NCM 118 Case Analysis #2

Susan Cortez is a 50 – year old female housewife who was brought to the hospital 3 days ago due to
“ahitao pirmi mio bariga”, “ta duele mio bariga y pecho akabar kome” “duele tambien mio costao”. She
also claimed of nausea and vomiting, bitter taste in the mouth, noticeable weight loss, very dark stools,
difficult urination and loss of appetite. She has a medical history of UTI 6 months ago and was treated
with antibiotics for 2 weeks without hospitalization. She admitted she is used to taking over-the-
counter drugs like ibuprofen and aspirin for pain and joint swelling. During admission her vital signs
revealed: Temp – 38.3 degrees Celsius, Pulse rate – 102 bpm, Respiratory rate – 22 br/min and BP –
140/100 mmHg. She was responsive and oriented and could answer questions correctly. She was able
to raise and lower her arms when instructed. She was accompanied by her husband and their son. The
doctor examined her and advised blood tests for renal function test, CBC, electrolytes and blood sugar.
Her random blood sugar result showed 142 mg/dL. A urinalysis was done with result showing “Color-
amber, turbid, pH-4.8, with 5 RBC’s hpf, moderate leukocyte esterase with wbc-11 mm3”. An ECG was
taken which showed minimally shortened RR intervals denoting tachycardia but otherwise normal
sinus rhythm. Her ABG result revealed: pH=7.32, aPCO2=39 mmHg, aPO2=92 mmHg, HCO3=20 mEq/L
and O2Sat=95%. The admitting diagnosis was “Duodenal Ulcer, UTI, Stage 1 Hypertension”. She was
placed in a private room and was kept under observation with her husband as the watcher.

Her orders on the day of admission were:

- Admit in a private room with one watcher 24/7
- NPO
- Strict I and O monitoring
- Repeat urinalysis and FBS in the morning
- Do LFT’s and electrolytes
- Oxygen @ 2 L/min via nasal cannula PRN for dyspnea
- IVF NaCl alternate with D5%LR for a total of 2,500 mL/ day
- Ciprofloxacin (Ciprobay) 200 mg IV q 12 hours (ANST) for 3days
- Esomeprazole Sodium (Nexium) 20 mg to incorporate in 50 mL 0.9% NaCl to run for 30 mins
- Cimetidine (Tagamet) 300 mg in 500 mL NSS to run at 25 mg/h continuous IV infusion
- Urine for C and S
- Refer as necessary

Nursing Assessment upon Admission in the Medical Unit Revealed:

- Conscious, responsive and coherent
- CBC: Hb – 12 mg/dL, Hct – 41%, WBC – 11,000/mm3 and platelets – 360,000/uL
- FBS – 130 mg/dL
- K – 3.9 mEq/L, Na – 142 mEq/L, Ca – 10 mg/dL
- BUN – 23 mg/dL, Serum Creatinine = 2.12 mg/dL
- LFT – ALT= 52 U/L, AST= 43 U/L, ALP= 121 U/L, Albumin= 5.9 g/dL, Total Protein= 8.4 g/dL,
Bilirubin= 1.1 mg/dL, GGT=57 U/L
- VS: T-38.4, PR-103 b/min, RR-22 br/min, BP-140/100 mmHg
- Urine output = 180 (6 hours since admission), no bladder distension, abdomen is soft and bowel
sounds appear 2 – 3x per minute in all 4 quadrants
- Vomited twice (each about 50-80 mL) greenish-yellowish fluids believed to be gastric in origin
- Can recognize her husband and the reason why she was brought to the hospital but kept asking
what was her illness and if she will be operated
- Patient gave the following information:
  High school graduate, housewife since before
 Married for 24 years, she has 1 son who was delivered NSVD, now married also
 Eats three times a day, favorite food is fried fish with “suka”, she also loves chips and
native foods like biko, drinks about 3 – 4 glasses of water per day with 3 – 4 cups of
native coffee almost every day. She loves “balut”. She complains of constipation at
times with some “dark stools” recently. She was also treated of UTI before but no other
history of medical illness or surgery was mentioned.
 She enjoys watching “teleserye” and Netflix at home. She also keeps a small garden.
 Usually sleeps an average of 5 hours per night and sleeps late from watching movies,
sometimes spends extra time until morning to finish some movie marathon, enjoys the
computer and cellular phones often for online communication with her son and
grandchildren, she had been on prescription glasses for being “myopic” since she was 22
years old. Recent visual acuity revealed OD-20/100, OS-20/60, OU-20/70.
 Follows Seventh Day Adventist and goes to church every Saturdays. “I am waiting for the
second coming of Jesus eagerly. I pray for my son, my grandchildren and my husband
every day. I also read the Bible with some friends once in a week”.
 Had “regular, monthly menstruation” before; menopause at 47; with no reports of any
unusual vaginal bleeding at present; confided that she is not very much sexually active
as she used to be.
 Few days before she was admitted she claimed she noticed “Resyo ta duele mio bariga y
bien negro mio susyo desde cuanto dia ya, ya nerbya man yo. Nuay tambien yo gana
kome y tan luya ya man gayot iyo. Tan digwa tamen yo. Mio miyaw otro otro el olor y ta
duele mio detras, tormento yo miya”.
 Husband claimed: “She is a loving and caring wife. She also cooks very well”.
 She delivered her son normally in the hospital. Her husband is a retired military colonel.
 Husband said that days before admission, the wife was complaining of ‘difficult
urination’ and was very irritable at home but refused to see a doctor. “Poreso ya manda
yo anda kunel di mio anak na casa para ele amo liba con el desu nana na ospital.”
 She was brought to the hospital through the private car of their son.

Physical examination revealed:

- Weight = 51 kilograms, height = 5’4”
- Mixed gray and black hair completely distributed in head, with minimal dandruff, no lesions, no
scars, no wounds noted. No offensive smell noted.
- Wears eyeglasses +2.0, pupils revealed PERRLA, corneal blinking reflexes present in both eyes,
sclerae appeared pinkish, minimal peri-orbital edema noted on both sides, complained of
“blurring” but managed to correctly identify letters in the magazine when shown to her.
- Upon whispering, patient was able to repeat all 5 words correctly as what the nurse said. Ears
had intact ear canal with minimal cerumen noted, no discharges noted. No unusual odor noted.
- The nasal passageways were patent, septum was in place, upon illumination, the sinuses
revealed faint red color, able to identify the scent of kalamansi when introduced.
- Mouth was clean, with complete upper and lower dentures (since 5 years). No odor noted from
the mouth, uvula was intact, tonsils not inflamed. On NPO due to nausea; speech was clear. Lips
appeared chappy, tongue had minimal cracks.
- Neck was aligned, no complaints of discomfort claimed, thyroid was hardly palpable, no bruit or
abnormal sounds identified, large vessels were intact and not swollen, carotid pulse rate was
104 b/min.
 - The posterior thorax showed no evidence of scars or wounds, percussion sounds showed no
abnormal results, no lesions nor masses palpated, breath sounds were clear. RR – 23 br/min.
- Anterior thorax showed no evidence of lesions, both breasts showed no signs of mass or
discharges during palpation, breath sounds were clear, RR -22 br/min.
- Abdomen was minimally hard on palpation, no scars and lesions noted, bowel sounds were
heard once every minute in all 4 quadrants, percussion sounds were dull at the epigastric
region and at hypochondriac regions; no masses palpated but showed facial grimace during
palpation on epigastric region, claimed of tenderness. Refused further palpation of abdomen.
- Refused to be assessed in her genital area but claimed that she is having difficulty urinating but
feels no itchiness or discomfort in her genitals. She confided she had a history of Gonorrhea
around 10 years back and blamed her husband for the infection. She said she was treated by a
private physician with penicillin injection that time. She said nobody knew about it except her
husband and the doctor.
- Extremities showed muscle strength 2+ scores in both upper and 2+ scores in both lower areas
for resistance.
- Can raise arms & legs but very slowly and can identify dull and sharp stimulations in all 4 limbs.
- Cranial nerves revealed: “difficult swallowing” (needs further data).

At present (day 3 since admission) (Morning):

- Vital signs T-37.6, PR-99 b/min, RR-19 br/min, BP-140/90 mmHg
- Urine C and S result showed “E.Coli” and sensitive to ciprofloxacin
- Latest CBC: Hb – 12 mg/dL, Hct – 42%, WBC – 9,800/mm3 and platelets – 340,000/uL
- FBS – 152 mg/dL
- K – 3.9 mEq/L, Na – 145 mEq/L, Ca – 10.2 mg/dL
- BUN – 20 mg/dL, Serum Creatinine = 1.62 mg/dL
- LFT – ALT= 51 U/L, AST= 45 U/L, ALP= 119 U/L, Albumin= 5.6 g/dL, Total Protein= 8.1 g/dL,
Bilirubin= 1.2 mg/dL, GGT=56 U/L
- Latest ABG result revealed: pH=7.35, aPCO2=44 mmHg, aPO2=94 mmHg, HCO3=22 mEq/L and
O2Sat=96%
- Latest urinalysis: Color-amber, minimally turbid, pH-5.7, with 4 RBC’s hpf, leukocyte esterase
with wbc-9.5 mm3”.
- On low protein soft diet; able to take 45% of breakfast, with 1 episode of nausea early morning
- Able to move within the room with some assistance from watcher
- Still complained of some flank pain and abdominal cramps, but “hinde mas gayot bien duele
egual del primero”
- Oxygen saturation at 96% on room air; no oxygen supplement since 2 days
- 24 hours input – 2,800 mL and urine output – 1, 600 mL (measured in urinal)
- Doctor came and discussed with the patient and husband about the case, agreed to prepare the
patient for possible shifting to oral meds if symptoms improve in the next 24 hours, for
endocrinology consultation of blood sugar.
- Patient asks the nurse: “No kyere pa yo muri. Kyere pa yo mira ta gradua mio mga apo.”

Students’ Tasks per GROUP

1. Analyze the given case. Work on a case study using the given data.
2. Using the nursing process, transfer the given data into power point presentation and fill in the
assessment (Gordon’s, Physical and Laboratory) emphasizing the significant cues.
3. Create the patient’s profile using the available information.
4. Present the case in a sequential manner. Begin with a short introduction of the case, the
significance of the case study, definition of important terms, review of the anatomy and physiology
of structures involved, review of literature, pathophysiology (general and specific), disease
management (not only based on the case scenario; you may also add information using other
reliable sources in terms of disease management).
5. Include a drug study and relate the drugs to the case.
6. Create a Nursing Care Plan (NCP) with 3 problems; to be presented according to sequence based on
priority. Use any nursing theory or model as basis. Use NANDA as guide in formulating the care
plan. The assessment data to be used should be based on the case scenario. Nursing diagnosis until
evaluation should come from you.
7. Make a Learning Plan for the client/family. One topic will be enough.
8. Give your conclusion and possible recommendations.
9. Include a short acknowledgement, appendices and references at the last part.
10. Present and defend your case as scheduled.
11. Submit a hard copy to your instructors when you submit your outputs for FINAL TERM.
12. Note that an online orientation will be done prior to starting this activity. Attendance is required.