LICEO DE CAGAYAN UNIVERSITY
R.N.P. Blvd., Carmen, Cagayan de Oro City
C OLLE GE OF NURSING
A family Care Study
PEPTIC ULCER DISEASE
Submitted to: Clinical Instructor
As Partial Requirement for NCM501202
Submitted by: NCM501202 Student
January 18, 2007
Table of Contents
I. II. III. IV. V. VI. VII. VIII. IX. X.
INTRODUCTION ----------------------------------------------------1 – 2 HEALTH HISTORY -------------------------------------------------3 – 4 DEVELOPMENTAL DATA ---------------------------------------5 - 6 MEDICAL MANAGEMANT ---------------------------------------7 - 17
ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY----------18 - 22
NURSING ASSESSMENT ----------------------------------------23 -25 NUSING MANAGEMENT -----------------------------------------26 -35 REFERRALS AND FOLLOW-UP--------------------------------36 EVALUATION AND IMPLICATIONS---------------------------37 BIBLIOGRAPHY -----------------------------------------------------38
I. INTRODUCTION Overview of the Case Too much stress, too much spicy food, and you may be headed for an ulcer or so the thinking used to go. A peptic ulcer is an ulcer of one of those areas of the gastrointestinal tract that are usually acidic. A more general term, peptic ulcer disease (PUD), is also in use. Most ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach. Ulcers can also be caused or worsened by drugs such as Aspirin and other NSAIDs. Contrary to general belief, more peptic ulcers arise in the duodenum (first part of the small intestine, just after the stomach) than in the stomach. About 4 % of stomach ulcers are caused by a malignant tumour, so multiple biopsies are needed to make sure. Duodenal ulcers are generally benign. The common belief was that peptic ulcers were a result of lifestyle. Doctors now know that a bacterial infection or medications — not stress or diet — cause most ulcers of the stomach and upper part of the small intestine (duodenum). Esophageal ulcers may also occur and are typically associated with the reflux of stomach acid. Although stress and spicy foods were once thought to be the main causes of peptic ulcers, doctors now know that many ulcers are caused by the corkscrewshaped bacterium Helicobacter pylori (H. pylori). H. pylori lives and multiplies within the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, H. pylori causes no problems. But sometimes it can disrupt the mucous layer and inflame and erode digestive tissues, producing an ulcer. One reason may be that people who develop peptic ulcers already have damage to the lining of the stomach or small intestine, making it easier for bacteria to invade and inflame tissues.
The most common ulcer symptom is gnawing or burning pain in the abdomen between the breastbone and the belly button. The pain often occurs when the stomach is empty, between meals and in the early morning hours, but it can occur at any other time. It may last from minutes to hours and may be relieved by eating food or taking antacids. Less common symptoms include nausea, vomiting, or loss of appetite. Sometimes ulcers bleed. If bleeding continues for a long time, it may lead to anemia with weakness and fatigue. If bleeding is heavy, blood may appear in vomit or bowel movements, which may appear dark red or black. Objective of the Study The objectives of this care study aims to: 1. Develop knowledge, which would make us or the readers aware on what are the possible causative agents and the signs & symptoms manifested by the patient on having this specific condition 2. Know the possible actions that would help alleviate or even prevent a certain problem related to the condition of the patient for the prevention of possible complications 3. 4. 5. Even give some interventions to those problems that were observed to the patient, but are not related to its diagnosis. Have a correct nursing care rendered to the patient on the entire therapy Identify what are the uses of the drugs being prescribed by the patients physician during the entire hospitalization Scope and limitation of the Study This study focuses mainly on the patient’s specific condition, which is bleeding peptic ulcer and even focused more on the condition of the patient before and upon admission to further evaluate what are the possible nursing and medical interventions would be applied to the patient on the entire course of therapies.
II. HEALTH HISTORY Patients Profile The name of the patient was, male; 74 years old; a Roman Catholic; and a Filipino citizen. He is married to Mrs. and have three siblings namely; and presently residing at. He was born on the. He is five feet four inches in height and 100 pounds in weight He is negative on food and drug allergies. His chief complains were Hematochezia and Hemoptysis. He was diagnosed by his physician Dr. Bacal, with T/C bleeding peptic ulcer disease. Personal Health History My patient has not received any blood from the past. He has no known food and medicine allergies. He had experienced having a cough when the time he stopped smoking and it gone out to be more severe on the following days. As his watcher said that he was hospitalized for several times because of his condition. , is susceptible to many diseases since the patient was to old and have vices that precipitates lots of diseases and complications. The patient also told me that when there were times that there is pain on his stomach, he sometimes skip his meals. As we all know, that, skipping a meal will lessen our body’s nutrients/strength and would become prone to diseases when the nutritive status of our body is altered. And due to tiredness and inadequate nutrients on his body, the patient would become weak and alters his daily activities. The above factors made my patient a susceptible individual to a certain disease. History of Present Illness and Chief Complains , presently residing in was admitted at Cagayan de Oro Polymedic General Hospital due to Hematochezia ( cause: bleeding in colon/rectum and results to loss of blood higher in the digestive tract or through defecation of bloody stools (melena); and also hemoptysis ( coughing up of blood from respiratory tract. Bloodsteaked sputum often is presented in minor upper respiratory infection or bronchitis). The patient was experiencing severe pain on his abdominal area when he does not eat his meals. Since the cause the discomforts felt by the patient on his abdomen, as 3
well as the bloody stools during defecation, and with laboratory examination taken by (e.g. CBC), the patient is then positive with a peptic ulcer disease. He was also noted with acute bronchitis; the patient was not able to talk clearly because of his productive cough or retained secretions/bronchospasm that obstructs the airway of the patient, that’s why he has dyspnea and some manifestations of hyperventilation and tachypnea, these was the cause why the patient has ineffective airway clearance during his hospitalization. Few minute prior to admission the patient encountered dizziness and brought patient to his room on a stretcher (condition upn admission) The result of his physical assessment was that he is febrile and is in respiratory distress. His vital signs during the first day of assessment were, temperature: 36.3oc; pulse rate: 88bpm; respiration rate: 28 cpm; and blood pressure: 140/70 mmHg. There was no skin lesions observed upon admission. Dr. Bacal’s admitting diagnosis to was Bleeding Peptic Ulcer Disease
III. DEVELOPMENTAL DATA
The stage of older adulthood is considered to begin at 65 years of age. Many physical, psychological, and social changes occur during later adulthood. The critical transition comes at the time of retirement for both the husband and the wife. In old age persons are moving toward completion of their life cycles. Old age can be a time when a person can enjoy his/her time with his/her grandchildren and leisure time activities, and forget about things caused him/her a great deal of stress and anxiety in the past three or four decades . During this stage a person must adapt to changing physical abilities. This stage is characterized by increased wisdom although many other things are lost such as health, friends, family and independence. The aging process of people in this stage of development varies greatly. Ego integrity Vs despair represents this stage in the psychosocial theory. The developmental tasks of the older adult are: adjusting to decreases physical strength and loss of health, adjusting to retirement and reduced income, coping with death of a husband or wife and preparing for one's own deatheating periods. According to Erik Erickson’s Psychosocial Development Theory lies on the stage 8 (integrity vs. Despair), wherein, ego integrity is the ego's accumulated assurance of its capacity for order and meaning. And despair is signified by a fear of one's own death, as well as the loss of self-sufficiency, and of loved partners and friends. This stage is focused on reflecting back on the person’s life, that is, those who are unsuccessful during this phase will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair. Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death. In general, this is the patients time for reflecting on and reviewing how he met previous challenges and lived his life. Adjusting to decreasing physical strength and health; Adjusting to retirement and reduced income; Establishing an explicit affiliation 5
with one's age group; and Meeting social and civil obligations are the right ways on how to establish a satisfactory physical living arrangements on his kind of stage.
IV. MEDICAL MANAGEMANT December 3, 2006 12:10 AM Please admit to Medical Ward TPR every four hours For further medical management and monitoring For baseline data of interventions and close monitoring of patients vital signs CBC- includes absolute number of percentages of erythrocytes, leukocytes,platelets, hemoglobin and hematocrit in blood sample. Used to evaluate blood if it is potential for infection or other disorders/abnormalities. This medication is an intravenous (IV) solution used to supply water, calories, and electrolytes Relaxes bronchial uterine and vascular smooth muscle by stimulating beta2 receptors that helps to prevent or treat broncho-spasm in patient with severe obstructive airway disease Proton Pump Inhibitor that reduces gastric acid secretion and decreases gastric acidity that helps eradicate Helicobacter Pylori. Short term treatment of ulcer (duodenal).Maintenance therapy for duodenal ulcer Inhibits the transport of calcium into myocardial and vascular 7
For – CBC and Chest PA
(#1 IVF therapy)
Combivent 1 neb every 6 hours
Esomemeprazole 20mg 1 tab BID, PO
Sucralfate (Iselpin) 1g/10ml BID, PO Isoptin 240 mg 1 tab OD, PO
smooth muscle cells, resulting in inhibition of excitationcontraction coupling and subsequent contraction. For management of hypertension Administer O2 For oxygen therapy of the patient since the patient cannot breath normally during admission.
December 4,2006 Lactulose (Dupholac), 20cc BID Produces an osmotic effect in colon, resulting distention promotes peristalsis. For or to treat constipation Stable in the presence of betalactamase enzyme. Used for acute bronchitis and acute exacerbations of chronic bronchitis
Cefixime (Tergeof) 200mg BID, PO
December 5,2006 IVF TF with D5NSS at 20 gtts / min This medication is an intravenous (IV) solution used to supply water, calories, and electrolytes (e.g., sodium, chloride) to the body.
December 6, 2006 On going IVF # 5 D5NSS @ 20 gtts / min. This medication is an intravenous (IV) solution used to supply water, calories, and electrolytes (e.g., sodium, chloride) to the body. The Patient is done with the Intravenous therapy and should continue his therapy with his medications.
Terminate when consume (IVF to consume)
December 7, 2006 Discontinue Nebulization This indicates that patient has alleviated his respiratory conditions and has change its conditions unlike before This indicate that the patient is in good condition and return to its functional level. The blood pressure of the patient was back on its normal ranges on a couple of days of admission. So the specific drug was discontinued. For the total wellness of his bronchospasm.
May Go Home Tomorrow
Resume spiriva 1 cap OD inhalation
LABORATORY RESULTS RADIOGRAPHIC REPORT (CHEST PA)
December 4, 2006
The lungs are clear. The heart is enlarged (CTR:067) exhibiting inferolateral displacement of the cardiac apex. There are crescentic calcifications in the aortic knob. The midline structures are not displaced. The costophrenic sulci and hemidiaphragms are intact. The rest of the included structures are unremarkable.
• CU cardiomegaly is considered. ECG correlation suggested • Atheromatous aorta
? DPBR, Radiologist
HEMATOLOGY REPORT Lab no. : 600066002 Date Received: 12-04-06 (5:58) Date Reported: 14-04-06 (7:18)
WHITE BLOOD CELLS RED BLOOD CELLS HEMOGLOBIN HEMATOCRIT MCV MCH MCHC DIFFERENTIAL COUNT Lymphocyte Neutrophil Monocyte Eosinophils Basophils
23.31 4.40 13.2 39.7 94.7 30.1 32.0
10^3/uL 10^6/uL g/dL % fL pg g/dL
5.0 - 10.0 4.2 - 5.4 12.0 – 16.0 37.0 – 47.0 82.0 – 98.0 27.0 – 31.0 31.5 – 35.0
7.5 89.2 7.4 .9 .2
% % % % %
17.4 – 48.2 43.4 – 76.2 4.5 – 10.5 1.0 – 3.0 0.0 – 2.0
150 - 400
Generic Name Brand Name Date ordered Classification Dose/ Frequency/ Route Mechanism of Action Indication Contraindication Side Effects Nursing Precaution
Verapami Isoptin December Anti3, 2006 hypertensiv e
240mg/ 1tab od/ PO
Inhibits the Managemen transport of t of calcium hypertension into myocardial and vascular smooth muscle cells, resulting in inhibition of excitationcontraction coupling and subsequent contraction.
Hypersensitivity, Anxiety, sick sinus confusion, syndrome Dizziness, headache, BP less than 90 nervousness, mmHg blurred vision, CHF, severe polyuria, ventricular vomiting dysfunction
Use cautiously in severe hepatic impairementgeriatric patient. History of serious ventricular arrhythmias.
Dose/ Frequency/ Route
Mechanism of Action
Sucralfate Iselpin December Antiulcer 3, 2006 drugs
1 gram qid/ PO (befire meals at HS)
Unknown. Probably adheres to and protects surface of ulcer by forming a barrier.
Short term treatment of ulcer (duodenal) Maintenance therapy for duodenal ulcer
Use cautiously to patient with chronic renal failure
Dizziness, headache, vertigo, constipation, nausea, gastric discomfort, diarrhea, dry mouth
Drug is minimally absorbed and causes few adverse effect Drug contains Aluminum but isn’t classified as Antacid. Monitor patients renal insufficiency for aluminum toxicity
Dose/ Frequency/ Route
Mechanism of Action
Decembe Antiulcer r 3, 2006 drugs
20mg/ 1 tab bid/ PO
Proton Pump Inhibitor that reduces gastric acid secretion and decreases gastric acidity
Helicoba cter Pylori eradicati on
Hypertensive to drug or some components of esomeprazole or omeprazole
Headache, dry mouth, diarrhea, nausea, abdominal pain, vomiting, and constipatio n
Give at least one hour before meals Monitor GI symptom s for improve ment or worsenin g.
Dose/ Frequency / Route
Mechanism of Action
December 3, 2006
1 neb q 6o
Relaxes bronchial uterine and vascular smooth muscle by stimulating beta2 receptors.
To prevent or treat bronchospasm in patient with severe obstructive airway disease
Hypertensive to drug or ingredients Use extended release tablets cautiously in patient with GI narrowing
Dizziness, headache, heartburn, nausea, vomiting, cough, increase sputum, tachycardi a
Drug may decrease sensitivity of spirometr y used for dx of asthma Patient may use tablet and aerosol together monitor for signs of toxicity.
Dose/ Frequenc y/ Route
Mechanism of Action
December Laxatives 4, 2006
20cc/ bid/ PO
Produces For or treat an constipation osmotic effect in colon, resulting distention promotes peristalsis.
Patient with a Abdomin low galactose al diet cramps, belching, Use diarrhea, cautiously in gaseous patient with distention diabetes , mellitus. flatulence , nausea, vomiting
Minimize sweet taste dilute with water or give with food. Monitor sodium level for hypernatre mia, especially when giving in higher doses to treat hepatic encephalo pathy. 16
Dose/ Frequency/ Route
Mechanism of Action
December Cephalospori 4, 2006 n / antibiotic
200mg/ bid/ PO
Stable in the presence of betalactamas e enzyme
Used for acute bronchitis and acute exacerbations of chronic bronchitis.
Hypertensive to drugs or other cephalosporin drugs.
Flatulence, elevated alkaline phosphatase level.
Once reconstituted, keep suspension at room temperature where it maintains potency for 14 days.
V. ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY
Digestive System, organs for changing food chemically into simple soluble substances absorbable by tissues. This process involves catalytic reactions between ingested food and enzymes secreted into the intestinal tract (see Intestine). Digestion of fatty substances appears to involve the assembly of bile salts, phospholipids, fatty acids, and monoglycerides that can pass through intestinal cells. Other nutrients such as iron and vitamin B12 are absorbed by specific “carrier proteins” that make them transferable by the intestinal cells. The process described here is typical of all vertebrates except ruminants. Digestion includes both mechanical and chemical processes. The mechanical processes include chewing to reduce food to small particles, the churning action of the stomach, and intestinal peristaltic action. These forces move the food through the digestive tract and mix it with various secretions. Three chemical reactions take place: conversion of carbohydrates into such simple sugars as glucose (see Sugar Metabolism), breaking down of protein into such amino acids as alanine, and conversion of fats into fatty acids and glycerol (see Fats and Oils). These processes are accomplished by specific enzymes. When food is eaten, the six salivary glands produce secretions that are mixed with the food. The saliva breaks down starches into dextrin and maltose, dissolves solid food to make it susceptible to the action of later intestinal secretions, stimulates 18
secretion of digestive enzymes, and lubricates the mouth and oesophagus for the passage of solids. Stomach and Intestinal Action
Gastric juice in the stomach contains agents such as hydrochloric acid and some enzymes, including pepsin, rennin, and traces of lipase. (The surface of the stomach itself is thought to be protected from acid and pepsin by its mucous coating.) Pepsin breaks proteins into peptones and proteoses. Rennin separates milk into liquid and solid portions; lipase acts on fat. Another function of stomach digestion is gradually to release materials into the upper small intestine, where digestion is completed. Some constituents of gastric juice become active only when exposed to the alkalinity of the small intestine; secretion is stimulated by chewing and swallowing and even by seeing or thinking of food (see Reflex). The presence of food in the stomach also stimulates production of gastric secretions; these in turn stimulate the production of digestive substances in the small intestine. The most extensive part of digestion occurs in the small intestine; here most food products are further hydrolysed and absorbed. Predigested material supplied by the stomach is subjected to the action of three powerful digestive fluids: pancreatic fluid, intestinal juice, and bile. These fluids neutralize the gastric acid, ending the gastric phase of digestion. Intestinal juice is secreted by the small intestine. It contains a number of enzymes; its function is to complete the process begun by the pancreatic juice. The flow 19
of intestinal juice is stimulated by the mechanical pressure of food partly digested in the intestine. The water-soluble substances, including minerals, amino acids, and carbohydrates, are transferred into the venous drainage of the intestine and through the portal blood channels directly to the liver. Many of the fats, however, are resynthesized in the wall of the intestine and are picked up by the lymphatic system (see Lymph), which carries them into the systemic blood flow as it returns through the vena caval system (see Heart), bypassing an original passage through the liver (see Circulatory System). Excretion Undigested material is formed into a solid mass in the colon by reabsorption of water into the body. If colonic muscles propel the excretory mass through the colon too quickly, it remains semi-liquid. The result is diarrhoea. Insufficient activity of the colonic musculature, on the other hand, produces constipation. The stool is held in the rectum until excreted through the anus. Many disorders of absorption are collectively called malabsorptive states, the most profound and difficult being a condition known as spruce.
Definition: Peptic Ulcer A circumscribed breaks or ulcerations of the gastrointestinal mucosa and underlying tissues caused by gastric secretions that have low pH(acid) Predisposing Factors Blood Type (tends to strike with type “A” blood; duodenal ulcers tends to afflict type “O” Blood. Genetic Predisposition/ Factors Normal Aging Exposure to irritants (alcohol use and tobacco smoking) Physical trauma Emotional stress or psychosomatic factors (e.g. chronic anxiety) Precipitating Factors Epigastric Pain which is burning Piercing and periodic Hyperacidity Nausea or vomiting
HCl = Pepsin
Irritants (Alcohol and tobacco)
Increase or excessive secretions (caused by stress or stimulants)
mucous or gastric acid secretions
Damage of mucous membrane
PEPTIC ULCER DISEASE
S/s: Pain (burning, Aching, or gowning) Epigastric Tenderness
Bleeding at the site (GIT) Passage of tarry stools (melena) May occur Complications: pyloric or duodenal obstruction, hemorrhage and perforation 22
VI. NURSINS ASSESSMENT
EENT: Impaired vision blind pain reddened drainage gums hard of hearing deaf burning edema lesions teeth assess eyes ears nose throat for abnormalities no problem RESP: Asymmetric tachypnea apnea rales cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea labored wheezing pain cyanotic asses resp. rate, rhythm, depth, pattern, breath sounds, comfort no problem CARDIO VASCULAR Arrhythmia tachycardia numbness diminished pulse edema fatigue irregular bradycardia murmur tingling absent pulses pain assess heart sounds, rate rhythm, pulse, blood pressure, circ., fluid retention, comfort no problem GASTRO INTESTINAL TRACT Obese distention mass dysphagia rigidly pain assass abdomen, bowel habits, swallowing, bowel sounds, comfort no problem GENITO-URINARY Pain urine color vaginal bleeding hematuria discaharge noctoria Assess urine freq., control, color, odor, comfort/gyn-bleeding, discharge no problem NEURO Paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision grip assess motor function, sensation, LOC, strength, grip, gait, coordination, orientation,speech, no problem MUSCULOSKELETAL and SKIN Appliance stiffness itching petechiae hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed atrophy pain ecchymosis diaphoretic moist assess mobility, motion, gait, alignment, joint function/skin color, texture, turgor, integrity no problem Place an (x) in the area of abnormality. Comment at the space provided indicate the location of the problem in the figure if appropriate, using (x)
_________________________ Pain at OD _________________________ _________________________ _________________________ O2 administration _________________________ (nasal Cannula) _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Tachypnea (RR 28cpm) Hyperventilation _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Abdominal Pain _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ IVF D5NSS 1l infusing at Right hand @ 20gtts/min _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Pain @ Right Knee / Leg (Arthritis) _________________________ _________________________ _________________________ _________________________ _________________________
Body is Weak
SUBJECTIVE “maayo raman
OBJECTIVE Glasses languages Contact lens hearing aide R L Pupil Size ___3.0mm__ γ speech difficulties Reaction ____PERRLA_____
akong paminaw, sakit COMMUNICATION: lang usahay akong tuo Hearing loss Comments___________ nga mata” Visual changes ____________________ Denied ____________________ ____________________ ____________________
OXYGENATION: Dyspnea Smoking history _____________
“gahanga- kon ko tungod sa akong ubo Resp. γ regular γ irregular Comments___________ na grabe ang plema Describe: __Patient exhibits hyperventilation a ___________________ panalagsa” manifestation of tachypnea on patient_______
cough __________________ sputum __________________ “gapaminhod denied ___________________ CIRCULATION: usahay and akong tiil ug usahay pud musakit Chest pain Comments___________ ____________________ tungod aning arthritis Leg pain ____________________ na hinungdan nganu ____________________ galisod kog lakaw Numbness of ____________________ usahay” Extremities ____________________ ____________________ Denied ____________________
R _side is symmetrical during inhalation/exhalation L _side is symmetrical during inhalation/exhalation Heart rhythm γ regular γ irregular Ankle edema ___________________________ Pulse Car. Rad. DP Fem.* R _+______+_______+______+_____+______ L _+______+_______+______+_____+______ Comments:_all pulses are palpable or noted during the assessment (positive) * if applicable γ none With Patient
NUTRITION: “Dili nagyud γ Dentures Diet___________________________________ kau ko g,a kaun wala N V Comments__________ man gyud koy gana Full Partial Character ____________________ Diet as bisag unsa nga pagkaun Upper Tolerated γγγ γ Recent change in ____________________ na ihatag sa akoa” wieght,appetite ____________________ γ Swallowing ____________________ Lower γγγ difficulty _____________________ “sige ko ug γ Denied _____________________ ELIMINATION: Usual bowel pattern γ urinary frequency ____2 x per day___ ____Every Hour______ Constipation γ urgency Remedy γ dysuria _December 5, 2006_ γ hematuria Date of last BM γ incontinence ________________ γ polyuria Diarrhea γ foly in place Character γ denied ________________ MGT. OF HEALTH & ILLNESS: Alcohol denied (amount, frequency)
kalibang ug tae na basa as verbalizad by the Comments __________ Bowel sound________ patient. Still his stool is ______Audible______ ___________________ black, tarry/bloody __________________ Abdominal Distension (melena), and wet ___________________ Present yes no (characteristics) ___________________ Urine* (color.,
___________________ ___________________ ___________________ ___________________ ___________________ consistency, odor) __________________ __________________ __________________ *if they are in place?
____as patient verbalized that he doesn’t drink alcoholic beverages any more __
SBE Last Pap Smear _____N/A__________ LMP: _________N/A_____________________
Briefly describe the patient's ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). Medications ordered by the doctor are always available and given at the right time but not similar to his diet. He seldom eat food because of his condition, as the patient stated
SUBJECTIVE SKIN INTEGRITY: “wala man koy γ Dry Comments sa akong katol-katol ___________ ____________________ panit, wla pud koy γ Itching ____________________ problema anang mga ____________________ samad samad sa akong γ Other ____________________ panit” ____________________ γ Denied ____________________ “gabatiun kog ACTIVITY/ SAFETY: kalipong dili napud ko γ Convulsion Comments ___________ tanto maka lakaw lakaw. γ Dizziness ____________________ γ Limited motion Kung magkaun ko ____________________ Of joints ____________________ taman rako lingkod sa ____________________ akong bed o sa akong Limitation in ____________________ higdaanan mukaun ug Ability to ____________________ ga diapers na gali ko γ Ambulate ____________________ kay lisod na kau γ Bathe self ____________________ maglakaw-lakw ” γ Other ____________________ γ Denied ____________________ COMFORT/SLEEP/AWAKE: γ Pain Comments“sigi ko ug ihi__________ (location) ihi___________________ sa gabie, dili pud ko Frequency ____________________ katulog ug tarong kay Remedies) ____________________ gaubuha ko ug mau” γ Nocturia ____________________ γ Sleep difficulties ____________________
OBJECTIVE γ Dry γ cold γ pale γ Flushed γ warm γ Moist γ cyanotic *ashes, ulcers, decubitus (describe size, location, drainage) __tenderness/ ulcerations or rashes are not noted during the assessment γ LOC and orientation _The patient is still aware of the time, date and place______________________________ Gait: γ walker γ cane other γ Steady γ unsteady____________________ γ Sensory and motor losses in face or extremities _______________________________ γ ROM limitations __cannot extremely move his right leg or even his lower extremities because of his arthritis____________________________________ __________________________________________ __________________________________________ __________________________________________ γ Facial grimaces γ Guarding Other signs of pain __there were no other signs of pains felted by the patient during my assessment_ ____________________________________________ Side rail release form signed ( 60 + years) _________________________________________
COPING: Observed non- verbal behavior Always touching his jaw Occupation _________None _____________ during my assessment when he speaks and even Members of household ___Melsa, Rebbeca Fe, after coughing. Lenthi Ann____________________________ The person and his phone number that can be reached any Most supportive person ____ Rebbeca Fe ____ time __________________________ ______________________________________ _________________________________________ SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) ______100 lbs ___ Daily Weight _____N/A_______PT/OT _____N/A_______ ___140/70 mmHg__ BP q Shift _____N/A____ Irradiation _____N/A________ Neuro vs. _____N/A____ Urine Test _____N/A_______ _____N/A________ CVP/SG. Reading _____N/A____ 24 hour Urine collection Diagnostic/ laboratory I.V. Fluids/Blood Date Date done Date Date disc. Exams ordered ordered 12-04-06
Complete Blood Count
D5NSS 1L @20 gtts/min
VII. NURSING MANAGEMENT
IDEAL NURSING MANGEMENT ACTIONS/INTERVENTIONS RATIONALE NURSING DIAGNOSIS: Diarrhea Diarrhea Management (NIC) May be related to Independent Inflammation, irritation, or malabsorption of the bowel Observe and recordtoxins frequency, Helps differentiate individual disease and Presence of stool characteristics, narrowing of the lumen assesses Segmental amount, and precipitating factors. severity of episode. Possibly evidenced by Increased bowel sounds/peristalsis Promote bedrest,and often severe, watery stools (acute phase) Rest decreases intestinal motility and Frequent, provide bedside commode. reduces the Changes in stool color metabolic rate when infection or Abdominal pain; urgency (sudden painful need to defecate), cramping hemorrhage is a DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: complication. Urge to defecate may occur Bowel Elimination (NOC) without Report reduction in frequency of stools, return to more normal stool consistency. warning and be uncontrollable, increasing Identify/avoid contributing factors Remove stool promptly. Provide room risk of deodorizers. incontinence/falls if facilities are not close at hand. Identify foods and fluids that precipitate diarrhea, e.g., raw vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products. Restart oral fluid intake gradually. Offer clear liquids hourly; avoid cold fluids. Reduces noxious odors to avoid undue patient embarrassment. Avoiding intestinal irritants promotes intestinal rest.
Administer medications as indicated: Antidiarrheals, e.g., diphenoxylate (Lomotil), Loperamide (Imodium), anodyne suppositories;
Provides colon rest by omitting or decreasing the stimulus 26 of foods/fluids. Gradual resumption of liquids may prevent cramping and recurrence of diarrhea; however, cold fluids can increase intestinal motility. Decreases GI motility/propulsion (peristalsis) and diminishes digestive secretions to relieve cramping and diarrhea. Note: Use with caution in UC because they may precipitate toxic megacolon.
NURSING DIAGNOSIS: Fluid Volume, risk for deficient Risk factors may include Excessive losses through normal routes (severe frequent diarrhea, vomiting) Hypermetabolic state (inflammation, fever) Restricted intake (nausea/anorexia) Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Hydration (NOC) Maintain adequate fluid volume as evidenced by moist mucous membranes, good skin turgor, and capillary refill; stable vital signs; balanced I&O with urine of normal concentration/amount. ACTIONS/INTERVENTIONS Fluid/Electrolyte Management (NIC) Independent Monitor I&O. Note number, character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. Measure urine specific gravity; observe for oliguria. Assess vital signs (BP, pulse, temperature). Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill. Weigh daily. Maintain oral restrictions, bedrest; avoid exertion. Observe for overt bleeding and test stool daily for occult blood. RATIONALE
Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement. Hypotension (including postural), tachycardia, fever can indicate response to and/or effect of fluid loss. Indicates excessive fluid loss/resultant dehydration. Indicator of overall fluid and nutritional status. Colon is placed at rest for healing and to decrease intestinal fluid losses. Inadequate diet and decreased absorption may lead to vitamin K deficiency and defects in coagulation, potentiating risk of hemorrhage. 27
Note generalized muscle weakness or cardiac dysrhythmias. Collaborative Administer parenteral fluids, blood transfusions as indicated. Administer medications as indicated: Antidiarrheal (Refer to ND: Diarrhea);
Excessive intestinal loss may lead to electrolyte imbalance, e.g., potassium, which is necessary for proper skeletal and cardiac muscle function. Minor alterations in serum levels can result in profound and/or life-threatening symptoms. Reduces fluid losses from intestines.
NURSING DIAGNOSIS: Pain, acute May be related to the effect of gastric acid secretion on damaged tissue Possibly evidenced by Reports of colicky/cramping abdominal pain/referred pain Guarding/distraction behaviors, restlessness Facial mask of pain; self-focusing DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Pain Level (NOC) Report pain is relieved/controlled. Appear relaxed and able to sleep/rest appropriately. ACTIONS/INTERVENTIONS Pain Management (NIC) Independent Encourage patient to report pain. Assess reports of abdominal cramping or pain, noting location, duration, intensity (0–10 scale). Investigate and report changes in pain characteristics. RATIONALE 28
Note nonverbal cues, e.g., restlessness, reluctance to move, abdominal guarding, withdrawal,
May try to tolerate pain rather than request analgesics. Colicky intermittent pain occurs with Crohn’s disease Predefecation pain frequently occurs in UC with urgency, which may be severe and continuous. Changes in pain characteristics may indicate spread of disease/developing complications, e.g., bladder fistula, perforation, toxic megacolon.
and depression. Investigate discrepancies between verbal and nonverbal cues. Review factors that aggravate or alleviate pain.
Body language/nonverbal cues may be both physiological and psychological and may be used in conjunction with verbal cues to determine extent/severity of the problem. May pinpoint precipitating or aggravating factors (such as stressful events, food intolerance) or identify developing complications. Reduces abdominal tension and promotes sense of control. Promotes relaxation, refocuses attention, and may enhance coping abilities. May indicate developing intestinal obstruction from inflammation, edema, and scarring. Complete bowel rest can reduce pain, cramping. Pain varies from mild to severe and necessitates management to facilitate adequate rest and recovery. Note: Opiates should be used with caution because they may precipitate toxic megacolon. Relieve spasms of GI tract and resultant colicky pain.
Encourage patient to assume position of comfort, e.g., knees flexed. Provide comfort measures (e.g., back rub, reposition) and diversional activities. Observe/record abdominal distension, increased temperature, decreased BP. Collaborative Implement prescribed dietary modifications, e.g., commence with liquids and increase to solid foods as tolerated.
Administer medications as indicated, e.g.: Analgesics; Anti-ulscer drugs;
ACTUAL NURSING MANAGEMENT “Subjective” •
The patient complained of difficulty of breathing because of his cough and even verbalized that his throat was very painful when he will swallow food
“Objective” • The patient manifests tachypnea or hyperventilation during the assessment. With a respiration Rate of 28 cpm, with a productive cough noted and shows facial grimace upon respiration or coughing. “Assessment”
Ineffective airway clearance related to increased production of secretions, retained secretions and bronchospasm.
“Planning” • At the end the interventions given to the patient, he would somehow perform with himself the skills or techniques on how to lessen, ease, or prevent dyspnea, cough or hyperventilation. The patient will also learn about the reason of the condition, how it occurs and how it would be prevented and what are the uses of the medications given by his physician. “Implementation” • Assist patient to assume position of comfort (e.g. elevate the head part of the bed).- Elevation of head facilitates respiratory function by use of gravity; however patients in severe distress will seek the position that most eases breathing. • Keep environment to a minimum (e.g. dust, smoke, and feather pillow)Precipitator of allergic reaction of respiratory reaction that can trigger or exacerbate onset of acute episode • Encourage or assist with abdominal or pursed lips breathing exercise.provide patient with some means to cope with control dyspnea and reduces air trapping • Increase fluid intake to 3000mL/day within cardiac tolerance. Provide warm/tepid liquids recommended intake of fluid between, instead of during 31 meals.- hydration helps reduces the viscosity of secretions, facilitating expectoration using warm liquids may decrease bronchospasm . Fluids during meals can increase gastric distention and pressure on the diaphragm. • Administer medications as prescribed by his doctor such as bronchodilator (e.g. ventolin, combivent)- this medication relaxes smooth muscles and reduce local congestion, reducing airway spasm, wheezing, and mucus production.
At the end of a couple of interventions done to the patient, he reports reduced difficulty in breathing that is, retained secretions are somehow lessened and coughing was also reduced. And he will be able to prevent bronchospasm if he continue using or performing the interventions for the wellness of his health
“Subjective” • The patient has a complaint of bloody and dark colored stool (melena). Also verbalized that he coughs or cough-up blood with sputum on it. And also experiences burning epigastric pain or discomfort on his abdominal part or area. “Objective” • Was diagnosed with bleeding peptic ulcer disease; on his complete blood count results found out that his hemoglobin was deceased and this is a sign for blood loss. And regarding his discomforts felt on his abdomen, wherein he show facial grimace when pains is felt. “Assessment” • • • Increase risk of anemia due to acute GI bleeding related to ulcer Acute pain related to pyloric obstructions complication of peptic ulcer 32
“Planning” At the end of the interventions done to the patient, he will be able to perform specific interventions with him self on how to lessen or prevent the discomforts felt by the patient and how to manage of having a regular or normal characteristics of stools upon defecation. By teaching patient the methods to minimize symptoms while maintaining adequate nutrition and also teaching patient about necessary life style changes aimed at decreasing stress and minimizing effectiveness of coping mechanism. “Implementation”
Provide small and frequent meals- Food prevents distenson and release of gastrins and has an acid neutralizing effect. Patient should eat meals on a regular basis.
Institute measures to neutralize or buffer hydrochloric acid, inhibit acid secretion and decreases the activity of pepsin Administer antacids as prescribed by the physician to reduce acidity and even anti ulcer drugs (e.g. esomeprazole)- to treat peptic ulcer or eradicate helicobacter pylori.
• • •
Diet regulation through the use of bland foods and restriction of irritating substances such as nicotine, caffeine, alcohol, spices, and gassy foods. To have some bed rest to reduce physical activity and promote comfort to the patient. Encourage hydration to reduce anticholinergic side effects and dilute the hydrochloric acid in the stomach
“Evaluation” • At the end of a several interventions, the patient somehow reports reduced pain; the patient verbalizes appropriate diet modification and even demonstrates compliance with the prescribed medication regimen in order to reach the total health and wellness. 33
“Subjective” • The patient complained of pain on his right leg and even numbness, and wasn’t able to walk with him self because of the pains and even because of his condition, as he verbalized. “Objective” • Has limitation on his range of motion: right leg, when tenderness is felt. There is facial grimace when patient wants to move his leg or when pain occurs. He was not able to ambulate by himself.
“Assessment” • • Acute Pain related to joint tenderness due to arthritis on right leg
“Planning” The patient would somehow perform the techniques on how to exercise or practice moving his affected area with himself and even would tolerate the pain for a short period of time. And even the patient would be aware on what are the significance of the said interventions and how it affects his total condition or how it can help him on the entire course of health teachings. “Implementation” • • • • • Elevate the affected portion or the foot of the patient with pillows under it. So hat it would promote blood circulation. To practice exercising his leg joints by extension or flexion of knees(range of motion exercise) Apply heat and colds to or on the affected area to provide relief or comfort to the area by constriction / dilation of blood vessels Promote rest and position of comfort to ease joint pains and encourage diet rich in nutrients – dense food such as fruit, vegetables or legumes Administer medications as prescribed by his doctor such as analgesics - this drug reduces pains felt by the patient.
“Evaluation” • At the end of a couple of interventions done to the patient, he reports reduced difficulty in breathing that is, retained secretions are somehow lessened and coughing was also reduced. And he will be able to prevent bronchospasm if he continue using or performing the interventions for the wellness of his health
VIII. REFERRALS AND FOLLOW-UP It is important to comply regularly its medication as prescribed by his attending physician and to continue and finish its entire therapeutic regimen. And explain to the patient the use and side effects of the medications so that he will be aware of its effects such as bronchodilators for the treatment of his cough that helps alleviate or prevent
bronchospasm (e.g. ventolin for Nebulization) and even anti-ulcer drugs to prevent reoccurrence of the disease (e.g. Sucralfate). He should practice moving his lower extremities to promote blood circulation and even to improve the range of motion of his foot or feet so that he could somehow, able to ambulate with him self in later times. To perform bed exercise such as leg exercise, since patient is always on bed and have limitations on his physical activity because his still weak. The patient was instructed to avoid over work for the following days and must have adequate bed rest to regain energy or strength. By means of anticipating the needs on the course of healing and curing process the patient must then focused to himself by not always depending on the interventions that are not highly needed just to ease or prevent any health problem regarding his condition . But he should focus entirely on how to prevent the problem on his actions by himself. Environmental sanitation is needed to provide a healthy and therapeutic way of curing himself. Smoking and alcohol consumption must be prevented totally by the patient so that his problem would not be worse again.. Upon discharged, he must come back to the hospital one week after, for the follow-up check-up to confirm if the patients condition is really restored. Also to know if there are complications sited during the check up to know if patients condition have worsen or not. And lastly, he should take note of the foods that are irritating to his GI tract to prevent reoccurrence of abdominal pain and even should eat adequate amount of foods every meals. Eating nutritious food would somehow help the patient on regaining some strengths or energy to his body, such as green leafy vegetables, fruits, and foods rich in 36 protein. IX. EVALUATION AND IMPLICATIONS At the end of my hospital duty, I as a student nurse was able to render care to my patient to help him resolve his problem regarding health. Through observing the patient’s status, I was able to identify some problems during my assessment. Because
of a couple of interventions or health teachings applied and imparted to the patient, I was able to lessen its respiratory pattern on the patients problem of breathing (ineffective Airway Clearance); alleviated pains felt by the patient due to the effects of the peptic ulcer or to the arthritis; and even have defecated a normal characteristics of stool. Patient was willing to pursue his medical therapy just to promote health and wellness for the betterment of his condition. During the treatment, the patient was able to develop or enhance health awareness on his disease and with this knowledge instilled to his mind, he was then aware on how the disease was transmitted and what are the proper ways or interventions done just to minimize or prevent this disease from getting worst. I have also made the patient realize the importance of completing the course of therapy by taking the medicines prescribed or ordered to him by his physician. In addition, eating healthy or nutritious foods that were prescribed to him by the health providers was further been explained to him especially the benefits he will gain in eating these nutritious foods. In general, the patient was very cooperative to what health measures administered to him by the health providers. Moreover, these several interventions given to the patient made his body functions different than as before
37 X. BIBLIOGRAPHY • Lippincott Williams and Wilkins, Nursing 2006 Drug Handbook, 26th Edition, • Barbara Kozier et al, Fundamentals of Nursing, 7th Edition, • Lippincott Williams and Wilkins, Nursing 2004 Drug Handbook, 24rd Edition, • Mosby’s Pocket Dictionary of Medicine, Nursing Allied Health, 4th Edition, Published in Elsevier Science (Singapore) PTE LTD
• Microsoft ® Encarta ® Premium Suite 2005. © 1993-2004 Microsoft Corporation. All rights reserved. • Mosby’s Comprehensive Review of Nursing, 13th Edition by: Saxton,Nugent,Pelikan • http://www.cnn.com/HEALTH/library/DS/00583.html • Smeltzer & Bare, medical Surgical Nursing, 10th ed. Vol. 1, Lippincott Williams & Wilkins, Philadelphia, USA pp.1015-1051 • Mosby’s MEDICAL ENCYCLOPEDIA, the definitive health reference • http://www.wrongdiagnosis.com/p/peptic_ulcer/symptoms.htm • http://en.wikipedia.org/wiki/Peptic_ulcer • http://www.emedicine.com/med/topic1776.htm • http://www.gicare.com/pated/ecdgs09.htm • http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=8
LICEO DE CAGAYAN UNIVERSITY
R.N.P. Blvd., Carmen, Cagayan de Oro City
C OLLE GE OF NURSING
A Care Study Moesis L. Labuntog
Ms. Asterie Revelo, RN
As Partial Requirement for NCM501202
Librea, Celso R.
January 18, 2007