You are on page 1of 25

College of Nursing NCM501205 A Case Study on


Submitted to: Mrs. Milagros Maghanoy RN, MN Clinical Instructor

Submitted by: Del Honey P. Baul Group B2

August 2008


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 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.


This study is conducted by NCM501205 cluster 1 student of Liceo de Cagyan University, 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.


The scope of this study focuses on patients past history of present illness, developmental data, pathophysiology of the disease, medical orders since July 13, 2008 and the nursing intervention implemented by the student. This study limits with the disease condition of the patient and so with the patient privacy. It also limits with the information gathered from the patient chart, gathered information from the significant others in 2 days of care, with the objective and subjective assessment from July 17, 18 & 19, 2008 and so with the nursing care & Medical care rendered from July 17, 18 & 19, 2008.



Patient MA a 41 yrs. Old belongs in the genital stage. In this stage, the energy is directed towards attaining a mature sexual relationship. This stage involves a reactivation of the progenital impulses. This impulses usually displaced and the individual passes to the genital stage of maturity. An inability to resolve conflicts can result in sexual problems, such as frigidity, impotence, and the inability to have a satisfactory sexual relationship.


Since MA is 41 yrs. Old in the theory of Erick Erickson, he belongs in the Middle Adulthood which is Generativity vs. Stagnation. It is concern of establishing and guiding the next generation. Socially valued work and disciplines are expressions of Generativity. Simply having or wanting children does not in and of itself achieve Generativity.


MA belongs in the Middle Age in Havighurst Developmental Task Theory. According to Havighurst, in the stage of Middle Age, this is the time where in the adult is achieving civic and social responsibility, establishing and maintaining an economic standard of living, assissting teenage children to become responsible and happy adults, relating onself to one's spouse as a person. To adjust and accept the physiological changes of the middle age and aslo adjusting to aging parents.


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. MA 41 yrs. Old Managok, Malaybalay City Bukidnon Married November 01, 1966 Malaybalay City Bukidnon Roman Catholic Filipino Laborer (Lapanday Company) 7, 500.00/mos Mr. RA (deceased) Mrs. JA (deceased) 5 feet and 5 inches 64 kg. July 13, 2008 10:30 p.m Epigastric Pain

Admitting Physician: Final Diagnosis: Language Spoken: Educational Attainment: Number of Siblings:

Dr. Cordero, Azalea Acute Gastritis Visayan 2 yrs. Course graduate 2 siblings- all girls PR: 95bpm RR: 25cpm T: 38.9 c

Initial Vital signs: BP: 140/100mmHg

NUMBER OF SIBLINGS: 2 CHILDREN 1. 2. BA 18 y.o JA 16 y.o

PAST MEDICAL HISTORY The patient did not experienced hospitalization for the past life, he was admitted for the first time on his present disease condition @ Bukidnon Provincial Hospital. Both on father and Mother side is non- hypertensive, non- diabetic and nonasthmatic. Patient has no known food and drug allergies.


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, Tuseran forte, Decolgen without any consultation done.


Patient is drinking alcoholic drinks occasionally with friends and was able to consume 2-3 bottles of beer na beer. The patient doesn't smoke.


A case of patient MA, 41 y.o, a laborer and who's married, residing at P-1 Managok, Malaybalay City Bukidnon was admitted last July 13, 2008 @ 10:30 p.m with the chief complaint of epigastric pain. 1 week prior to admission, patient was experiencing tolerable headache, after he was releived by the headache by taking paracetamol, according to him, 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 night prior to admission, patient vomit with saliva in minimal amount with headache.

MEDICAL MANAGEMENT DOCTOR'S ORDER July 13, 2008 10:30 p.m - please admit - secure consent to care - TPR q shift - PA: epigastric pain, vomiting, cough - Diet: Soft diet - IVF start with PNSS 1 L to run @ 20 gtts/min - LABS: CBC, U/A, Fecalysis - Meds: - Metochlopramide 1 amp. IVT q 8 hrs - Ranitidine 50mg IVT q 8 hrs - Captopril 25mg tablet 1 tab BID - monitor v/s q shift & record - refer accordingly Dr. Cordero Addition: - Cefuroxime 750 mg IVT q 8 hrs ANST - Paracetamol 500mg tab 1 Tab q 4 hrs - Ambroxol 75mg tab 1 tab OD Dr. Cordero July 14, 2008 - continue meds - IVF PNSS 1 L to run @ 20 gtts/min Dr. Cordero July 14, 2008 8:00 p.m - pls. Give Tramadol 100mg IV now - X-ray of the abdomen flat plate & upright Dr. De Castro July 15, 2008 - Nothing per Orem - for further evaluatiuon - to treat epigastric pain - to check for any abnormalities - for continuation of treatment - This is to sustain body fluids and electrolytes - to treat infection - for pain relief and fever - treatment for cough - to prevent nausea & vomiting - to inhibit gastric secretions - to treat hypertension - to check for any deviations - To prevent error in managing the patient - to determine any abnormal results - to provide further management and observation - for legal documentation purposes - to know any deviations or abnormalities - for proper nutrition - This is to sustain body fluids and electrolytes RATIONALE

- refer to surgery for evaluation - IVFTF with D5LR 2 L @ 30 gtss/min 5:45 p.m T: 40 c - paracetamol 300 mg IVTT now, then q 4 hrs. for T above 38. 0 c Dr. De Castro SURGICAL NOTES July 16, 2008 (-) complaints of abd. Pain - may have DAT - a non- surgical abdomen of intestine - pls. Cont. present management - refer to SROD if abd. Pain occur - persist & perform Dr. Generalao July 16. 2008 - carry out Sx suggestion - cont. meds - IVF PNSS 1 L to run @ KVO rate 2:00 p.m - pt. Seen and examined Hx reviewed - Labs checked - for medical mngt. - Thank you for your referral Dr. Generalao July 17, 2008 - TUBEX test stat! - start Ceftriaxone 750mg IVT q 8 hrs. ANST - cont. other meds - IVFTF PNSS 1 L to run @ 30 gtts/min Dr. Cordero July 17, 2008 -start Losartan (Ecozar) 50mg tab OD - kindly start Ceftriaxone ASAP

- This is to sustain body fluids and electrolytes - to treat for fever

- to provide proper nutrition - to provide proper treatment - for referal & evaluation

- for treatments - This is to sustain body fluids and electrolytes - for evaluation - to checked for any deviation

- to check for deviation - treatment for infection -for treatment - This is to sustain body fluids and electrolytes

- treatment for hypertension - to treat infection

Dr. De Castro


Physical Assessment Name: MA BP: 140/80 mmHg T: 38.8C HR: 92 bpm Date/ Time: 07/17/08 7:00 am RR: 25 cpm Height: 55 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. rate, rhythm, pulse blood [ ] breath sounds, comfort [x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ]numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain [x] Assess heart sounds, rate rhythm, pulse, blood Pressure, circ., fluid retention, comfort [x] no problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ x ] pain [ ] assess abdomen, bowel habits, swallowing [ ] bowel sounds, comfort [x] no problem GENITO URINARY AND GYNE [ ] pain [ ] polyuria [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [x] assess urine frequency, control, color, odor, comfort [ ] gyne bleeding [ ] discharge [x] no problem NEURO: [ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] treamors [ ] confused [ ] vision [ ] grip [ ] assess motor, function, sensation, LOC, strength [ ] grip, gait, coordination, 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, motion gait, alignment, joint function [ ] skin color, texture, turgor, integrity [ ] no problem

Alopecia noted @ the front head part with productive cough

febrile T: 38.8 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, yellowish in color



COMMUNICATION: [ ] hearing difficulty [ ] visual changes [x] denied Comments:"wala may problema sa akung verbalized by the patient. [ ] 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- smoker [x] cough [ ] sputum [ ] denied Comments: dili man ko gapanigarilyo pero naa koy ubo as verbalized by the patient.

Resp. [ ]regular

[ x] irregular

Describe: Respiratory rate is above normal with the range of 25cpm. 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. [ ]dentures Complete [x]none Incomplete Comments: wala may sakit akung dughan ug kalawasan. as verbalized by the patient. 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; strong and palpable.

ELIMINATION: Usual bowel pattern: once a day___ [ ] constipation Remedy Date of last BM July 17, 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.

Bowel sounds Audible normoactive bowel sounds every 10-15 sec. Abdominal Distention Present [ ] yes [x] no Urine* (color, consistency, odor) Urine color is yellow, hazy and faint aromatic odor. Foley if they are in place: none

MGT. 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 patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). Patient was able to follow treatments given, the deit, medications that has been prescribed by the physician.

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, maka lakaw-lakaw man ko, di pud ko gakalipong As verbalized by the patient. Comments: wala man pud katolkatol na akung nabati As verbalized by the patient. [ ] dry [x] flushed [ ] moist


[ ] cold [x] warm [ ] cyanotic

[ ] pale

*rashes, ulcers, decubitus (describe size, location, drainage: none

[ ] LOC and orientation Patient is oriented as to the place, and person, 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

COMFORT/SLEEP/ AWAKE: [ ] pain (location,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. [ ] facial grimaces [ ] guarding [x] other signs of pain : He can tolerate the pain.

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___

LABORATORY RESULTS Diagnostic Exam Result Normal Significance

X-ray of the abdomen flat Radiologic Opinion Report no radiographic abnormality plate & upright in the chest


color: yellow character: Loose - 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 12.6 Hematocrit 36.5 Platelet count adequate Differential Count Segmenters 71 Lymphocytes 29 100%



recent hemorrhage and fluid retention Anemia, hemodilution

Urine Analysis

color: yellow Transparency: Hazy pus cells: 0-1/Hpf RBC 2-5/ Hpf

normal infection in the Urinary Tract Trauma, Tumors




- does not indicate current typhoid fever infection boderline, inclusive score. Repeat analysis at a later date. Weak positive- indication of current typhoid fever infection. Positive- strong indication of current typhoid fever infection




Structure and function of the GI tract

Overview This section describes the general structure and function of the GI tract wall, as well as the anatomy and function of the upper GI regions the mouth, oesophagus, stomach, and duodenum. The function of the GI tract The function of the GI tract is to carry out the digestive processes within the body. Large food molecules are metabolised into small, soluble molecules that can be absorbed into the blood stream and lymphatic system and incorporated into cells. Digestion occurs both mechanically by physical means, such as chewing, peristalsis and churning movements of the stomach and small intestine, and chemically through enzyme-mediated metabolic reactions. General structure of the GI tract The GI tract or alimentary canal forms a continuous tube from the mouth to the anus, therefore, food is not actually inside the body until it has been metabolised and absorbed into the bloodstream. The wall of the GI tract is permeable to digested food molecules but impermeable to some potentially harmful organisms and other foreign particles, which remain outside the body. The GI tract wall comprises four basic tissues surrounding the lumen: (secretion, absorption, protection)

Inner mucosa Submucosa Muscle layer Outer serosa

(support, blood supply, nerves controlling secretion) (circular constriction, longitudinal contraction, nerves controlling motility) (secretes lubricating fluid)

The inner mucosa The mucosa is the innermost layer of the digestive tract, and its surface comes into direct contact with food particles in the GI tract. It is responsible for absorption of digested food. The mucosa lubricates solid contents to facilitate their movement along the digestive tract, and it contains glands and cells that produce digestive juices and mucus. It provides a degree of protection to the outer layers against harmful substances and pathogens present in the gut

lumen. Some muscle fibres (the muscularis mucosa) are also present. The submucosa The submucosa lies under and around the mucosal layer. It consists of tough, fibrous tissues and acts as a supporting structure for the GI tract. The submucosa carries the major blood vessels into which digested food molecules are absorbed. It also contains the main lymph vessels of the GI tract, and the Meissner's plexus a network of nerves that control digestive and hormonal secretions. 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 stomach has an additional internal layer of oblique muscles. Contractions of these muscles help to mechanically break down and mix food with digestive juices, and move food along the GI tract using peristalsis. The major nerve supply of the GI tract, known as the myenteric or Auerbachs plexus, is also contained in the muscle layer. It makes sensory connections through the layers, as well as along the length of the GI tract to control motility.

The outer serosa The serosa, the outermost layer, is only found covering the abdominal digestive organs, and is an extension of the peritoneum, which lines the wall of the peritoneal cavity. In areas of the GI tract that lack epithelium, for example the oesophagus, this layer is known as the adventitia. 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. The serosa secretes a watery lubricant that allows parts of the gut to move smoothly over each other without friction.


S: O: Sakit ang akung tiyan, gahapdus pud. as verbalized by the patient - pain as claimed with painscale of 6 out of 10 - facial grimaces - guarding - restless A: P: I: 1. encouraged deep breathing exercise 2. provided quiet environment, calm activities 3. provided comfort measures such as backrub, changes of position 4. provided adequate rest period 5. administered medications as indicated such as analgesic E: At the end of 15 mins. 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. Patient will be able to verbalized relief of pain


Init kaayo ang akung pamati, apil ang akung lawas init hikapon. as verbalized by the patient


- body Temperature of 38.8 c - skin is hot to touch - flushed skin - increased respiratory rate of 25cpm

A: P: I:

Hyperthermia related to increased metabolic rate secondary to possible infection At the end of 30 mins. Pts. Body temperature will decreases into normal range

1. encouraged to increase fluid intake 2. promoted surface cooling by means of undressing 3. provided a cool environment 4. Tepid sponge bath applied especially in groin and axillae 5. administered medication as prescribed by the physician E: At the end of 30 mins. Pts. Body temperature was decreased and returned into normal range


Naay plemas inig mangluwa ko, tungod sa akung ubo. as verbalized by the patient


- presence of phlegm - changes in respiratory rate - restless

A: P: I:

Ineffective Airway Clearance related to retained secretions At the end of the shift, the patient will be able to improve respiratory pattern

1. placed patient in semi-fowlers position 2. provided with calm and quiet environment 3. provided adequate rest periods 4. provided with hand cuffed exercise 5. administered medication as ordered by the physician E: At the end of the shift, the patient was able to improved and have effective respiratory


Before discharge, instructions for continuing care are given to the patient and the family or significant others. All instructions should be given not only verbally but also in writing, so that the patient can refer to them later. Instructions included information about prescribed medication, treatments, diet, and activity. There may be some limitations depending on severity of the disorder, Resume sexual relations at better condition and the symptoms are continue for control, appropriate rest, sleep and avoidance of stress is important. And strictly contact a health care provider or schedule follow-up appointments. It is imperative that instructions are written legibly, use simple language, and are clear in the teachings of our patient. In order to emphasize the home management be effective and not forgotten.

PROGNOSTIC INDICATORS A. Onset of illness B. Duration of illness C. Precipitating factors D. Attitude and willingness to take medication E. Family support POOR GOOD / / / / /

After having interacted with the client for 3 days and rendered nursing interventions, i have concluded that the objectives were partially met. Also based on thorough observation and data gathered, the group identified that the client has a good prognosis. Since the family support system towards the client is good, the group encourages the family to continue on supporting the medical and emotional support of the client in gearing towards hospitalization and consultation. They are encouraged to be sensitive to the needs and care of the patient since he is in adulthood stage. The group implied for a continue support system towards the client and be cautious if theres any complains from the client or any signs of another health problems.


Patient is advised to take all the medications prescribed MEDICATIONS dosage, prescribed route, time, and on how many days will it be consumed. This will help the patient for past treatment or recovery.

Patient is encouraged to have exercise upon discharge like walking every morning but he should stop whenever he felt EXERCISE tired. Patient was also advised to do deep breathing exercise.

Patient is advised to follow treatment being prescribed by the TREATMENT physician


Upon discharged, patient is advised to have a follow-up checkup, 1 week or 3 days after discharge in the hospital and prescrbed by the physician at the out patient department


Upon the hospital, patient is at Soft Diet, so patient can eat foods which is soft. He was then ordered by the physician Diet as Tolerated, so patient can eat any foods considering it is nutritious foods. He is also advised to increase his fluid intake


Smeltzer, Susann and Brenda Bare. Textbook of Medical Surgical Nursing 9th
edition. Published J.B Lippincott Company.

Lippincott Williams and Wilkins. Nursing drug Handbook. A Wolter's Klawer

business 27th edition.

Kozier, B.E, Gleonora, K, Blais, J.M Wilkinson (2001) Fundamentals of Nursing.

5th edition. JB Lippincott Company. Philadelpia. Pages 759 & 1227