REVISED PUD g3

UNIVERSAL COLLEGES OF PARAŇAQUE INC.
8273 Dr. A. Santos Ave., Parañaque City

COLLEGE OF NURSING
A Case Study of
(PEPTIC ULCER DISEASE)
From (Medicine Ward- APOLINARIO MABINI) of (JUSTICE JOSE ABAD SANTOS GENERAL
HOSPITAL)
Presented to the Faculty of College of Nursing
In Partial Fulfillment for
The Course Requirement of Related Learning Experience (RLE)
1st semester, School Year of 2022-2023
Submitted by:
Dejolde, Rosgen L.
Estrada, Jacob
Estreller, Bea Shaira T.
Flores, Camille S.
Lagan, Christine
Lucanas, Ma.fe
Submitted to:
Mr. Henry Apolinar
Date: January 14, 2023
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COLLEGE OF NURSING
TABLE OF CONTENTS
Page Number
I. Introduction ……………………………………………………………..……… 3
II. Nursing Health History ………………………………………………… 12
ii.a. Biographic Data ……………………………………………………. 12
ii.b. Chief Complaint …………………………………………………….. 13

ii.c. History of Present Illness…………………………………………… 13
ii.d. Past Medical History ………………………………………………… 13
ii.e. Social History ……………………………………………………….. 13
ii.f. OB-GYNE history (if female) ……………………………………… 13
ii.g. Family History ………………………………………………………. 14
ii.h. Environmental History ……………………………………………... 15
ii.i. Developmental History ……………………………………………… 15
ii.j. Gordon’s Functional Health Pattern ………………………………. 15
III. Physical Examination ……………………………………………………….. 26

IV. Neurologic Examination (GCS, Mental Status, Cranial Nerves) – if applicable
V. Anatomy and Physiology …………………………………………………… 35
VI. Pathophysiology …………………………………………………………….. 37
vi.a. Book Based
vi.b. Client Based
VII. Diagnostic Exam / Procedures ……………………………………………. 39

VIII. Course in the Ward …………………………………………………………. 44
IX. Drug Study …………………………………………………………………... 50
X. Nursing Care Plans …………………………………………………………. 59
XI. Discharge Summary (METHODS) ………………………………………... 74
XII. Personal Insights …………………………………………………………… 76
XIII. References ………………………………………………………………….. 78
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(PEPTIC ULCER DISEASE)
I. Introduction
Peptic ulcers
- are open sores that develop on the inside lining of your

stomach and the upper portion of your small intestine.
-most common symptom of a peptic ulcer is stomach pain.
Peptic ulcers include:

· Gastric ulcers that occur on the inside of the stomach
· Duodenal ulcers that occur on the inside of the upper portion
of your small intestine (duodenum)
MORBIDITY/MORTALITY
According to the latest WHO data published in 2020 Peptic Ulcer Disease Deaths in Philippines
reached 6,865 or 1.02% of total deaths. Ranks #17 in the Philippines and #12 in the world.
Risk factors
 Smoke. Smoking may increase the risk of peptic ulcers in people who are infected with H.
pylori.
 Drink alcohol. Alcohol can irritate and erode the mucous lining of your stomach, and it
increases the amount of stomach acid that's produced.
 Diet.
 Have untreated stress.
 NSAIDS
 Eat spicy foods (Alone, these factors do not cause ulcers, but they can make ulcers
worse and more difficult to heal).
SIGNS AND SYMPTOMS
 Burning stomach pain

 Feeling of fullness, bloating or belching
 Intolerance to fatty foods
 Heartburn
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 Nausea
Less often, ulcers may cause severe signs or symptoms such as:
 Vomiting or vomiting blood — which may appear red or black

 Dark blood in stools, or stools that are black or tarry
 Trouble breathing
 Feeling faint
 Nausea or vomiting
 Unexplained weight loss
 Appetite changes
LABORATORY PROCEDURES
 Blood test: To check for the presence of H pylori.
 Breath test: To check H pylori infection (bacterial infection). Most accurate.
 Stool test: To check H pylori infection (bacterial infection).
DIAGNOSTIC PROCEDURES
 Endoscopy. Your doctor may use a scope to examine your upper digestive system
(endoscopy). During endoscopy, your doctor passes a hollow tube equipped with a lens
(endoscope) down your throat and into your esophagus, stomach and small intestine.
Using the endoscope, your doctor looks for ulcers.
If your doctor detects an ulcer, a small tissue sample (biopsy) may be removed for
examination in a lab. A biopsy can also identify whether H. pylori is in your stomach lining.
Your doctor is more likely to recommend endoscopy if you are older, have signs of
bleeding, or have experienced recent weight loss or difficulty eating and swallowing. If the
endoscopy shows an ulcer in your stomach, a follow-up endoscopy should be performed
after treatment to show that it has healed, even if your symptoms improve.
 Upper gastrointestinal series. Sometimes called a barium swallow, this series of X-rays
of your upper digestive system creates images of your esophagus, stomach and small
intestine. During the X-ray, you swallow a white liquid (containing barium) that coats your
digestive tract and makes an ulcer more visible.
TREATMENT
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Treatment for peptic ulcers depends on the cause. Usually, treatment will involve killing the H. pylori
bacterium if present, eliminating or reducing use of NSAIDs if possible, and helping your ulcer to heal
with medication.
Medications can include:
 Antibiotic medications to kill H. pylori. If H. pylori is found in your digestive tract, your
doctor may recommend a combination of antibiotics to kill the bacterium. These may
include amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl), tinidazole
(Tindamax), tetracycline and levofloxacin.
The antibiotics used will be determined by where you live and current antibiotic resistance
rates. You'll likely need to take antibiotics for two weeks, as well as additional medications
to reduce stomach acid, including a proton pump inhibitor and possibly bismuth
subsalicylate (Pepto-Bismol).
 Medications that block acid production and promote healing. Proton pump inhibitors
— also called PPIs — reduce stomach acid by blocking the action of the parts of cells that
produce acid. These drugs include the prescription and over-the-counter medications
omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole
(Nexium) and pantoprazole (Protonix).
Long-term use of proton pump inhibitors, particularly at high doses, may increase your
risk of hip, wrist and spine fracture. Ask your doctor whether a calcium supplement may
reduce this risk.
 Medications to reduce acid production. Acid blockers — also called histamine (H-2)
blockers — reduce the amount of stomach acid released into your digestive tract, which
relieves ulcer pain and encourages healing.
Available by prescription or over the counter, acid blockers include the medications
famotidine (Pepcid AC), cimetidine (Tagamet HB) and nizatidine (Axid AR).
 Antacids that neutralize stomach acid. Your doctor may include an antacid in your drug
regimen. Antacids neutralize existing stomach acid and can provide rapid pain relief. Side
effects can include constipation or diarrhea, depending on the main ingredients.
Antacids can provide symptom relief but generally aren't used to heal your ulcer.
 Medications that protect the lining of your stomach and small intestine. In some
cases, your doctor may prescribe medications called cytoprotective agents that help
protect the tissues that line your stomach and small intestine.
Options include the prescription medications sucralfate (Carafate) and misoprostol

(Cytotec).
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Nursing Management
Administer prescribed medications.
 Medications may include antacids, anticholinergics, histamine-receptor antagonist, proton-

pump inhibitors, and mucosal protective agents.
 Medication for ulcers caused by H. pylori include bismuth subsalicylate, metronidazole,
and tetracycline. These medications administered together eradicate H. pylori bacteria in
the gastric mucosa.
Provide client and family teaching.
 Instruct the client to quit smoking, which decreases the secretion of bicarbonate from the
pancreas into the duodenum, resulting in increased acidity in the duodenum.
 Teach the client about necessary lifestyle modifications aimed at decreasing stress and
maximizing effective coping. Biofeedback, hypnosis, or behavior modification may be
suggested.
Teach the client methods to minimize symptoms while maintaining adequate nutrition.
 Avoid foods that previously have caused pain. Specific dietary restrictions vary from client
to client.
 Eat three regular meals a day, small, frequent meals are unnecessary as long as the
medication is taken before meals.
 Avoid a diet rich in milk and creams, which are acid stimulants.
Prepare the client for diagnostic procedures and provide post procedure care.
 Prepare for barium swallow includes no oral intake after midnight and possible laxatives to
clean the GI tract.
 After a barium swallow, administer a laxative if indicated to prevent constipation.
 Stools are monitored until all barium has been eliminated.
Prepare the client for surgery if indicated. (e.g. ulcers that have not responded to treatment
after 12 to 16 weeks, life-threatening hemorrhage or perforation)
Preoperative care
 Obtain informed consent

 Clear and empty the GI tract by administering enemas and allowing nothing by mouth
Postoperative care
 Ensure that the nasogastric tube (surgically placed) is not manipulated

 Observe nasogastric tube aspirate
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 Assess the surgical dressing

 Provide routine postoperative care
 Provide discharge teaching
UPPER GASTROINTESTINAL BLEEDING
Upper gastrointestinal (GI) bleeding refers to bleeding that occurs

anywhere in the esophagus, the stomach, or the upper part of the small
intestine. It is a symptom of an underlying disorder, and it can be serious.
MORBIDITY/MORTALITY
Upper gastrointestinal bleeding (UGIB) is a common problem that is estimated to occur in 80 to 150
out of 100,000 people each year. Estimated mortality rates are between 2 and 15 percent.
UGIB accounts for 75% of all acute gastrointestinal (GI) bleeding cases. Its annual incidence is
approximately 80 to 150 per 100,000 population.
On the other hand, the elderly had a significantly higher mortality than the young when the source
was gastric ulcer.
RISKS
-smoker
-history of peptic ulcer disease
-alcohol consumption
-age
-people with GERD
-NSAIDS
Signs & Symptoms
The location of a GI bleed and the rate of bleeding influence the type of symptoms a person may
experience.
The symptoms of a GI bleed can include:
 black, tarry stool

 vomit that is bright red or resembles coffee grounds
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 stomach cramps
 unusually pale skin
 feeling faint, dizzy, or tired
 weakness
People can also experience occult bleeding, which occurs when there is blood in the stool that is not
visible. Doctors can detect this blood using a stool test.
Laboratory tests
 Stool tests: These can detect inflammation, occult bleeding, or infection

ns, such as H. pylori.
 Blood tests: These tests can reveal anemia.
Diagnostic tests
 Nasogastric lavage. A tube is passed through your nose into your stomach to remove
your stomach contents. This might help determine the source of your bleed.
 Upper endoscopy. This procedure uses a tiny camera on the end of a long tube, which
is passed through your mouth to enable your doctor to examine your upper
gastrointestinal tract.
 Capsule endoscopy. In this procedure, you swallow a vitamin-size capsule with a tiny
camera inside. The capsule travels through your digestive tract taking thousands of
pictures that are sent to a recorder you wear on a belt around your waist. This enables
your doctor to see inside your small intestine.
 Balloon-assisted enteroscopy. A specialized scope inspects parts of your small

intestine that other tests using an endoscope can't reach. Sometimes, the source of
bleeding can be controlled or treated during this test.
 Imaging tests. A variety of other imaging tests, such as an abdominal CT scan, might be
used to find the source of the bleed.
Treatment
Medication Summary
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Rebleeding in patients with upper gastrointestinal (GI) hemorrhage (UGIB) is associated with
increased morbidity and mortality; therefore, prevention of rebleeding is the major goal of therapy.
 If you have an upper GI bleed, you might be given an IV drug known as a proton pump
inhibitor (PPI) to suppress stomach acid production. Once the source of the bleeding is
identified, your doctor will determine whether you need to continue taking a PPI.
Nursing management
o Nutrition
 Observe for symptoms of nausea and vomiting
 Recurrence of bleeding
 Feedings: initially clear fluids given hourly
 Gradually introduce of foods as tolerated
 Ambulatory Care
o Patient teaching
 Patient/family taught how to avoid future bleeding episodes
 Made aware of consequences of not adhering to drug therapy
 Emphasize that no drugs other than those prescribed should be taken
 No smoking or alcohol
 Need for long-term follow-up care
 Instruction if an acute hemorrhage occurs in future
For patient having blood transfusion

 If blood transfusion reaction occurs: STOP THE TRANSFUSION.
 Start IV line (0.9% NaCl)
 Place the client in Fowler’s position if with Shortness of Breath and administer O2 therapy.
 The nurse remains with the client, observing signs and symptoms and monitoring vital signs as
often as every 5 minutes.
 Notify the physician immediately.
 The nurse prepares to administer emergency drugs such as antihistamines, vasopressor,
fluids, and steroids as per physician’s order or protocol.
 Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a
result of RBC hemolysis.
 Blood container, tubing, attached label, and transfusion record are saved and returned to the
laboratory for analysis.
Anemia
-Anemia is a condition in which you lack enough healthy red blood

cells to carry adequate oxygen to your body's tissues. Having
anemia, also referred to as low hemoglobin, can make you feel
tired and weak. There are many forms of anemia, each with its
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own cause. Anemia can be temporary or long term and can range from mild to severe. In most cases,
anemia has more than one cause. It can be a warning sign of serious illness.
Type of Anemia:
 Aplastic anemia
 Iron deficiency anemia
 Sickle cell anemia
 Thalassemia
 Vitamin deficiency anemia
Morbidity/Mortality
According to the latest WHO data published in 2020 Anemia Deaths in Philippines reached
3,435 or 0.51% of total deaths. The age adjusted Death Rate is 4.91 per 100,000 of population
ranks Philippines #2 in the world.
Risk factors
These factors place you at increased risk of anemia:
 A diet lacking in certain vitamins and minerals. A diet consistently low in iron, vitamin
B-12, folate and copper increases your risk of anemia.
 Intestinal disorders. Having an intestinal disorder that affects the absorption of nutrients
in your small intestine — such as Crohn's disease and celiac disease — puts you at risk
of anemia.
 Menstruation. In general, women who haven't had menopause have a greater risk of iron
deficiency anemia than do men and postmenopausal women. Menstruation causes the
loss of red blood cells.
 Pregnancy. Being pregnant and not taking a multivitamin with folic acid and iron,
increases your risk of anemia.
 Chronic conditions. If you have cancer, kidney failure or another chronic condition, you
could be at risk of anemia of chronic disease. These conditions can lead to a shortage of
red blood cells.
Slow, chronic blood loss from an ulcer or other source within your body can deplete your
body's store of iron, leading to iron deficiency anemia.
 Family history. If your family has a history of an inherited anemia, such as sickle cell
anemia, you also might be at increased risk of the condition.
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 Other factors. A history of certain infections, blood diseases and autoimmune disorders
increases your risk of anemia. Alcoholism, exposure to toxic chemicals and the use of
some medications can affect red blood cell production and lead to anemia.
 Age. People over age 65 are at increased risk of anemia.
Signs and Symptoms
Depending on the causes of your anemia, you might have no symptoms.
Signs and symptoms, if they do occur, might include:
 Fatigue
 Weakness
 Pale or yellowish skin
 Irregular heartbeats
 Shortness of breath
 Dizziness or lightheadedness
 Chest pain
 Cold hands and feet
 Headaches
At first, anemia can be so mild that you don't notice it. But symptoms worsen as anemia worsens.
Diagnostics/ Laboratory tests
To diagnose anemia, your doctor is likely to ask you about your medical and family history, perform a
physical exam, and run the following tests:
 Complete blood count (CBC). A CBC is used to count the number of blood cells in a
sample of your blood. For anemia, your doctor will likely be interested in the levels of the
red blood cells contained in your blood (hematocrit) and the hemoglobin in your blood.
Healthy adult hematocrit values are generally between 38.3% and 48.6% for men and
35.5% and 44.9% for women. Healthy adult hemoglobin values are generally 13.2 to 16.6
grams per deciliter for men and 11.6 to 15 grams per deciliter for women. These values
may differ slightly from one medical practice to another.
Numbers might be lower for people who engage in intense physical activity, are pregnant
or of older age. Smoking and being at high altitude might increase numbers.
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 A test to determine the size and shape of your red blood cells. Some of your red
blood cells might also be examined for unusual size, shape and color.
Treatment
For some types of mild to moderate anemia, your doctor may recommend prescription supplements:
 Iron supplements can increase the iron in your body. This may help treat iron-deficiency
anemia. Iron supplements are generally not given to people who do not have iron-deficiency
anemia because too much iron can damage your organs.
 Vitamin B12 supplements or shots can help treat vitamin B12–deficiency anemia.
 Blood Transfusion- for the anemia that are caused by bleeding.
Nursing management
Nursing interventions are based on the data assessed by the nurse and on the symptoms that the
patient manifests.
To manage fatigue:
 Prioritize activities. Assist the patient in prioritizing activities and establishing balance
between activity and rest that would be acceptable to the patient.
 Exercise and physical activity. Patients with chronic anemia need to maintain some
physical activity and exercise to prevent the deconditioning that results from inactivity.
To maintain adequate nutrition:
 Diet. The nurse should encourage a healthy diet that is packed with essential nutrients.
 Alcohol intake. The nurse should inform the patient that alcohol interferes with the
utilization of essential nutrients and should advise the patient to avoid or limit his or her
intake of alcoholic beverages.
 Dietary teaching. Sessions should be individualized and involve the family members
and include cultural aspects related to food preference and preparation.
To maintain adequate perfusion:
 Blood transfusion monitoring. The nurse should monitor the patient’s vital signs and
pulse oximeter readings closely.
To promote compliance with prescribed therapy:
 Enhance compliance. The nurse should assist the patient to develop ways to
incorporate the therapeutic plan into everyday activities.
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 Medication intake. Patients receiving high-dose corticosteroids may need assistance

to obtain needed insurance coverage or to explore alternative ways to obtain these
medications.
Why did we choose this case?
Our group has chosen this case due to its relativity when it comes to prevention. It reminds us how
one’s neglect of health can introduced a couple of new complications. It also made us realized how
the marginalized people of our society suffer from health. Health is never accessible for those who
are below the society’s hierarchy. This case also taught us how Filipinos responded when it comes to
health. Neglecting small aches or pains just to prevent hospital bills can make those illnesses worst.
The WHO can never achieve the goals of good health and well-being if we can never eradicate
hunger to those who are below the society. Health is wealth; let’s make healthcare accessible to
everyone.
II. Nursing Health History
ii.a. Demographic Data

Name: Patient JJ
Age: 54
Sex: Female
Address: Tondo, Manila, City of Manila
Date & Place of Birth: 06/18/1968 & born in Mindoro
Civil Status: Widowed
Occupation: Cook
Educational Attainment: High School
ii.b. Chief Complaint
Abdominal Pain
ii.c. Confinement Details
Date of Confinement/Admission: 11/09/2022 (November 9, 2022) at 7 am

Initial Impression: Anemia Probable to UGIB; HTN 2, Acute Uncomplicated Cystitis; R/O
Intraabdominal mass.
Final Diagnosis: Peptic Ulcer Disease Secondary to UGIB going to Anemia
Attending Physician: R.R.E, M.D.
Handle Dates: November 10, 2022
ii.d. History of Present Illness
4 days prior to admission, the patient experienced epigastric and right lower abdominal pain
with a pain scale of 8/10. Accompanied with 1 episode of vomiting, tarry stools and poor
appetite.
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ii.e. Past Medical History
-Last January 2021, patient is diagnosed with peptic ulcer disease.
-Last October 2020, Patient is diagnosed with hypertension 2 with maintenance of Amlife
(Amlodipine).
-The patient’s last hospitalization was January 2021.
ii.f. Social History
Patient stated that she’s a heavy drinker and a chain smoker. She smokes and drinks
whenever she’s stressed out. She’s busy with her work therefore, she doesn’t do exercise.
When her peptic ulcer pain occurs, she did self-medication with NSAIDS like Ibuprofen.
ii.g. OB-GYNE history
MENSTRUAL HISTORY
Age at first period: 13-year-old.
Menstrual Period regular or Irregular? Regular
Duration of bleeding: 3- 5 days
Does bleeding or spotting occur between period? No
Does bleeding or spotting occur after intercourse? No
First day of last menstrual period: May 2020
Is pain associated when period? Yes, before and during menses
PREGNANCY HISTORY
YEAR PLACE OF DURATION TYPE OF COMPLICATION SEX

DELIVERY OF DELIVERY ON MOTHER
PREGNANY OR INFANT
2003 Justice 38 Weeks Normal None Female
Jose Delivery
Abad
Santos
General
Hospital
BIRTH CONTROL HISTORY
What birth control method(s) do you currently use? N/A
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Past Obstetrical/Gynecological Surgeries? None
Are you smoking or drinking alcohol? Smoker/ Heavy drinker
Any Illicit drug? None
ii.h. Family History
Without diagnosed Hypertensive

Father
complications Mother
Patient
Patien
Diagnosed with: Without
t JJ Father
JJ
- PUD diagnosed
- Hypertension 2 complications
- Anemia
Daughte
- Cystitis
r
ii.i. Environmental History
Living in a congested area. Meralco provides the electricity. Maynilad is used as a

source of water. The area is reachable by jeep and tricycle.
ii.j. Developmental History
Theory/Theorist Task Patient Description

Psychosocial (Erickson) Generativity vs. Patient is very passionate about her
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Stagnation job as a cook. She uses her job to

provide for her daughter as she
wants her to have a better life
Psychosexual (Freud) Genital Stage Patient is widowed with 1 child. In
this stage, patient's sexual desires
aren't met and is having conflicts
forming relationships after the death
of husband.
Cognitive (Piaget) Formal Operational Patient is able to say that she has
stage history of ulcer in the past which
may cause her pain
Moral (Kohlberg) Postconventional Patient has her own set of moral
Morality guidelines. As she is a roman
catholic. She vocalized that she
values human rights and decency
even if you are poor.
Spiritual (Fowler) Universalizing Stage Patient is very religious as she
always remembers to vocalize the
importance of prayer in a life. She is
an approachable person, lucid and
simple.
ii.j. Gordon’s Functional Health Pattern
Date &Time of Assessments/Interview: November 10, 2022 (10:00 PM)
NURSING
BEFORE DURING
QUESTIONS PROBLEM
CONFINEMENT CONFINEMENT
IDENTIFIED
I. HEALTH PERCEPTION AND MANAGEMENT
a. How has general health Patient stated Patient stated Activity
been? that she has that her body is Intolerance
presence of weak and needs related to
hypertension assistance for inadequate
2; taking bathroom oxygen to body
maintenance of privilege. tissue as
amlodipine. evidenced by
Patient is dizzy body
(+) Presence of due to anemia. fatigue/weakness
chronic pain
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from peptic and dizziness.

ulcer disease.
Low appetite.
b. Any colds in past year? Patient stated None Hyperthermia
When appropriate: absences that she had 2x related to
from work? fever and 3x of infection as
flu in the past evidence by
year. She had weakness and
only 1 absence dehydration.
from work.
c. Most important things you Patient stated Patient stated Knowledge
do to keep healthy? Think that she takes that she always deficit related to
these things make a herbal topical touched rosary poor health
difference to health? (Include medicines for and do rosary literacy as
family folk remedies when the relief of every 6pm for evidenced by
appropriate.) Use of abdominal fast healing. seeking
cigarettes, alcohol, drugs? pain. additional
Breast self-examination? Patient smoke information.
and drink
alcohol for the
relief of stress.
d. Accidents (home, work, None None No problem
driving)? identified
e. In past, been easy to find Yes Still the same No problem
ways to follow suggestions before identified
from physicians or nurses? confinement
f. When appropriate: what do Patient stated Patient stated Knowledge
you think caused this ill- that she has no that she now deficit related to
ness? Actions taken when knowledge has knowledge poor health
symptoms perceived? Results what caused what caused the literacy as
of action? the illness. The illness. Actions evidenced by
action taken taken when seeking
when symptoms additional
symptoms perceived are information.
perceived is calling the
taking of attention of
NSAIDS nurses/doctors.
(ibuprofen) for
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the relief of Actions resulted

pain and herbal to relief from
topical pain.
medicines.
Action results
to much severe
pain that
resulted to
upper
gastrointestina
l bleeding.
g. When appropriate: things Patient stated Patient stated No problem
important to you in your that it’s that it’s identified
health care? How can we be important to important for
most helpful? have good the pain to be
health with no relieved and
pain or any blood will be
other illnesses. normal. It will be
It will be most most helpful if
helpful if healthcare
healthcare will providers can
be accessible. be able to
explain
everything
regarding
patient’s health.
II. NUTRITIONAL AND METABOLIC PATTERN
a. Typical daily food intake? Patient stated Patient stated Imbalanced
(Describe.) Supplements she eats 1 cup she can only eat Nutrition related
(vitamins, type of snacks)? of rice in the 1 to 2 cups of to pain and
morning rice per day. anorexia as
usually with Patient still has evidenced by
canned goods no appetite due appearance of
or noodles. to UGIB. No thin muscle,
Eats less than snacks eaten weight loss and
3 times a day. and is currently flaky skin.
Snacks are having blood
usually transfusion due
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candies or to anemia.
chips. No
vitamins taken.
Low appetite.
b. Typical daily fluid intake? Patient stated Patient stated Fluid Volume
(Describe.) she only takes she only takes 2 Deficit related to
2-3 glasses of glasses of water dehydration as
water per day. per day. evidenced by
skin turgidity,
dark yellow urine
output, flaky skin
and profuse
sweating.
c. Weight loss or gain? Weight loss Patient stated Imbalanced diet
(Amount) Height loss or gain? that she is nutrition: less
(Amount) starting to turn than body
back to her requirement
usual feeding related to weight
routine loss.
d. Appetite? Patient stated Patient stated Imbalanced diet
she has low she has low nutrition: less
appetite appetite than body
requirement
related to weight
loss.
e. Food or eating: Patient stated Patient stated Imbalanced diet
Discomfort? Swallowing? Diet that she has that she has low nutrition: less
restrictions? low appetite appetite with than body
with abdominal abdominal pain. requirement
pain. No diet Is under LSLF related to weight
restrictions. diet. loss as
manifested by
abdominal pain
and low appetite.
f. Heal well or poorly? Patient stated Patient stated No problem
that she heals that she heals identified
poorly well
g. Skin problems: Lesions? Patient stated Patient stated Fluid Volume
Dryness? that her skin is that her skin is Deficit related to
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dry and flaky. dry and flaky. dehydration as

There’s There’s evidenced by dry
presence of presence of and flaky skin.
purplish purplish bruises
bruises on her on her left thigh Ineffective tissue
left thigh and and right upper perfusion related
right upper arm. to decreased
arm. hemoglobin and
hematocrit as
manifested by
purplish bruises
on left thigh and
right upper arm.
h. Dental problems? None None No problem
identified
III. ELIMINATION PATTERN
a. Bowel elimination pattern? Patient stated Patient stated Constipation
(Describe) Frequency? that she had 2x that she had 0 related to
Character? Discomfort? a week of stool dehydration as
Problem in control? bowel elimination in 3 evidenced by
Laxatives? elimination. days during hard stool and
Stool is hard confinement. discomfort of
and patient has Dulcolax stool delivery.
discomfort of (laxatives) is
stool delivery. prescribed by
No laxatives physician.
taken.
b. Urinary elimination pattern? Patient stated Patient stated Fluid Volume
(Describe.) Frequency? that her urine that her urine is Deficit related to
Problem in control? is dark yellow. dark yellow. dehydration as
Patient Patient evidenced by
frequency of frequency of dark yellow urine
urine urine and low urine
elimination is elimination is 1x output.
1x daily. No daily. No
problem of problem of
control. control.
c. Excessive perspiration? none none No problem
Odor problems? identified
20
COLLEGE OF NURSING
d. Body cavity drainage, none none No problem

suction, and so on? (Specify.) identified
IV. ACTIVITY-EXERCISE PATTERN
a. Sufficient energy for Patient stated Patient stated Impaired
desired or required activities? that she has no that she has no physical
sufficient sufficient mobility related
energy. energy. to decreased
strength as
evidenced by
less sufficient
energy to do
desired
activities.
b. Exercise pattern? Type? Patient stated Patient stated Impaired
Regularity? that she that she doesn’t physical
doesn’t exercise. Patient mobility related
exercise. is weak. to decreased
Patient is strength as
weak. evidenced by
body weakness.
c. Spare-time (leisure) Patient stated Patient stated Impaired
activities? Child: play that she only that she only physical
activities? uses phone for uses phone for mobility related
leisure. leisure. to decreased
strength as
evidenced by
body weakness.
d. Perceived ability (code for
level) for:
Feeding II II Decreased
Dressing II II Activity
Cooking N/A N/A Tolerance
Bathing II II related to
Grooming II II decreased
Shopping N/A N/A strength as
Toileting II II evidenced by
General mobility II II body weakness
Bed mobility II II and assistance
Home maintenance N/A N/A or supervision
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COLLEGE OF NURSING
for mobility.
Functional Level Codes:
Level 0: full self-care
Level I: requires use of
equipment or device
Level II: requires assistance
or supervision from another
person
Level III: requires assistance
or supervision from another
person and equipment or
device Level IV: is
dependent and does not
participate
V. SLEEP-REST PATTERN
a. Generally rested and ready Patient stated Patient stated Decreased
for daily activities after sleep? that she rested that she rested Activity
well but are well but are still Tolerance relate
still tired to do tired to do daily d to imbalance
daily activities activities between oxygen
supply and
demand as
evidenced by
verbal reports of
fatigue and
weakness.
b. Sleep onset problems? Patient stated Patient stated Disturb sleep
Aids? Dreams (nightmares)? that she can that she had pattern related to
Early awakening? easily wake up lots of excess
after nightmares consumption of
nightmares. regarding death alcohol or
She then and she just caffeine.
drinks coffee take her rosary
to relieve for the relief of
herself from stress.
stress.
c. Rest-relaxation periods? Patient stated Patient stated Activity
that she that she now Tolerance relate
usually doesn’t have lots of rest d to imbalance
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COLLEGE OF NURSING
have lots of each day. between oxygen

rest. supply and
demand as
evidenced by
verbal reports of
fatigue and
weakness.
VI. COGNITIVE – PERCEPTUAL PATTERN
a. Hearing difficulty? Hearing None None No problem
aid? identified
b. Vision? Wear glasses? None None No problem
Last checked? When last identified
changed?
c. Any change in memory None None No problem
lately? identified
d. Important decision easy or Patient stated Patient stated No problem
difficult to make? that it is easy that she can still identified
to make a make important
decision. decision easy.
e. Easiest way for you to None None No problem
learn things? Any difficulty? identified
f. Any discomfort? Pain? Patient stated Patient stated Chronic pain
When appropriate: How do she has she now has related to
you manage it? epigastric pain minimal pain in gastrointestinal
and right lower the abdomen. bleeding.
quadrant pain.
She usually
takes
Ibuprofen or
herbal
medicine for
relief of pain.
VII. SELF-PERCEPTION AND SELF-CONCEPT PATTERN
a. How describe self? Most of Patient stated Same as before Chronic Low
the time, feel good (not so she don’t feel confinement Self-Esteem relat
good) about self? good about ed to repeated
herself. expression of
worthlessness.
b. Changes in body or things Patient stated Patient stated Chronic Low
23
COLLEGE OF NURSING
you can’t do? Problem to that she can no that she still Self-Esteem relat
you? longer work needs ed to repeated
like she used assistance in expression of
to. She felt doing activities worthlessness.
worthless not such as going
being able to to the bathroom.
support her She felt
family. worthless.
c. Changes in way you feel Patient stated Patient stated Decreased
about self or body (since ill- her body that her body is Activity
ness started)? started to starting to feel Tolerance relate
become weak more stronger d to imbalance
as days goes compared to between oxygen
by while her when she supply and
abdominal pain wasn’t confined. demand as
is still evidenced by
occurring. verbal reports of
fatigue and
weakness.
d. Things frequently make None None No problem
you angry? Annoyed? identified
Fearful? Anxious?
e. Ever feel you lose hope? None None No problem
identified
VIII. ROLES-RELATIONSHIPS PATTERN
a. Live alone? Family? Family Patient J.J has Still the same No problem
structure (diagram)? a daughter and before identified
a niece confinement
currently living
with her
b. Any family problems you None None No problem
have difficulty handling (nu- identifies
clear or extended)?
c. Family or others depend on Patient stated Patient stated No problem
you for things? How that her that her family identified
managing? grandchildren now don’t
and daughter depend on her
depended on that much as
her money for they did back
24
COLLEGE OF NURSING
school, food then.

and other
personal
expenses.
d. When appropriate: How Family gets Family is feeling Alteration in
family or others feel about ill- problematic down about the communication
ness or hospitalization? knowing how patient’s current pattern related to
much situation. incapacity to cope

with crisis.
expenses it is
to have if
patient is
hospitalized.
e. When appropriate: None None No problem
Problems with children? identified
Difficulty handling?
f. Belong to social groups? Yes patient Patient stated Low Self-
Close friends? Feel lonely stated that she that she is now Esteem related
(frequency)? have lots of feeling lonely. to repeated
friends. expression of
worthlessness.
g. Things generally go well at Patient stated Patient stated No problem
work? (School?) that she is that she might identified
absent at work get no
for 4 days. customers for
the next few
days.
h. When appropriate: Income No No No problem
sufficient for needs? identified
i. Feel part of (or isolated in) No No No problem
neighborhood where living? identified
IX. SEXUALITY-REPRODUCTIVE PATTERN
a. When appropriate to age Patient stated Patient stated Impaired sexual
and situations: Sexual that she is not that she is not satisfaction
relationships satisfying? focused on focused on related to
Changes? Problems? sexual sexual absence of
relationships relationships sexual intimacy
since she is since she is and financial
widowed and widowed and worries
has a family to has a family to
25
COLLEGE OF NURSING
support. support.
b. When appropriate: Use of None None No problem
contraceptives? Problems? identified
c. Female: When Patient stated Patient stated No problem
menstruation started? Last that her first that she is now identified
menstrual period? Menstrual menstrual in menopause.
problems? Para? Gravida? period is when
she was 13
years old and
her last
menstrual
period is when
she was 52
years old. Her
menstruation
is regular and
has no
problems
during
menstruation
cycle. Patient
stated that she
had 1
pregnancy
X. COPING-STRESS TOLERANCE PATTERN
a. Any big changes in your life None Patient stated Alteration in
in the last year or two? that they now communication
Crisis? have financial pattern related to
crisis. They can incapacity to
no longer shop cope with crisis.
or do groceries
unlike before.
b. Who’s most helpful in Daughter Niece and No problem
talking things over? Available daughter identified
to you now?
c. Tense or relaxed most of Patient stated Patient stated Alteration in
the time? When tense, what that she easily that she is still communication
helps? gets tense tense especially pattern related to
most of the not knowing of incapacity to
26
COLLEGE OF NURSING
time because what will cope with crisis.

of stress from happen to her. A
work and rosary keeps
family. Going her free from
to church stress.
helps her from
stress.
d. Use any medicines, drugs, Patient stated Patient stated Deficit
alcohol? that she used that she is now knowledge
NSAIDS avoiding alcohol related cessation
(Ibuprofen) to and is currently alcohol as
relieve herself taking evidenced by
from pain. She medicines seeking
also drinks prescribed by additional
alcohol. physician. information.
e. When (if) have big Praying Praying No problem
problems (any problems) in identified
your life, how do you handle
them?
f. Most of the time is this (are Not applicable None No problem
these) way(s) successful? identified
XI. VALUES-BELIEFS PATTERN
a. Generally get things you Patient stated Patient stated Chronic Low
want from life? Important that she wants that she now Self-Esteem relat
plans for the future? her kids and only wants to be ed to repeated
family to have healthy. She expression of
good health doesn’t want to worthlessness.
and be be a burden to
successful. Her her family and
plans in the spend money in
future are to the hospitals.
her
grandchildren
graduate from
college.
b. Religion important in life? Patient stated Patient stated No problem
When appropriate: Does this that she’s a that she’s a identified
help when difficulties arise? devoted devoted
follower of God follower of God
27
COLLEGE OF NURSING
and it helps her and it helps her

ease all her ease all her
problems problems
c. When appropriate: Will None None No problem
being here interfere with any identified.
religious practices?
III. PHYSICAL EXAMINATION

Date &Time of Assessments/Interview: November 10, 2022
GENERAL APPEARANCE:
VITAL SIGNS: (BP:110/80 mmHg, HR:124 bpm, RR:23 bpm, TEMP:36.9°C, O2 SAT:97%,
Pain scale (8/10)
ATHROPOMETRIC MEASUREMENTS: (Weight: 38kgs, Height: 149cm, BMI: 17.1)
INTAKE & OUTPUT MONITORING:

I and O Monitoring Sheet
Intake
Date RM/BED# TIME IVF ORAL/NGT Total
11/09/2022 TAW 1 PM D5NR 1L Water 240 1240 mL
mL
11/10/2022 TAW 1 AM D5LR 1L Water 240 1240 mL
mL
11/10/2022 TAW 1 PM PNSS 1L Water 240 1240 mL
mL
11/10/2022 TAW 2 PM PRBC 450 mL --- 450 mL
11/11/2022 TAW 10 PM PRBC 285 mL --- 285 mL
Output
Date Urine BM DRAINAGE
11/09/2022 1x --- ---
11/10/2022 --- 1x ---

(6am-2pm)
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COLLEGE OF NURSING
11/10/2022 1x --- ---

(2pm-10pm)
11/10/2022 --- --- ---

(10pm-6am)
11/11/2022 --- --- ---
SKIN The patient has fair Present of

Methods of skin and the bruises indicate
assessment: pigmentation is an iron
equally distributed. deficiency. Poor
Inspection - Fair to tan skin No edema and skin turgor,
color. lesions. However, saggy, dry and
- No edema and any have some purplish flaky skin can
lesions bruises in left thigh indicate
- Skin pigmentation and right upper dehydration
equally distributed. arm. The skin is
saggy.
- Normal body
Palpation temperature skin
Has poor skin
promptly recoils to
turgor, dry and flaky
its normal position
skin with a
temperature of
36.9⁰C
Hair Not adequately
- Color varies distributed of
The patient has
- It has fine to coarse hair and being
wavy- short hair
texture dry and brittle
and it is color black.
- No sign of indicate an iron
It is not adequately
infestations deficiency.
distributed
- Body hair is
throughout the
uniformly distributed
scalp there have
29
COLLEGE OF NURSING
parts where hair is

- Hair is smooth to lacking. There has
touch no presence of
parasites.
Hairs are dry and

brittle upon
touching.
Nail - Nails are smooth, The nail bed raised These abnormal
non-tender, and ridges and it is thin findings in nails
firmly adherent to and curved inward, indicate an iron
the nail bed and it is brittle and deficiency
not smooth.
- A pink color should
return in less than 2
seconds after The nail bed
pressing. became pallor and

it is not return in
less than 2 seconds
after testing
NECK - The trachea should Central placement The actual

Methods of be midline, and in the midline of the findings are
assessment: there should not be neck and spaces normal.
Inspection any noticeable are equal.
Palpation enlargement of Lymph nodes are
lymph nodes or the not palpable and
thyroid gland enlarged
Symmetrical and no
visible masses. The
gland ascends
during swallowing
and there is no
presence of bruits
BREASTS - Symmetry, contour, Patient refused the No data has
and the presence of assessment in been recorded to
any lesions breast area respect the right
- Areola is round or of the patient
oval and bilaterally
30
COLLEGE OF NURSING
the same. Color

varies widely, from
light pink to dark
brown. .
- Nipples are round or

oval and everted
with no discharge.
- Non palpable lymph
nodes (<1 cm). It is
warm, with no
masses and
swelling.
THORAX & BACK - Symmetrical anterior The spine is The actual
thorax, downward vertically aligned findings are
sloping ribs, trachea and straight with no normal.
and sternum tenderness. Skin
midline, no thorax intact with uniform
deformities, masses, temperature, no
or swelling lesions and no
masses.
- No pain, Fremitus is
temperature warm symmetrical and
to touch, equal have no denser felt
bilaterally, no both sides in tactile
moisture, masses, fremitus
swelling, or
deformities, equal No pulsation,
tactile fremitus. tenderness, and
masses are present
LUNGS - Lungs are resonant Lungs are no The actual

and breath sounds retractions, findings are
vesicular without bronchovesicular normal.
adventitious sounds. breath sounds
heard over
- The external chest
mainstem bronchi.
is normal in
appearance without
lifts, heaves, or
thrills.
31
COLLEGE OF NURSING
HEART - PMI is in the mid- PMI is in the mid There is

Methods of clavicular line clavicular line and Presence of
assessment: - No murmurs are no murmurs are Tachycardia
Palpation heard heard. However,
Aucultation - the heart rate should heartrate is
be in 60-100 with 124bpm with
regular rhythm irregular rhythm
ABDOMEN - Skin color is The skin color is The actual

uniform, no lesions. equally distributed findings are
May have scar, no with no lesions scar normal.
Methods of venous and venous
assessment: engorgement, the engorgement. The
Inspection contour may be flat, color of abdomen is
rounded and flat but slightly
scaphoid. flabby and smooth.
Auscultate - There is audible The bowel sound is The actual
bowel sound and active. No bruits, no findings are
absence of arterial venous hums and normal.
bruit and friction rub. friction rubs.
Percussion - Tympany over the Tympany sound The actual

stomach and gas- was heard over findings are
filled bowel with stomach and normal
dullness sound over epigastric area.
the liver and spleen Dullness sound
and full bladder. over liver and full
- bladder
- No tenderness, Positive tenderness Tenderness and
Palpation relaxed abdomen and tightness of tightness of

with smooth, abdomen upon abdomen
consistent tension. palpation especially indicates a pain
- Liver border, spleen in right lower and underlying
border, and bladder quadrant. The liver inflammation.
are not palpable. and spleen are not
palpable.
EXTREMITIES - Extremities are Upper and Lower Muscle strength
atraumatic in There have no reduced and
32
COLLEGE OF NURSING
Upper and Lower appearance without tenderness and weakened

tenderness or lesion seen upon indicates low
deformity. inspection and no oxygen in the
Extremities are tenderness upon blood that
without swelling or palpation. However, reaches the
erythema. Full range the muscles body’s tissue.
of motion is noted to strength is reduced
all joints. Muscle and weakened
strength is 5/5 bilaterally.
bilaterally
LYMPH NODES - No abnormal Lymph nodes The actual
Neck enlargement of are not enlarged findings are
Axillary lymph nodes and it and painful normal.
Epitrochlear is not painful during upon palpation.
Superficial Inguinal palpation.
(horizontal and
vertical)
GYNECOLOGIC - Shaped liked an Patient refused the No data has
EXAM (FEMALE) inverse triangle, no assessment in been recorded to
External Genitalia nits or lice. private areas. respect the right
Inspection of Cervix - Labia majora and of the patient.
and Vagina minora must be
Bimanual Exam symmetrical with
Rectovaginal Exam smooth wrinkled,
Inspect anus unbroken, slightly
Stool for Occult pigmented skin
Blood surface. No purulent
discharge
- No lesions, swelling,
rash or redness.
- Smooth and dark
pink to brown.
- Anal sphincter tone
is strong
- Cervix is glistening
pink
IV. ANATOMY AND PHYSIOLOGY

33
COLLEGE OF NURSING
Circulatory System
o Function is to move blood throughout the body. This blood circulation keeps organs, muscles
and tissues healthy and working to keep you alive.
o Heart is the only circulatory system organ. Blood goes from the heart to the lungs to get
oxygen. The lungs are part of the respiratory system. The heart then pumps oxygenated blood
through arteries to the rest of the body.
- High blood pressure: Arteries work hard to circulate blood throughout the body. When the
pressure (force of blood against the blood vessel walls) gets too high, you develop high blood
pressure. When the arteries become less elastic (stretchy), less blood and oxygen reaches
organs like the heart. High blood pressure puts at risk for cardiovascular disease, heart attacks
and strokes. Blood made up of red and white blood cells, plasma and platelets. Blood
circulates through heart.
34
COLLEGE OF NURSING
Gastrointestinal System
o The gastrointestinal tract consists of the oral cavity, pharynx, esophagus, stomach, small
intestine, and large intestine. The accessory organs are the teeth, tongue, and glandular
organs such as salivary glands, liver, gallbladder, and pancreas.
o Gallbladder-It stores and concentrates bile from the liver, and then releases it into the
duodenum in the small intestine to help absorb and digest fats.
Upper Abdomen
Right Upper Quadrant- The right upper quadrant primarily contains the liver, gallbladder, and biliary
system. Portions of the right kidney, small intestine, and ascending/transverse colon can also extend
into the RUQ.
Epigastric- The epigastric region contains the stomach (as well as the lower part of the esophagus
and first part of the duodenum/small intestine) and part of the pancreas. The liver and biliary system
can also extend into the epigastric region. The descending aorta travels posteriorly through the
epigastric region as well.
Lower Abdomen
Right Lower Quadrant- The main structures in the right lower quadrant for both males and females
are the appendix and cecum. The cecum is the junction of the small intestine and large intestine. It is
35
COLLEGE OF NURSING
also important to note that the right ovary and part of the fallopian tube can extend into the right lower
quadrant in females as well.
Suprapubic- The primary structure in the suprapubic region for both males and females is the
bladder. The uterus also resides in this location in females.
Excretory system
o The function of the excretory system to remove wastes from the body.
o Urinary bladder- sac-like structure with muscular walls that holds urine until it is expelled from
the body during micturition. The bladder receives urine through two ureters – one from each
kidney –that enter through openings called ureteric orifices. These orifices are located at the
convex fundus of the organ. Urine exits the bladder through the urethra.
o Urethra- The female urethra is a relatively simple tubular structure that has the sole purpose
of conducting urine from the bladder to the outside of the body.
V. PATHOPHYSIOLOGY: Book & Client Based Book Based

A. Book based
36
COLLEGE OF NURSING
B. Client Based
37
COLLEGE OF NURSING
VI. LABORATORY/DIAGNOSTIC
Laboratory Results/Findings
Laboratory Type & Normal Result Remarks Interpretation
Date Range Values
Hemoglobin: 62 g/L Low Hemoglobin,
125 – 165 g/L hematocrit,
and RBC are
Hematocrit: 0.18 Low below normal
0.37 – 0.42 range indicate
anemia
WBC: 5 – 10 x 12.0 x 109 /L High
109 /L WBC are
above normal
RBC: 4.2– 5.4 2.14 x 1012/L Low range indicate
x 1012/L an infection
MCV: 75.0 – 85.7 fL Normal

38
COLLEGE OF NURSING
90.0 fL
MCV, MCH,
MCH: 25.0 – 28.8 pg Normal MCHC and
32.0 pg Platelet are
Complete Blood within normal
Count MCHC: 32.0 – 33.7 g/dL Normal range no
November 9, 2022 36.0 g/dL remarkable
findings.
Platelet: 150 – 258 x 109 /L Normal
400 x 109 /L
Differential Count:
Neutrophil: 0.89 High

0.36 – 0.66
Neutrophils are
Lymphocyte: 0.11 Low above normal
0.22 – 0.40 range while
lymphocytes
Monocyte are below
0.04 – 0.08 normal range
Eosinophil: indicate a
0.01 – 0.04 bacterial
infection.
Basophil: 0.0 –
0.01
Sodium: 135 – 149 mmol/L Slightly High

148 mmol/L
Potassium: 3.5 3.3 mmol/L Slightly low The

Electrolyte Test – 5.3 mmol/L electrolytes
November 9, 2022 imbalance
Chloride: 98 – 112.6 mmol/L High indicates a
106 mmol/L dehydration.
Urea is above
normal range
39
COLLEGE OF NURSING
Urea: indicate
2.14 – 7.14 7.70 mmol/L High dehydration
mmol/L and urinary
Kidney Test tract
November 9, 2022 obstruction.
Creatinine 92.4 µmol/l High
PAP: 49.00 – Creatinine
90.00 µmol/l PAP is slightly
elevated may
indicate a
dehydration.
Ventricular Ventricular High
Rate: 60 -100 Rate: 106
bpm bpm
QRS Duration: QRS Normal

60 – 120 ms Duration: 76 Sinus
ms tachycardia
Left ventricular
Electrocardiogram QT/QTc: 360 – QT/QTc: Normal hypertrophy
November 9, 2022 460 ms 312/414 ms with
repolarization
PR Interval: PR Interval: Normal abnormality
120 – 200 ms 124 ms Abnormal ECG
P Duration: 80 P Duration: Low

– 120 ms 54 ms
RR Interval: RR Interval Normal

600 – 1200 ms 566 ms
P-R-T axes: - P-R-T axes: High

30 - 90 64 66 265
Physical Examination:
Color: Yellow Dark Abnormal The color of
(light/pale to Yellow urine indicates
dark/deep a mild
40
COLLEGE OF NURSING
amber) dehydration
Transparency: Slightly turbid

Clear or Slightly Turbid Abnormal indicate an
transparent infection on the
body.
Chemical Examination:
The protein
Protein: Negative Normal has no
Trace/None remarkable
Urinalysis findings.
November 9, 2022
Sugar: +4 Abnormal Having sugar
Negative in the urine
indicate
hyperglycemia
Specific 1.015 Normal The specific

gravity: 1.005- gravity and pH
1.025 have no
remarkable
findings.
pH: 4.5-8 6.0 Normal
Microscopic Examination:
WBCs: ≤2-
5 /hpf 15 – 20/hpf High
The above
RBCs: ≤2/hpf 15 – 20/hpf High normal range
of WBCs,
Epithelial cells: +2 Abnormal RBCs, and
None abnormal
findings in
epithelial cells
and bacteria
41
COLLEGE OF NURSING
indicate urinary
tract infection.
Bacteria: +2 Abnormal
None
Amorphous +1 Abnormal The

Materials: amorphous
None material
indicates
presence of
large quantities
of uric acid.
Mucus +2 Abnormal The abnormal

Threads: None findings in
mucus threads
indicate urinary
tract infection.
Others: 1-3/LPF High The hyaline

Hyaline Cast cast is above
0-2/LPF normal range
indicate
decreased
urine flow.
Laboratory Results/Findings
Laboratory Normal Range Result Remarks Interpretation

Type & Date Values
SARS-CoV-2
(causative
agent of
COVID-19)
viral antigen
detected
Indicate a
negative for
42
COLLEGE OF NURSING
Rapid Antigen SARS-CoV-2 SARS-CoV-2

Test (causative Rapid Antigen
SARS-CoV-2 Negative
agent of (causative
November 9, (causative
COVID-19) agent of
2022 agent of
viral antigen COVID-19)
COVID-19)
not detected.
viral antigen
not detected
Invalid due to
specimen
quality
SARS-CoV-2
(causative
agent of
COVID-19)
viral RNA
detected.
Indicate a
negative for
SARS-CoV-2
SARS-CoV-2 SARS-CoV-2
(causative
RTPCR Test Negative (causative
(causative agent of
November 9, agent of agent of
COVID-19)
2022 COVID -19) COVID-19)
viral RNA not
viral RNA not detected
detected.
Invalid due to
specimen
quality
Laboratory for Blood Transfusion
Laboratory Possible Blood Result Interpretation

43
COLLEGE OF NURSING
Type & Date Type
A Rh Positive/ A Rh
Negative
B Rh Positive/ B Rh
Negative
Blood Typing B Rh
AB Rh Positive/ AB
POSITIVE
November 9, Rh Negative The patient blood is
2022 B+.
O Rh Positive/ O Rh
Negative
Patient Blood Type:

B Rh POSITIVE
Blood Bank The donor and the
Crossmatching Donor’s Blood Type: patient blood type are
B Rh POSITIVE the same, thus, the
November 10,
Compatibl blood transfusion can
2022 Packed RBC
e proceed. 2 PRBC
Volume: 1 unit was already
transfused.
VII. COURSE IN THE WARD
44
COLLEGE OF NURSING
Date/Time Doctor’s Order Nursing Rationale

Responsibilities
11/9/22 Please admit to Admitting the For further

TAW under the patient as monitoring,
7am ordered. management,
service of Dr.
Roxanne R. and
Escalada. Assisting the evaluation of
patient to the patient’s condition
doctor’s ordered
room.
11/9/22 Vital signs q 4 hour Obtain initial vital To monitor
signs and record it deviation
2pm from normal
accordingly.
values and
to have
baseline
data.
Secure consent for Preparing and filling To have ethical
admission and out necessary considerations
management documents. and to protect
patient’s freedom
to make.
healthcare
decisions.
LSLF diet Informed and To maintain

explained to patient’s nutritional
patient and status since
guardian the reducing sodium
importance of and fat intake
ordered diet. lowers blood
pressure.
Informed the
dietary department
regarding the diet
plan of the patient.
Therapeutics:
IVF: PNSS1L x To ensure the order
8hrs Verify the doctor’s is accurate and the
order and regulate IVF are
IVF TR: PNSS1L the right drop appropriately given.
x 12hr x 2 cycles factors, put on IV
to KVO during BT tag, and record it. For electrolyte
replacement and to
prevent blood clot.
Medications: Observed the 10R’s To ensure the
of drug medicines are
administration and appropriately given.
administer the
medications as
ordered by the
physician.
45
COLLEGE OF NURSING
Decrease the
amount of acid in
Omeprazole 40mg
the stomach
TIV q 12hrs
Speed the healing

Rebamipide 100mg
of the ulcer.
PO TID
Relieves the pain of

HNBB 1amp TIV q
stomach and bowel
8hrs
cramps.
Laboratory Exam Explain to patient Patient be aware to

the laboratory procedures that will
exams and filled be done.
out necessary
request form.
To evaluate if
RAT patient has COVID
or not.
To detect heart
12 Led ECG problem
Refer to the For further

laboratory evaluation of
department about condition.
the diagnostic
exams.
Results attached to For the record and

the patient’s chart. baseline data.
Urinary To evaluate
alterations in
examination
urine
components
46
COLLEGE OF NURSING
CBC To evaluate
alterations in blood
components
ABO Typing
To determine your
blood group.
Na, Cl, K To measures if

there’s an
electrolyte
imbalance in the
body.
To reveals
important
Serum Creatine information about
and BUN Test how well the
kidneys are
working.
Blood Bank Cross To examine the

Matching compatibility
between donor and
recipient blood
groups.
Treatment Monitor vital signs Some life-
for the first 15mins threatening
Secure and
and watch out for reactions may
transfuse 3 units of
any BT reactions occur after the
PRBC properly
infusion.
typed and
screened. Replace the blood
loss because of the
bleeding.
Check I and O q Monitored patient’s For monitoring of
shift I & O every shift, fluid status.
recorded and report
any deviation.
Inform GI service Referred and For further
about this endorsed assessment and
admission and refer accordingly for treatment.
continuous of care.
11/9/22 Medicine: Monitored vital To have baseline
signs and record it. data.
10 pm
47
COLLEGE OF NURSING
Check the doctor’s To ensure that the

order and give the order is accurate
medications and drugs are
appropriately given.
Empty the bowels

before other
Dulcolax intestinal medical
suppository at 5am procedure
prior to procedure
To treat bacterial
infections
Ceftriaxone 1g TIV
OD
11/10/22 Medications for Run the BT with To prevent blood
BT: PNSS clot
1:30 pm
Check the vital Some life-

signs for first threatening
15mins and reactions may
observe patient for occur after the
any adverse infusion.
reaction.
Reduce allergic
Diphenhydramine Give the medicine reactions to blood
1amp TIV prior to BT. products.
Paracetamol Reduce the

300mg incidence of fever.
Transfuse 1unit Replace blood loss

PRBC for 4hrs because of
bleeding
11/10/22 Monitored vital To have baseline
signs. data.
6:00pm
Check the doctor’s To ensure that the

order and give the order is accurate,
medications. and drugs are
appropriately given.
48
COLLEGE OF NURSING
Paracetamol
600mg PO
Reduce the pain
Ceftriaxone 1g TIV
To treat bacterial
now then OD infection.
IVF to follow Regulated the right. To ensure the
D5LR1L by 12hr ordered is
drop factors, put.
accurately given.
on IV tag and
record it.
For daily
maintenance of
body nutrition and
rehydration.
11/10/22 Run the BT with To prevent blood
PNSS clot
10:00 pm
(First Duty and
Last Duty)
Some life-
threatening
Transfuse 2nd unit reactions may
PRBC for 4hrs occur after the
infusion.
Check the vital

signs for first
15mins and
Reduce allergic
observe patient for
reaction and fever.
any adverse
reaction.
Give the medicine Replace blood loss

prior to BT. because of
bleeding
49
COLLEGE OF NURSING
VIII. DRUG STUDY

Date & Time of Administration: November 9, 2022 at 12 pm
DRUG NAME MECHANISM INDICATION CONTRAINDICATION ADVERSE NURSING
OF ACTION EFFECT CONSIDERATION
Generic Name: Inhibits the Buscopan Contraindicated with Some -Raise side rails
Hyoscine N- smooth helps your Patient who have a adverse as a precaution
butylbromide muscle walls digestive history of effects because some
(HnBB) muscarinic tract and hypersensitivity to include: patients become
receptors. bladder hyoscine-N- temporarily
This means relax, which butylbromide or any dry mouth disoriented and
Brand Name: that it lessens reduces other product some become
Buscopan spasms and cramping in ingredient. constipation drowsy because
contractions your of the adverse
Drug by preventing stomach and Also contraindicated blurred effect of the drug.
Classification: the action of period pain. with patients who vision
Antispasmodic acetylcholine It have: -Do not
Anticholinergic on receptors accomplishe dizziness administer if the
located inside s this by heart failure client has
Route: the smooth lessening coronary heart tachycardia, abdominal muscle
Intravenously muscle of the the muscle disease, cardiac weakness.
gastrointestin contractions arrhythmia, or hypotension
Dosage: al and urinary that produce hypertension -Overdose may
20mg in 1ml tract. waves in the anaphylaxis cause curare-like
(solution) walls of the effects, such as
bladder, bradypnea respiratory
Frequency: intestine, disturbances so
PRN (as and keep emergency
needed) or as stomach. equipment
prescribed by Buscopan available.
the physician. helps
manage
period
discomfort
and stomach
cramps but
does not
completely
eliminate
them.
50
COLLEGE OF NURSING
Date & Time of Administration: November 9, 2022, at 8:45 pm
MECHANISM ADVERSE NURSING

DRUG NAME INDICATION CONTRAINDICATION
OF ACTION EFFECTS CONSIDERATION
Generic Name: Omeprazole, Used to treat Omeprazole is Common in GI symptoms
Omeprazole a proton indigestion, contraindicated in omeprazole (such as
pump heartburn, patients who have a adverse heartburn,
Brand Name: inhibitor, and history of effects: gastritis, and so
Prilosec prevents the disorders hypersensitivity to the Headache on) to assess the
production of where there medication or any of Nausea efficacy of
Drug stomach acid is too much the dosage form's Diarrhea pharmacological
Classification: by acid in the active ingredients. treatment.
abdominal
Proton Pump permanently stomach. discomfort • Assess
Inhibitor impeding the Constipation dizziness that
hydrogen/pot Farting might affect gait,
Route: assium (flatulence) balance, and other
Intravenously adenosine Dizziness functional
triphosphatas Itching and activities. Report
Dosage: e enzyme rash may balance problems
occur
40 mg system, or and functional
"proton limitations to the
pump," of the physician and
Frequency: gastric caution the patient
q12 hours parietal cell. and
family/caregivers
to guard against
falls and trauma.
Always put the
side rails up.
• Monitor
other CNS side
effects
(drowsiness,
fatigue, weakness,
headache), and
report severe or
prolonged effects.
• Monitor any
chest pain and
attempt to
determine if pain is
51
COLLEGE OF NURSING
drug induced or
caused by
cardiovascular
dysfunction

Generic By boosting - Patients with a history The common -Check for potential
Name: the Rebamipide of hypersensitivity to side-effects restrictions and
Rebamipide expression of is a any ingredient of this include: warnings,
epidermal gastroprotect drug. including: any
Brand Name: growth factor ive drug that Constipation history of antacid
Mucosta (EGF) and is commonly bloating, allergy to prevent
EGF used in diarrhea, hypersensitivity
Drug receptors, combination nausea reactions; renal
Classification: rabamipide with other vomiting. dysfunction, which
Antacids, aids in complement could affect the
Antireflux replacing lost ary drug's excretion;
Agents & tissue. These medicines to electrolyte
Antiulcerants EGFs treat gastritis disturbances,
promote and protect which could be
Route: circulation, the gastric made worse by the
PO (Orally) enhanced mucosa drug's effects; and
granulation (such as the current status
Dosage: tissue proton pump of pregnancy or
100 mg formation, inhibitors). lactation due to
52
COLLEGE OF NURSING
and tissue - Also, a potential effects on

Frequency: regeneration treatment of the fetus or
TID (three of ulcer acute and newborn.
times a day) healing. acutely
exacerbating - Conduct a
cases of physical
chronic examination to
gastritis establish baseline
includes the data prior to
treatment of starting therapy,
stomach assess the efficacy
mucosal of the therapy, and
lesions look for any
(erosions, potential negative
bleeding, effects related to
redness, and the drug.
edema) To guarantee GI
stomach motility, examine
sores. the belly and listen
for bowel noises.
To identify potential
issues with
hydration and
absorption, assess
the health of the
mucous
membranes.
-Monitor laboratory
test results,
including serum
electrolyte levels
and renal function
tests, to monitor for
adverse effects of
the drug and
potential alterations
in excretion that
may necessitate
53
COLLEGE OF NURSING
dose adjustment.
Date & Time Given: November 9, 2022, at 10 pm

Generic Bactericidal: Antibiotic Contraindicated with CNS: -Watch for
Name: Inhibits that is used allergy to Headache, seizures; notify
Ceftriaxone synthesis of to cephalosporins or dizziness, physician
bacterial cell treat many penicillin. Use lethargy, immediately if
Brand Name: wall causing kinds of cautiously with renal seizures patient develops or
Rocephin cell death. bacterial failure. (high doses) increases seizure
infections, activity.
Drug including GI: Nausea,
Classification: severe or vomiting, - Monitor adverse
Cephalosporin life- diarrhea, effect including
antibiotics threatening anorexia, diarrhea,
forms such pseudomem abdominal pain,
Route: as E. coli, H. branous fever, pus or
Intravenously pylori, colitis mucus in stools,
pneumonia, and other severe
Dosage: or LOCAL: or prolonged GI
1g/50ml meningitis. pain, problems (nausea,
inflammation vomiting,
Frequency: of IV Site heartburn). Notify
OD (Once a physician or
day) nursing staff
immediately of
these signs.
- Monitor signs of
allergic reactions
and anaphylaxis,
including
pulmonary
symptoms
(tightness in the
throat and chest,
wheezing, cough
dyspnea) or skin
54
COLLEGE OF NURSING
reactions (rash,
pruritus, urticaria).
Notify physician or
nursing staff
immediately if
these reactions
occur.
- Monitor injection
site for pain,
swelling, and
irritation. Report
prolonged or
excessive injection
site reactions to
the physician.

OF ACTION EFFECT CONSIDERATIO
N
Generic Name: Acetaminophen Used to Contraindications to Generally, -Assess for the
Paracetamol blocks pain by relieve mild- using acetaminophen side effects contraindication.
inhibiting the to-moderate include hypersensitivity to
Brand Name: synthesis of pain and to acetaminophen, acetaminop -Routinely
Tylenol prostaglandin fever. active alcoholism, hen monitor the
(Prostaglandins hepatic disease, and (paracetam effectiveness of
Drug are made at all conditions of which ol) skin acetaminophen
Classification: sites of tissue increase the risk of rashes and by assessing pain
Acetaminophen; damage or hepatotoxicity. other levels.
Non-Opioids infection, allergic
Analgesics where they reactions -Assess for
(Pain reliever) cause occur alcohol usage.
and antipyretics inflammation, occasionally
(fever reducers). pain and fever . -Assess for
as part of the clinical
Route: healing improvement and
PO (Orally) process) in the relief of pain.
central nervous
55
COLLEGE OF NURSING
Dosage: system, leading -Advise not to

300 mg to its analgesic take for a long
and antipyretic period of time.
Frequency: effects.
TID (three times
a day) or as
ordered
Date & Time Given: November 10, 2022, at 5:00 am

Generic In the colon, -Dulcolax is  Hypersensitivity - -Monitor frequency
Name: bisacodyl used to treat to the Abdominal and character of
Bisacodyl directly constipation components of cramps stool.
stimulates or to empty the drug -nausea
Brand Name: parasympath the bowels . -diarrhea -Monitor closely
Dulcolax etic neurons, before -rectal the occurrence of
causing surgery, burning the adverse effect.
Drug smooth colonoscopy, -
Classification muscle to x-rays, or hypokalem -Swallow the tablet
: contract or other ia (chronic whole and do not
Laxatives, generate intestinal use) crush or chew.
Stimulant peristalsis. medical -muscle
procedure. weakness
Route: Dulcolax (chronic
PO (Orally) tablets use)
generally
Dosage: produce a
5mg/tablet bowel
56
COLLEGE OF NURSING
movement in
Frequency: 6 to 12 hours.
BID (Two
times a day)
DRUG NAME MECHANISM INDICATION CONTRAINDI ADVERSE NURSING

OF ACTION CATION EFFECT CONSIDERATION
Generic Name: Diphenhydra Used to Patients with  Constipation -Monitor patient
Diphenhydramine mine acts as relieve red, antihistamine  blurred response, and
Hydrochloride an inverse irritated, allergies should vision arrange for
agonist at the itchy, watery not take this  memory adjustment of
Brand Name: H1 receptor, eyes; medication. problems dosage to lowest
Benadryl thereby sneezing;  anxiety possible effective
reversing and runny  Hypotension dose
Drug effects of nose caused  Fatigue
Classification: histamine on by high  Dizziness/ -Give with food if
Antihistamine capillaries, fever. Drowsiness GI upset occurs -
reducing For allergies, instruct to avoid
Route: allergic and the alcohol to avoid
Intravenously reaction common serious sedation
symptoms. cold.
Dosage: -Educate patient on
1 ampule its common and
serious adverse
57
COLLEGE OF NURSING
Frequency: effects
Timing/ as
ordered -Instruct to report if
there is DOB,
hallucinations,
tremors, loss of
coordination,
bleeding or
bruising, ;visual
disturbances and
cardiac
arrhythmias.
IV Fluids:
1. PNSS (0.9% Sodium Chloride Solution) – Isotonic Solution
 Normal Saline is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment.
 It contains no antimicrobial agents.
 It contains 154 mEq/L Sodium and Chloride.
 Monitor the IV Site
2. Lactated Ringer's in 5% Dextrose – Hypertonic Solution
 Administer through IV pump and closely monitor for circulatory overload.

 Don’t give to patient with impaired heart and kidney function.
IX. NURSING CARE PLANS

NURSING PROBLEM PRIORITY LIST
A. ACTUAL
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Chronic Pain STG: Independent:

related to
“Sobrang sakit After 15-30 Conducting and For the Goal is met.
abdominal
nang tiyan ko mins. of documenting a development of After 2 days
pain as
apat na araw nursing comprehensive the individualized of nursing
evidenced by
na,” as interventions, pain assessment, pain interventions,
pain in the
verbalized by patient will using appropriate management patient was
epigastric;
patient JJ. be able to pain assessment plan. able to
with a pain
verbalize tools. verbalize
scale of 8/10.
gradual relief relief of pain
Objective: from pain; and
Advising to avoid
58
COLLEGE OF NURSING
P- Used herbal from 8/10 to drinking coffee, To prevent discomfort.

topical oil to pain scale of tea, colas, and irritation of GI
Pain scale of
relieve pain. 6/10. alcohol. tract.
5/10.
Q- LTG:
burning/scaldin
After 2 Encourage To provide
g pain Patient has
weeks of verbalization of necessary
increased
R- Epigastric nursing pain or any interventions to
knowledge of
interventions, discomforts. lessen pain if it
S-Pain scale- preventive
the patient occurs.
8/10 measures
will be able
and
T- 4 days of to have relief Encourage the
use of treatment
abdominal pain from pain. Nonpharmacologi
nonpharmacologic modalities.
before Pain scale al pain relief cal relaxation
measures:
admission to will be techniques will
-Acupressure
hospital. ranging from -Biofeedback decrease the
-Distraction
3/10 to 2/10. production of
-Guided imagery
-Massage gastric acid,
Vital Signs: -Music therapy
which in turn will
-HR- 124 bpm Patient will reduce pain.
also be able Instruct the client
(tachycardia) These
to avoid NSAIDs
to increase such as aspirin.
-RR- 23 medications may
knowledge of
(tachypnea) cause irritation of
preventive
the gastric
-(+) facial measures
mucosa.
grimace Dependent:
and
treatment -Administer
- (+) agitated
modalities. antibiotic -For further
behavior
medications as treatment of
-Elevated WBC
prescribed by upper
(Neutrophil: 89
physician. gastrointestinal
and
bleeding and to
Lymphocyte:
prevent infection.
0.11)
-(+) dizziness -Administer

-For relief of pain.
-(+) tenderness analgesic as
and tightness of prescribed by
abdomen upon physician.
palpation Collaborative:
59
COLLEGE OF NURSING
- (+) guarding -Laboratory tests -For further

behaviour evaluation
-minimal
ambulation and
needs
assistance
-diversional
activity by using
phone to divert
pain.
Subjective: Ineffective Short Term Independent: Short Term

tissue Goal: Goal:
“Nahihilo at
perfusion
nanghihina After 1-2 hours The goal was
related to -Monitor and -To have a
ako” as of nursing met, after 1
decreased record V/S baseline data.
verbalized intervention, the hour of nursing
hemoglobin
by the patient will intervention,
and
patient. report gradual -Provide quiet -To promote the patient
hematocrit
relief of and comfortable adequate and report gradual
secondary to
dizziness and environment. peaceful rest. relief of
Objective: Upper GI
fatigue. dizziness and
bleed as
-Low fatigue (hindi
evidenced
Hematocrit -Maintain patient - The heart and na ako
by pallor, Long term
(0.18) on bed rest. other organs nahihilo pero
fatigue, Goal: require less nanghihina
-Low dizziness,
After a week of oxygen when padin ako as
Hemoglobin purplish
nursing there is restricted verbalized by
(62) bruises on
intervention, the activity. the patient.)
left thigh and
-Pallor patient's CBC
right upper Long term
-Fatigue will be Goal:
arm, -Put side rails -To provide
normalized,
excessive safety and avoid
ranging
60
COLLEGE OF NURSING
-Dizziness hair loss and (Hematocrit up. the occurrence of The goal was
being dry (0.37), fall and injury. met, after a
-Purplish
and brittle Hemoglobin week of
bruises on
with (125-165)), skin nursing
left thigh
respiratory will be pinkish -Cooperation and intervention,
and right -When PR and
rate of 23 in color understanding the patient's
upper arm. RR becomes
bpm and (absence of are not impaired CBC was in
normal render
-Excessive pulse rate of pallor), there is if there is no the normal
health teachings
hair loss 124 bpm no excessive stress. To range
regarding deep
(dry and hair loss, no support the (Hematocrit
breathing
brittle) notices of patient's comfort, (0.37),
exercises and
fatigue or breathing pattern Hemoglobin
Vital signs comfort
dizziness as and lung (128)), skin
of: measures.
indicated by the expansion. was pinkish
BP- 110/80
patient, bruises (absence of
Temp.- 36.9 were yellow in pallor), there is
degree color (signifying no excessive
Celsius that they will -To increase the hair loss, no
- Promote the capacity of the
soon be fully notices of
RR- 23 bpm
consumption of RBC to carry
healed), and fatigue or
PR- 124 foods rich in iron oxygen
RR (ranging dizziness as
bpm and vitamin C. throughout the
from 12 to 20 indicated by
O2 Sat. – bpm) and PR body. the patient,
97% (ranging 60-100 bruises were
bpm) were both yellow in color
normal. (signifying that
they will soon
be fully
healed), and
Dependent: -To maintain RR (ranging
circulating 18 bpm) and
-Administer IV
volume to PR (ranging
fluids as ordered.
maximize tissue 92 bpm) were
perfusion. both normal.
-Serve as
prophylaxis
against severe
-Administer
allergic reaction
diphenhydramine
cause by blood
61
COLLEGE OF NURSING
as needed and transfusion

as instructed by
the physician.
-To increase
Collaborative:
number of
-Administer oxygen carrying
packed RBC as capacity.
ordered by the
expert.
Subjective: Deficient fluid STG: Independent STG:

volume related
“matigas ang tae ko” After 8 1. Monitor 1.To have a After 8
to
as verbalized by the hours of Vital signs baseline and hours of
Gastrointestinal
patient nursing every 4 hours identify nursing
bleeding as
intervention, clinical intervention,
Objective: evidenced by:
the patient deterioration the goal
- Pallor will have and other was met.
- Poor skin stable vital medical Patient
- presence of
turgor signs and problems have
melena
- Dry and improved improved
flaky skin - Poor skin skin turgor. vital signs
- Hair is dry turgor 2. measure and skin
2. Assess
and brittle weight, turgor.
- dry and flaky nutritional
- Dry mouth LTG: intake and
skin status
output and
After a
- hard stool other LTG:
Vital Signs: week of
-Hair is dry and variables
nursing After a
HR:124 bpm brittle such as
intervention, week -of
vomiting as
RR: 23 bpm the patient’s nursing
this may
laboratory intervention
62
COLLEGE OF NURSING
BP:110/80 mmHg values will have an the goal

be in adverse was met
O2 Sat: 97%
normal effect on
Laboratory Findings range. fluid intake
Vital Signs:
Sodium: Vital Signs:
HR:88 bpm
149 mmol/L HR:110 3. Encourage 3. to improve
bpm patient to stay electrolyte RR: 18 bpm
Potassium:
hydrated imbalance
RR: 17 bpm BP:110/80
3.3 mmol/L
mmHg
Chloride: Laboratory
results: 4. Maintain 4. Activity O2 Sat:
112.6 mmol/L bed rest and 97%
may
Sodium:
provide increase
132.2
schedule for intra-
mmol/L Laboratory
undisturbed abdominal results:
Potassium: rest period pressure
6.2 mmol/L Hgb:130g/L
which can
Chloride: trigger Hct:0.39
112.6 further
RBC:4.7 x
CBC: bleeding
mmol/L 1012/L
- Hemoglobin CBC: Dependent
Sodium:
62g/L
Hemoglobin 1. Administer
- Hematocrit 136.2
- 62g/L electrolyte
0.18 1. to improve mmol/L
Hematocrit replacement
- WBC: 12.0 electrolyte
as ordered Potassium:
0.18 imbalance
- RBC:
WBC:12.0 3.62
2.14 x 1012/L
RBC: mmol/L
2.
2.14 x1012/L
Administering Chloride:
packed RBC 103 mmol/L

and monitor To maintain
Hemoglobin
for 15 minutes fluid volume
125g/L
for any and increase
Hematocrit
adverse number of
0.38
reactions. cells carrying
Collaborative oxygen
1. Evaluate
lab results
63
COLLEGE OF NURSING
(Hb, Hct, and Aids in

RBC count) establishing
blood
replacement
needs and to
monitor its
effectiveness
NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Activity SHORT INDEPENDENT SHORT
intolerance
“Nitong mga TERM - Monitor the vital - Serve as TERM:
related to
nakalipas na inadequate After 8hrs of signs and record it baseline.
araw mabilis oxygen to After 8 hours
akong nursing accordingly. of nursing
body tissue
mapagod at as interventions, interventions
halos di ko evidenced the goal was
magawa mga the patient - Side rails up - For the safety. met.
by body
gusto kong weakness, can
- The patient
gawin, kaya fatigue,
demonstrate - Promote a calm moved slowly
lagi akong dizziness,
pale skin - A gradual environment and - For relaxation. side to side
nakahiga lang,
and demonstrated
as verbalized increase adequate rest.
conjunctiva, an increase
by the patient.”
tachycardia, activity in activity
OBJECTIVE: tachypnea, tolerance.
tolerance by - Position the patient
hypotension
- Body - The pulse
and moving on in to comfortable - Avoid the bed
weakness decreased rate of the
bed slowly position and slowly sore and patient is
Hgb, Hct
- Fatigue and RBC. side to side. while monitoring the promotes decreased by
90bpm.
dizziness. comfort.
- Dizziness - The
- Relieve in
respiratory
- Pale skin and tachycardia - Recommend an rate
& tachypnea assistance in ADLs - Alleviates strain decreased by
64
COLLEGE OF NURSING
conjunctiva and ambulation w/ on respiratory 19bpm.

- Display rest rest period allowing systems. Self- - Rest
Vital Signs:
comfortably client to be an active esteem is comfortably
- HR: 124 bpm without any
without participant as much enhanced when follow up
- RR: 23 bpm distraction. as possible. client does some complain.
things for self.
Laboratory
LONG - Plan an activity
Result Long Term:
TERM progression and - Promotes
Complete After a week increase activity gradual return to After a week
of nursing
Blood Count of nursing levels, as tolerated. a more normal interventions,
interventions, activity level and the goal was
Hemoglobin:
met.
the patient improved muscle
62g/L
can able to tone. - Patient can
Hematocrit: tolerate minor
- Act - Instruct client to exercises
0.18 such as
tolerance in stop current activity - Stress may
walking and
RBC: 2.14 x exercises if palpitations, chest lead to
prolonged
1012/L such as pain, weakness, or decompensatio sitting without
walking and dizziness occur. n and failure. difficulty and
dizziness.
prolonged
- Performed
sitting Dependent ADL without
without assistance.
- Administer
difficulty and - Laboratory
PRBC’s, as
dizziness Result within
ordered by the normal range
doctor and in:
- Perform - Increases
monitor it Hgb: 130g/L
activities of number of
closely for oxygen-carrying Hct: 0.39
daily living cells.
15mins for any RBC: 4.7 x
without 1012/L
allergic
assistance.
reactions.
- Display
laboratory - Administer pre-
medications for - Reduce the
values within allergic
normal range BT such as reaction and
diphenhydramin fever to blood
especially in
product
Hgb, Hct and e and
RBCs. paracetamol as
ordered by the
doctor.
- Administer
PNSS1L by 12hr - To prevent
65
COLLEGE OF NURSING
KVO during BT, as blood clot.

ordered by the
doctor.
Collaborative
- Discuss the
condition of - For
patient to mobilization
physical
therapist, for
patient activity
such as ROM
exercises.
- Identifies
- Provide referral for deficiencies in
another CBC RBC
components and
laboratory result.
response to
therapy.
- Discuss the
condition of the - For the
patient to other continuity of care
health care
team.

Subjective: Imbalance Short Term Independent: -For baseline
nutrition Goal: data
“Wala akong -Monitored vital Goal was met.
related to
gana kumain After 4 hours signs
pain and Short Term
dahil masakit of nursing
anorexia as - Patients may Goal:
ang tyan ko” interventions,
evidence by become weak
the patient will - Assessed After 4 hours of
as verbalized appearance and unable to
be able to patient’s mobility nursing
by the patient. of thin complete their
verbalize status interventions,
muscle, flaky regular activities
accurate the patient was
skin and if not taking in
knowledge of able to verbalize
Objective: weight loss the appropriate
condition and accurate
nutrition
S/S: knowledge of
understanding
- To gain condition and
BP-110/80 of nutritional
knowledge in understanding
needs,
RR-23bpm the area of how of nutritional
- Educate the to independently needs.
patient on the care for oneself
66
COLLEGE OF NURSING
HR-124bpm Long Term body’s nutritional upon discharge

Goal: needs
Sat: 97% - Improved Long Term
Within 5 days nutritional status Goal:
Weight: 38kgs of nursing enhances
- Establish a
intervention, thinking ability,
Height: 149cm minimum weight
allowing Within 5days of
the patient will goal and daily
BMI: 17.1 initiation of nursing
be able to: nutritional
psychological intervention,
-Eats less than requirements.
-Demonstrate work.
3 times a day the patient was
appropriate
- Gastric dilation able to:
- Appearance changes in
may occur if
of thin muscle lifestyles and -Demonstrate
refeeding is too
behavior - Provide smaller appropriate
-anorexia rapid following a
includes meals and changes in
period of
- Flaky skin eating pattern supplemental lifestyles and
starvation
snacks, as dieting. behavior
- weight loss appropriate. includes eating
-brittle nail and - Maintain gain - Fluids pattern
loss of hair weight in eliminate the
desired goal at need to choose
least 1-2 between foods – - Maintained
pounds of - Liquids are more something the gain weight in
weight. acceptable than patient with desired goal at
solid. anorexia may least 1-2
find difficult. pounds of
- Having a weight.
variety of foods
available
- Provide diet and enables the
snacks with patient to have
substitutions of a choice of
preferred foods potentially
when available. enjoyable foods.
- Good oral
hygiene can
- Provide good increase an
oral hygiene. individual’s
appetite.
- Providing
Dependent:
appropriate
- Administer antiemetics will
antiemetics as allow for
needed before patient's
meals appetite to
potentially
increase and
tolerate intake
better.
- To treat for too
- Administer much acid in the
omeprazole as
67
COLLEGE OF NURSING
ordered. stomach.
-Nutriotional
supplements
Collaborative:
may be
-Refer to dietitian prescribed as
necessary by
the dietician. To
ensure patient is
receiving and
taking these
supplements to
further
strengthen the
body.
NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE Risk for fluid SHORT INDEPENDENT SHORT TERM:
- “Parang volume TERM - Monitor the The I and 0 of
namamaga ang After 5hrs of
excess After 5hrs of patient’s input is one of the
paa ko” as nursing
verbalized by related to nursing and output indicators of
the patient”. interventions the
PRBC interventions, thoroughly. fluid volume
goal was met.
OBJECTIVE: transfusion the patient status.
- Monitor the
- Body will be free - The patient has
vital signs and
weakness from fluid - Sinus been free from
note any
volume tachycardia fluid volume
- Fatigue significance
excess as and increased excess as the
Vital Signs: especially in
the vital blood vital signs
blood pressure
- HR: 124 bpm signs is pressure are showed:
and heart rate.
within normal early stages BP:110/80mmHg
- RR: 23 bpm
range, no of fluid
HR: decreased
other - Side rails up volume
by 90bpm.
alterations excess
- Promote a
happen. No RR: decreased
calm
complain that - For the by 19bpm.
environment
notify the safety.
and adequate
68
COLLEGE OF NURSING
nurses and rest. Temp: 37.3

the patient
- Position the
rest - For O2 Sat: 97%
patient into
comfortably. relaxation. - The patient did
comfortable
not have any
position while
complain that
monitoring the
notify the nurses
dizziness.
and rest
- Avoid the comfortably.
- Elevate bed sore and
edematous promotes
extremities if comfort.
present and
treat them with
caution and - Elevation of
care. affected areas

reduces
edema by
increasing
venous return
to heart.
Edematous
skin is
vulnerable to
- Regulate the
injury;
rate of IV fluids.
therefore,
caution is
highly
advised.
Dependent - Strict
- Administer adherence to
diuretics as prescribed
prescribed by rates of fluid
the physician. is necessary

to avoid the
aggravation of
fluid volume.
69
COLLEGE OF NURSING
- Diuretics are
usually
Collaborative
ordered in
- Discuss the case of fluid
condition of the volume
patient to other excess it aids
health care in the
team. excretion of
excess body
fluid.
- For the
continuity of
care.
ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Risk for falls STG: Independent -To avoid falls STG:
"Gusto ko may related to After 4 hours -Place items and patient After 4 hours
nagbabantay fatigue, of nursing within easy reach tries to reach of nursing
sa akin dahil dizziness, interventions with patient. out for the interventions
madalas ako body the patient items the goal was
mahilo at weakness will be able to met, Patient
manghina", as and verbalize - Secure the bed -To provide was able to
verbalized by decreased gradual or such as putting safety verbalize
the patient. Hgb, Hct and controlled side rails up as measures and gradual or
Objective: RBCs relief from needed. avoid falls controlled
-Fatigue dizziness. relief from
-Dizziness -Familiarize the -Patients is dizziness.
-Body LTG: patient on the lay less likely falls
Weakness After a week out of the room. LTG:
-Side rails up of nursing After a week
interventions, -Provide -To increase of nursing
Laboratory the patient appropriate room the patient’s interventions,
Values: will be able to lightning visibility the goal was
-Hemoglobin do daily met, Patient
62g/L activities -Encourage the -Having an was able to do
70
COLLEGE OF NURSING
-Hematocrit without relatives to watch assistant/ daily activities

0.18 assistance the patient. guide greatly without
-WBC: 12 and no reduces the assistance
-RBC: complains of risk for falls. and no
2.14x1012 body complains of
weakness Teach the patient -Teaching the body
and and relatives the client weakness and
dizziness. factor that precautionary dizziness
contribute to fall. measures will
greatly reduce
the incidence
of it.
- Inform the
relative to assist -To avoid
the patient when injury
she wants to go
to the bathroom
Dependent
Take medication For further
as prescribed by treatment
physician
Collaborative
Consider Physical For the further
therapist for gait health and
techniques wellness of
the patient
X. DISCHARGE SUMMARY
DISCHARGE GOALS:
Dealing with current situation realistically
Pain relieved and controlled
To engage patients and family member in the transition from hospital to home reducing adverse
events and preventable re admissions.
PURPOSE:
To ensure continuity of quality care and support individual needs of patient, and to reduce hospital
length of stay and unplanned readmission.
71
COLLEGE OF NURSING
Medications
- Give adequate instructions about the importance of the following medication and dietary regimen.
- Informed the patient for any adverse effect and possible side effect of the medication.
- Continue taking home medication as prescribed by the physician on exact date and time to
complete her regimen.
- Seek care immediately return if the symptoms of the medication return.
Exercise & Environment
- Tell patient to avoid exerting too much effort on muscles such as doing strenuous exercise to avoid
injury.
- Make things easily accessible to patient to avoid fall.
- Give patient support or assistance when going to the bathroom.
- Teach stress management techniques as indicated, including appropriate exercise program.
- Eliminate things that are hazardous that might cause accidents
Treatment
After being discharged, patients and watchers with UGIB are urged to fully participate in ongoing
treatment
Health teaching
- Teach the patient the importance of monitoring the progress and compliance with the treatment
regimen.
- Implement ongoing education and reinforcement on the multiple dietary requirements.
- Explain the underlying and treatment plan.
- Lifestyle change (balanced diet, quiet smoking, and proper food intake)
- General health measures (adequate sleep, proper diet and maintaining a clean surrounding)
- Emphasize the patient importance having regular check-up to know her present condition.
- Instruct patient to limit his activity for 24 to 48 hrs after discharge.
- Provide written and oral instructions about activity, diet recommendations, medication and follow up
visits.
- Help the patient learn about and preventive or manage recurrent cystitis.
- Personal hygiene. The patient should be informed to wipe from front to back after urination or bowel
movement and to wear cotton under wear.
- Increase fluids. The patient should increase fluid intake to promote voiding and dilution of the urine.
- Patterns of voiding. Voiding regularly and emptying the bladder completely would avoid recurrent
infection.
- Compliance. Strict compliance with the medication regimen ensures nonresistance of bacteria from
the drug.
Do not smoke:
72
COLLEGE OF NURSING
Smoking increases your risk of developing ulcers. Nicotine and other chemicals in cigarettes and
cigars can also cause lung damage. E-cigarettes or smokeless tobacco still contain nicotine.
Take your medicine as directed.
To avoid worsening of upper gastrointestinal bleeding,

 Do not have carbonated drinks, alcohol, or caffeine. Caffeine is found in some coffees, teas,
and sodas. It is also found in chocolate.
 Do not eat foods that upset your stomach. These include spicy or acidic foods, such as
oranges.
 Eat small meals more often rather than big meals less often. An empty stomach may make
your symptoms worse.
 Low salt low fat diet for patient’s hypertension.
Output follow-up
 Remind the patient to have a follow up check-up even though she already feels better.
 Follow up checkup for her hypertension and her peptic ulcer.
After the discharged, patient may go to clinic for follow up checkup after a week. As part to check for
level of her CBC and HGB.
Diet
For anemia
-Encourage high on iron containing food like legumes, spinach, peas, and dark other green leafy
vegetable to prevent anemia.
-The patient should eat iron-rich foods which also contain Vitamin C (ascorbate) to improve iron
absorption.
-Enforce strictly compliance in taking iron supplements as prescribed by the physician
For hypertension
- DASH diet (Dietary Approaches to Stop Hypertension) diet is an eating plan habit to lower or control
high blood pressure. The DASH emphasizes foods that lower in sodium as well as foods that are rich
in potassium, magnesium, and calcium - nutrients that help lower blood pressure. DASH stands for
Dietary Approaches to Stop Hypertension. The diet is simple: · Eat more fruits, vegetables, and low-
fat dairy foods · Cut back on foods that are high in saturated fat, cholesterol, and trans fats · Eat more
whole-grain foods, fish, and nuts.
For UGIB DIET
High fiber foods such as:
-whole green
73
COLLEGE OF NURSING
-fruits vegetables and beans
-low fats food such as fish, and vegetables may decrease Acid.
-Avoid or limit caffeine and spicy food, those foods that causes heartburn nausea or diarrhea.
Spiritual Counseling
 Encourage the patient to pray daily and ask for God’s continues healing
 Encourage the patient for her fast recovery and give words of encouragement
 Encourage relatives/significant others to show more support for the patient’s well being.
XI. CASE INSIGHTS

Peptic ulcer are open sores that develop on the inside lining of the stomach or the upper
portion of the small intestine; wherein the patient experienced epigastric pain. Most common causes
of peptic ulcer are H.pylori that’s present in her medical history. The peptic ulcer of the patient got
worst, and it resulted to the presence of black tarry stool. Black tarry stool indicates upper
gastrointestinal bleeding that is caused by the peptic ulcer. The bleeding resulted to anemia. Loss of
red blood cells in excess of new blood cell production causes anemia due to excessive bleeding.
Patient felt dizzy and have low blood pressure when blood flow is rapid. Blood loss occurs gradually,
and patient get tired, and pale. Aside from the UGIB, patient also experienced cystitis that is evident
from her right lower quadrant pain. Cystitis is the inflammation of the bladder that causes pain from
right lower quadrant.
Since the patient is in middle age, it is the age of generativity vs. stagnation. Patient is widowed;
hence, she needs the warmth of her family by caring. Caring for her grandchildren by guiding them
through life is an example of generativity. Research indicates that middle-aged adults who develop a
sense of generativity are more motivated to make positive health decisions. Thus, they would also
likely tend to their healthcare needs regularly. Conversely, someone with a sense of stagnation may
experience less motivation to look after themselves, resulting in less stringent healthcare routines—
and a lower level of health later in life.
In the patient’s health situation and age, it is best to still make her feel useful. Let her engage in
caring for the future generation and community. Without the “care” of family and community from her,
patient may feel the rejectivity, or a lack of meaning in one's life and in one's actions, can occur.
As nursing students, we realized that a person’s health if left untreated; can lead to longer
hospitalizations and more complications. Most Filipino, we only go to hospital if the symptoms are
severe and just neglect the mild ones. These mild symptoms can then develop more complications
that could lead us to more hospitalizations. Therefore, our health should always be our first priority.
Lastly, prevention is better than cure. Our patient’s diseases can be preventable if there is proper
hygiene and balanced diet with proper nutrition. Health is wealth, therefore, promote health
prevention for wellness.
74
COLLEGE OF NURSING
XII. REFERENCES
ACCESS Physiotherapy,F.A DAVIS PT COLLECTION ( year ) Retrieved from

https://fadavispt.mhmedical.com/content.aspx?bookid=1873&sectionid=139020495
Ackley,B,J Ladwig,G.B.Makic,M.B.,Martinez- Kratz,M.R ,Zanotti,,M. (2020) Retrieved from
https://nursestudy.net/nursing-diagnosis-for bloodtransfusion/?
fbclid=IwAR1M0KkiOxALeDDW2uJVja_7oEEPlUnihlGW5Bw4GJjAYGMNer0UN6bCDkw
Anna C. Rn, A. B. (2022, May 18) Retrieved from. Blood Transfusion Nursing Diagnosis and Nursing
Care Plan. NurseStudy.Net. Retrieved from https://search.yahoo.com/search?
fr=mcafee&type=E210US91213G0&p=S03onLWx5eSo_vtT9NfIfnteyDEAyJwVwHA
Belleza, M. (2018). Gastroenteritis Nursing Care Management.
Nurseslabshttps://nurseslabs.com/gastroenteritis/
Casburn-Jones, A. C. & Farthing, M. J. G. (2004). Management of Infectious
DiarrhoeaPubMedCentral.Retrieve from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774945/
Calista Roy And Dorothea Orem ( 3/18/2013) Nursing Grand Theory and Theorist Retrieved from
https://nursingtheoryandtheoristsroyorem.weebly.com/roy-theory-description/roy-adaptation-model-
theory-descriptionDrug Bank Online ( Year ) Retrieved from
https://go.drugbank.com/drugs/DB09020EZMED community ( Year) Retrieved from
https://l.facebook.com/l.php?u=https%3A%2F%2Fwww.ezmedlearning.com%2Fblog%2Fabdominal-
pain-chart%3Ffbclid
%3DIwAR0DKuXyLkq6AOZelq1HNTHAYFjuTrUDqNDbuAI6z9WP2mRRBHQPqZO2jWo&h=AT2UG
94-
BcInYC9pBwATWgttKQIhrDeLz7Xu3P13wBmfQYxFDQ6vv0O_TAn5TC902ZiYRuR5d5hL2_GDaTkb
yjkELPCfij10obeGaO4MZutjIBsjhH0H2oyTEOScjbWO4792NVuXiV0OGyxMQi8VQA
F.A. DAVIS Drug Guide for Rehabilitation( Year) Retrieved from
https://fadavispt.mhmedical.com/content.aspx?bookid=1873&sectionid=139004956
Gulanick,M.,Myers J.L,( 2017) Retrieved from Nursing Care plan s: Diagnoses,
Interventions,&Outcomes,St.Louis, MO: Elsevier Ignatavicuis,D.D,Workman,C.R.,Heimgartner N.M
75
COLLEGE OF NURSING
(2018) Retrieved from Medical - Surgical Nursing :Concept for Collaborative Care, St. Louis ,MO;
Elsevier
JohnP.Cunha,DO.FACOEP ,Medical Pharmacy Editor (4/5/22) Retrieved from
https://www.rxlist.com/consumer_bisacodyl_dulcolax/drugs-condition.html
Jrwon Kim, PHARMA Chant,Pharm,D., BCSHP Retrieve from MANAGEMENT AND PREVENTION
OF UPPER GI BLEEDING
Kenneth Kee M.B.,BS. ( 2013) Retrieved from https://scribfree.com/document/133215432/Drug-
Study-Ceftriaxone
MIMS CLINICAL AND MEDICAL NEWS ( Year ) Retrieved from
https://www.mims.com/philippines/drug/info/rebamipide?mtype=genericNicole France
BPharm Medically reviewed( Aug29,2022) Retrieved
fromhttps://www.drugs.com/paracetamol.htmlRoy Adaptation Model (Year) The Journal of
Breast Health Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5351537/#:~:text=According%20to%20Roy
%20adaptation%20model,aiming%20to%20provide%20holistic%20c ScribFree.com ( 2021)
Retrieved from https://scribfree.com/document/527071737/DRUG-STUDY-
DIPHENHYDRAMINEScience Direct. (2020). Acute Gastroenteritis. Science Direct.
XIII. APPENDICES / STUDENT PROFILE
DEJOLDE, ROSGEN L.
Address: 026-H Purok 5, Silverio Compound,
Brgy. San Isidro, Parañaque City
Contact Number: 09102944669
E-Mail Address: rosgen.dejolde@ucp.edu.ph
PERSONAL INFORMATION
Date of Birth: December 10, 2000
Gender: Female
Civil Status: Single
Religion: Born Again Christian
EDUCATIONAL BACKGROUND
Elementary: Justiniana Edera Elementary School (2007-2013)
High School: Parañaque National Highschool- Baclaran (2013-2017)
Senior High School: Universal College of Parañaque (2017-2019)
College: Universal College of Parañaque (2019 - Present)
76
COLLEGE OF NURSING
Estrada, Jacob A
Address: 1 Engineering Street Scienceville Paranaque City
E-mail Address: Jacobestrada402@gmail.com
Date of Birth: January 4, 2001
Gender: Male
Religion: Roman Catholic
Elementary School: Sacred Heart School (2006-2013)
Junior High School: Regina Maria Montessori (2013-2017)
Senior High School: AMA College Para (2017-2019)
College: Southville International School and Colleges (2019-2020)
Universal College of Parañaque (2020 up to present)

77
COLLEGE OF NURSING
ESTRELLER, BEA SHAIRA T.
Address: 9580 Jaime St., Airport Village,
Brgy. Vitalez, Parañaque City
E-Mail Address: beashaira.estreller@ucp.edu.ph
Date of Birth: September 17, 2000
Gender: Female
Elementary: Jamorawon Elementary School (2012-2013)
High School: Parañaque National Highschool- Baclaran (2013-2017)
Senior High School: Universal College of Parañaque (2017-2018)
78
COLLEGE OF NURSING
College: Universal College of Parañaque (2019 up to present)
FLORES, CAMILLE S.
Address: 157 Saint Jude Street Multinational Village,
Moonwalk, Parañaque City
E-mail Address: iamcamilleflores01@gmail.com
Date of Birth: June 14 2001
Gender: Female
Religion: Seventh Day Adventist
Elementary School: Parañaque Elementary School – Central (2007 – 2013)
Junior High School: Parañaque National Highschool – Main (2013 – 2017)
Señior High School: Olivarez College – Parañaque (2017 – 2019)
College: Manila Adventist College (2019 – 2020)

79
COLLEGE OF NURSING
Universal College of Parañaque (2020 – Present)
LAGAN, CHRISTINE F.
Address: 153 Manggahan Bf Resort Talon Dos, Las Piñas City
E-mail Address: laganchristine19@gmail.com
Date of Birth: March 10, 1999
Gender: Female
Religion: Roman Catholic
Elementary School: Ampihanon Elementary School (2006-2012)
Junior High School: Golden Acres National Highschool (2012-2016)
Senior High School: AZGH College INC (2016-2018)
College: Universal College of Parañaque (2019 up to present)
80
COLLEGE OF NURSING
LUCAÑAS, MA FE L.
Address: 18-B Subic St, Greenheights Village Paranáque City
Contact Address: 09950266042
Email address: mafe.lumampao67@gmail.com
Date of Birth: January 07, 1967
Gender: Female
Elementary: Barangay Canroma Pontevedra (1974-1979)
High School: Puntevedra National High School (1980-1984)
Tesda: Philippine Army Livelihood and Training Center (2012)
College: Universal College of Parañaque City (2019 up to present)
81
COLLEGE OF NURSING
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UNIVERSAL COLLEGES OF PARAŇAQUE INC.

8273 Dr. A. Santos Ave., Parañaque City

(PEPTIC ULCER DISEASE)

Presented to the Faculty of College of Nursing

In Partial Fulfillment for

The Course Requirement of Related Learning Experience (RLE)

1st semester, School Year of 2022-2023

Estreller, Bea Shaira T.

Mr. Henry Apolinar

Date: January 14, 2023

ii.b. Chief Complaint …………………………………………………….. 13

III. Physical Examination ……………………………………………………….. 26

VII. Diagnostic Exam / Procedures ……………………………………………. 39

(PEPTIC ULCER DISEASE)

- are open sores that develop on the inside lining of your

Peptic ulcers include:

 Have untreated stress.

SIGNS AND SYMPTOMS

 Burning stomach pain

 Intolerance to fatty foods

 Vomiting or vomiting blood — which may appear red or black

 Unexplained weight loss

Medications can include:

Options include the prescription medications sucralfate (Carafate) and misoprostol

Administer prescribed medications.

 Medications may include antacids, anticholinergics, histamine-receptor antagonist, proton-

 Obtain informed consent

 Ensure that the nasogastric tube (surgically placed) is not manipulated

 Assess the surgical dressing

UPPER GASTROINTESTINAL BLEEDING

Upper gastrointestinal (GI) bleeding refers to bleeding that occurs

Signs & Symptoms

The symptoms of a GI bleed can include:

 black, tarry stool

 Stool tests: These can detect inflammation, occult bleeding, or infection

 Blood tests: These tests can reveal anemia.

 Balloon-assisted enteroscopy. A specialized scope inspects parts of your small

For patient having blood transfusion

-Anemia is a condition in which you lack enough healthy red blood

These factors place you at increased risk of anemia:

 Age. People over age 65 are at increased risk of anemia.

Signs and Symptoms

Depending on the causes of your anemia, you might have no symptoms.

Signs and symptoms, if they do occur, might include:

 Pale or yellowish skin

 Cold hands and feet

Diagnostics/ Laboratory tests

 Blood Transfusion- for the anemia that are caused by bleeding.

 Medication intake. Patients receiving high-dose corticosteroids may need assistance

II. Nursing Health History

ii.a. Demographic Data

ii.b. Chief Complaint

ii.c. Confinement Details

Date of Confinement/Admission: 11/09/2022 (November 9, 2022) at 7 am

ii.d. History of Present Illness

ii.e. Past Medical History

-Last January 2021, patient is diagnosed with peptic ulcer disease.

-The patient’s last hospitalization was January 2021.

ii.f. Social History

ii.g. OB-GYNE history

Age at first period: 13-year-old.

Menstrual Period regular or Irregular? Regular