NCM 118 Case Analysis #1

Sarah Malik is a 46 – year old bank manager who was brought by an ambulance to the hospital
yesterday due to epigastric pains that worsen with food, shortness of breath, nausea and vomiting,
difficulty swallowing, diaphoresis and loss of appetite. During admission her vital signs revealed: Temp
– 38.6 degrees Celsius, Pulse rate – 109 bpm, Respiratory rate – 25 br/min and BP – 150/100 mmHg.
She was responsive during admission but could not immediately answer questions when asked
because “aray, masakit talaga ang tiyan ko”. She was able to open and close her mouth when
instructed but with facial grimacing. She was accompanied by her husband. The ER doctor examined
her and advised ECG, blood test for ABG, CBC, electrolytes and blood sugar. The cardiac enzyme test
revealed: Troponin I = 0.40ng/mL, Troponin T = 0.12 ng/mL, LDH = 86 ng/mL and CK-MB = 6.8 ng/mL .
The ECG showed “shortened R-R intervals in all leads with no apparent abnormalities.” The ABG result
revealed: pH = 7.33, aPCO2 = 56mmHg, aPO2=85mmHg, HCO3=25mEq/L and O2 Sat= 93%. The
admitting diagnosis was “Acute Gastritis probably from GERD, Stage 1 Hypertension; r/o Myocardial
Injury”. She was placed in a private room and was kept under observation with her husband as the
watcher.

Her orders upon admission were:

- Admit in private room with one watcher 24/7
- NPO
- Bed rest with bathroom privileges
- Oxygen 2 – 3 L/min via nasal cannula PRN
- O2 sat once every shift
- IVF D5%W and 0.9%NaCl alternately at a total of 3,000 mL/ day
- Omeprazole 40 mg stat diluted in 100 mL D5%W infused slowly for 1 hour
- Cimetidine (Tagamet) 150 mg slowly to consume in 6 hours; start only once omeprazole
is consumed
- Metoclopramide (Plasil) 5mg/ml IM at 0.15mg/kg body weight every 8 hours
- Sodium bicarbonate 5 mEq/Kg slow IV infusion; hold if ABG results reveal alkalosis
- Continue maintenance nifedipine on sips of water
- Repeat ABG 2 hours after Sodium bicarbonate was initiated
- Strict I/O and VS monitoring every 4 hours
- Refer as needed

Nursing Assessment upon Admission in the Medical Unit (Private Room) Revealed:
- Conscious, moderately responsive with signs of irritability (needs additional data)
- VS: T-38.8, PR-108 b/min, RR-24 br/min, BP-150/100 mmHg
- No urine output since admission, bladder slightly distended but no sensation reported
- Can recognize her daughter and the hospital where she is
- Husband gave the following information about the patient:
 Manager of RVM Bank for 12 years
 Married for 20 years, 2 children, all girls and both are in senior high school now
 Eats three times a day, favorite food is meegoreng and satti, complains of
episodes of loose bowel movement at times, had a history of Pyrosis 11 months
ago and was advised antacids.
 Bowel habits regular, had history of Streptococcal Pharyngitis 4 years ago with
“some oral antibiotics called amoxicillin” prescribed
  Works overtime in most cases, comes home late, sleeps late to finish reports,
goes to work even during holidays, stays late at night for Zoom conference.
 Diagnosed with Primary Hypertension at the age of 32 with nifedipine (Calcibloc)
30 mg PO as daily maintenance. Her BP is mostly at 150/100 mmHg.
 Islam as religion but seldom goes to the Masjid. She prefers to “do the ‘salah’
quietly alone”
 Still menstruating regularly with no reports of anything unusual
 “She was always loud and talkative but since yesterday she was quiet most of
the time and seen going to the bathroom often due to nausea.”
 “She is a very kind person but also a disciplinarian as a mother”
 “She spends more time at work and to serve people and lacks time for her own
self”
 She underwent Cesarean section when she was 28 years old. No other history of
surgery.
 She was first admitted at the age of 5 because of Cholera and was isolated and
given antibiotic therapy that time.
 2 days before the epigastric pain now, she was complaining of "nagsusuka man
ako” and “maasim ang sikmura ko” but did not pay much attention to it.
 Hours before the admission she was at the bank entertaining clients. She was
seen by her secretary who accordingly reported that the patient said loudly
“Aray ko, hindi ko na kaya ang sakit” while grabbing her abdomen and facial
grimacing. An ambulance was called and so she was rushed to the hospital. Her
husband was informed and followed behind.

Physical examination in the Medical Unit revealed:

- Weight = 51 kilograms, height = 5’6”
- Dyed hair completely distributed in head, no dandruff, no lesions, no scars, no wounds
noted.
- Wears eyeglasses +1.5 (since 20 years old), pupils were reactive to light and
accommodation, corneal blinking reflexes present, sclerae were white and correctly
identified letters in the magazine when shown to her.
- During whisper test, patient kept asking the nurse to repeat what she said because she
“did not hear” anything from the right ear. Ears had intact ear canal with minimal
cerumen noted; no discharges present.
- Nasal passageways were patent, septum was in place, upon illumination, the sinuses
revealed faint red color, able to identify the scent of mild soap when introduced.
- Mouth was clean, with missing right upper molar 1, left lower molar 1 and right lower
molar 1. No odor noted from the mouth, uvula was intact, tonsils not inflamed. Able to
drink well from a cup, Speech was soft but clear. Sometimes took pauses before
answering questions due to “epigastric pain”.
- 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 108 b/min.
- Posterior thorax showed no evidence of lesions, scars or wounds, percussion sounds
showed no abnormal results, no lesions nor masses palpated, breath sounds were clear.
RR – 24 br/min.
- Anterior thorax showed no evidence of lesions, both breasts showed no signs of mass or
discharges, breath sounds were clear, RR -24 br/min.
 - Abdomen was tender, no scars and lesions noted, bowel sounds were not heard in all 4
quadrants with 1 minutes of waiting, percussion was not done due to non-tolerance;
tenderness identified with light palpation; hard palpation was not done due to non-
tolerance.
- Genital area appeared intact, no discharges noted, no hemorrhoids or any sign of
abnormality noted with inspection and palpation.
- Extremities: 2+ scores in both upper and 3+ scores in both lower areas for resistance.
- Able to raise arms and legs independently but weakly; can identify dull and sharp
stimulations in all 4 limbs. With some “difficulty and pain” experienced during the
activity.
- Cranial nerves revealed: “difficulty swallowing and some hearing difficulty” (needs
further data)

At present (1 day since admission):

- Vital signs T-38.8, PR-105 b/min, RR-21 br/min, BP-150/100 mmHg
- Still NPO; same IV fluids ongoing
- Able to turn to sides with some assistance but complained “sumasakit talaga ang tiyan ko kapag
gumagalaw ako”.
- Had epigastric pains twice; once at 6AM and another at 9AM today
- Still complained of epigastric pain, difficulty of breathing and poor appetite; no bowel
movement since admission until today
- Oxygen saturation at 97% while in intermittent Oxygen at 2L/min via nasal cannula
- 24 hours input – 2,200 mL and output – 2, 400 mL, urinated 4 times in the past 24 hours
- Doctor came and discussed with the husband about the case, the patient is scheduled for
gastroscopy the following day. Repeated diagnostic results are still pending.
- Nifedipine PO tolerated on sips of water
- Repeat ABG result shows: pH 7.33, aPCO2 = 47 mmHg, aPO2 = 91 mmHg, HCO3 = 19 mEq/L and
O2Sat = 94% (blood tested at room air)
- Patient asks the nurse: “How long would it take for me to recover from gastritis? Do you think
the doctor will plan for a surgery?”
- Patient had been seen “awake most of the time since last night, kept asking how the kids at
home are doing” according to the husband.

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 of output to your instructors.
12. Note that an online orientation will be done prior to starting this activity. Attendance is required.

Acute pain related to irritation of the gastric mucosa secondary to psychological stress and diet

Impaired gas exchange related to altered oxygen supply as evidenced by shortness of breath, RR-25
cpm 02 SAT - 93%

Elevated body temperature related to inflammation of gastric mucosa as evidenced by epigastric pain
that worsens with food, nausea and vomiting