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IDENTIFICATION DATA

Name : Mrs.sanjukta Naik

Age : 40 years
Sex : Female
Address : At- Dergapada
Po-Kamindi
P.S-Bhanjanagar
Dist-Ganjam
Qualification : High school
Occupation : House wife
Marital Status : Married
Religion : Hindu
Registration Number : 1700056416
Name of the Hospital : MKCG, MCH
Ward : Female Medicine Ward
Date of admission : 19/1/17
Diagnosis : Peptic ulcer
Provisional diagnosis :  Abdominal pain
 Nausea And vomiting
 Burning sensation
 Anorexia
 GI Bleed
Name of doctor : Assist.Prof.Dr R.N.Sahoo
Date of data collection : 20/1/17

SOCIO ECONOMIC STATUS

Mrs Sanjukta Naik is belongs to nuclear middle class family.The breadwinner

of the family is the Mr.Rakesk Naik.Monthly income is 10000/- per month
.They lives in there own house with adequate light, ,toilet ,bathroom and good
electric supply. They used PHD supply water for drinking purpose .
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FAMILY HISTORY
SLN Name of the Relation Age Se Education Occupatio Health
O
members with x n status
client
1. Mr. Rakesh Husband 46yr. M Higher Business Apparentl
Naik secondary y healthy
Housewife
Mrs. High school apparently
2 Sanjukta Client 40yr F health
Naik s Graduation
Son Private job
Apparentl
3 M
Chandan 22 Higher
yrs secondary Dependent y healthy
4 Naik Daughter F
16yr Dependent Apparentl
5 Reena Naik F High school
Daughter s y health
Sabita Naik 12yr apparently
s health

FAMILY GENOGRAM

Rakesh Naik sanjukta Naik

(46 years ) (40years)

Chandan Naik Reena Naik Sabita Naik

Keys term :- (22years ) ( 16years) ( 12years )

 Client

-Male
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 Female

FAMILY MEDICAL HISTORY

There is no any communicable and hereditary disease history or surgical

history of family members .

PERSONAL HISTORY

The client is non –vegetarian . having thrice meal per day .she is having fasting
most of the time due to some ritual beliefs. Now she is not taking adequate meal
due to abdominal pain . the client bowel and bladder patter is regular. Sleeping
patter is disrobed due to epigastric pain at night 12-3 am . she is doing normal
household work .she had no bad habits of chewing tobacco or betel leaf.The
relationship with family members is good.

PAST ILLNESS HISTORY

There is nil significance regarding past medical and surgical history .

PERSONAL HEALTH HISTORY

Mrs sanjukta Naik is admitted in M.K.C.G medical hospital with the chief
complaint of epigastric pain ,anorexia, heart burn nausea and vomiting .she
undergone the investigation complete blood count ,amylase, lipase , stool for
occult blood test ,chest x-ray , endoscopy etc .Doctor diagnosed as a peptic
ulcer .Now client is under treatment.

OBSTETRICAL HISTORY

The client got menarche at age of 15 years with regular cycles of 5/30 days
interval. Her LMP is 10.5. 18. Gravid -3,para-3, living-3,abortion-3.

CHIEF COMPLAINT

 Abdominal pain x2 weeks

 Nausea and vomiting x 7days
 Melena x 3days heart burn x 3days
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 Anorexia x 7days

INVESTIGATION

Sl Name of the investigation Client’s Normal Remark

no value value
1. Blood test 13-18mg/dl

Haemoglobin 12.2mg/d 4.2-5.4 Decreased

l million
RBC Normal
4.8 range
million
WBC 8,000 4000- Normal
11000 range

1.5-4.5 Normal
Platelet 2.2 lacks
lacks
2 Stool for OBT +ve - positive
occult blood

3 UGI endoscopy Ulcer and - Abnormal

lesion

PHYSICAL EXAMINATION

General appearance – Muscular

Posture –Normal
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Gait- Coordinated

Hygiene & grooming – Well maintained

Speech – Understandable

Height – 156cm

Weight – 54 kg

VITAL SIGNS

Temperature – 98.90F

Pulse -86 beats /min

Respiration -22 breaths / min

Blood pressure – 130/80 mmHg

SKIN
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Colour of the skin – Fair

Skin texture –Hydrated

Skin turgor –Good skin turgor

Temperature – warm

HAIR AND SCALP

Colour of hair – Black

Distribution of hair –Equally distributed

Texture – Curly

Scalp -The client ‘s scalp is free from pediculosis , psoriasis and other infection .

EYES

Eyebrows –Bilaterally symmetrical

Eye lashes –Bilaterally equally distributed

Conjunctiva –Clear

Sclera- Whitish

Pupil –Reaction to light

Eye glasses – Not using

Vision -6/6

EARS

Pinnae- Bilaterally symmetrical

Hearing capacity - Normal hearing capacity .

Tympanic membrane- No perforation

Hearing acquity – Good

Vertigo- Absent

Any discharge or presence of cerumen-Absent

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NOSE

Size and shape –Bilaterally symmetrical

Nostril – Clear

Deformity – No deformity

Any discharge –Absent

Nasal septum –Slightly deviated to right

Epistaxis- Absent

MOUTH AND PHARYNX

Lips –Pink in colour

Odour of mouth- Not present

Dental hygiene –Well maintained

Gum and mucous membrane –Healthy

Teeth- White in colour

Throat and pharynx –No infection

Tongue – Well flexed

Temporomandibular joint –Well range of motion maintained

tonsil –not enlarged

NECK

Lymph node- Not palpable

Thyroid gland – Not enlarged

Range of motion-Well range of motion

RESPIRATORY SYSTEM

shape of thorax – bilaterally symmetrical

respiratory rate -22 breaths /min

lung auscultation –no any abnormality sound found

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breath sound –normal visceral sound

respiratory pattern-

CARDIOVASCULAR SYSTEM

Heart sound-s1 and s2 heard

Apical pulse -74 beats/min

Carotid pulse –palpable

Peripheral pulse-86 beats/min

Blood pressure-130/80mm Hg

BREAST AND AXILLA

Shape of breast –Bilaterally symmetrical

Nipple - Everted ,no any discharge

Palpation-No tenderness

Lymph nodes –Not palpable

ABDOMINAL EXAMINATION

Skin –stretch mark present

Contour – Rounded

Bowel sound- Audible bowel sound

Palpation- No evidence of mass

Percussion- Shifting dullness

MUSCULOSKELETAL SYSTEM

Back-No any abnormalities

Vertebral column alignment –Absence of lordosis and kyphosis

Lower and upper extremities-Well range of motion present

GENITOURINARY AND RECTUM

Rectum-absent of fissure and haemorrhoids

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Genital-Well developed

Bad odour- Absent

Any discharge or abnormalities – Not found

IMPRESSION

From above examination i found that having spleenomegaly and tenderness

found in abdomen on palpation
NURSING DIAGNOSIS AS PER CLIENTS PRIORITIES

1. Acute pain related to increased gastric secretions as evidenced by

burning cramping like pain in epigastrium .
2. Nausea and vomiting related to acute exacerbation of disease process as
evidenced by clients verbal response .
3. Imbalanced nutrition less than body requirements related to nauea and
vomiting as evidenced by lack of interest in food.
4. Haemorrhage secondary to eroded mucosal tissue related to disease
condition as evidenced by melena.
5. Activity intolerance related to weakness as evidenced by inactive
movement .

NURSING PROCESS AND THEORY APPLICATION

Orem’s is one of the foremost nursing theorists. Dorothea Elizabeth Orem was born on
1914 at Baltimore, Maryland. And she received master of science in nursing education from
catholic university of America, in 1945.

Orem’s conceptual framework for nursing ..

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APPLYING THE OREM’S THEORY OF SELF CARE DEFICIT :-

1. Therapeutic self care demand : Reduced pain

 Adequacy of self care agency : Inadequate
 Nursing diagnosis: Acute pain related to increased gastric secretions
as evidenced by burning cramping like pain in epigastrium.
 Design of the nursing system :wholey compensatory.
 Method of helping: guidance,assisting,providing an environment
promoting personal development .
2. Therapeutic self care demand: Reduced nausea and vomiting
 Adequacy of self care agency: Inadequate
 Nursing diagnosis: Nausea and vomiting related to acute
exacerbation of disease process as evidenced by clients verbal
response.
 Design of the nursing system: Partially compensatory
 Method of helping:Supporting,teaching
3. Therapeutic self care demand: Maintain nutrition
 Adequacy of self care agency: Inadequate
 Nursing diagnosis: Imbalanced nutrition less than body requirements
related to nausea and vomiting as evidenced by lack of interest in
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food.

 Design of the nursing system: partially compensatory

 Method of helping: Teaching ,guiding
4. Therapeutic self care demand: Prevent haemorrhage
 Adequacy of self care agency:Inadequate
 Nursing diagnosis: Haemorrhage secondary to eroded mucosal tissue
related to disease condition as evidenced by melena.
 Design of the nursing system: Inadequate
 Method of helping: Supporting, Teaching
5. Therapeutic self care demand: Promote activity
 Adequacy of self care agency: Inadequate
 Nursing diagnosis: Activity intolerance related to weakness as
evidenced by inactive movement.
 Design of the nursing system: Partially compensatory
 Method of helping: supporting, guiding
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SL ASSESSMENT NURSING GOAL IMPLEMENTATION RATIONALE EVALUATIO

NO DIAGNOSIS N

1 Subjective data Acute pain related To reduce  Established rapport.  To have good Client’s pain is
Clients complaint to increased gastric the pain. nurse-client reduced pain
“I am having pain secretions as  Performed a comprehensive relationship. after some
in abdomen .” evidenced by assessment of pain including  It helps in to extent .Pain
Objective data burning cramping location, characteristics, onset, determine score 2.
 Pain score 5 like pain in frequency and severity of pain. appropriate
 Restlessness epigastrium. intervention
 Crampy pain  It promote the
 Provided comfortable environment. likelihood of
decrease pain.
 Taught the client use of non-  It increases the
pharmacologic techniques such as release of
music therapy,distraction,massage. endorphins and
enhances the
therapeutic
effects of pain
relief
medications.

 Administered analgesics  To relieve

pain.
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SLNO ASSESSMEN NURSING GOAL IMPLEMENTATION RATIONALE EVALUATION

T DIAGNOSIS

2 Subjective data Nausea and To reduce  Assessed the client  To know the client Nausea and
Client says “I vomiting related nausea and condition. base line data vomiting reduced
am having  Provided adequate rest .  It facilitate nausea
to acute vomiting. after some extent .
nausea and  Encouraged the client to relief .
vomiting .” exacerbation of take adequate water  Helps to maintain
Objective data disease process  Performed complete the fluid status of the
 Dehydrated as evidenced by assessment of nausea body
skin clients verbal including frequency,  To plan appropriate
 Sunken eye response . duration, severity. intervention.
 Provided frequent oral  To promote comfort
hygiene .  To manage nausea
 Taught the use of non- and vomiting .
pharmacologic
techniques.
 Administered antiemetic  To prvent nausea
drugs. and vomiting .
.
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SL ASSESSMEN NURSING GOAL IMPLEMENTATION RATIONALE EVALUATION

NO T DIAGNOSIS
3 Subjective data Imbalanced To maintain the  Assessed the nutritional status  To know the Client’s nutrional
Client says “ I nutrition less nutritional status of the client. nutritional status. status maintained
am not interest .  Provided oral care before  To increase after some extent .
than body
to take food”. meals. patient’s appetite.
Objective data requirements  Encouraged eating small  It prevent feeling of
 Aversion to related to amount of food that are fullness and
eating nauea and appealing to the client . maintain nutritional
 Inadequate vomiting as status.
food intake evidenced  Taught the client to use of  To manage nausea
non-pharmacologic to avoid use of
by lack of
techniques. antiemetic drugs .
interest in  Helps to increase
food.  Ascertained patient’s food nutritional appeal.
preferences .
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SL ASSESSMENT NURSING DIAGNOSIS GOAL IMPLEMENTATION RATIONALE EVALUATION

NO
4 Subjective data Haemorrhage Haemorrhage  Assessed the evidence of  To plan
Client says iam secondary to eroded will be hematemesis,bright red or appropriate Client’s
having blood in reduced melena,clammy skin interventions bleeding is
mucosal tissue
stool. ,hypotension etc. reduced after
Objective data related to disease  Monitor the vital signs  Helps to some extent .
 Melena condition as determine
 Clammy evidenced by patients
skin melena hemodynamic
 Maintained IV infusion line status.
 To provide ready
access for blood
and fluid
replacement .
 Monitored the haemoglobin  To know
level haemoglobin
level.
 Administered the 1 unit  To maintain
PRBC. circulating blood
volume .
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SLN ASSESSMENT NURSING GOAL IMPLEMENTATION RATIONALE EVALUATION

O DIAGNOSIS
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5 Subjective data Activity Client will  Monitor vital signs .  To know the present The client
Client says “I intolerance be able to srtatus of the client. achieved optimal
am feeling achieve  Encouraged to increase  To optimize hydration level of activity
related to
weakness”. optimal fluid intake. status. after some
weakness as level of extent.
Objective data evidenced by activity .
 Not able to inactive  Encourage to eat foods rich  Increase body
move movement in vitamin and nutrious resistance.
 Weakness food.

 Evaluated the need for  Coordinated efforts are

additional help at home .
 Assist with ADLs while
avoiding patient
dependency .
more meaningful &
effective in assisting the
patient in conserving
energy.
 Enhance the patient’s
activity tolerance .

 Encouraged physical  Helps promote a sense

activity consistent with the of autonomy .
patient’s energy level .
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HEALTH EDUCATION

 Medicines:

 Medicines that decrease the amount of acid secretion and protect

stomach lining from acid and antibiotics to treat H. pylori infection.
 Take medicine as directed. Contact your healthcare provider if you
think your medicine is not helping or if you have side effects. Tell
him or her if you are allergic to any medicine. Keep a list of the
medicines, vitamins, and herbs you take. Bring the list or the pill
bottles to follow-up visits. Carry your medicine list with you in case
of an emergency.
 Follow up with your healthcare provider as directed:
 Nutrition:

 Avoid carbonated drinks, alcohol, and caffeine. Caffeine is found in

some coffees, teas, and sodas. It is also found in chocolate.
 Do not eat foods that upset your stomach. These include spicy or
acidic foods, such as oranges.
 Eat small meals more often rather than big meals less often. An
empty stomach may make your symptoms worse.

 Quit smoking:

If you smoke, it is never too late to quit. Smoking increases your risk
of developing ulcers. Ask your healthcare provider for information if you
need help quitting.

 Contact your healthcare provider if:

 You have a fever, diarrhoea or constipation.

 Your stomach pain does not go away or gets worse after you take
medicine.
 You have questions or concerns about your condition or care.
 Seek care immediately or call 911 if:

 You have a fast heartbeat, fast breathing, or are too dizzy or weak to
stand up.
 You have severe pain in your stomach.
 Your vomit looks like coffee grounds or has blood in it.
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 Your bowel movements are bloody or black.

 You have sudden shortness of breath.

CONCLUSION
From above I conclude that client is suffering from peptic ulcer disease
and she is under treatment .Health education is given regarding life style
modification ,avoid smoking, identify complication to prevent further
complication.
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SUBMITTED TO SUBMITTED BY
MRS. P.LAKSHMI BAI MISS PRATIMA TOPNO

LECTURER(MSN) M.SC,NURSING 1ST YEAR

CON BERHAMPUR CON, BERHAMPUR

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SUBMITTED ON