COLLEGE OF NURSING

RELATED LEARNING EXPERIENCE (RLE)

A CASE STUDY

ON

BLEEDING PEPTIC ULCER DISEASE

Presented by: BSN 4A-GROUP 1

Submitted by:

CATAINA, ANGEL JOY R OLIDAN, NOVELYN

CONCEPCION, HENSON L. ORPILLA, ERICA B.

ENCARNACION, MERRIN M. SALVADOR, KAYLA ZHAINE T.

JANDOC, AILA TRICIA S TASSIE, RUTH M.

Presented to:

Level 4 Clinical Instructors + Other Panelists

March 2023
GOALS AND OBJECTIVES

General:

By the end of this study, BSN 4A Group 1 students will have a better understanding of
Bleeding Peptic Ulcer disease and will be able to produce synthesize based on actual events.

In this case study, we'll look at how to effectively manage patients with Bleeding Peptic Ulcer
Disease and improve any nurse interventions that may be required in their treatment.

The BSN 4A Group 1 will be able to specify the following after finishing this case analysis. The
following actions are intended to accomplish the General Goals:

OBJECTIVES:

• Research the possible causes of Bleeding Peptic Ulcer Disease to gain a better
understanding of the issue.
• Evaluate the patient's medical history and how it may impact the present situation.
• To understand how the current illness is portrayed physio pathologically.
• Discuss the normal outcomes of a Bleeding Peptic Ulcer Disease physical exam,
diagnostic tests, patient signs and symptoms, and nursing care for Bleeding Peptic
Ulcer illness.
• Do a drug study to learn about the function, side effects, and contraindications of the
medication given to the patient.
• Identify the standard Bleeding Peptic Ulcer disease therapies that are available and
devise a successful nursing care strategy for the patient.
• Develop a home care and health promotion plan.
OVERVIEW OF THE DISEASE

DEFINITION

Peptic ulcer disease are open sores that

develop on the inside lining of your stomach and
the upper portion of your small intestine. Peptic
ulcer includes Gastric ulcers that occur on the
inside of the stomach and Duodenal ulcers that
occur on the inside of the upper portion of your
small intestine (duodenum)

SIGNS AND SYMPTOMS

o Burning stomach pain

o Feeling of fullness, bloating or belching
o Intolerance to fatty foods
o Heartburn
o Nausea

The most common peptic ulcer symptom is burning stomach pain. Stomach acid makes the
pain worse, as does having an empty stomach. The pain can often be relieved by eating
certain foods that buffer stomach acid or by taking an acid-reducing medication, but then it
may come back. The pain may be worse between meals and at night.

Diagnostic

Peptic Ulcer Disease is usually diagnosed using the following test.

EGD Test - a simple procedure to examine your upper GI tract. The test involves an
endoscope, a lighted camera on the end of a tube, which is passed down your throat to
visualize your esophagus, stomach and duodenum. It’s also called an upper endoscopy exam.

Upper GI Series - a radiographic (X-ray) examination of the upper gastrointestinal (GI) tract. It
can help to diagnose structural or functional abnormalities of the esophagus, stomach, and
duodenum
Other Test may include:

➢ Blood test
➢ Stool Test
➢ Urea breath Test

Treatment

Peptic ulcers can cause major health complications if not treated. There are several treatment
options available depending on the cause and severity of the disease.

Lifestyle adjustments - Limiting or eliminating alcohol and smoking from your life might help
in reducing ulcer inflammation.
Medications - Depending on the case, proton pump inhibitors or antibiotics can help treat
ulcers. Proton pump inhibitors help reduce acid levels and antibiotics help treat a helicobacter
pylori infection
If you have a serious complication from an ulcer, such as acute bleeding or a perforation, you
may require surgery. Minimal bleeding caused by a peptic ulcer can be treated with an upper
endoscopy. However, surgery is needed far less often now than previously because of the
many effective medications available.

Prevention

Maintaining a healthy lifestyle by quitting smoking cigarettes and other tobacco use and eating
a balanced diet rich in fruits, vegetables, and whole grains will help you prevent developing a
peptic ulcer.
Patients Profile

o Name: Patient SR
o Age: 27 yrs. old
o Sex: Male
o Weight: 70 kg.
o Height: 162.5 cm
o Date of birth: September 28, 1995
o Religion: Roman Catholic
o Civil Status: Single
o Occupation: Police
o Admission Date: March 10, 2023
o Admission Time: 8:39 am
o Chief Complaint: Vomited 2 times with block-material then lost consciousness.
o Admitting Diagnosis: Upper Gastrointestinal Bleeding secondary to Bleeding Peptic Ulcer
Disease
o Final Diagnosis: Bleeding Peptic Ulcer Disease

Past Medical History

According to the patient, he was admitted at De Vera Medical Hospital Inc. last year 2021 due
to Bleeding Peptic Ulcer Disease. The patient was donated blood three (3) times on medical
missions. He had his mandatory regular checkup on his work as part of the Philippine National
Police. He also completed his immunization/vaccines. According to him he hasn’t had any
asthma and allergies.

Present Medical History

According to the patient, some of his colleagues rushed him to Flores Medical Hospital on the
3rd day of March 2023, 8;39 AM. He vomited an approximate of one (1) glass black colored
bloody material in the morning and lost his consciousness at that time.

Vital Signs:

Temperature: 35.5 ◦C

Pulse Rate: 80 bpm

Respiratory Rate: 19 cpm

Blood Pressure: 110/70 mmHg

SPo2: 90%

Social/Psychological History

The patient work as a Police Officer at Checkpoint of Barangay Patul, Santiago City. He
worked 5 days in a week for almost 24 hours, as part of his work. He stayed in the outpost
checkpoint for 5 days and go home for 2 days to get rest. He used to drink hard drink alcohol
twice a week and sometimes he didn’t eat meal when he drink alcohol and according to the
patient, he never tried to smoke cigarette. On his day-off he only stayed in their house to get
rest to get recharge. He do exercise every morning on his work as their mandatory morning
exercise.

Family History

According to the patient, his parents live overseas for a long time.

Father Mother
HTN + -
Asthma - -
Ulcer - -
COPD - -
Allergies - -
PHYSICAL ASSESMENT (HEAD TO TOE)

GENERAL SURVEY: The 27 years old is on Semi- Fowler's position in

bed, he is conscious and coherent. Patient is oriented about place, time
and date.
Date of Physical Assessment: March 12, 2023
Time: 3:00 am
Body built: Mesomorph
Weight: 60 kg
Height: 5’6
VITAL SIGN:
BP: 110/70 mm/hg
TEMP: 35.7 C
RR: 19 cpm
PR: 80 bpm
SPO2: 98%

Head
AREAS TECHNIQUE FINDINGS INTERPRETATION
Generally Round, with
Skull Inspection prominence in the NORMAL
frontal and occipital
area. (Normocephalic)

Palpation No tenderness upon

palpation.
Lighter in color than the
Scalp Inspection complexion, moist, no NORMAL
scars noted, free from
lice, nits, and dandruff.

No lesions, no
tenderness or masses
Palpation on palpation.
Black colored hair with
Hair Inspection no artificial color and NORMAL
evenly distributed, no
evidence of alopecia,
thick and smooth
Face (CN 5 and 7 -TRIGEMINAL AND FACIAL NERVE)
AREA TECHNIQUE FINDINGS INTERPRETATION
Face is
Face Inspection symmetrical, oval NORMAL
shape, no
involuntary
movements, can
move facial muscles
at will, no drooping
down of face

Eyes (CN 3,4 and 6- OCULOMOTOR, TROCHLEAR, ABDUCENS)

AREA TECHNIQUE FINDINGS INTERPRETATION
Eyebrows Inspection Symmetrical and in
line with each other, Normal
color black and
evenly distributed.
Eyes Inspection Evenly placed and
in line with each Normal
other, none
protruding and
equal palpebral
fissure, no
complaining of pain,
no nystagmus is
noted.
Eyelashes Inspection Color black, evenly
distributed and Normal
turned outward.
No PTOSIS noted.
Eyelids Inspection Meets completely Normal
when eyes are
closed, Symmetrical
Sclera is white
Sclerae Inspection (anicteric sclerae), Normal
no yellowish
discoloration (icteric
sclerae) some
capillaries are
visible.
Lacrimal Non palpable, no
apparatus Palpation tenderness on Normal
palpation

Cornea Inspection Normal

 No irregularities in
surface, looks
smooth, clear and
transparent, iris is
visible through the
cornea and positive
corneal reflex.

Iris Inspection Color of iris is black, Normal

appear flat from
side view, no
crescent shadow
casted on the other
side when
illuminated from one
side

Pupil Inspection Pupil are equal in Normal

size of 2mm,
equally round
constrict briskly
when light is
directed to the eye
pupils dilate when
looking at distant
objects and
constrict when
looking at nearer
objects.

Ears (CN 7- VESTIBULOCOCHLEAR)

AREA TECHNIQUE FINDINGS INTERPRETATION
Earlobes are bean-
shaped, parallel,
and symmetrical;
the skin is the same
color as the
Ears Inspection/Palpation complexion; there Normal
are no lesions; the
auricles have firm
cartilage; the pinna
recoils when folded;
there is no
discomfort upon
touch; and the ear
canal has some
cerumen but no
discharge.
- Patient hears
whispered words
 and finger snaps in
both ears

Nose (CN 1-OLFACTORY)

AREA TECHNIQUE FINDINGS INTERPRETATION
No discharges, no
Nose Inspection flaring, both nares Normal
are patent, patient is
able to described
the odor presented

Palpation No tenderness, no
masses and lesions Normal
upon palpation

Mouth (CN 10,11-VAGUS and HYPOGLOSSAL)

AREA TECHNIQUE FINDINGS INTERPRETATION
Lips Inspection Pinkish in color, Normal
symmetrical
movement.
Pinkish in color, no
Gums Inspection bleeding, no Normal
receding gums.
Three teeth are
Teeth Inspection extracted, carries Abnormal
and 2 cavities are due to poor oral
noted hygiene
Pinkish, no lesion,
Tongue Inspection/Palpation Gag reflex is Normal
present, tongue is in
midline, able to
move the tongue
freely and with
strength, no oral
thrush is noted
Position in the
midline, pinkish in
Uvula Inspection color, no swelling or Normal
lesion noted, moves
upward and
backward when
asked to say “ah”

Neck
AREA TECHNIQUE FINDINGS INTERPRETATION
Neck is straight, no
visible mass or
Neck Inspection lumps, symmetrical, Normal
 no Jugular Vein,
patient can move
their neck without
Palpation difficulty

Distension, trachea
is palpable, lymph
nodes are palpated.

Thorax (Cardiovascular System)

AREA TECHNIQUE FINDINGS INTERPRETATION
Inspection No lift or heaves. Normal

Apical pulsation can Normal

Heart Palpation be felt upon
palpation, no
abnormal heaves.
Normal
Auscultation S1 & S2 can be
heard, no abnormal
heart sounds are
heard.

Heart rate: 80 bpm

Lungs
AREA TECHNIQUE FINDINGS INTERPRETATION
Lungs Auscultation Resonant sounds
Respiratory rate of Normal
19 cpm

Abdomen
AREA TECHNIQUE FINDINGS INTERPRETATION
Abdomen Inspection Skin color is
uniform, no lesions,
mild distended, Normal

Auscultation 20 bowel sounds of

clicks and gurgles Normal
and occasional
borborygmus
sounds

Abnormal due to
Palpation BPUD
 No masses noted,
mild tenderness is
present

Extremities
AREA TECHNIQUE FINDINGS INTERPRETATION

Both extremities are

Extremities Inspection equal in size, no Normal
involuntary
movement, no
edema, can perform
complete Range of
Motion(active)

With minimal scars,

no lesions, no
Palpation tenderness and Normal
masses upon
palpation

Integument
AREA TECHNIQUE FINDINGS INTERPRETATION
Brown complexion
and Uniform in
Skin Inspection/Palpation color, no foul odor, Normal
no masses, lesions,
no wound, no
laceration, no
rashes, warm and
uniform to touch,
good skin turgor.
Smooth and has an
intact epidermis with
Nail Inspection/Palpation a short and clean Normal
pinkish fingernails
and toenails
Convex and with a
good capillary refill
time of 2 seconds
GORDON’S 11 FUNCTIONAL HEALTH PATTERN

DATE OF INTERVIEW: March 12 ,2023

TIME OF INTERVIEW: 3:00 am

Days of Confinement: 2 days

LOC: Conscious and coherent

FUNCTIONAL BEFORE DURING

HEALTH HOSPITALIZATION HOSPITALIZATION
PATTERN

The patient stated that health is very He mentioned that he

vital to him.The patient stated that he needs to look out his
never saw himself being diagnosed health more, and
with Bleeding Peptic Ulcer Disorder maintained his
.He claimed that he is strong and can medicines and he also
carry out any heavy tasks, so He never consider taking food
HEALTH saw it coming although sometimes he supplements and
PERCEPTION skip meals due to call of duty .Every vitamins to boost his
AND time he felt pain, he would only take a immune system
painkiller or apply a hot compress,
MANAGEMENT
believing that this would temporarily
cure his discomfort Patient doesn't
take any herbal remedies or food
supplements, no allergies and initially,
he did not seek medical attention
whenever he felt pain.

The patient stated that he is not picky

about what he eats and favors red
meat; he also rarely consumes fruits
NUTRITIONAL/ He also stated that he enjoys eating
METABOLIC salty and fatty dishes. Can consume 4-
PATTERN 5 glass of water a day and consumes
up to 2-3 cups of rice The patient
mentioned that he drinks alcoholic
beverages twice a week, mainly strong
drinks like gin and emperador light
Provided meals were at
the table, fruits and
water is also present.
Patient can consume 3-4
glasses of water a day
since he don’t do
extraneous activity as he
claimed.
 patient don’t smoke, also He weighs 60
kg and stands 5'6.
The patient indicated that he defecates
well twice a day with yellowish tool, but
sometimes just once a day with a black
hard tool or no defecating at all, and
ELIMINATION that he never encounters urinary
PATTERN resistance or incontinence and urine
color of yellowish or dark yellow and
that he has no history of hospitalization
due to a urinary problem.
Patient was not wearing
any diaper or foley
catheter. He defecates
once only with black
hard tool as verbalized
by the patient and urines
well with no foul-smelling
odor or fruity smell.

The patient stated that he will exercise Patients claimed that he

for 30 minutes after work by jogging spends the majority of
EXERCISE AND and strolling, and that he will play his time lying in bed and
ACTIVITY basketball as a pastime. He also stated sleeping and only
PATTERN that his work serves as his workout. occasionally moves
Patient claimed that he has no cardio- around his room.
respiratory disease.

The patient claims that because he The patient stated that

must work at the station and can only
get 4-5 hours of sleep per night, he is
no longer able to get enough rest or
sleep, and there are occasions when
he cannot even get any sleep at all,
SLEEP/REST particularly when there are
PATTERN emergencies that require him to work
overtime. Also, he claimed that
anytime the pain in his right upper
quadrant radiates, he struggles to
obtain adequate sleep.
he sleeps and lie all the
time, he mentioned that
he gets adequate sleep
and rest, but sometimes
can’t sleep due to his
wariness about his
condition

The patient indicated that he speaks The patient is pleasant to

COGNITIVE Tagalog, Ilocano, and English, that he be around, and answers
PERCEPTION has no hearing or vision difficulties, all of the healthcare
PATTERN and that he does not use glasses or providers' questions
contact lenses. Because he about him.
cooperates and speaks effectively, the
patient has a high recall and a lengthy
attention span.
 The patient stated that he has no The patient is unable to
issues with his body image, that he take a regular shower,
SELF feels insecure at times, but that he has but he has his lover to
PERCEPTION a wonderful partner who adores him. give him a tepid sponge
AND SELF
He bathes every day and showers bath instead.
CONCEPT
before going to bed, and he
PATTERN
occasionally attends gym workouts to
maintain his body in shape. No history
of plastic surgery.

The patient indicated that since both of The patient's loving

his parents are away 27 years of girlfriend keeps an eye
working in the overseas, he is much over him while he is in
fonder and closer to his aunt who the hospital.
raised him since he was a baby. He
chose criminology as his major
ROLE
RELATIONSHIP because he was inspired by his uncle,
PATTERN and he is now a three-year police
officer. He also revealed that he
intends to marry and have children; he
wishes to have four children.

The patient has no issues with

Not applicable
reproduction. He also said that he
SEXUALITY AND wants to be married and have four
REPRODUCTIVE
kids. The patient also said that
PATTERN
because his girlfriend is LDR, they
don't have any sex and expressed how
much he appreciated her.

If the patient has a problem, he will He spends most of his

COPING AND most likely communicate in his time lying down, resting,
STRESS girlfriend, or he will engage in some watching television, or
TOLERANCE diverting hobbies such as basketball, talking to his partner.
PATTERN watching humorous videos, and
usually listening to music, or he may
indulge in alcoholic drinks with his
friends or coworkers.

The patient is a devout Roman The patient stated that

Catholic who defies superstitions and difficulties are a normal
conventional practices. He claimed part of life and that he
that since he must work every day in
VALUE-BELIEF order to support his family and his must remain positive and
PATTERN basic needs, going to church is his face them.
least important concern, although he
will attend mass with her girlfriend.
Course in the Ward

Date and Time Doctor's Order Rationale

March 10, 2023 ➢ Secure consent ➢ It is an ethical consideration
7:30 am for the patient in making
decisions for their health
care.
➢ Diet: NPO ➢ To improve the control of
temporarily gastric secretions.

➢ IVF: PNSS X 8 ➢ For electrolytes and fluid

hours, FD 300ml balance

DIAGNOSTIC TESTS

➢ CBC ➢ To heck the adequacy of

blood platelet

➢ BUN, CREA ➢ To determine if patient has a

renal failure and kidney
damage
➢ Na, K, RBS ➢ To determine if the patient is
having electrolyte
imbalances thus the result of
her other signs and
symptoms
➢ Urinalysis ➢ To assess urinary
abnormalities.

➢ CXR ➢ To visualize lungs and the

size of the heart. To check for
any abnormalities.
➢ ECG ➢ To assess the electrical
conductivity of the heart
➢ SGPT, SGOT ➢ To asses liver function
 ➢ BT ➢ To replace components of blood
loss

MEDICATIONS:
➢ Omeprazole 80mg ➢ To inhibit the production of acid
IV LD then as drip: in the stomach

➢ Tranexamic Acid ➢ To decrease bleeding

500 mg IV Q8

➢ Monitor vital signs ➢ For baseline data an

every 2 hours comparison

➢ I & O shift ➢ For monitoring of fluid status

.
➢ WOF: hypotension, ➢ To prevent hypovolemic
signs of bleeding shock
➢ Secure three unit of ➢ For BT
PRBC, each unit to
run for 4 hours with
4hours interval
➢ Continue ➢ It may reduce the symptoms of
medication Peptic ulcer

➢ May have DAT

March 11, 2023 ➢ To follow D5LRS ➢ To prevent electrolyte loss

1L every 8 hours
➢ Continue
medication
➢ Repeat CBC ➢ to check if there are other
complications
MEDICATIONS:
➢ Tranexamic acid ➢ To decrease bleeding
500mg IV Q8
➢ Omeprazole 80mg ➢ To inhibit the production of acid
IV LD in the stomach
➢ Rebamipide 10mg It is used to prevent stomach
TID diseases
LABORATORIES AND DIAGNOSTICS

Patient Name: SR (HEMATOLOGY)

Age: 27 Sex: Male
Study Date: March 10, 2023 Time: 9:54 am
Parameters Result Ref. Ranges Interpretation
Unit.
Hemoglobin 12.8 (L) 13.00-18.00 Due to blood loss
g/dL
Hematocrit 37.9 (L) 40.00-55.00% Due to fluid correction
specifically, FD 300 ml as
ordered
RBC unit 4.49 4.00-6.00 10^ Within normal range
WBC 8.8 5.00-10.00 10^3/uL Within normal range
Platelet 330 150.00-400.00 Within normal range
10^3/uL
MCV 84.4 82.50-98.00 FL Within normal range
MCH 28.5 26.10-32.80 pg Within normal range
MCHC 33.8 30.70-35.90 g/dL Within normal range
Segmenters 53 50.00-65.00% Within normal range
Lymphocyte 40 (H) 25.00-35.00% Due to infection
Monocytes 05 3.00-7.00% Within normal range
Eosinophils 02 1.00-3.00% Within normal range

CLINICAL CHEMISTRY
BUN 31.28 (H) 7.00-20.00 ng/dL Due to blood loss
CREA 106.96 80.00-115.00 Within normal range
umol/uL
Sodium 135.0 135.00-150.00 Within normal range
mmol/L
Potassium 1.35 3.50-5.50 mmol/L Within normal range
RBS 173.61 (H) 0.00-120.00 Above normal
mg/dL
SGOT (AST) 23.04 0.00-37.00 U/L Within normal range
SGPT (ALT) 18.21 0.00-45.00 U/L Within normal range
Patient Name: SR (URINALYSIS)
Age: 27 Sex: Male
Study Date: March 10, 2023 Time: 11:25 am
ROUTINE URINALYSIS
Physical Examination Interpretation
Color LIGHT YELLOW Normal
Transparency Clear Presence of alkaline
Specific Gravity 1.010 Normal
pH 6.0 Slightly acidic
Chemical Examination
Protein NEGATIVE
Glucose NEGATIVE
Ketone

CASTS
Crystals
OTHERS ASCORBIC ACID: NEGATIVE
OCCULT BLOOD: NEGATIVE
LEUKOCYTES: +1

Microscopic Examination
White Blood Cells 0-1 /HPF
Red Blood Cells 0-1 /HPF
Amorphous PO4/Urates OCCASIONAL
Epithelial Cells RARE
Bacteria RARE
Mucus Threads OCCASIONAL
Patient Name: SR
Age: 27 Sex: Male
Study Date: March 10, 2023
ABDOMINAL ULTRASOUND
March 10, 2023 Impression:
➢ Fatty infiltration of the liver
➢ Normal sonogram of the 6B, pancreas,
spleen, kidneys, urinary bladder and
prostate
➢ Non-dilated duct

Patient Name: SR
Age: 27 Sex: Male
Study Date: March 10, 2023
CHEST X-RAY
March 10, 2023 Radiological findings:
➢ There are no parenchymal infiltration in
both lung field
➢ The heart is not enlarged
➢ Aorta is unremarkable
➢ Chest wall, hemi diaphragms, costophrenic
sulcus & visualized bones are intact.

Impression:
Unremarkable chest x-ray.

Patient Name: SR
Age: 27 Sex: Male
Study Date: March 10, 2023 Time: 2:23 pm

BLOOD COMPONENT PRBC NO. OF UNITS 3

ISSUED
Date of Extraction 02.27.2023 - -
Date of Expiration 04.03.2022 - -
Antibody Screening Result NEGATIVE - -
 BLOOD UNIT SCREENING RESULT CROSSMATCHING RESULT
ABO and Rh Blood Group “A” RH ABO and Rh Blood “A” RH POSITIVE
POSITIVE Group
Hemoglobin/ Hematocrit PASSED Saline Phase NO
AGGLUTINATION
Malaria NEGATIVE Bovine Phase NO
AGGLUTINATION
HBsAG NONREACTIVE AHG Phase NO
AGGLUTINATION
Anti-HCV NONREACTIVE REMARKS COMPATIBLE
HIV COMBO NONREACTIVE COOMB’S TEST
Syphilis NONREACTIVE Direct Coomb’s -
Test (DAT)
Indirect Coomb’s -
Test (IAT)
Patients Antibody NEGATIVE
Screening
Date Released Time Completed
Anatomy and Physiology

Stomach

The stomach is located in the upper part of the abdomen just beneath the diaphragm. The
stomach is distensible and on a free mesentery, therefore, the size, shape, and position may
vary with posture and content. An empty stomach is roughly the size of an open hand and when
distended with food, can fill much of the upper abdomen and may descend into the lower
abdomen or pelvis on standing. The duodenum extends from the pylorus to the ligament of Treitz
in a sharp curve that almost completes a circle. It is so named because it is about equal in length
to the breadth of 12 fingers, or about 25 cm. It is largely retroperitoneal and its position is
relatively fixed. The stomach and duodenum are closely related in function, and in the
pathogenesis and manifestation of disease. The stomach may be divided into seven major
sections. The cardia is a 1–2 cm segment distal to the esophagogastric junction. The Fundus
refers to the superior portion of the stomach that lies above an imaginary horizontal plane that
passes through the esophagogastric junction. The antrum is the smaller distal one-fourth to one-
third of the stomach. The narrow 1–2 cm channel that connects the stomach and duodenum is
the pylorus. The lesser curve refers to the medial shorter border of the stomach, whereas the
opposite surface is the greater curve. The angularis is along the lesser curve of the stomach
where the body and antrum meet, and is accentuated during peristalsis.
 NURSING CARE PLAN
ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Nausea related to Within 5 hours of ➢ Note systemic ➢ Helps After 5 hours of
“parang may gastrointestinal nursing conditions that determining nursing
maasim sa aking irritation as intervention may result in appropriate intervention GOAL
bunganga” as evidenced by nursing, the client nausea and interventions PARTIALLY MET,
verbalized by the increased will be free of vomiting ➢ May be able to the client were free
patients salivation and nausea and ➢ Ask the client limit or cc of nausea and
swallowing vomiting. about the exposure to vomiting.
➢ Client report situations that situation
nausea and The client will be perceives as controls or take The client were
vomiting able to do the distasteful, medication able to do the
➢ Reports following after the anxiety prophylactically following after the
about nursing inducing or nursing
gagging intervention: threatening. intervention:
sensation 1. List situations ➢ Determine if ➢ Suggest 1. List situations
that might regard nausea is severity of that might regard
as disagreeable, potentially self- effect on fluid as disagreeable,
Objective: anxiety-inducing, limiting or mild, and electrolyte anxiety-inducing,
or frightening. severe and balanced and or frightening.
➢ Nausea 2. Specify whether prolonged nutritional 2. Specify whether
➢ Increase in his nausea is status his nausea is
salivation potentially self- potentially self-
➢ Increase in limiting and/or ➢ Recommend ➢ To reduce limiting and/or
swallowing light, or whether it client to try dry gastric acidity light, or whether it
is severe and foods such as and improve is severe and
prolonged. crackers and nutrient intake prolonged.
also Suggest
patient to eat
bland foods
such as
skinless
chicken, non -
acidic fruit
juice, caffeine
 free non-diet
carbonated
beverages

➢ Recommend to ➢ This may

avoid milk, increase
dairy products, nausea and or
overly sweet, difficult to
and fatty foods digest

➢ Recommend ➢ To reduce GI
patient to discomfort and
remain seated aid digestion
after meal
➢ Instruct patient ➢ To enhance
to eat slowly, digestion
chew food well
➢ Encourage ➢ To promote
deep and slow relaxation and
breathing refocuses
attention away
from nausea

➢ Provide and ➢ To cleanse

suggest oral mouth and
care minimize bad
specifically taste
after vomiting

➢ Instruct ➢ To limit
patients to severity of
avoid sudden nausea
changes in
position
 ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for Within 2 hours After 2 hours
“Di ako imbalance nursing ➢ Demonstrate ➢ All factors that can nursing intervention
masyadong nutrition; less intervention patient client’s ability affect ingestion patient were able to
kumakain kasi than body will be able to to chew, and digestion of demonstrate
minsan requirements demonstrate swallow and nutrients changes in
sumasakit tiyan related to pain changes in taste food behavior as
ko kapag upon food behavior as manifested by
kumakain ako” as ingestion manifested by ➢ Ascertain - Patients
verbalized by the - Patients understanding ➢ To determine identify risk
patient identify risk of individual informational need factors for
factors for nutritional of the client nutritional
nutritional needs imbalances.
Objective: imbalances. - Recognize
- Recognize ➢ Assess ➢ Identify the
➢ Seen with the nutritional deficiencies, importance
unfinished importance history suspect the of
meal of including possibility of appropriate
appropriate preferred food intervention nutrition and
nutrition eating
and eating ➢ Observe and ➢ Observing caloric habits.
habits. recorded the intake /lack of - Exhibited
- Exhibited patient food quality food acceptable
acceptable intake consumption approaches
approaches of increasing
of ➢ Administered ➢ To provide appetite
increasing medication as nutritional support
appetite prescribed As evidenced by
finished meal is
➢ Gave food a ➢ Little food can seen at the bedside
little but often reduce table
vulnerabilities and
increase input also
prevent gastric
distention
➢ Promote ➢ To reduce
adequate and possibility of early
timely fluid satiety
intake, limits
fluid 1 hour
prior to meal

➢ Promote ➢ To enhanced food

pleasant and intake
relaxing
environment
 ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: ➢ Reviewed ➢ To determine
Anxiety related to Within 4 hours of coping skills those that GOAL PARTIALLY
“Madik inasahan threat or changes nursing intervention used in the might be MET After 4 hours of
atuy a sakit ko in health status the patient will: past helpful in nursing intervention
maam ,kasla current the patient:
kimmaru payen - Appear circumstances
garud tuy relaxed and - Appeared
marikriknak kaysa level of ➢ Noted ➢ Which may be relaxed and
idi first admission anxiety and reports of behavioral level of
,madik ammo nu report that excessive indicators of anxiety and
anya ti anxiety is sleeping use of report that
aramidekon,“ as reduced to withdrawal to anxiety is
verbalized by the manageable deal with reduced to
patient level problems manageable
- Identify level
“ balbalewalaek healthy ways ➢ Accepted ➢ If defenses - Identified
lang ngem di ak to deal with client are not healthy ways
maka-igna nu and express defenses, do threatened, to deal with
dadduma anxiety not confront the client may and express
,kapapanunot atuy - Demonstrate and argue or feel safe anxiety
sasaadek” as problem debate enough to - Demonstrated
verbalized by the solving skills look at the problem
patient behavior solving skills

Fear; awareness of ➢ Allowed and ➢ Expressing of

physiological reinforce feeling
symptoms client reduces
personal anxiety
reactions
towards the
threaten to
Objective: well-being,
be available
➢ Increase of to the client
wariness
➢ Restlessness for listening
and talking

➢ Provided ➢ Helps client

accurate identify what
information is reality
about the based
situation

➢ Encouraged ➢ Which may

the patient to serve to
have his reduce level
regular or of anxiety by
develop relieving
exercise tension

➢ Suggested ➢ To help
diversional reduce
activities escalating of
anxiety levels
 DRUG STUDY

DRUG NAME MECHANISM OF INDICATION & SIDE EFFECT AND NURSING

ACTION CONTRAINDICATION ADVERSE REACTION RESPONSIBILITIES
Generic Name: Limiting the interaction Indication: Side Effects: Before:
Tranexamic Acid of plasminogen with Indicated for the CNS: • Monitor blood
produced plasmin and treatment of hereditary • Dizziness pressure, pulse
Brand Names: fibrin by blocking lysine angioedema, cyclic EENT: rate, and
Lysteda binding sites on heavy menstrual • Visual Abnormalities respiratory status
Cyklokapron plasminogen bleeding in CV: as indicated by
molecules. premenopausal females. • Hypotension severity of
Classification And other instances of • Thromboembolism bleeding.
Hemostatic agents significant bleeding in GI:
the context of • Diarrhea • Monitor for overt
Dosage: hyperfibrinolysis. • Nausea bleeding every 15–
500mg Used to treat Heavy • Vomiting 30 min.
bleeding.
Route: During:

IV Contraindication: • Stabilize IV
Adverse Effect:
Contraindicated in catheter to
seizures, headaches,
minimize
Frequency: patient hypersensitivity backache, abdominal pain, thrombophlebitis.
Q8 to tranexamic acid or fatigue, pulmonary Monitor site
any of the ingredients embolism, deep vein closely.
Timing:
8 am, 4 pm, 12 am thrombosis, anaphylaxis, After:
impaired color vision, and • Instruct patient
other visual disturbances. to notify the
nurse
immediately if
bleeding recurs
or if
thromboembolic
symptoms
develop.
• Caution patient
to make position
changes slowly
to avoid
orthostatic
hypotension.
 DRUG NAME MECHANISM OF INDICATION & SIDE EFFECT AND NURSING RESPONSIBILITIES
ACTION CONTRAINDICATION ADVERSE REACTION
Generic Name: it is a mucosal Indication: Side Effects: Before:
Rebamipide protective agent It is prescribed for the • Rash • Do not give more than three
and is postulated treatment of peptic • Pruritus tablets per day of this
Brand Names: to increase gastric ulcer, gastroduodenal • Constipation During:
Mucosta blood flow, ulcers, and gastric • Diarrhea • Instruct the client to
prostaglandin disorders. It is also • dry mouth increase fluid intake
Classification: biosynthesis and used to prevent • dry lips because the drug may
Antiulcers decrease free stomach diseases • abdominal distention cause dry mouth
oxygen radicals caused by non-steroidal
• constipation
Dosage: anti-inflammatory drugs After:
• Nausea and Vomiting
100 mg (NSAIDs).
• Bloating • Instruct the client to report
presence of rash
Route: Contraindication:
Adverse Effect: • Encourage the client to
Oral contraindicated in verbalize relief from
Shock or anaphylactoid
patients who are allergic hyperacidity
reactions may occur.
Frequency: to the drug. • Monitor intake and output
TID

Timing:
 DRUG NAME MECHANISM OF INDICATION & SIDE EFFECT AND NURSING RESPONSIBILITIES
ACTION CONTRAINDICATION ADVERSE REACTION
Generic Name: Used to reduce Indication: Side Effect: Before:
Omeprazole the risk of stroke in Indicated for the short- CNS: • give drug at least 30 to 60
patients who are term treatment of active • Dizziness minutes before meals; best
Brand Name: at risk in benign gastric ulcer. • Drowsiness if taken before breakfast
Prilosec developing a • Fatigue
stomach ulcer. • Headache During:
Classification: • weakness. • monitor CNS side effects
Anti-ulcer Drugs CV: (drowsiness, fatigue,

• chest pain weakness, headache), and

Dosage: GI: report severe or prolonged
500mg • abdominal pain effects.

• acid regurgitation
Route: After:
• Constipation
IV
• Diarrhea • Report any changes in
urinary elimination such as
• Flatulence
pain or discomfort
• Nausea and vomiting
Frequency: associated with urination,
Contraindicated: Adverse Effect:
Q8 or blood in urine
Contraindicated in It can Decreased absorption
• Tell patient to Caution
patient hypersensitive to of iron, calcium, magnesium,
Timing: patient to avoid hazardous
drugs or its components vitamin B12 and Increased
activities if dizziness
and in patients receiving
occurs.
rilpivirine containing risk of clostridioides difficile
products. infection, pneumonia
 DISCHARGE PLAN

MEDICINE ➢ Advise patient and SO regarding his home medications.

➢ Medication should be taken regularly as prescribed, on exact dosage,
time and frequency.
➢ Inform SO the actions of each medication
➢ Discuss the importance of taking drugs
➢ Discuss the possible contraindications and side effects of the drugs.
➢ Encouraged to comply with medications to prevent further complications.
➢ Emphasized the importance of regular follow-up check-ups and as
instructed by physician
ENVIRONMENT AND EXERCISE ➢ Encourage the patient and SO to create a tranquil, well-ventilated
environment favorable to healing and healthy living.
➢ Recommend the patient and SO to maintain the environment clean and
stress-free.
➢ Encourage patient to have a regular
➢ Encourage patient to have a regular rest period during the day.
TREATMENT ➢ Continue home medications
➢ Encourage patient to take multivitamins to enhance his immunity
HEALTH TEACHING/ EDUCATION ➢ Discuss with the patient his understanding of his condition and how it
affects his body.
➢ Advise the patient to limit extraneous activity and to have adequate rest
and sleep.
 ➢ Encourage patient to avoid taking over the counter pain killers without
consulting a health professional.
➢ Advise the SO to give the client the whole support needed.
➢ Encourage patient to open up his problem or concerns with his girlfriend
or close relatives or to his friends
➢ Advise patient to follow the discharge instructions given by the doctor.

OUTPATIENT ➢ Instructed to phone a doctor, ambulance, family member, or friend to drive

you to the hospital if you're experiencing severe pain.
➢ See a physician if you experience any issues or difficulties.
DIET ➢ Instruct the patient to eat healthy foods such as vegetables and fruits. To
limit intake of meat
➢ Advise patient to refrain from alcoholic beverages.
➢ Advise patients not to skip meals.
➢ Eat a variety of foods, as directed by your doctor, to obtain a balanced diet
of vitamins, minerals, proteins, carbohydrates, and fats.
➢ Consume less fat by avoiding high-fat foods and cooking with less fat.
Avoid also acidic or spicy foods
➢ To improve your fiber intake, eat at least 5 servings of fruits and vegetables
every day.
➢ Reduce your consumption of sugary foods such as sodas, fruit-flavored
drinks, and sugar-sweetened tea or coffee. Consume additional water to
aid your body's waste removal.
 ➢ Reduce your salt intake when cooking and eating. Reduce your intake of
processed meats, canned and boxed soups, pickles, and other high-
sodium foods.
➢ Encourage to take food rich in Vitamin A and probiotics as they can inhibit
H. Pylori

SPIRITUAL AND SEXUAL TEACHING ➢ Encouraged to continue seeking God's guidance and wisdom.
➢ emphasized the importance of prayer in healing
➢ Encouraged to seek divine assistance in all situations
➢ Encouraged to retain a positive outlook in life.