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Submitted to: Mrs. Milagros Maghanoy RN, MN Clinical Instructor
Submitted by: Del Honey P. Baul Group B2
a term used to describe a group of conditions characterized by inflammation of
the lining of your stomach. Commonly, the inflammation of gastritis results from infection with the saIn some cases, gastritis can lead to ulcers and an increased risk of stomach cancer. For most people, however, gastritis isn't serious and improves quickly with treatment. Acute gastritis occurs suddenly and is more likely to cause nausea and burning pain or discomfort in your upper abdomen. Chronic gastritis develops gradually and is more likely to cause a dull pain and a feeling of fullness or loss of appetite after a few bites of food. For many people, though, chronic gastritis causes no signs or symptoms at all.Occasionally, gastritis may cause stomach bleeding, but it's rarely severe. But be aware that bleeding in your stomach that causes you to vomit blood or pass black, tarry stools requires immediate medical care. Gastritis usually develops when your stomach's protective layer becomes overwhelmed or damaged. A mucus-lined barrier protects the walls of your stomach from the acids that help digest your food. Weaknesses in the barrier allow your digestive juices to damage and inflame your stomach lining.me bacterium that causes most stomach ulcers. Yet other factors - including traumatic injury and regular use of certain pain relievers - also can contribute to gastritis.Gastritis may occur suddenly (acute gastritis), or it can occur slowly over time (chronic gastritis). In spite of the many conditions associated with gastritis, the signs and symptoms of the disease are very similar: a burning pain in your upper abdomen and, occasionally, bloating, belching, nausea or vomiting.
medical orders since July 13.OBJECTIVE OF THE STUDY This study is conducted by NCM501205 cluster 1 student of Liceo de Cagyan University. gathered information from the significant others in 2 days of care. 18 & 19. developmental data. This study limits with the disease condition of the patient and so with the patient privacy. 2008 and the nursing intervention implemented by the student. 2008. 2008 and so with the nursing care & Medical care rendered from July 17. It also limits with the information gathered from the patient chart. pathophysiology of the disease. SCOPE AND LIMITATION OF THE STUDY The scope of this study focuses on patients past history of present illness. 18 & 19. . complying the task given to us in participating and understanding the health condition and health problems of the client in the Medical Ward of Bukidnon Provincial Hospital in Malaybalay. with the objective and subjective assessment from July 17.
To adjust and accept the physiological changes of the middle age and aslo adjusting to aging parents. B. impotence. he belongs in the Middle Adulthood which is Generativity vs. In this stage. This stage involves a reactivation of the progenital impulses. Stagnation. An inability to resolve conflicts can result in sexual problems. ROBERT HAVIGHURST MA belongs in the Middle Age in Havighurst Developmental Task Theory. According to Havighurst. Socially valued work and disciplines are expressions of Generativity. ERICK ERICKSON Since MA is 41 yrs. such as frigidity. the energy is directed towards attaining a mature sexual relationship. Simply having or wanting children does not in and of itself achieve Generativity. . relating onself to one's spouse as a person. Old in the theory of Erick Erickson.GROWTH AND DEVELOPMENT A. establishing and maintaining an economic standard of living. in the stage of Middle Age. This impulses usually displaced and the individual passes to the genital stage of maturity. assissting teenage children to become responsible and happy adults. It is concern of establishing and guiding the next generation. SIGMUND FREUD'S PSYCHOSEXUAL DEVELOPMENT Patient MA a 41 yrs. C. this is the time where in the adult is achieving civic and social responsibility. and the inability to have a satisfactory sexual relationship. Old belongs in the genital stage.
1966 Malaybalay City Bukidnon Roman Catholic Filipino Laborer (Lapanday Company) 7.PATIENT'S PROFILE Name: Age: Address: Civil Status: Date of Birth: Place of Birth: Religion: Nationality: Occupation: Income: Father's Name: Mother's Name: Height: Weight: Date of Admission: Time Admitted: Chief Complaint: Mr.00/mos Mr. Malaybalay City Bukidnon Married November 01. 2008 10:30 p. RA (deceased) Mrs.m Epigastric Pain . JA (deceased) 5 feet and 5 inches 64 kg. MA 41 yrs. Old Managok. July 13. 500.
Cordero. BA – 18 y.9 c Initial Vital signs: BP: 140/100mmHg NUMBER OF SIBLINGS: 2 CHILDREN 1.all girls PR: 95bpm RR: 25cpm T: 38.o .o JA – 16 y. Course graduate 2 siblings. 2. Azalea Acute Gastritis Visayan 2 yrs.Admitting Physician: Final Diagnosis: Language Spoken: Educational Attainment: Number of Siblings: Dr.
HISTORY OF PRESENT ILLNESS A case of patient MA.m with the chief complaint of epigastric pain. according to him. Tuseran forte. Malaybalay City Bukidnon was admitted last July 13. PREVIOUS ILLNESS Patient MA has this previous illness of headache but only tolerable and also experienced fever by only taking the ober the counter drug such as the paracetamol. . 1 week prior to admission. patient was experiencing tolerable headache. residing at P-1 Managok. he was spraying an insecticide in their garden and then experiencing on and off fever for also 1 week without any check-up done. The patient doesn't smoke. SOCIAL HISTORY Patient is drinking alcoholic drinks occasionally with friends and was able to consume 2-3 bottles of beer na beer. a laborer and who's married.o. Patient has no known food and drug allergies. patient vomit with saliva in minimal amount with headache. 2008 @ 10:30 p. non. Both on father and Mother side is non. 41 y. he was admitted for the first time on his present disease condition @ Bukidnon Provincial Hospital. after he was releived by the headache by taking paracetamol. The night prior to admission. Decolgen without any consultation done.PAST MEDICAL HISTORY The patient did not experienced hospitalization for the past life.hypertensive.diabetic and nonasthmatic.
for legal documentation purposes .Cefuroxime 750 mg IVT q 8 hrs ANST .continue meds .to inhibit gastric secretions .to treat infection .to check for any abnormalities .Captopril 25mg tablet 1 tab BID .secure consent to care . De Castro July 15.for pain relief and fever . 2008 .to treat epigastric pain .to determine any abnormal results .m . 2008 .to treat hypertension .to prevent nausea & vomiting . Cordero Addition: . vomiting. IVT q 8 hrs . Cordero July 14.MEDICAL MANAGEMENT DOCTOR'S ORDER July 13. U/A.Nothing per Orem .to know any deviations or abnormalities .for continuation of treatment .pls.refer accordingly Dr.monitor v/s q shift & record .Paracetamol 500mg tab 1 Tab q 4 hrs .please admit .LABS: CBC.IVF PNSS 1 L to run @ 20 gtts/min Dr.to provide further management and observation .for proper nutrition .This is to sustain body fluids and electrolytes RATIONALE . cough . 2008 8:00 p.To prevent error in managing the patient .IVF start with PNSS 1 L to run @ 20 gtts/min .Meds: .m .Diet: Soft diet .Metochlopramide 1 amp.X-ray of the abdomen flat plate & upright Dr. Fecalysis .Ranitidine 50mg IVT q 8 hrs . Give Tramadol 100mg IV now .to check for any deviations .treatment for cough . 2008 10:30 p. Cordero July 14.TPR q shift .for further evaluatiuon .Ambroxol 75mg tab 1 tab OD Dr.This is to sustain body fluids and electrolytes .PA: epigastric pain.
De Castro SURGICAL NOTES July 16.kindly start Ceftriaxone ASAP .surgical abdomen of intestine .This is to sustain body fluids and electrolytes .m T: 40 c . Pain occur .may have DAT . . 2008 (-) complaints of abd.TUBEX test stat! .to provide proper nutrition .m . present management . for T above 38.treatment for infection -for treatment . then q 4 hrs.cont.paracetamol 300 mg IVTT now.to checked for any deviation . Cont. 2008 -start Losartan (Ecozar) 50mg tab OD .a non.pt.Thank you for your referral Dr.to treat for fever . Generalao July 17. Generalao July 16.to treat infection .for evaluation .pls.treatment for hypertension .to provide proper treatment .to check for deviation . other meds .refer to SROD if abd.This is to sustain body fluids and electrolytes .refer to surgery for evaluation . 2008 .carry out Sx suggestion .cont.IVFTF with D5LR 2 L @ 30 gtss/min 5:45 p..for referal & evaluation . Pain .IVFTF PNSS 1 L to run @ 30 gtts/min Dr.Labs checked . ANST .start Ceftriaxone 750mg IVT q 8 hrs.for treatments .IVF PNSS 1 L to run @ KVO rate 2:00 p. Cordero July 17.for medical mngt. 2008 .persist & perform Dr. 0 c Dr.This is to sustain body fluids and electrolytes . Seen and examined Hx reviewed . meds .
Dr. De Castro .
pulse. bowel habits. gait. circ. odor. function.8 c skin is hot to touched complained of sligthly tolerable epigastric pain with ongoing IVF of PNSS 1 L @ kvo rate defecated once tinged with blood in moderate consistency. pulse blood [ ] breath sounds. rhythm. color. LOC. texture. integrity [ ] no problem Alopecia noted @ the front head part with productive cough febrile T: 38. comfort [ ] gyne bleeding [ ] discharge [x] no problem NEURO: [ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] treamors [ ] confused [ ] vision [ ] grip [ ] assess motor. coordination. motion gait. strength [ ] grip. joint function [ ] skin color. rate. yellowish in color .NURSING ASSSESSMENT (System Review Chart) Physical Assessment Name: MA BP: 140/80 mmHg T: 38. turgor.. blood Pressure. sensation. speech [ x ] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechie [x] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist [ ] assess mobility. alignment. fluid retention. control. comfort [x] no problem GENITO – URINARY AND GYNE [ ] pain [ ] polyuria [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [x] assess urine frequency. swallowing [ ] bowel sounds. comfort [x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ]numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain [x] Assess heart sounds.8°C HR: 92 bpm Date/ Time: 07/17/08 7:00 am RR: 25 cpm Height: 5”5’ inches EENT: [ ] Impaired vision [ ] blind [ ] pain redden [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion teeth [ ] assess eyes ears nose [ ] throat for abnormality [x] no problem RESP: [ ] Asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [x] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic [x] assess resp. comfort [x] no problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ x ] pain [ ] assess abdomen. rate rhythm.
[ ]regular [ x] irregular Describe: Respiratory rate is above normal with the range of 25cpm. Heart Rhythm Pulse Car R L not assessed not assessed [x] regular Rad. 92bpm 92bpm DP [ ] irregular Fem Ankle Edema: No ankle edema is present on both extremities not assessed not assessed not assessed not assessed Comments: Right and left pulses are equal.”as verbalized by the patient. . [ ]dentures Complete [x]none Incomplete Comments: “wala may sakit akung dughan ug kalawasan. strong and palpable. [ ] glasses [ ] contact lenses [ ] languages [ ] hearing difficulties due to age [ ] speech difficulties Pupil size:R:3 mm L:3mm Reaction: PERRLA (Pupil Equally Round and Reactive to Light Accommodation) OXYGENATION: [ ] dyspnea [ ] smoking history non. Resp.smoker [x] cough [ ] sputum [ ] denied Comments: “dili man ko gapanigarilyo pero naa koy ubo” as verbalized by the patient. R: symmetrical to the left lung L: symmetrical to the right lung CIRCULATION: [ ] chest pain [ ] leg pain [ ] numbness of extremities [x] denied NUTRITION: Diet: Diet as Tolerated Character [ ] recent change in weight [ ] swallowing Difficulty [x] denied Lower  [x] Upper [ ] [x] Comment: “okay raman ang akung pagkaon” as verbalized by the patient.SUBJECTIVE OBJECTIVE COMMUNICATION: [ ] hearing difficulty [ ] visual changes [x] denied Comments:"wala may problema sa akung pandungog.” as verbalized by the patient.
hazy and faint aromatic odor. Abdominal Distention Present [ ] yes [x] no Urine* (color. decubitus (describe size. odor) Urine color is yellow. OF HEALTH & ILLNESS: [x] alcohol [ ] denied (amount/frequency) 2-3 bottles/ occasionally [ ] SBE: N/A LMP: N/A Last Pap Smear: N/A Briefly describe the patient’s ability to follow treatments (diet. meds. Gait: [ ] walker [ ] cane [ ] other [x] steady [ ] unsteady [ ] sensory and motor losses in face or extremities No sensory and motor losses on face or extremities [ ] ROM limitations: none . ulcers. 2008 watery and yellowish with moderate consistency [x] diarrhea [ ] constipation [x] urinary frequency 3 x a day [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] foley in place [x] denied Comments:Our patients has a normal sound as we auscultate via use of stethoscope. the deit. consistency. location. Comments: “wala man pud katolkatol na akung nabati” As verbalized by the patient.) for chronic health problems (if present).ELIMINATION: Usual bowel pattern: once a day___ [ ] constipation Remedy Date of last BM July 17. di pud ko gakalipong” As verbalized by the patient. maka lakaw-lakaw man ko. Patient was able to follow treatments given. Foley if they are in place: none MGT. medications that has been prescribed by the physician. [ ] dry [x] flushed [ ] moist OBJECTIVE [ ] cold [x] warm [ ] cyanotic [ ] pale *rashes. Bowel sounds Audible normoactive bowel sounds every 10-15 sec. SUBJECTIVE SKIN INTEGRITY: [ ] dry [ ] other [ ] denied ACTIVITY/ SAFETY: [ ] convulsion [ ] dizziness [ ] limited motion of Joints Limitation in Ability to [ ] ambulate [ ] bathe self [ ] other[x] denied Comments: “wala man problema. etc. drainage: none [ ] LOC and orientation Patient is oriented as to the place. and person.
COMFORT/SLEEP/ AWAKE: [ ] pain (location. [ ] facial grimaces [ ] guarding [x] other signs of pain : He can tolerate the pain.frequency) [ ] nocturia [x] sleep difficulties [ ] denied COPING: Occupation: Laborer (Lapanday Company) Members of household: 4 members of household Most supportive person: his wife Observed non-verbal behavior: none Phone number that can be reached anytime: Confidential Comments: “naa jud usahay na di ko makatulog tungod sa akung ubo ug akung tiyan pag mutokar” as verbalized by the patient. SPECIAL PATIENT INFORMATION _Not ordered Daily weight ____N/A___ PT/OT __ N/A __ ____N/A___ Irradiation __ done _Urine test ___________ __No Order__24 hour Urine Collection _every 4 hrs _ BP q shift ____N/A___ _ Neuro vs ____N/A_ _ CVP/SG Reading __N/A___ .
Tumors INTERPRETATION GUIDE SCORE .6 Hematocrit 36.negative for any intestinal parasitic ova Pus cells: 1-3/ Hpf Red Blood Cells: 3-4/ Hpf Bacteria: Plenty White cell count 10-0 Hemoglobin 12.LABORATORY RESULTS Diagnostic Exam Result Normal Significance X-ray of the abdomen flat Radiologic Opinion Report “ no radiographic abnormality plate & upright in the chest” FECALYSIS color: yellow character: Loose . hemodilution Urine Analysis color: yellow Transparency: Hazy pus cells: 0-1/Hpf RBC 2-5/ Hpf normal infection in the Urinary Tract Trauma.5 Platelet count adequate Differential Count Segmenters 71 Lymphocytes 29 100% Normal CBC recent hemorrhage and fluid retention Anemia.
strong indication of current typhoid fever infection 4 POSITIVE 6-10 . inclusive score.TUBEX TEST NEGATIVE 3 . Repeat analysis at a later date.indication of current typhoid fever infection. Positive. Weak positive.does not indicate current typhoid fever infection boderline.
oesophagus. Digestion occurs both mechanically by physical means.ANATOMY AND PHYSIOLOGY Structure and function of the GI tract Overview This section describes the general structure and function of the GI tract wall. It provides a degree of protection to the outer layers against harmful substances and pathogens present in the gut . It is responsible for absorption of digested food. The wall of the GI tract is permeable to digested food molecules but impermeable to some potentially harmful organisms and other foreign particles. and its surface comes into direct contact with food particles in the GI tract. as well as the anatomy and function of the upper GI regions – the mouth. and chemically through enzyme-mediated metabolic reactions. peristalsis and churning movements of the stomach and small intestine. and it contains glands and cells that produce digestive juices and mucus. nerves controlling secretion) (circular constriction. blood supply. therefore. Large food molecules are metabolised into small. protection) − − − − Inner mucosa Submucosa Muscle layer Outer serosa (support. absorption. soluble molecules that can be absorbed into the blood stream and lymphatic system and incorporated into cells. The GI tract wall comprises four basic tissues surrounding the lumen: (secretion. which remain outside the body. and duodenum. The function of the GI tract The function of the GI tract is to carry out the digestive processes within the body. General structure of the GI tract The GI tract or alimentary canal forms a continuous ‘tube’ from the mouth to the anus. nerves controlling motility) (secretes lubricating fluid) The inner mucosa The mucosa is the innermost layer of the digestive tract. food is not actually inside the body until it has been metabolised and absorbed into the bloodstream. such as chewing. stomach. The mucosa lubricates solid contents to facilitate their movement along the digestive tract. longitudinal contraction.
The stomach has an additional internal layer of oblique muscles. which lines the wall of the peritoneal cavity. is only found covering the abdominal digestive organs. It also contains the main lymph vessels of the GI tract. It makes sensory connections through the layers. known as the myenteric or Auerbach’s plexus. The peritoneum itself is a membrane that holds the organs of the GI tract in place in the abdomen and encloses the vessels associated with absorption from the stomach and intestine. for example the oesophagus. and move food along the GI tract using peristalsis. Contractions of these muscles help to mechanically break down and mix food with digestive juices. The outer serosa The serosa. The serosa secretes a watery lubricant that allows parts of the gut to move smoothly over each other without friction. In areas of the GI tract that lack epithelium. The muscle layer The muscle layer is composed of two layers of smooth muscle – an inner layer of circular muscle fibres (which narrow the lumen when contracted) and an outer layer of longitudinal muscle fibres (which shorten and widen the lumen). the outermost layer. It consists of tough. Some muscle fibres (the muscularis mucosa) are also present. this layer is known as the adventitia. The major nerve supply of the GI tract. as well as along the length of the GI tract to control motility. . and the Meissner's plexus – a network of nerves that control digestive and hormonal secretions. The submucosa carries the major blood vessels into which digested food molecules are absorbed. is also contained in the muscle layer. and is an extension of the peritoneum. The submucosa The submucosa lies under and around the mucosal layer.lumen. fibrous tissues and acts as a supporting structure for the GI tract.
administered medications as indicated such as analgesic E: At the end of 15 mins. Patient will be able to verbalized relief of pain . calm activities 3. “ as verbalized by the patient . provided adequate rest period 5. changes of position 4.pain as claimed with painscale of 6 out of 10 .guarding . Patient was able to verbalized relief of pain Acute Pain related to inflammation of the lining of the stomach At the end of 15 mins.restless A: P: I: 1. encouraged deep breathing exercise 2.facial grimaces . gahapdus pud. provided quiet environment.ACTUAL NURSING MANAGEMENT S: O: “ Sakit ang akung tiyan. provided comfort measures such as backrub.
administered medication as prescribed by the physician E: At the end of 30 mins.increased respiratory rate of 25cpm A: P: I: Hyperthermia related to increased metabolic rate secondary to possible infection At the end of 30 mins. Body temperature was decreased and returned into normal range .8 c . provided a cool environment 4.skin is hot to touch .S: “ Init kaayo ang akung pamati. Body temperature will decreases into normal range 1.body Temperature of 38.” as verbalized by the patient O: . Tepid sponge bath applied especially in groin and axillae 5. encouraged to increase fluid intake 2. Pts. apil ang akung lawas init hikapon. promoted surface cooling by means of undressing 3.flushed skin . Pts.
changes in respiratory rate . administered medication as ordered by the physician E: At the end of the shift. tungod sa akung ubo.restless A: P: I: Ineffective Airway Clearance related to retained secretions At the end of the shift.presence of phlegm . provided with calm and quiet environment 3. placed patient in semi-fowlers position 2. the patient was able to improved and have effective respiratory pattern .S: “ Naay plemas inig mangluwa ko. the patient will be able to improve respiratory pattern 1. provided adequate rest periods 4.” as verbalized by the patient O: . provided with hand cuffed exercise 5.
It is imperative that instructions are written legibly. the group encourages the family to continue on supporting the medical and emotional support of the client in gearing towards hospitalization and consultation. sleep and avoidance of stress is important. and are clear in the teachings of our patient. Instructions included information about prescribed medication. Since the family support system towards the client is good. In order to emphasize the home management be effective and not forgotten. Precipitating factors D. Attitude and willingness to take medication E. EVALUATION / IMPLICATION PROGNOSTIC INDICATORS A. appropriate rest. Also based on thorough observation and data gathered. There may be some limitations depending on severity of the disorder. And strictly contact a health care provider or schedule follow-up appointments.DISCHARGE PLANNING Before discharge. Resume sexual relations at better condition and the symptoms are continue for control. HEALTH TEACHINGS . so that the patient can refer to them later. All instructions should be given not only verbally but also in writing. Onset of illness B. and activity. treatments. use simple language. The group implied for a continue support system towards the client and be cautious if there’s any complains from the client or any signs of another health problems. i have concluded that the objectives were partially met. the group identified that the client has a good prognosis. instructions for continuing care are given to the patient and the family or significant others. They are encouraged to be sensitive to the needs and care of the patient since he is in adulthood stage. Family support POOR GOOD / / / / / After having interacted with the client for 3 days and rendered nursing interventions. Duration of illness C. diet.
1 week or 3 days after discharge in the hospital and prescrbed by the physician at the out patient department DIET Upon the hospital. A Wolter's Klawer . patient is at Soft Diet. Patient is advised to follow treatment being prescribed by the TREATMENT physician OUTPATIENT (Check-up) Upon discharged. Susann and Brenda Bare. Published J. Patient is encouraged to have exercise upon discharge like walking every morning but he should stop whenever he felt EXERCISE tired.Patient is advised to take all the medications prescribed MEDICATIONS dosage. so patient can eat foods which is soft. Textbook of Medical Surgical Nursing 9th edition. so patient can eat any foods considering it is nutritious foods. and on how many days will it be consumed. patient is advised to have a follow-up checkup. prescribed route. time. He is also advised to increase his fluid intake BIBLIOGRAPHY: Smeltzer. Patient was also advised to do deep breathing exercise. Nursing drug Handbook.B Lippincott Company. Lippincott Williams and Wilkins. This will help the patient for past treatment or recovery. He was then ordered by the physician Diet as Tolerated.
Philadelpia. Blais. Gleonora. K. 5th edition.business 27th edition. B.E. Pages 759 & 1227 . Kozier. J.M Wilkinson (2001) Fundamentals of Nursing. JB Lippincott Company.
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