daughter described their meals as
quite unhealthy because they usually have oily and salty food. And also Mrs. Bleed
smokes and is a heavy drinker ( 1-2 lapad of Emperador).
Mrs.Bleed is an Elementary graduate, she wasnt able to pursue her studies due
to financial problem. She used to work in a factory, a 555 sardines manufacturer for 10
years, from year 1986-1996. And, also in a dressmaker factory for another 10 years from
year 1996-2006. The family of Mrs. Bleed was from Minalin,Pampanga. Mrs.Bleed
daughter verbalized that they believe that when someone in the family is having health
problems, they immediately seek a doctor for medical attention. They also use over the
counter drugs for minor illnesses such as fever, coughs and colds, and headaches
(eg.Paracetamol,Alaxan)
9
3. History of Past Illness
Mrs. Bleed had mumps and measles when she was 4 years old, she encountered
fever, diarrhea, coughs and cold. Wherein, she managed it by buying and using over the
counter drugs such as analgesic and antibiotic. She doesnt have any allergies to
medications, nor acquired any accident trauma. When dealing with fever, she relies with
over the counter drugs like Paracetamol tablets, performing tepid sponge bath and
increasing fluid intake. On the other hand, when she is experiencing diarrhea, she just
increases her fluid intake and does not take any medication to stop diarrhea. She also
had anemia when she was 20 years old due to early pregnancy at age of 16 and without
ideal birth spacing for her children. She treated it with iron supplements such as Ferrous
Sulfate and Folic Acid plus Vitamin B12. She was hospitalized last 2014 at Tertiary
Hospital for 7 days because of pneumonia, the said hospital managed her disease
condition by providing antibiotics and oxygen inhalation. She was also diagnosed
hypertensive patient then, with blood pressure of 150/100 and currently taking Metoprolol
and Amlodipine.
On September 13, 2016 (Tuesday) afternoon, Mrs. Bleed have fever, productive cough,
no appetite and with body malaise. At 2am of September 14 (Wednesday) she vomits
blood (hematemesis) for 5 times, estimated 2 cups. She also have blood in urine
(hematuria) for 3 times, as if urinating red blood according to her. The said manifestations
continuous until her daughter decided to take her to a Tertiary Hospital around 6am. She
was admitted at 6:50 am of September 14. The said hospital provided her: PNSS
regulated at 30 gtts/min; oxygen via nasal cannula at 4 L/min; Requested for CBC with
platelet, BUN, Creatinine, NA, K; Started omeprazole 80mg IV q8, metoclopramide 10mg
IV q8, tranexamic acid 500mg IV q8; Requested for ABO RH typing and crossmatched
because she was subjected to blood transfusion of 1 unit Packed RBC on September 15
at 9pm; she also had Pre-BT meds paracetamol 300mg IV and diphenhydramine 50mg
IV prior to blood transfusion; She was also referred to Gastro for upper gasto-intestinal
examination.
10
5. Physical Examination (Cephalocaudal Approach)
Admitted a 69 year old patient accompanied by her daughter with chief complaint of
(hematemesis) vomiting of blood and (hematuria) blood in urine.
With initial vital signs of:
TEMPERATURE: 38.8 C
PULSE RATE: 84 bpm
PAST MEDICAL HISTORY: (-) DM, (-) Thyroid Disease, (-) CA, (+) HPN
FAMILY MEDICAL HISTORY: (-) DM, (-) Thyroid Disease, (-) CA, (-) HPN
11
1st day of NPI (September 16, 2016 )
General Survey
Vital signs
T: 38.5 C
RR: 24 cpm
Integumentary System
Skin: Pale and dry poor skin turgor. Warm to touch, flushed skin, Delayed capillary refill
time of 5 seconds.
Nails: The fingernails are pale and dirty same as the toenails.
Head
Scalp: Hair is thick black and evenly distributed absence of lice and flakes. With intact
skin. No masses noted upon palpation
Face: Facial expressions are symmetrical, with intact skin absence of lesions. No masses
noted upon palpation.
12
Eyes
Eyes: Normal position and alignment in relation to the tip of the pinna.
Visual field: She can see and identify the penlight on her periphery when looking
forward.
Eyebrows: With black, thick hair evenly distributed. Alignment is symmetrical with intact
skin and equal movement
Eyelashes: Equally distributed black hair, short and curled slightly outward.
Cornea: Transparent, smooth and shiny; blink reflex is observed upon introduction of
the cotton ball to the cornea.
Sclera: Anicteric
Pupils: Pupils are equal in size with consensual and direct response upon introduction
of light. Pupils dilate when staring at distant objects and constricting when staring at
near objects.
Ears
Auricle: The color is uniform with the facial skin, absence of redness or swelling and
with intact skin. Aligned with the outer canthus of the eye. It recoils after folding with no
pain felt upon application of pressure behind the ear.
13
Nose and Sinuses
Nose: The external part has intact skin, the nasal septum is intact and in midline
position. No masses noted upon palpation.
Sinuses: No pain noted upon palpation of facial sinuses. No redness and swelling
observed
Oral Mucosa: with intact skin, slightly dryand pale. No lesions or redness noted.
Gums: No tenderness
Palate and uvula: slightly dry, pale. The anterior palate is hard whereas the posterior
palate is soft. Uvula is positioned in midline of the soft palate.
Pharynx: Absence of redness and swelling and with non-inflamed, pink tonsils.
Neck
Neck: No masses observed upon inspection. Absence of palpable lymph nodes. The
neck muscles are equal in size and smooth movement without discomfort is observed.
The head is centrally positioned.
14
Thyroid Gland: Absence of nodules or tenderness upon palpation.
Respirations:
Posterior chest: The spinal column is centrally aligned, without any deviations. Upon
palpation there were no tenderness observed. Presence of productive cough, presence
of wheezes upon expiration
Anterior chest: Symmetrical chest expansion and with intercostal retractions observed
during inspirationwith labored breathing noted, with intact skin. Upon palpation there is
no tenderness
Cardiovascular system
Breast: The skin is intact with uniform color, no tenderness or masses observed.
Symmetrical, absence of dimpling or flattening..
Abdomen
15
Peripheral Vascular system
Upper extremities: Symmetric, absence of swelling with strong palpable pulsation, pale
skin and nails. Hair is evenly distributed, muscles are equal in size, no bone deformities.
Lower extremities:Symmetric, Hair is evenly distributed on the calf muscle, pale skin
and nails, Weak palpable pulse.
Musculoskeletal System:
General Survey
Mrs. Bleed is lying on bed, accompanied by her daughter; oriented to time, place
and person; wearing hospital gown; with oxygen therapy via nasal cannula regulated at
2-4 L/min; with ongoing IVF of PNSS 1L at 480 cc level, regulated at 30 gtts/min infusing
well on her left hand; appears weak; with productive cough;
Vital signs
T: 36.5 C
RR: 24 cpm
Integumentary System
16
Head
Scalp: Hair is thick black and evenly distributed absence of lice and flakes. With intact
skin. No masses noted upon palpation
Face: Facial expressions are symmetrical, with intact skin absence of lesions. No masses
noted upon palpation.
Eyes
Eyes: Normal position and alignment in relation to the tip of the pinna.
Visual field: She can see and identify the penlight on her periphery when looking
forward.
Eyebrows: With black, thick hair evenly distributed. Alignment is symmetrical with intact
skin and equal movement
Eyelashes: Equally distributed black hair, short and curled slightly outward.
Cornea: Transparent, smooth and shiny; blink reflex is observed upon introduction of
the cotton ball to the cornea.
Sclera: Anicteric
Pupils: Pupils are equal in size with consensual and direct response upon introduction
of light. Pupils dilate when staring at distant objects and constricting when staring at
near objects.
Ears
17
Auricle: The color is uniform with the facial skin, absence of redness or swelling and
with intact skin. Aligned with the outer canthus of the eye. It recoils after folding with no
pain felt upon application of pressure behind the ear.
Nose: The external part has intact skin, the nasal septum is intact and in midline
position. No masses noted upon palpation.
Sinuses: No pain noted upon palpation of facial sinuses. No redness and swelling
observed
Oral Mucosa: with intact skin, slightly dryand pale. No lesions or redness noted.
Gums: No tenderness
Palate and uvula: slightly dry, pale. The anterior palate is hard whereas the posterior
palate is soft. Uvula is positioned in midline of the soft palate.
Pharynx: Absence of redness and swelling and with non-inflamed, pink tonsils.
Neck
18
Neck: No masses observed upon inspection. Absence of palpable lymph nodes. The
neck muscles are equal in size and smooth movement without discomfort is observed.
The head is centrally positioned.
Respirations:
Posterior chest: The spinal column is centrally aligned, without any deviations. Upon
palpation there were no tenderness observed. Presence of productive cough, presence
of wheezes upon expiration
Cardiovascular system
Breast: The skin is intact with uniform color, no tenderness or masses observed.
Symmetrical, absence of dimpling or flattening..
Abdomen
19
Peripheral Vascular system
Upper extremities: Symmetric, absence of swelling with strong palpable pulsation, pale
skin and nails. Hair is evenly distributed, muscles are equal in size, no bone deformities.
Lower extremities:Symmetric, Hair is evenly distributed on the calf muscle, pale skin
and nails, Weak palpable pulse.
Musculoskeletal System:
20
6. Diagnosis and Laboratory Procedures
HEMATOLOGY
Hematology is the branch of medicine concerning the study of blood, the blood-forming organs, and blood diseases.
Hematology tests include laboratory assessments of blood formation and blood disorders.
A complete blood count (CBC) gives important information about the kinds and numbers of cells in the blood, especially red
blood cells, white blood cells, and platelets. A CBC aids the physician check any symptoms, such as weakness, fatigue, or
bruising, that the client has. A CBC also helps the doctor diagnose conditions, such as anemia, infection, and many other
disorders
21
DATE
RESULT(S)
RECEIVED:
09/14/16
22
RBCs to bind to
oxygen in the
lungs and carry it
to tissues and
organs
throughout the
body
Since there is
affectation in the
cardiovascular
system as well as
the respiratory
system of the
patient, it is
indicated to the
client to assess
adequacy of her
tissue
oxygenation
primarily in the
23
heart and other
parts of the body.
24
blood. Platelets doesnt have
are parts of the adequate amount
blood that help of platelet to
the blood clot. provide
They are smaller coagulation, and
than red or white she is in risk for
blood cells. The bleeding
number of
platelets in your
blood can be
affected by many
diseases.
Platelets may be
counted to
monitor or
diagnose
diseases, or to
look for the cause
of too much
bleeding or
clotting.
25
White blood cell White blood cells 11.5 4-10 x 109/L Above normal.
exist in the blood, The WBC count
the lymphatic is elevated in
system, and response to
tissues and are infection, stress,
an important part and inflammatory
of the body's disorders
defense system. (referred to as
Some diseases reactive
trigger a leukocytosis)
response by the
immune system
and cause an
increase in the
number of WBCs.
It is substantial
determinant of
infection or
inflammation.
26
Neutrophils It is the most 69 0.55-0.65 Above normal.
common The neutrophils is
polymorphonucle elevated in
ar leukocytes response to acute
(PMN) which is a infection and
division of WBC acute stress
in granulocytes.
It is indicated to
the patient to
determine acute
bacterial
infection.
27
temporary rise in
the number of
lymphocytes after
an infection.
28
Nursing Responsibilities
Prior:
After:
Record the date and time of blood collection. Attach a label to each blood tube.
Properly dispose of contaminated materials.
Fill-up the laboratory form properly and send to the laboratory technician.
Check the venipuncture site for bleeding.
Obtain results and secure it to the patients chart.
Refer the result to the physician.
29
BLOOD CHEMISTRY
Blood chemistry tests or panels are groups of tests that measure many chemical substances in the blood that are released
from body tissues or are produced during the breakdown (metabolism) of certain substances. These tests are performed
on ablood sample
This is a test The result of Mrs. Bleeds creatinine level is within above
Creatinine DO and specific for the 190 44-80 normalrange. It indicates that her kidneys are not
DR: assessment of ummol/ functioning well.
Septembe renal function L
r14, 2016 of
Mrs. Bleed
DO and This is a test 6.53 2.78 - The result of Mrs. Bleeds creatinine level is within normal
BUN DR: specific for the 8.07 range. This cannot indicates that her kidneys are
Septembe assessment of mmol/L functioning well or not, since BUN can be altered through
r14, 2016 diet and hydration
30
renal function
of
Mrs. Bleed
Sodium DO and This test is 133 135-145 Below normal range. Sodium is particularly important for
DR: specific for the mmol/L nerve and muscle function. Hyponatremia can cause
Septembe assessment of damage to cells. It makes them swell up with too much
r 14, 2016 electrolytes water. This may be particularly dangerous in areas such as
imbalances the brain.
Potassium DO and This test is 6.90 3.5-5.1 Above normal. The most common cause of high potassium
DR: specific for the mmol/L is kidney failure. When your kidneys fail, they cant remove
Septembe assessment of extra potassium from the body. This can lead to potassium
r 14, 2016 electrolytes buildup.
imbalances
31
NURSING RESPONSIBILITIES:
Prior:
After:
If the patient is too weak and has no SO, assist him/her during the extraction of
blood.
32
URINALYSIS
Urinalysis is a test that evaluates a sample of your urine. Urinalysis is used to detect and assess a wide range of disorders,
such as urinary tract infection, kidney disease and diabetes. Urinalysis involves examining the appearance, concentration
and content of urine.
This was done to Color: yellow Color: Mrs. Bleeds results are
Urinalysis DO: the patient as a amber/yellow within above normal range.
September screening for This means that her urine is
14, 2016 abnormalities within Transparenc Transparency: concentrated that there are
DR: the urinary system y: Clear more solutes and less water
September as well as for Slightly turbid pH: 4.8-8.0 in the urine. Solutes are
14, 2016 system problems pH: 7.5 Specific gravity: dissolved particles, such as
that may manifest Specific 1.010- sugars, salts, and proteins. A
gravity: 1.030 1.025 urine concentration test can
33
through the urinary also be used to evaluate
tract. dehydration, kidney failure,
heart failure, other hormone
problems, complications of a
urinary tract infection
34
NURSING RESPONSIBILITIES:
Prior:
After:
35
ABO TYPING, RH TYPING
The ABO system consists of A, B, AB, and O blood types. People with type A have antibodies in the blood against type B.
People with type B have antibodies in the blood against type A. People with AB have no anti-A or anti-B antibodies.
People with type O have both anti-A and anti-B antibodies. People with type AB blood are called universal recipients,
because they can receive any of the ABO types. People with type O blood are called universal donors, because their
blood can be given to people with any of the ABO types. Mismatches with the ABO and Rh blood types are responsible
for the most serious, sometimes life-threatening, transfusion reactions. But these types of reactions are rare. Rh system
The Rh system classifies blood as Rh-positive or Rh-negative, based on the presence or absence of Rh antibodies in the
blood. People with Rh-positive blood can receive Rh-negative blood, but people with Rh-negative blood will have a
transfusion reaction if they receive Rh-positive blood. Transfusion reactions caused by mismatched Rh blood types can
be serious.
36
Diagnostic/ Date
Laboratory ordered; General Indication Results
Procedures Date results
in
37
ANATOMY AND PHYSIOLOGY
mouth,
pharynx (throat),
esophagus,
stomach, and
duodenum (first part of the small intestine).
Mouth
Your mouth is the first part of your digestive tract. It is where food is chewed and mixed
with saliva until it becomes a soft mass that can be swallowed. Saliva is released into the
38
mouth even before food enters itthe odor or thought of food can make you salivate. An
enzyme in saliva called amylase starts breaking down the carbohydrates from food in
your mouth. When you swallow, food moves into your pharynx, a passageway that is 5
inches long and carries both food and air.
Esophagus
From the throat, food enters the esophagusa hollow, muscular tube about 10 inches
long. At the upper end of the esophagus is a circular area of muscle tissue called the
upper esophageal sphincter. When you swallow, this sphincter relaxes to allow food to
enter the esophagus.
After you swallow, the sphincter contracts to prevent air in the throat from entering the
esophagus. A structure called the epiglottis closes over the trachea to prevent the food
from entering the airways or lungs. Peristalsis pushes food through your esophagus.
The esophagus descends into the stomach through an opening in the diaphragm (a thin
muscle that separates your chest cavity from your abdominal cavity). At the lower end of
the esophagus is a ring of muscle tissue called the lower esophageal sphincter. When
food approaches, the lower esophageal sphincter relaxes to allow food to pass through
to the stomach. It then contracts to prevent reflux (the backflow of stomach contents into
the esophagus).
The esophagus contains a protective inner lining called the mucosa. In a healthy
esophagus, the mucosa is smooth and pink. The place where the esophagus makes
contact with the stomach is called the gastroesophageal junction; it forms an irregular
white line called the Z-line that can be seen by your doctor with an endoscope.
Your stomach is a large, stretchy bag located slightly to the left in the upper portion of
your abdomen. Its function is to hold ingested food and to continue the digestive process
39
that began in your mouth by secreting gastric acid and digestive enzymes. Your stomach
has four sections:
The pylorus is a circular muscle below the antrum that connects the outlet of the stomach
with the duodenum. The duodenum, the first portion of the small intestine, is a C-shaped
tube that curves around the head of the pancreas. The part of the duodenum closest to
the stomach is called the duodenal bulb.
Farther along in the duodenum is the major duodenal papilla, a protuberance where the
common bile duct and main pancreatic duct enter the duodenum. The common bile duct
carries bile secreted from the liver after it is stored in the gallbladder into the duodenum;
the main pancreatic duct carries enzymes formed in the pancreas. The bile and
pancreatic enzymes help digest food in the duodenum.
Upper gastrointestinal bleeding (sometimes upper GI, UGI bleed, Upper gastrointestinal
hemorrhage, gastrorrhagia) is gastrointestinal bleeding in the upper gastrointestinal tract,
commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood
may be observed in vomit (hematemesis) or in altered form in the stool (melena).
Depending on the severity of the blood loss, there may be symptoms of insufficient
circulating blood volume and shock. As a result, upper gastrointestinal bleeding is
considered a medical emergency and typically requires hospital care for urgent diagnosis
and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric
erosions, esophageal varices, and some rarer causes such as gastric cancer.
40
The initial assessment includes measurement of the blood pressure and heart rate, as
well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid
replacement is often required, as well as blood transfusion, before the source of bleeding
can be determined by endoscopy of the upper digestive tract with an
esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be
applied to reduce rebleeding risk. Specific medical treatments (such as proton pump
inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage)
may be used. Recurrent or refractory bleeding may lead to need for surgery, although this
has become uncommon as a result of improved endoscopic and medical treatment.
A number of medications increase the risk of bleeding including NSAIDs and SSRIs.
SSRIs double the rate of upper gastrointestinal bleeding. There are many causes for
upper GI hemorrhage. Causes are usually anatomically divided into their location in the
upper gastrointestinal tract. People are usually stratified into having either variceal or non-
variceal sources of upper GI hemorrhage, as the two have different treatment algorithms
and prognosis.
41
The causes for upper GI hemorrhage include the following:
42
o Vascular malformation, including aorto-enteric fistulae. Fistulae are usually
secondary to prior vascular surgery and usually occur at the proximal
anastomosis at the third or fourth portion of the duodenum where it is
retroperitoneal and near the aorta.[3][4][5]
o Hematobilia, or bleeding from the biliary tree
o Hemosuccus pancreaticus, or bleeding from the pancreatic duct
o Severe superior mesenteric artery syndrome
43
8. PATIENT AND HIS ILLNESS
PATHOPHYSIOLOGY
44
Blood flow to skin: Pallor Blood flow to kidneys: Blood flow to GI Blood flow to brain:
Urine output structures hypoxia, anxiety,
confusion, stupor, coma
Tubular necrosis
Abdominal Pain
Renal Failure:
Oliguria or Anuria Bowel infarction and Liver
necrosis
Anaerobic
metabolism
Metabolic acidosis
Vasoconstriction
Compensatory failure:
45
DEATH
b. Synthesis of the Disease
b.1. Definition of the Disease (Book-Centered)
UPPER GI BLEEDING
Gastrointestinal (GI) bleeding is a potentially life-threatening abdominal emergency
that remains a common cause of hospitalization. Upper gastrointestinal bleeding (UGIB)
is defined as bleeding derived from a source proximal to the ligament of Treitz.
The incidence of UGIB is approximately 100 cases per 100,000 population per year.
Bleeding from the upper GI tract is approximately 4 times more common than bleeding
from the lower GI tract and is a major cause of morbidity and mortality. Mortality rates
from UGIB are 6-10% overall.
The diagnosis of and therapy for nonvariceal upper gastrointestinal bleeding (UGIB)
has evolved since the late 20th century from passive diagnostic
esophagogastroduodenoscopy with medical therapy until surgical intervention was
needed to active intervention with endoscopic techniques followed by angiographic and
surgical approaches if endoscopic therapy fails.
The underlying mechanisms of nonvariceal bleeding involve either arterial
hemorrhage, such as in ulcer disease and mucosal deep tears, or low-pressure venous
hemorrhage, as in telangiectasias and angioectasias. In variceal hemorrhage, the
underlying pathophysiology is due to elevated portal pressure transmitted to esophageal
and gastric varices and resulting in portal gastropathy.
In patients with UGIB, comorbid illness, rather than actual bleeding, is the major cause
of death. Comorbid illness has been noted in 50.9% of patients, with similar occurrences
in males (48.7%) and females (55.4%).
One or more comorbid illnesses have been noted in 98.3% of mortalities in UGIB; in
72.3% of patients, comorbid illnesses have been noted as the primary cause of death.
Significant comorbidities have become more prevalent as the patient population with
UGIB has become progressively older. Rebleeding or continued bleeding is associated
with increased mortality; therefore, differentiating the patient with a low probability of
rebleeding and little comorbidity from the patient at high risk for rebleeding with serious
comorbidities is imperative.
46
b.2. Predisposing/Precipitating Factor
a. Peptic Ulcer Disease - Bleeding peptic ulcers account for the majority of patients
presenting with acute upper gastrointestinal bleeding (UGIB). Peptic ulcer disease is
strongly associated with H pylori infection. The organism causes disruption of the
mucous barrier and has a direct inflammatory effect on gastric and duodenal mucosa.
In cases of ulcer-associated UGIB, as the ulcer burrows deeper into the
gastroduodenal mucosa, the process causes weakening and necrosis of the arterial
wall, leading to the development of a pseudoaneurysm. The weakened wall ruptures,
producing hemorrhage.
b. BoerhaaveSyndrome- During vomiting, the lower esophagus and upper stomach are
forcibly inverted. Vomiting attributable to any cause can lead to a mucosal tear of the
lower esophagus or upper stomach. The depth of the tear determines the severity of
the bleeding. Rarely, vomiting can result in esophageal rupture (Boerhaave
syndrome), leading to bleeding, mediastinal air entry, left pleural effusion (salivary
amylase can be present) or left pulmonary infiltrate, and subcutaneous emphysema.
c. Mallory-Weiss Tear- The massive UGIB results from a tear in the mucosa of the
gastric cardia. This linear mucosal laceration is the result of forceful vomiting, retching,
coughing, or straining. These actions create a rapid increase in the gradient between
intragastric and intrathoracic pressures, leading to a gastric mucosal tear from the
forceful distention of the gastroesophageal junction.
d. Gastritis- Acute stress gastritis results from predisposing clinical conditions that have
the potential to alter the local mucosal protective barriers, such as mucus,
bicarbonate, blood flow, and prostaglandin synthesis. Any disease process that
disrupts the balance of these factors results in diffuse gastric mucosal erosions.
47
may induce necrosis of the vessel wall. Alcohol consumption is reportedly associated
with the Dieulafoy lesion.
49
PATOPHYSIOLOGY
a. Schematic Diagram (Patient-Centered)
50
b. Synthesis of the Disease
b.1. Definition of the Disease (Patient-Centered)
UPPER GI BLEEDING
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper
gastrointestinal tract, commonly defined as bleeding arising from the esophagus,
stomach, or duodenum. Bleeding occurs when the inner lining of the esophagus,stomach,
or proximal intestine is injured, exposing the underlying blood vessels, or when blood
vessels themselves rupture. Upper gastrointestinal bleeding (UGIB) is defined as
hemorrhage that emanates proximal to the ligament of Treitz.
Duodenal peptic ulcer disease is a ulcerative disorders that occur in areas of the
upper gastrointestinal tract that are exposed to acid-pepsin secretions. The most common
forms of peptic ulcer are duodenal and gastric ulcers. Peptic ulcer disease, with its
remissions and exacerbations, represents a chronic health problem. Duodenal ulcers
occur five times more commonly than gastric ulcers. Ulcers in the duodenum occur at any
age and frequently are seen in early group, with a peak incidence between 55 and 70
years of age. Both types of ulcers affect men three to four times more frequently than
women.
c. Peptic Ulcer Disease - Bleeding peptic ulcers account for the majority of patients
presenting with acute upper gastrointestinal bleeding (UGIB). Peptic ulcer disease is
strongly associated with H pylori infection. The organism causes disruption of the
mucous barrier and has a direct inflammatory effect on gastric and duodenal mucosa.
In cases of ulcer-associated UGIB, as the ulcer burrows deeper into the
gastroduodenal mucosa, the process causes weakening and necrosis of the arterial
wall, leading to the development of a pseudoaneurysm. The weakened wall ruptures,
producing hemorrhage.
51
NON-MODIFIABLE RISK FACTORS
d. AGE (50-60 y/o) Result of natural thinning of the gastric mucosa with aging therefore
increasing risk for damage of the gastric mucosa which could then result to bleeding.
52
B. PLANNING (NURSING CARE PLANS)
Ineffective tissue perfusion related to decreased oxygen carrying capacity of the blood
53
Vital signs were taken amounts of glycosylated interventions 4. Review 4. It determines the patient shall
hemoglobin, that indicates the patient will laboratory extent of anemia have verbalized
and as follows:
poorer control of blood verbalize result for and its effect on understanding
glucose levels. The oxygen understanding hemoglobin energy output of condition,
T=37 C
supply that should be of condition, and appropriate therapy
carried by the red blood cell therapy hematocrit. measures regimen, and
PR= 106 bpm
is replaced by the glucose, regimen, and side effect of
so there is a decreased side effect of medication.
RR= 24 cpm
oxygen supply going to medication.
systemic circulation.
BP= 120/70 mmHg
54
toileting and
bathing.
7.This is to
provide rest and
7. Provide
enough sleep
health
which decreases
teaching on
the demand on
maintaining
the kidneys to
a schedule
function.
that contains
adequate
time rest and
sleep should
be
considered.
8.Administer
medication
as ordered 8.This is to
pharmacologically
treat the client.
9. Refer to
medical
social
55
services as 9.This is to
necessary. counsel in about
the impact of
having such
10.Collabora disease.
te in
treatment of
underlying 10. To maximize
condition,suc systemic
h as circulation and
hypertension organ perfusion
,diabetes,car
diopulmonar
y conditions
and blood
disorders
Problem #2: Impaired gas exchange related to altered oxygen-carrying capacity of the blood as evidenced by
decreased level of hemoglobin
S= Impaired gas exchange Short Term: 1.Establish therapeutic 1.To gain patients
is a state in which an relationship trust and
Patient may verbalize: Impaired gas individual experiences After 4-5 hours of cooperation
exchange related an excess or deficit in nurse-patient
>Dyspnea to altered oxygen- oxygenation and/or interventions, the
carrying capacity of carbon dioxide patient will
56
upon the blood as elimination at the demonstrate non
>Headache 2.Monitor and record 2. to acquire
evidenced by alveolar capillary pharmacologic
awakening vital signs baseline data
decreased level of membrane. Transport management as
>Visual Disturbances hemoglobin of oxygen is impaired evidenced by 3. Provide comfort 3. to provide
in anemia. Hemoglobin patient doing deep measures such as comfort
is lacking or the breathing, stretching bed linens,
number of RBCs is too coughing and cleaning bedside and
low to carry adequate turning exercises providing am care.
oxygen to tissues and
hypoxia develops. The 4. Encourage frequent
body attempts to position changes and
O= Long Term:
compensate for tissues deep breathing or
hypoxia by coughing exercises
Patient manifested: After 1-2 days of
nurse-patient 4. to promote
increasing the rate of 5. Encourage adequate
interventions, the optimum expansion
RBC production, rest and limit activities
patient will of the lungs and
>Hemoglobin level of increasing cardiac within client tolerance
demonstrate drainage of
90 g/L (9-14-16) output by increasing
adequate secretion
stroke volume or heart 6. Maintain adequate
rate, redistributing intake and output 5. to help limit
oxygenation of
blood from tissues of oxygen needs or
>Hematocrit level tissue by
low oxygen needs to consumption
hemoglobin result
tissues with high
Of 0.27 g/L(9-14-16) within clients 7. Provide psychological
oxygen needs, and
normal limits and support, active-listen
shifting of oxygen-
>pale bulbar and absence of
hemoglobin
palpebral conjunctiva respiratory questions/concern
dissociation curve to
distress.
the right to facilitate
the removal of more
57
oxygen by the tissues
>diaphoresis 8. Administer 6. to mobilize
at the same partial medication as indicated secretions
>restlessness pressure of oxygen such as recombinant
making the ability of human erythropoietin-
>vital signs were blood to carry oxygen beta
taken and as follows: decreased. Even
though there will be
T=37 C enough oxygen coming 7. to reduce anxiety
from the lungs, there is 9.Reinforce need for
PR= 106 bpm
a lesser carrying adequate rest, while
RR= 24 cpm capacity of oxygen to encouraging activities
the blood hence there such as deep breathing
BP= 120/70 mmHg is inadequate exercises and coughing
distribution of oxygen exercises
in the different parts of 8.to treat
the body giving rise to underlying
the problem impaired condition; to
gas exchange. increase red blood
cells
Patient may manifest:
>Confusion
>Abnormal breathing
9. to decrease
>hypoxia/hypoxemia dyspnea and
improve quality of
>Tachycardia life
58
Problem #3: Activity Intolerance
r/t muscle weakness secondary to decreased hemoglobin level
59
pressure / glucose. This with the patient and walking
response to deficiency in and/or SO. along corridor..
activity energy will Motivation and
ECG affects muscle cooperation are
changes and may lead to enhanced if the
reflecting muscle patient
arrhythmias weakness or participates in
or ischemia activity goal setting.
Dyspnea intolerance Have the patient
Fatigue at perform the
rest activity more
slowly, in a
longer time with
more rest or
pauses, or with
assistance if
necessary.
Helps in
increasing the
tolerance for the
activity.
60
Gradually
increase activity
with active
range-of-motion
exercises in
bed, increasing
to sitting and
then standing.
Gradual
progression of
the activity
prevents
overexertion.
Dangle the legs
from the bed
side for 10 to 15
minutes.
Prevents
orthostatic
hypotension.
Refrain from
performing
61
nonessential
activities or
procedures.
Patient with
limited activity
tolerance need
to prioritize
important tasks
first.
Assist with
ADLs while
avoiding patient
dependency.
Assisting the
patient with
ADLs allows
conservation of
energy.
Carefully
balance
provision of
assistance; facili
62
tating
progressive
endurance will
ultimately
enhance the
patients activity
tolerance and
self-esteem.
Provide bedside
commode as
indicated.
Use of
commode
requires less
energy
expenditure
than using a
bedpan or
ambulating to
the bathroom.
Teach energy
conservation
63
techniques,
such as: Sitting
to do tasks;
Frequent
position
changes;
Pushing rather
than pulling;
Sliding rather
than lifting;
Resting for at
least 1 hour
after meals
before starting a
new activity.
These
techniques
reduce oxygen
consumption,
allowing a more
prolonged
activity.
64
Encourage
verbalization of
feelings
regarding
limitations.
This helps the
patient to cope.
Acknowledgmen
t that living with
activity
intolerance is
both physically
and emotionally
difficult.
Encourage
physical activity
consistent with
the patients
energy levels.
Helps promote a
sense of
autonomy while
65
being realistic
about
capabilities.
Dependent:
Administer
oxygen via
nasal cannula
as indicated
To deliver
supplemental
oxygen and
prevent
hypoxemia
Refer to
physical/
occupational
therapy for
programmed
daily exercise
and activities
To increase
strength muscle
66
tone and
enhance sense
of well-being
67
extremiti vascular, day, normal access, extremiti
es cellular, or blood set an es
capillary intracellular pressure, appropriat capillary
refill dehydration pulse and e IV refill
within 4 due to current body infusion within 4
seconds condition, thus temperature flow rate seconds
tissue the need for and To detect and tissue
perfusio hydration is a administer prevent perfusion
n within priority at a occurrence of within 4
4 Long term: constant hypovolemia seconds
seconds After 3 days of flow rate frequent
frequent nursing as passing
passing interventions, ordered. of black
of black the patient will colored
be able to Body weight stool
colored maintain fluid Watch for changes (approxi
stool volume at a early signs reflect mately 3
(approxi functional level of changes in times)
mately 3 as evidenced hypovolem body fluid with
times) by individually ia, volume vomitus
with adequate including of
vomitus urinary output restlessne approxim
of with normal ss, ately 2
approxi specific weakness, cups
mately 2 gravity, stable muscle To determine if characte
cups turgor and cramps there is an rized as
characte prompt and existing bloody
rized as capillary refill postural deficiency in
bloody fluid volume
68
hypotensio The client may
The client may n. manifest:
manifest:
Monitor neck
neck daily veins flat
veins flat weight for when
when sudden client is
client is decreases, supine
supine especially change
change in the in mental
in mental presence status
status of To inform elevated
elevated decreasing physician of BUN and
BUN and urine the present Hct
Hct output or condition of decrease
decreas active fluid the patient and in urine
e in loss be able to output
urine carry out any with
output Monitor immediate increase
with total fluid orders to d
increase intake and prevent any specific
d output complications gravity
specific every 8
gravity hours.
Render
health
teachings:
69
o Avoid
humid
places to
reduce
insensible
fluid
losses
o Replenish
lost fluids
after daily
activities
through
intake of
water and
other liquid
products.
Collaborative
Refer the
patients
frequent
passing of
stool and
vomiting to
the
attending
physician.
70
Problem #5: Ineffective Protection
Assessment Nursing Scientific Objectives Intervention Evaluation
Diagnosis Explanation
S> Risk for infection Bleeding is the Short-term: Independent: Short-term:
name commonly After 6 hrs. Of Monior and After 6 hrs. Of
used to describe nursing record vital signs nursing
O> blood loss. It can interventions, the To obtain interventions, the
The patient may refer to blood patient will baseline data and patient shall have
manifests: loss inside the demonstrate assess changes demonstrated
Presence of body (internal techniques, techniques,
Establish
infections bleeding) or lifestyle changes lifestyle changes
guidelines and
Presence of blood loss to promote safe to promote safe
goals of activity
damaged outside of the environment. environment.
71
tissues upon body (external with the patient
diagnostic bleeding). and/or SO.
procedures Infection is the Motivation and
Increased WBC invasion of an cooperation are
count organism's body enhanced if the
tissues by
patient
disease-causing
participates in
agents, their
goal setting.
multiplication,
Emphasize
and the reaction
constant and
of host tissues to
proper hand
these organisms
and the toxins hygiene
72
Cover perineal
and pelvic region
dressing when
using bedpan
To prevent
contamination
maintain
adequate
hydration
To prevent
urinary infections
73
MEDICAL MANAGEMENT
INTRAVENOUS FLUID THERAPY
Medical Date General Indication Clients reaction
Management description
PNSS 1L x Date A isotonic solutions This solution is Patient responded
120cc/hr Ordered: having the same meant to replace well to the treatment
09/14/16 concentration of fluid loss caused and received the
solutes maintain by upper bleeding. nutrients needed by
Date Started: cell size and Since the patients the body such as
09/14/16 hydration. It blood was water, sodium and
contains 154 mEq hypertonic due to chloride. He did not
of Na and 154 mEq increase blood experience any
of chloride glucose level, an potential IVF therapy
isotonic solution related complications
counter the such as febrile
problem by diluting response, infection at
the excess solute, the site of injection,
which will cause a venous thrombosis or
decline in the phlebitis extending
tonicity of patients from the site of
blood. This causes injection,
an increase of extravasations and
fluids in the hypovolemia
intravascular
space to increase
the blood pressure
of the patient.
NURSING RESPONSIBILITIES:
2. In administering and starting the IV line of the patient, always start with
identifying the patient and explaining the procedure to the SO to gain their trust
3. Always observe and check for the correct type of IVF as well as the clarity of fluid
74
1. Select vein and apply tourniquet
2. Clean the site using cotton with alcohol in a circular motion going outwards
3. Puncture the vein, advance catheter then remove the needle and release the
tourniquet
6. Adhere to standard precaution, then regulate flow rate as per doctors order
1. Check and observe the puncture site for bleeding, edema or thrombophlebitis
75
D5 W 90cc + Date Dextrose 5% in Source of The patient
80mg Ordered: Water (D5W) with water, didnt
omeprazole 09/14/16 omeprazole raises electrolytes experience
sidedrip total fluid volume it and calories or any adverse
regulated @ Date is also helpful in as an reaction upon
80 cc / hr Started: rehydrating, alkalinizing administration
09/14/16 excretory agent. of the drug
purposes and such as
reduce gastric acid headache,
and protects the fever, pain
GI lining and mild
diarrhea
NURSING RESPONSIBILTIES
Before:
During:
76
5. Ensure appropriate infusion flow
6. Adhere to standard precaution, then regulate flow rate as per doctors order
After:
Blood Transfusion
Medical Date General Indication Clients
Management description reaction
Blood Date The transfer of Transfusions The patient
Transfusion Ordered: blood or blood are given to had
1 unit Packed 09/14/16 components from restore lost developed
RBC Type B+, Date one person (the blood, to reactions
Properly started: donor) into the improve such as
cross-matched 09/15/16 bloodstream of clotting time, having
another person and to improve erythematous
(the recipient). the ability of skin
the blood to inflammation
deliver oxygen on the face
to the body's and difficulty
tissues. of breathing
NURSING RESPONSIBILITIES:
BEFORE:
77
Check physicians order, including blood type, product and number of units and
period of time blood must be transfused.
Transfusion must be started 30 minutes after blood is taken from the refrigerated
storage.
DURING:
Stay with the patient with at least 15 mins. or the first 50ml of transfusion in order
to observe reactions and complications.
Blood should not be allowed to hang at 4-6 hours at room temperature because
of the danger of proliferation and RBC hemolysis.
AFTER:
78
Oxygen Date Oxygen therapy is To deliver Patient
Inhalation via Ordered: the administration relatively low tolerated the
nasal cannula 09/14/16 of oxygen as a concentration management
4 LPM medical of oxygen and
intervention, which when minimal improved
can be a variety of oxygen support condition as
purposes in both is required. evidenced
chronic and acute by absence
patient care. of pallor and
Oxygen is dyspnea. No
essential for cell presence of
metabolism and in wheezes
turn tissue upon
oxygenation is exhalation
essential for all
normal
physiological
functions
NURSING RESPONSIBILITIES:
Before:
During:
Regulate for the proper flow rate and monitor patients respiratory rate
The nurse should place the patient in a comfortable position, preferably semi-
fowler or full fowlers position to assist breathing.
Note the patients level of consciousness
After:
79
The nurse should stay with the patient for a while to reassure the patient and
observe his or her reaction to the therapy
The patients vital signs should be monitored, along with the level of
consciousness, comfort with the oxygen apparatus and oximetry levels
Oxygen connections and settings should be checked
DRUGS
Name of Date Route/ General Indication/ Clients
drug ordered/ Dosage/ action/mecha Purpose response
Date Frequency of nism of action to medicine
started/ administration with actual
Date s/e
change
d
Generic Date Route of It works by For gastric Had given
name: Ordered Administration: enhancing mucosal and reaction
09/14/16 Oral mucosal lesions in occurred.
Rebamipide defense, acute
scavenging gastritis and
Brand name: Dosage and free radicals, acute
Frequency: and temporarily exacerbation
Mucosta 50 mg/cap, 1 activating of chronic
cap TID genes gastritis.
encoding
cyclooxygenas
e-2.
NURSING RESPONSIBILITIES:
BEFORE:
Explain the procedure, purpose, indication and side effects of the drug
80
Be alert for adverse reactions and interactions
DURING:
AFTER
Chart the procedure including the time, name and dosage of the drug and the
clients response to the administration.
81
Generic name: Date Route of Forms a This is This is due to
Ordered: Administrati reversible indicated for upper
Tranexamic acid 09/14/16 on: complex that patients gastroesopha
IVP displaces with geal bleeding,
Brand name: plasminogen bleeding the desired
Dosage and from fibrin disorder effect of the
Cyklokapron Frequency: resulting in such as drug was
500 mg now inhibition of treatment of achieved as
Classification: then q 8 fibrinolysis; it severe evidenced by
hours x 3 also inhibits the localized an absence
Antifibrinolytic doses proteolytic bleeding by of bleeding
activity of helping the and
plasmin blood to clot hematemesis
normally as
in the case
NURSING RESPONSIBILITIES:
Before:
Explain the procedure, purpose, indication and side effects of the drug
Perform ANST prior to admission, should not be given if positive skin test
Inform the patient about the possible side effects of the drug
During:
82
After:
83
excessive
gastric acid.
NURSING RESPONSIBILITIES:
BEFORE:
DURING:
AFTER:
84
Patient may experience anorexia; small frequent meals may help to maintain
adequate nutrition
Report severe headache, unresolved severe diarrhea, or changes in respiratory
status.
Stay with the client for at least 15-30 minutes after giving the drug
NURSING RESPONSIBILITIES:
BEFORE:
Check the doctors order
Explain the procedure and the action of the drug
85
Make sure that it is the right drug, right dosage. Check for the expiration of the
drug
Assess allergy to any anti-histamines
Do not combine drug with amobarbital, amphotencin, B hydrocortisone
Do not mix with foscarnet
DURING:
Give without regards to meals
Ensure that the syringe containing the medication has no bubbles in it
Give the medication via slow push
AFTER:
Monitor patients response
Monitor blood pressure
Tell the patient that she may experience side effects such as dizziness, sedation
and drowsiness
Explain to the client that arising quickly form a lying or sitting position may cause
orthostatic hypotension
Document what have done and all the necessary outcomes
86
decreased fluid will decreased
result to decreased blood
blood volume leading pressure
to decreased blood upon the
pressure course of
treatment of
furosemide
NURSING RESPONSIBILITES:
Before:
During:
After:
87
Name of drug Date Route/ General Indication/ Clients
ordered/ Dosage/ action/mechanism Purpose response to
Date Frequency of of action medicine
started/ administration with actual
Date s/e
changed
Generic name: Date Route of Stimulates motility of This can be The desired
Ordered Administration: upper GI tract used to treat effect of the
Metoclopromide 09/14/16 IVP without stimulating nausea and drug was
gastric, biliary, vomiting, it achieved by
Brand name: Dosage and or pancreatic can also decreasing
Frequency: secretions; appears raise lower the
Plasil 50 mg to sensitivity tissues esophageal intravariceal
to action of sphincter blood flow
acetylcholine; pressure. as
relaxes pyloric evidenced
sphincter, which, by an
when combined with absence of
effects on motility, vomiting
accelerates gastric episodes
emptying and and
intestinal transit little hematemesi
effect on gallbladder s
or colon motility,
increases lower
esophageal
sphincter pressure;
has
sedative properties;
induces release of
prolactin
NURSING RESPONSIBILIITIES
Before
88
5. Have phentolamine readily available in case of hypertensive crisis.
During
After
89
helps dissipate common during the
heat. colds and procedure
headache. like fever,
rashes or
difficulty of
breathing.
This means
that the
blood
product is
compatible
with the
patient.
NURSING RESPONSIBILTIES
Before:
During:
After:
90
Instruct the patient to consult physician if experienced adverse effects like
unusual bleeding, bruising and changes in the voiding pattern
.
NURSING RESPONSIBILITIES:
Before:
91
Check for doctors order
Explain the procedure, purpose and indication of the drug
Monitor response of symptoms of hyperkalemia (fatigue, muscle weakness,
paresthesia, confusion, dyspnea, peaked T waves, depressed ST segments,
prolonged QT segments, widened QRS complexes, loss of P waves, and
cardiac arrhythmias).
Assess for development of hypokalemia (weakness, fatigue, arrhythmias, flat
or inverted T waves, prominent U waves).
Monitor intake and output ratios and daily weight.
Assess for symptoms of fluid overload (dyspnea, rales/crackles, jugular
venous distention, peripheral edema). Concurrent low-sodium diet may be
ordered for patients with HF.
In patients receiving concurrent digoxin, assess for symptoms of digoxin
toxicity (anorexia, nausea, vomiting, visual disturbances, arrhythmias).
Assess abdomen and note character and frequency of stools.
Discontinue sodium polystyrene sulfonate if patient becomes constipated.
Concurrent sorbitol or laxatives may be ordered to prevent constipation or
impaction. Some products contain sorbitol to prevent constipation. Patient
should ideally have 1 2 watery stools each day d
During:
92
Irrigate colon (after enema solution has been expelled) with 1 or 2 quarts
flushing solution (non-sodium containing). Drain returns constantly through a
Y-tube connection.
Store remainder of prepared solution for 24 h; then discard.
After:
Observe patient closely for early clinical signs of severe hypokalemia (see
Appendix F). ECGs are also recommended.
Consult physician about restricting sodium content from dietary and other
sources since drug contains approximately 100 mg
Clear liquid 09/16/16 The clear used to juice, gelatin The patient was
liquid diet maintain and complaint and
93
has traditiona hydration while vegetable tolerated the diet
lly been minimizing broth as evidenced by
composed of colonic residue absence of
foods that abdominal pain
are and
transparent hematemesis
and liquid at and melena
body
temperature.
Soft diet 09/20/16 Foods that For patient -oatmeal Able to comply
are mashed who has -porridge
or pureed, difficulty -mashed
placed in swallowing, potatoes
soups, stews, surgery
chili, curries, involving the
or made into mouth or
sauces. gastrointestinal
tract, and pain
from newly
adjusted
braces.
NURSING RESPONSIBILITIES:
BEFORE:
Relieve illness symptoms that depress appetite prior to meal time (e.g. give an
analgesic for pain)
Provide familiar food that the person likes.
Avoid unpleasant or uncomfortable treatments immediately before meals.
Provide a tidy, clean environment that is free of unpleasant sights and odors.
Wash hands and other appropriate infection control.
94
DURING:
Warn the patient if the food is hot or cold.
Allow ample time for the client to chew and swallow the food before offering
more.
Provide fluid as requested and needed.
Use a straw or special drinking cup to avoid spills.
AFTER:
Assist the client to clean the mouth and hands.
Have the client rest for 30 minutes to one hour to prevent aspiration.
Reposition the client.
Table 14.Exercise
Type of Date General Indication/ purpose Clients
exercise started description response to
activity/
exercise
Active September Isotonic exercise To maintain or The patient
ROM 23, 2008 in which the increase muscle was able to
patient strength and move freely.
independently endurance and
movers each joint health to retain
in the body cardiorespiratory
through its Function.
complete range of To prevent
movement, deterioration of
maximally joint capsules.
stretching all ankylosis, and
muscle groups contractures.
within each plane
over the joint.
(Active ROM of
upper extremities
95
may include
combing of hair,
bathing and
dressing)
NURSING RESPONSIBILITIES:
BEFORE:
Assess patients ability to move
Raise side rails
Cloth patient with loose gown
Teach/demonstrate the exercise
DURING:
Perform each ROM to point of slight resistance, but not beyond never to point
discomfort
Assist the patient during exercise
AFTER:
Let the patient take enough rest after the exercise
RECORDNURSING MANAGEMENT (Actual SOAPIERs)
S=
O= Received patient on bed in supine position, awake and coherent with an ongoing IVF
of 0.9Nacl IL x 30 gtts/min at 800 cc level infusing well on her left hand.
P= After 4-5 hours of nurse-patient interventions, the patient will demonstrate non
pharmacologic management as evidenced by patient doing deep breathing, coughing and
turning exercises
96
I=
>Provided comfort measures such as stretching bed linens, cleaning bedside and
providing am care.
>Reinforced need for adequate rest, while encouraging activities such as deep breathing
exercises and coughing exercises
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D. EVALUATION
1. Clients Daily Progress Chart (From admission to last nurse-patient interaction)
DAYS September 14, 2016 September 16, 2016 September 22, 2016
Admission 3rd day 9th day
Nursing Problems
1.Ineffective tissue
perfusion
2.Impaired gas exchange
3.Activity intolerance
4.Risk for fluid volume
deficit
5.Risk for infection
Vital Signs
Temperature T: 36C T: 36.8C T: 38.5C
Pulse Rate PR: 65 bpm PR: 83 bpm PR: 110 bpm
Respiratory rate RR: 20 cpm RR: 25 cpm RR: 24 cpm
Blood Pressure BP: 100/70 mmHg BP: 100/70 mmHg BP: 110/70 mmHg
Dx/Lab Procedures
CBC
ECG test
Blood Typing
Cross Matching
Blood Chemistry
Drugs/Medications Metoclopramide 10mg IV q8 Metoclopramide 10mg IV q8 Metoclopramide 10mg IV q8
Paracetamol 350mg IV Paracetamol 350mg IV Paracetamol 350mg IV
Omeprazole 80mg IV OD Omeprazole 80mg IV OD Omeprazole 80mg IV OD
Furosemide 4mg IV q6 Furosemide 4mg IV q6 Furosemide 4mg IV q6
Tranexamic 500 mg q8 Tranexamic 500 mg q8 Salbutamol neb. q6
Kayaxelate sachet + 50cc OD
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Kayaxelate sachet + 50cc Kayaxelate sachet + 50cc Diphenhydramine 50mg IV
OD OD
Diphenhydramine 50mg IV Diphenhydramine 50mg IV
Diet NPO Clear liquid diet Soft diet
Activity/Exercise Active ROM Active ROM Active ROM
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2. Discharge Planning
a. General Condition of Client upon Discharge
The client can now be discharge because he can walk on his own, he showed no
complications and the laboratory results are within normal ranges. The client verbalizes
understanding about the disease condition and demonstrated ways how to prevent the
recurrent of the disease. METHOD should be emphasized to the client upon
discharged.
b. METHOD
Medication - Continue medications as prescribed.
- Explained important reminders and
their side effects.
Exercise - Encouraged to exercisefor at least
30mins./day for 3-4 times a week.
Treatment - Stress importance in complying to
medications.
- Follow up check-ups as scheduled.
Health Teachings - Taught client to avoid gastric irritants
- Avoid stressful activities
- Avoid vices such as smoking and
alcohol.
Observation - Encouraged client to observe
appearance of urine, stool and other
secretions.
Diet - Instructed client to eat iron-rich foods
to rebuild the iron stores that were
lost during bleeding episodes.
- Instructed client to eat high-fiber diet
to soften stools to prevent straining
due to constipation.
- Instruct to eat high protein diet to
promote faster healing of damaged
tissues.
- Avoid intake of alcohol, caffeine,
spicy foods, because these are
potential gastric irritants. Re-introduce
these foods into diet slowly, until GI
tract can handle them.
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III. SUMMARY OF FINDINGS
1. The nurse researchers gathered all the needed information concerning to the
patient condition especially those risk factors that may contribute to the patients
condition. The patient cooperated and provided an accurate information needed
by the researchers and complied well during the nurse cooperated and-patient
interaction.
2. The nurse researchers intensively analyzed and interpreted the gathered
abnormal data.
3. The nurse researchers gain more knowledge and understanding of the existing
condition and provided interventions for the wellness of the patient.
4. The nurse researchers provided health teachings such as in taking medications,
the effects of the drug, their importance and their mechanism of action.
5. The nurse research team handled the patient for 1 day and performed physical
assessment 5 problems were identified and prioritized according to severity.
Nursing care plans were implemented to deal with the problems of the patient.
6. The nurse research team provided health teaching/interventions concerning to a
specific problem and were explained why there were explained why these were
necessary. Hygiene, food preparation, stable environment and health teachings
were emphasized during the nurse-patient interactions.
7. The evaluation was made to know if the interventions done were effective.
8. The patient verbalized understanding of the condition and health teachings and
cooperated through the course of the case study.
9. The patient receives the possible nursing care for the client as evident in the
client improvement during the study.
10. The patient put into action the health teachings given by the nurse researchers
for the clients health improvement.
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IV. CONCLUSION
The nurse research team gain more knowledge and understanding of the condition; the
pathophysiology, the etiology, and the risk factors involve in its development and
progression. The team explains to the client the different procedures and interventions
and their importance in treating his condition. The researchers handled the patient for 1
day and formulated nursing care plans and implemented them. The researchers also
provided health teachings regarding the condition and explained the necessary
interventions to promote cooperation with the patient. Hygiene, food preparation, stable
environment were emphasized during the course of the nurse-patient interaction. Other
problems of the patient were referred to the attending physician. The patient verbalized
understanding of the health teachings and for his condition.The research team provided
comfort and relaxation to the patient to prevent stress and to minimize complications.
V. RECOMMENDATION
At the course of the study, the research team had found out that in-depth knowledge
about the condition process will benefit not only the patient and its family but also the
nurse and the medical staff as well. The following is a list of recommendations made by
the research team:
For the Student Nurses it is recommended knowing the proper interventions and
management to provide an efficient nursing care to their client that has the same
condition. To have a sufficient knowledge is a must to improve the health teachings to
attain their optimum level of functioning.
For the Nurse Educators the study can become a basis for nursing educator
because it provides depth information about the condition and its complications. The
researchers recommend the nurse educator to provide health teachings regarding the
risk factors that could lead to the condition.
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For the Health Care Provider learning never stops in comes to the medical practitioner
and nurses because new innovation are made to improve patient quality of life everyday
in health care. Health care delivery system plays an important role in helping patient with
this condition and thats why nurses and medical practitioners update themselves in the
different new discoveries with this condition.
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VI. LEARNING DERIVED
What the quote would like to point out is that a person should know how to prevent
different diseases and what to do when he/she is sick. We student nurses were able to
hear from the different patients in the ward that they admitted that they are the cause why
theyre hospitalized. They told us that theyre not taking good care of their health. One of
our responsibility as a nurses is to educate the people for them to become an independent
individuals and to prevent different diseases and to prevent different complications that
may arise if the disease is not treated immediately. We were able to emphasized to our
patients the health teachings and they were able to verbalized and understand it.
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BIBLIOGRAPHY
BOOKS
Medical-Surgical Nursing Clinical Management for positive outcomes Joyce M Black and
Jane Hokanson Hawk 8th edition
Pathopysiology: The Biologic Basis for Diseases in Adults and Children Kathryn L.
McCance, Sue E. Huether 2nd Edition
WEBSITES
https://www.nice.org.uk/guidance/cg141?unlid=805622976201622522739
http://emedicine.medscape.com/article/187857-treatment
http://patient.info/doctor/upper-gastrointestinal-bleeding-includes-rockall-score
http://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-
adults
http://www.aafp.org/afp/2012/0301/p469.html
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