Individual Pedia

THE COLLEGE OF MAASIN
“Nisi Dominus Frustra”

College of Nursing & Allied Health Services
Maasin City, Southern
A CASE STUDY OF ACUTE GASTRITIS
Semester A.Y 2021-2022
Presented to:
Ms. Julie Gulane, RN
Faculty of the College of Nursing the College of Maasin
Presented by:
Espere, Angeli Alisandra R.
BSN II- PEPLAU
JULY 2022
1
INTRODUCTION
Acute gastritis is a sudden inflammation or swelling in the lining of the stomach.
Acute gastritis is a term that encompasses a broad spectrum of entities that induce inflammatory
changes in the gastric mucosa. Several different etiologies share the same general clinical
presentation; however, they differ in their unique histologic characteristics. The inflammation
may involve the entire stomach (eg, pangastritis) or a region of the stomach (eg, antral gastritis).
Acute gastritis can be divided into two categories: erosive (eg, superficial erosions, deep
erosions, hemorrhagic erosions) and non-erosive (generally caused by Helicobacter pylori).
2
TABLE OF CONTENTS
Cover Page
Introduction
Table of Contents
I. Nursing Health History 4
II. Physical Assessment 5
III. Gordon’s Functional Health Pattern 6-8
IV. Concept Map 9
V. Laboratories/ Diagnostic Studies 10
VI. Drug Studies 11-15
VII. Nursing Care Plan 16-26
VIII. Health Teaching 27-28
IX. FDAR 29-35
X. References 36
XI. Curriculum Vitae 37
3
I. NURSING HEALTH HISTORY
A. BIOGRAPHIC DATA
1) NAME: Aliyah Buenafe

2) ADDRESS: Aguinaldo, Macroho
3) AGE: 1 year and 8 months
4) GENDER: Female
5) MARITAL STATUS: Single
6) OCCUPATION: N/A
7) RELIGIOUS ORIENTATION: Roman Catholic
8) HEALTH CARE FINANCING: Philhealth
9) INFORMANT: Mother
B. CHIEF COMPLAINT/ REASON FOR VISIT: Fever and vomiting
C. HISTORY OF PRESENT ILLNESS: Admitted due to Fever and Vomiting, with Acute
Gastritis
D. PAST HISTORY: N/A
E. FAMILY HISTORY OF ILLNESS: N/A
4
II. PHYSICAL ASSESSMENT
Physical Assessment Actual
Vital Signs T- 35.8 degrees, P-124 bpm, R- 38 cpm
GENERAL SURVEY Client lying on the bed seem less energetic than normal, pale,
limp, and cry more than usual.
Head The head is normal with presence of tenderness and full-

thickness of burns in the lower part of the face. Hair is evenly
distributed.
Skin Skin is pale and dry.
Eyes Sunken eyes
Ears The canal is skin-colored and has small hairs. Yellowish-

brown earwax is present and the eardrum is a light-gray color
Nose Normal
Mouth No complications noted
Neck No complications noted
Pharynx No complications noted
Chest and Lungs Clear breath sounds
Breast and axillae Normal
Heart Normal
Abdomen Bloated Stomach
Back and extremities No complications noted
Genito-urinary Normal
5
III. GORDON’S FUNCTIONAL HEALTH PATTERN
Name: Aliyah Buenafe
Age: 1 year and 8 months
Address: Aguinaldo, Macrohon
1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
A. History of present Illness: Admitted due to Fever and Vomiting, with Acute Gastritis
B. Past Illness: None
C. History of hospitalization: Admitted for second time
D. History of illness in the family: Diabetes (both side)
2. NUTRITION AND METABOLIC PATTERN
A. Usual food intake:
Breakfast: Rice and hotdog
Snack: Pandesal with hotdog
Lunch: Pansit, Porkchop and rice
Dinner: Fried Chicken, and rice
B. Usual fluid intake: 8 bottles of milk per day
C. Any food restrictions: N/A
D. Any problems with ability to eat: N/A
E. Any supplements: N/A
3. ELIMINATION PATTERN
A. Bladder: Normal (with diaper)

6
B. Bowel: Normal
Complaints of usual pattern of bowel movement: None
Home remedies: N/A
C. Any assertive device: None
D. Skin: Normal
4. ACTIVITY EXERCISE PATTERN:
A. Usual daily/weekly activities: Eat, Sleep, watching cartoons, and playing of toys
B. Any limitations of physical ability: None
C. History of dyspnea or fatigue: None
5. SLEEP-REST PATTERN:
A. Usual sleep pattern:
Bedtime: 7 pm
Hours of Sleep: 11 Hours of sleep
Numbers of Pillow: 2 pillows
B. Any problems regarding sleep: None
6. COGNITIVE-PERCEPTUAL
A. Any deficits in sensory perception: None
B. Ability to read and write. Any difficulty in learning: The patient is unable to read and write
C. Any complaints? None
7. SELF-PERCEPTION
A) What the client is most concerned about: Having difficulties in doing physical activities with
friends
7
B) Present health goal: Obtain good health
C) Effect of present illness to self: Body weakness
8. ROLE RELATIONSHIP PATTERN
A) Language spoken: Bisaya
B) Manner of speaking: “Ma, Pa”
C) Significant person to client: Mother
D) Complaints regarding family: None
E) Living with (members of the family): Grandfather, mother, father and brother
9. SEXUALITY AND SEXUAL FUNCTION
A) Anticipated change in sexual relations because of illness: N/A
B) Knowledge of sexual functioning: N/A
10. COPING STRESS MANAGEMENT PATTERN
A) Decision making ability: Decision is made by the mother
B) Management of stress: N/A
C) Expectations from nurses to provide comfort and security during hospitalization:

Childcare
11. VALUE BELIEF SYSTEM
A) Source of strength and meaning: Her family (mother, father, and older sisters) are her source
of strength because they have always been there for her.
B) Importance of God to client: Very Important
C) Religious practices (type & frequency): Visits church every Sunday
D) Request for religious person/practice: None
8
IV. CONCEPT MAP
CONCEPT MAP
RISK FACTORS
LABORATORY RESULTS
PREDISPOSING FACTORS:
Vital signs:
GENES
T- 35.8 degrees
PRECIPITATING FACTORS:
P- 124 bpm
Bacterial infection
R- 38 cpm
PATHOPHYSIOLOGY
H.pylori-associated gastritis CLINICAL MANIFESTATIONS

transmission is via the fecal-oral
route. H. pylori possess several virulence
factors which facilitate cell adhesion Weak looking
(e.g., BabA/B, sabA, OipA), cell damage
and disruption of tight junctions (e.g., Bloated stomach
Ure A/B), and evasion from the immune Less interactive
response (e.g. LPS). In particular, the
cytotoxin-associated gene a (CagA) is
considered a potent inducer of
inflammation and correlate with gastric
cancer development.
9
V. LABORATORY AND DIAGNOSTIC STUDY
LABORATORY/ INDICATIONS REFERENCES ACTUAL FINDINGS

DIAGNOSTIC VALUE
TEST
Blood Test To check for normal: 77- Positive (+) for Acute
other causes of 99mg/dL gastritis
gastritis or signs
of complications.
For a blood test, a
health care
professional will
take a blood
sample from you
and send the
sample to a lab.
SIGNIFICANCE OF FINDINGS NURSING CONSIDERATIONS
Find out how well organs such as your Teach the patient what to expect.
kidneys, liver, heart, or thyroid are  Describe the procedure, what part of the body will
working. Help diagnose diseases such be evaluated, whether or not the procedure is
as cancer, diabetes, gastritis, coronary invasive, where the procedure will take place, and
heart disease, and HIV/AIDS. who will participate in performing the study.
 Inquire about and document the patient's known
allergies.
 Explain that it is essential the patient be positively
and properly identified at each and every
encounter before care, treatment, or services are
provided.
10
VI. DRUG STUDY
DRUG MODE OF INDICATI CONTRA- SIDE EFFECT NURSING

NAME ACTION ONS INDICATIONS CONSIDERATIONS
Brand Name: The Active History of acute Headache, GI - Assses pt with

Tantac reversible duodenal or porphyria: not disturbances, ulcers; epigastric
inhibition of benign recommended. jaundice, pain and occult
H2-receptors gastric ulcer. Renal hepatitis, rash; blood in stool.
Generic in gastric Maintenance impairment: rare: CNS - Monitor I&O
Name: parietal cells of healing of reduce dose. disturbances, - Inform pt that it may
Ranitidine results in a duodenal or Hepatic arrhythmias, cause drowsiness
reduction in gastric ulcer. dysfunction. blurred vision, - Inform pt that
both gastric Pathological Discontinue if arthralgia, product must be
Therapeutic
acid volume hypersecretor hepatic disorders myalgia, inj site continued for
class: H2
and y conditions occur. Monitor reactions, blood prescribed time.
Histamine
concentration (eg, SGPT if on high- dyscrasias, - Advise pt to person
Receptor
. Zollinger- dose IV therapy anaphylaxis, bruising, fatigue,
antagonist
Ellison for ≥5 days. angioneurotic malaise, blood
syndrome Pregnancy edema, acute dyscrasias may
and systemic (Cat.B). Nursing interstitial occur.
Pharmacolog
mastocytosis mothers. nephritis, - Inform pt to report
ic class: H2
). GERD. bradycardia s/s.
antagonist
Erosive with rapid - Inform pt to avoid
esophagitis. administration taking other
Actual Time, Maintenance (IV); increased medications without
Dosage, and of healing of risk of consult.
Route: 30 erosive pneumonia .
mg, IVTT esophagitis.
11

Brand Name: The exact Metronidazol Patients with: It can give you  Avoid use unless
mechanism e is indicated severe side necessary.
Flagyl  meningitis not
of action of for the effects such Metronidazole may
due to an
metronidazo treatment of as feeling or be carcinogenic.
infection.
Generic le has not confirmed being sick,
 Administer oral
been fully trichomonias  low levels of stomach pain,
Name: doses with food.
established, is caused by a type of hot flushes,
Metronidazol white blood  Apply topically
however, it Trichomonas difficulty
e cell called (MetroGel) after
is possible vaginalis breathing, a
that an (except for in neutrophils. pounding cleansing the area.
intermediate the first heartbeat Advise patient that

Classification:  alcoholism.
in the trimester of (palpitations) cosmetics may be
Antibiotic, An  alcohol
reduction of pregnancy) and headaches. used over the area
tibacterial, A intoxication.
metronidazo and the after application.
mebicide, Ant
le which is patient's  a low seizure  Reduce dosage in
iprotozoal
only made sexual threshold. hepatic disease.
by partners,
 a painful
Actual Time, anaerobic bacterial
condition that
Dosage, and bacteria and vaginosis,
affects the
Route: protozoa, certain types
nerves in the
binds of amebiasis,
 Anaerobic legs and arms
deoxyribonu and various
bacterial called
cleic acid anaerobic
infection: peripheral
and infections.
Not neuropathy.
electron-
12
recommen transport  prolonged QT

ded. proteins of interval on
organisms, EKG.
 Amebiasis
blocking
: 35–50  seizures.
nucleic acid
mg/kg/day
synthesis.
PO in
three
doses for
10 days.
13

Brand Name: The Ampicillin is Contraindicated Common Side  Avoid use unless
mechanisms used to treat to Patients with: effects of necessary.
Principen
of action of certain Ampicillin Metronidazole may
Hypersensitivity
ampicillin infections include: be carcinogenic.
Generic are that are Infectious

 acute  Administer oral
Name: interference caused by mononucleosis
inflammator doses with food.
with cell bacteria such
Ampicillin y skin
wall as meningitis  Apply topically
eruption
synthesis by (infection of (MetroGel) after
(erythema
attachment the cleansing the area.
Drug Class: multiforme)
to penicillin- membranes Advise patient that
Penicillins,
binding that surround  redness and cosmetics may be
Amino peeling of used over the area
proteins the brain and
(PBPs), spinal cord); the skin after application.
inhibition of and (exfoliative

 Reduce dosage in
Actual Time,
cell wall infections of dermatitis)
hepatic disease.
Dosage, and
peptidoglyc the throat,  rash.
Route:
an synthesis sinuses,
 hives.
Pediatric: and lungs,
inactivation reproductive  fever.
 400
mg/kg/day of inhibitors organs,  seizure.
intravenou to autolytic urinary tract,
 black hairy
sly/intram enzymes. and
tongue.
uscularly gastrointestin
divided al tract.  diarrhea.

Ampicillin is
14
every 6 in a class of
hours medications
called
 50-100
penicillins. It
mg/kg/day
works by
orally
killing
divided
bacteria.
every 4-6
hours, not
to exceed
12 g/day
 Severe
infection:
200-400
mg/kg/day
intravenou
sly/intram
uscularly
divided
every 6
hours
 Potential
toxic dose:
Children
under 6
years: 300
mg/kg
15
VII. NURSING CARE PLAN
PATIENT’S NAME: ALIYAH BUENAFE
DIAGNOSIS: ACUTE GASTRITIS
CUES/DATA NURSING NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS GOAL/ INTERVENTIONS
DESIRED
OUTCOME
Subjective Acute Pain After 8 hours  Introduce self To gain trust After 8 hours
Data: (abdominal) of Nursing and establish and comfort. of Nursing
related to Intervention rapport. Interventions,
“Usahay
muscle s, the Pt will the Pt learned
kay mukalit  Promote
spasms learn to To refocus and understood
raman ni effective
secondary to express pain and develop to express pain
sijag hilak coping
gastritis. alleviation a sense of alleviation
maam, strategies and
verbally and control, and verbally and
basin nay emotional
will be able may will be able to
sakit sa support such
to participate improve participate in
ijang as guided
in activities coping activities with
tiyan”, as imagery.
with fewer mechanisms fewer reports
verbalized
reports of to deal of discomfort,
by the SO.
discomfort. stress. and goal was
We must met.
 Assess pain
Objective have a
Data: detailed
baseline to
Bloated
treat
Stomach
appropriatel
y and know
16
Mild Body if it has

Weakness changed.
Less Assessing
 Assess bowel
Interactive bowel
movements
movements
(color,
will aid in
consistency,
making
frequency,
clinical
amount)
decisions.
Patients
 Ensure with
adequate abdominal
hydration; pain may
may require have a
intravenous diminished
fluids appetite, be
NPO, or not
want to
drink fluids.
It is essential
 Facilitate
to
normal bowel
proactively
patterns
address
nausea,
vomiting,
constipation
,as clinically
appropriate.
17
Patients
 Record intake with
and output abdominal
pain may not
be taking in
the
necessary
amount of
fluids or
foods.
Patients may
 Assess
be
abdominal
experiencin
distention,
g abdominal
report changes
distention as
in size and
part of the
quality as
underlying
appropriate
disease
process.
18

DESIRED
OUTCOME
Subjective Risk for After 8  Introduce self To gain trust After 8 hours
Data: Infection hours of and establish and comfort of Nursing
“Nagbutod related to Nursing rapport. to patient. Interventions,
man ijang multiplicatio Intervention Client
tijan”, as n of s, Client will  Ensure that This reduces remained free
verbalized pathogenic remain free any articles or of infection, as
by the So. organisms of infection, used are eliminates evidenced by
which may as evidenced properly germs. normal vital
Objective compromise by normal disinfected or signs and
Data: health. vital signs sterilized absence of
Episodes of and absence before use. signs and
vomiting of signs and  Wash hands or Washing symptoms of
symptoms of perform hand between infection, and
Bloated infection. hygiene procedures the goal was
Stomach before having reduces the met.
contact with risk of
the patient. transmitting
Also, impart pathogens
these duties to from one
the patient and area of the
their body to
significant another.
others
19
 Educate Knowledge
clients and SO of ways to
(significant reduce or
other) about eliminate
appropriate germs
cleaning, reduces the
disinfecting, likelihood of
and sterilizing transmission
items. .
 Encourage Proper
intake of nutrition and
protein-rich a balanced
and calorie- diet support
rich foods and the immune
encourage a systems’
balanced diet. responsiven
ess
 Perform To help
measures to break the
break the chain of
chain of infection
infection and and prevent
prevent conditions
infection. that may be
suitable for
microbial
growth
 Encourage
increased
20
fluid intake Fluids help

unless promote
contraindicate diluted
d urine,
frequent
emptying of
the bladder,
and
reducing the
stasis of
 Instruct client urine.
not to share Explain to
personal care the client
items how
infections
can be
transmitted
from sharing
personal
 Encourage sle items.
ep and rest. Adequate sl
eep is an
essential
modulator
of immune
responses.
21

DESIRED
OUTCOME
Subjective Deficient After 8 hours  Introduce self To gain Pt’s After 8 hours
Data: Knowledge of Nursing and establish trust and of Nursing
Intervention rapport. comfort. Interventions,
The mother Related to
s, Pt/ SO will Pt/SO
stated that  Grant a calm A calm
 Lack be able to demonstrateda
“wa ko and peaceful environment
of/misinte demonstrate wareness of
kahibaw lge environment allows the
rpretation awareness of illness
maam kay without patient to
of illness processes,
ana man interruption. concentrate
informati processes, potential
ang doctor and focus
on potential problems and
basin nay more
nakaon  Lack of problems completely.
therapy
ahong anak interest in and therapy regimen, and

Conveying
” learning, regimen. goal was met.
lack of  Provide an respect is
recall atmosphere of especially

respect, important
Objective
 Inaccurat when
Data: openness,
e/incompl
trust, and providing
Presence of ete
collaboration. education to
questions informati patients with
on different
Statements
presented values and
of concern
beliefs about
22
health and
illness.
Goal setting
 Include the
allows the
patient in
learner to
creating the
know what
teaching plan,
will be
beginning
discussed
with
and
establishing
expected
objectives and
during the
goals for
session.
learning at the
beginning of
the session. Allowing
 Consider what the patient to
is important to identify the
the patient. most
significant
content to be
presented
first is the
most
effective.
Patient
 Involve
involvement
patient in
improves
writing
compliance
specific
with health
23
outcomes for regimen and

the teaching makes
session, such teaching and
as identifying learning a
what is most partnership.
important to
learn from
their
viewpoint and
lifestyle.
Assessment
assists the
 Explore
nurse in
reactions and
understandi
feelings about
ng how the
changes.
learner may
respond to
the
information
and possibly
how
successful
the patient
may be with
the expected
changes.
Patients
know what
 Support self- difficulties
directed, self-
24
designed will
learning. transpire in
their own
environment
s, and they
must be
encouraged
to approach
learning
activities
from their
priority
needs.
Patients are
 Provide clear,
better able to
thorough, and
ask
understandabl
questions
e explanations
when they
and
have basic
demonstration
information
s.
about what
to expect.
Different
 Give people take
information in
with the use of information

media. in different
ways.
25
26
VII. HEALTH TEACHING PLAN
LEARNING CONTENT LEARNING TIME LEARNING PROCESSING

OUTCOME METHODOLOGY ALLOTMENT MATERIALS QUESTIONS
After 30
minutes of
Health
Teaching,
the PT/SO
will be able
to;
Understand Importanc Face to Face 15 minutes Cellphone  Do you

the e of Proper Discussion Pictures or have any
importance Hygiene Demonstration Illustrations idea about
of Proper Videos proper
Hygiene hygiene?
 How often
do you
wash your
hands?
 Do you
have a
cleaning
schedule
at your
house>
Learn that Good Face to Face 15 minutes Cellphone  What
intake of Nutrition Discussion Pictures or foods do
nutritious and Illustrations
27
foods and Balanced Videos you prefer

having a Diet to eat?
balanced  Do you eat
diet is vegetables
important. ?
 How often
do you eat
in a day?
28
IX. FDAR
TIME DATE DIET REMARKS SIGNATURE

3-11 0714/22 DFA F- Risk for Infection related to
multiplication of pathogenic
organisms which may
compromise health, as manifested
by verbal concerns about episodes
of vomiting, bloated stomach,
mild body weakness, fear of
physical threat, and less
interactive, by the reason of
current diagnosis of having Acute
Gastritis with moderate signs of
dehydration, admitted for 4 days.
D- “Nagbutod man ijang tijan”, as
verbalized by the SO.
- Received Pt lying in bed with
ongoing IVF #3 PLR 1L @36;
infusing at R metacarpal vein;
regulated well.
- Episodes of Vomiting
- Bloated Stomach
- Vital Signs:
T- 35.8 degrees
P- 124 bpm
R- 38 cpm
A- Introduced self and established
rapport
- Bed side care done.
29
- Vital signs taken and

monitored.
- Maintained a calm attitude
while dealing with the client.
- Practiced and emphasized
constant and proper hand
hygiene.
- Identified underlying cause
- Monitored possible signs and
symptoms.
- Assessed nutritional status of
client.
- Performed measures to break
the chain of infection.
- Encouraged ambulation
- Rendered health teachings
 Importamce of proper
hygiene
 Good nutrition and a
balanced diet
R- Seen pt resting on bed
comfortably, observed no signs of
bloatedness, no vomiting; vital
signs stable, no complications
noted; Endorsed to next shift.
30
3-11 0714/22 DFA F- Acute Pain (abdominal)

related to muscle spasms
secondary to gastritis as
evidenced by reports of
discomfort and modifications
in muscle tone, by the reason
of current diagnosis of having
Acute Gastritis with moderate
signs of dehydration,
admitted for 4 days.
D- “Usahay kay mukalit

raman ni sijag hilak maam,
basin nay sakit sa ijang tiyan”,
as verbalized by the SO.
- Received Pt lying in bed

with ongoing IVF #3 PLR
1L @36; infusing at R
metacarpal vein;
regulated well.
- Bloated Stomach
- Mild Body Weakness
- Less Interactive
- Vital Signs:
T- 35.8 degrees
P- 124 bpm
R- 38 cpm
31
A- Introduced self and

established rapport
- Provided comfort
monitored.
- Maintained a calm
attitude
- Noted client’s age and
developmental level
- Identified underlying
cause
- Evaluated pain
characteristics and
intensity.
- Performed pain
assessment each time pain
occurs.
- Rendered health teaching
 Importance of having
adequate rest periods
 Ways to assist pt with
pain management.
comfortably, observed
relieved pain, noticed lessen
inflammation at the R foot;
vital signs stable; Endorsed to
next shift.
32
3-11 0714/22 DFA F- Deficient Knowledge
related to Lack of or
misinterpretation of
information, as evidenced by
improper follow-through
directions and the emergence
of avoidable clinical
manifestations, by the reason
of current diagnosis of having
Acute Gastritis with moderate
signs of dehydration,
admitted for 4 days.
D- The mother stated that “wa

ko kahibaw lge maam kay ana
man ang doctor basin nay
nakaon ahong anak ”
- Received Pt lying in bed

with ongoing IVF #3 PLR
1L @36; infusing at R
metacarpal
- Presence of questions
- Statements of concern
- Vital Signs:
T- 35.8 degrees
P- 124 bpm
R- 38 cpm
33
A- Introduced self and

established rapport
- Provided comfort
monitored.
- Maintained a calm
attitude
- Noted client’s age and
developmental level
- Grant a calm and peaceful
environment without
interruption.
- Provided an atmosphere
of respect, openness,
trust, and collaboration.
- Considered what is
important to the patient.
- Rendered health teaching
 Proper Lifestyle
 Ways to prevent the
reoccurrence of
condition.
comfortably, observed
presence of understanding
towards the health teachings
imparted; vital signs stable,
34
no signs of complication;
Endorsed to next shift.
35
X. REFERENCES
https://www.healthline.com/health/gastritisacute#:~:text=Acute%20gastritis%20is%20a%20sudd
en,drugs%20(NSAIDs)%20and%20corticosteroids.
https://emedicine.medscape.com/article/175909-overview
https://www.ncbi.nlm.nih.gov/books/NBK544250/#_article-22085_s5_
https://go.drugbank.com/drugs/DB00916
https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/metronidazole/
https://ldh.la.gov/assets/oph/Center-PHCH/Center-CH/infectious-
epi/VetInfo/VetAntibioResSen/LADDL/AntimicrobialClasses/beta-
lactams/penicillins/ampicillin.pdf
https://nurseslabs.com/risk-for-infection/
36
XI. CURRICULUM VITAE
Personal Data
Name: Angeli Alisandra R. Espere
Address: San Rafael, Maasin City, Southern Leyte
Age: 20 yrs. old
Mobile number: 09126018639
Date of Birth: April16, 2002
Place of Birth: Maasin City, Southern Leyte
Civil Status: Single
Email Address: angelialisandraespere@gmail.com
Educational Background
Elementary- Maasin City Sped Center (2008-2014)
Junior High School- Pintuyan National Vocational High School (2014-2018)
Senior High School- The College of Maasin (2018-2020)
37

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THE COLLEGE OF MAASIN

“Nisi Dominus Frustra”

A CASE STUDY OF ACUTE GASTRITIS

Semester A.Y 2021-2022

Ms. Julie Gulane, RN

Faculty of the College of Nursing the College of Maasin

Espere, Angeli Alisandra R.

BSN II- PEPLAU

Acute gastritis is a sudden inflammation or swelling in the lining of the stomach.

I. Nursing Health History 4

II. Physical Assessment 5

III. Gordon’s Functional Health Pattern 6-8

IV. Concept Map 9

V. Laboratories/ Diagnostic Studies 10

VI. Drug Studies 11-15

VII. Nursing Care Plan 16-26

VIII. Health Teaching 27-28

IX. FDAR 29-35

XI. Curriculum Vitae 37

I. NURSING HEALTH HISTORY

1) NAME: Aliyah Buenafe

B. CHIEF COMPLAINT/ REASON FOR VISIT: Fever and vomiting

D. PAST HISTORY: N/A

E. FAMILY HISTORY OF ILLNESS: N/A

II. PHYSICAL ASSESSMENT

Physical Assessment Actual

Vital Signs T- 35.8 degrees, P-124 bpm, R- 38 cpm

Head The head is normal with presence of tenderness and full-

Skin Skin is pale and dry.

Eyes Sunken eyes

Ears The canal is skin-colored and has small hairs. Yellowish-

Mouth No complications noted

Neck No complications noted

Pharynx No complications noted

Chest and Lungs Clear breath sounds

Breast and axillae Normal

Abdomen Bloated Stomach

Back and extremities No complications noted

III. GORDON’S FUNCTIONAL HEALTH PATTERN

Name: Aliyah Buenafe

Age: 1 year and 8 months

Address: Aguinaldo, Macrohon

1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

B. Past Illness: None

C. History of hospitalization: Admitted for second time

D. History of illness in the family: Diabetes (both side)

2. NUTRITION AND METABOLIC PATTERN

A. Usual food intake:

Breakfast: Rice and hotdog

Snack: Pandesal with hotdog

Lunch: Pansit, Porkchop and rice

Dinner: Fried Chicken, and rice

B. Usual fluid intake: 8 bottles of milk per day

C. Any food restrictions: N/A

D. Any problems with ability to eat: N/A

E. Any supplements: N/A

A. Bladder: Normal (with diaper)

Complaints of usual pattern of bowel movement: None

Home remedies: N/A

C. Any assertive device: None

4. ACTIVITY EXERCISE PATTERN:

B. Any limitations of physical ability: None

C. History of dyspnea or fatigue: None