Anemia of a 42-year-old Male Secondary to Upper Gastrointestinal Bleeding

Presented to the faculty of

SCHOOL OF HEALTH and NATURAL
SCIENCES NURSING DEPARTMENT

In Partial Fulfillment of the Requirements for

Care of patient with Problem in Infectious Inflammatory and Immunologic Response, , Fluids
and Electrolytes, Oxygenation, Cellular Aberration, Acute and Chronic
NCM 112RLE

Submitted by:

Dogwe, Fevie Grace A.

Submitted to:
NCM112 RLE INSTRUCTORS
Clinical Instructor

Date Submitted
December 2023 TABLE
OF CONTENTS

I. 3P’s

II. Brief Description

III. Anatomy and Physiology

 IV. Pathophysiology

V. Laboratory Results and Diagnostic Studies

VI. Physical Assessment and Its Physiological Basis

VII. Drug Study

VIII. Course in the Ward

IX. Nursing Care Plan

References
I. 3Ps (Personal Profile, Past Health History, Present Health History)

A. Personal Profile

Name Mr. ST

Sex Male

Age 42 years old

Birthday May 26, 1981

Birthplace Aritao, Nueva Vizcaya

Address Aritao, Nueva Vizcaya

Nationality Filipino

Ethnicity Ilocano

Primary Language Ilocano

Civil Status Married

Religion Roman Catholic

Highest Educational Attainment Elementary (Grade 6)

Occupation Farmer

Weight 55kg

Height 5’4

BMI 20.8 (Normal)

Hospital Nueva Vizcaya Provincial Hospital,

Bambang, Nueva Vizcaya

Ward Medical Ward

Bed Number 10

Medical Insurance PhilHealth

Admitting Diagnosis Peptic ulcer secondary to UGIB

Final Diagnosis Anemia secondary to UGIB

Significant Other’s Profile:

Name Mrs. LT

Age 38 years old

Sex Female

Civil Status Married

Occupation Farmer

Religion Roman Catholic

Highest Educational Attainment Elementary (Grade 6)

 Relationship to the patient Wife
B. Present history of illness

Mr. S.T. indicated that he didn't have this kind of disease as a child, it only occurred
spontaneously this year. However, he revealed that he had been experiencing abdominal pain for
the past few months, for at least one to two months when he estimated it. Mr. S.T felt and acted
normally in the morning, with no signs of discomfort or pain. He was able to have coffee for
breakfast and did his job as usual. In the afternoon, he was able to go to their garden, but as he
continued to work, he felt nauseous which he disregarded. He drank soft drinks that day with his
lunch. During the following hour, he still felt dizzy, but he thought that it was because of his
tiredness since he worked earlier that day. But during the night, he experienced diarrhea wherein
he defecated three times with a consistent characteristic of red and watery stool. They were
alarmed, so they decided to go to the hospital for a checkup early in the morning.

The admission day, September 16, 2023, when Mr. S.T. sought for a check-up, he was
immediately admitted to NVPH with chief complaints of epigastric pain with body weakness and
melena. His admitting diagnosis of upper gastrointestinal bleeding secondary to bleeding peptic
ulcer disease. His final diagnosis was upper gastrointestinal bleeding secondary to anemia. He
went through a physical assessment and different examinations, such as blood chemistry, serum
electrolytes, cross-matching, and a radiograph, received BT, also inserted PNSS IV fluid 1L
every 8 hours with 3 cycles and started some medications such as omeprazole, rebamipide,
lactulose, and metoclopramide. Mr. S.T. was instructed to have adequate rest and oral
rehydration and was monitored for time and stool.

First day of admission, September 17, 2023, Mr. S.T. defecated once late during the night
with a yellow and dark red color. The doctor ordered for CBC, and the patient was given a
consent form for the blood transfusion. He was only continuing the regimen, drug medication,
and oral rehydration that day while recovering. 8:00 pm when the transfusion was administered,
and it was done after 4 hours.

Second day of admission, September 18, 2023, Mr. S.T defecated once early in the
morning with a yellow color. He was required again for a CBC and physical assessment. On the
last assessment, September 19, 2023, the patient was now negative for melena, hematochezia,
dizziness, and hematemesis. He also had normal vital signs. Then, the doctor ordered a Fecal
Occult Blood Test and H. Pylori test and to consume an omeprazole drip, IVF TF of PNSS
1Lx12hrs (2 cycles). He was also advised to refer to the laboratory.

C. Past Health History

When Mr. S.T. was three years old, he was diagnosed with dengue fever. He couldn’t
remember a lot about his experience during this time since he was just a child, so he couldn’t add
more information about it. Whenever he was experiencing fever, cough, or colds he just self-
medicates with paracetamol, neozep, or tuseran since these are the common drugs for these
conditions. For his vaccinations, he stated that he already completed his Covid vaccination which
was Pfizer for his 1st and 2nd dose. His first booster was Moderna and still hasn't received his
second booster.

D. Family History

Mr. S.T. has no known family history of any disease since he stated that both his parents
don't have a disease.
E. Socioeconomic History

Mr. S.T. 's family's primary source of income is vegetable gardening. Their family owns a
small plot of farmland, and the harvest was insufficient to meet the family's needs, affecting their
eating routine. Sometimes they only eat twice a day, because they don’t have enough money to
eat more food. The estimated finance of the family every month was about four thousand (4,000)
pesos that was only allotted for their necessities such as food, bills, and liquor.

F. Lifestyle History
Mr. S.T. works in their vegetable garden everyday which he considers as his basic
exercise and hobby. During breakfast, he only drinks coffee before going to their garden. For his
lunch and sometimes dinner, he eats rice with different vegetable recipes, whatever they can
think of. Sometimes he also eats meat when they can afford to buy it. Sometimes, he eats past his
eating time because of his work. He doesn’t smoke cigarettes, but drinks liquor, specifically gin
known as 2x2 more than three times a week.
II. Brief Description

Definition

Upper Gastrointestinal Bleeding (UGIB) - Upper gastrointestinal bleeding (UGIB), UGIB is

described as blood loss from a gastrointestinal source above the ligament of Treitz. It can
manifest as Hematochezia, which leads to melena. This can lead to Anemia due to excessive
bleeding.

Anemia - Anemia is a condition in which the body does not have enough healthy red blood cells.
Red blood cells provide oxygen to body tissues.

Causes

Upper gastrointestinal bleeding that leads to anemia because of Peptic ulcer, this is the
most common cause of upper GI bleeding. Peptic ulcers are open sores that develop on the inside
lining of your stomach and the upper part of your small intestine. Stomach acid, either from
bacteria or use of anti-inflammatory medicines, such as ibuprofen or aspirin, damages the lining,
causing sores to form.

Risk Factors

NON-MODIFIABLE RISK FACTORS

● Socioeconomic Factor. Lower socioeconomic status (SES) is thought to be associated

with higher prevalence of H. pylori infection because low SES is associated with poor
hygiene and unfavorable sanitary conditions, which are considered important risk factors
for H. pylori infection.
● Age. The prevalence of Helicobacter pylori increases with age and can have an important
role in the development of ulcers.

MODIFIABLE RISK FACTORS

● Chronic Alcohol Abuser. Drinking alcohol can exacerbate the condition and worsen the
symptoms that the patient is experiencing.
● Diet. Food doesn't cause or treat ulcers, some can make your pain worse, while others
may help you heal faster.
● Feeding. Skipping meals can lead to peptic ulcer disease.

Sign and Symptoms

The early signs and symptoms of acute gastrointestinal bleeding are:

● Blood in the stools. ● Black, tarry stools.

Symptoms associated with blood loss can include:

● Fatigue or feeling tired
● Weakness
● Nausea
● Shortness of breath
● Tachycardia
● Abdominal pain and cramps
● Pale appearance
Diagnostic Tests
● Blood Chemistry. A blood chemistry study is a procedure in which a blood sample is
checked to measure the amounts of certain substances released into the blood by organs
and tissues in the body. An unusual (higher or lower than normal) amount of a substance
can be a sign of disease in the organ or tissue that makes it.
● Complete Blood Count. A complete blood count (CBC) is a blood test. It's used to look
at overall health and find a wide range of conditions, including anemia.
● Serum Electrolytes. Electrolytes play an important role in controlling acid base balance,
blood clotting, and body fluid and muscle contractions. Serum electrolytes concentrations
are most commonly used tests for assessment of a patient's clinical conditions.

Medical and Pharmacologic Management

Administer the prescribed drug therapy:

● Antacids. Antacids buffer gastric acid and prevent the formation of peptin. This
mechanism of action promotes healing of the ulcer.
● Antibiotics. Such as amoxicillin, clarithromycin, metronidazole, tetracycline. Antibiotics
treat the Helicobacter pylori infection and promote the healing of the ulcer. As the ulcer
heals, the patient experiences less pain.
● Histamine receptor antagonists. H2 receptor antagonists block the secretion of gastric
acid. Prostaglandin analogue reduces acid secretion and enhances the integrity of the
gastric mucosa to resist injury. Example: Ranitidine
● Proton pump inhibitor. Proton pump inhibitors block the production and secretion of
gastric acid and thereby reduce gastric pain. Example: Omeprazole
● Sucralfate. Sucralfate forms a barrier at the base of the ulcer crater to protect the healing
ulcer from gastric acid

Prevention

To help prevent GI bleed that leads to anemia:

● Limit your use of nonsteroidal anti-inflammatory drugs. Gastrointestinal side effects

such as indigestion, stomach upset (including nausea or feeling sick) or stomach pain are
commonly caused by NSAIDs. Use of NSAIDs can also cause ulcers and bleeding in the
stomach and other parts of the gastrointestinal tract (gut).
● Limit your use of alcohol. If you already have a peptic ulcer, drinking alcohol can
exacerbate the condition and worsen the symptoms that you are experiencing.
● Don’t Smoke. Ulcers are more likely to heal if you stop smoking. Smoking also raises
the risk for infection from Helicobacter pylori. This is bacteria commonly found in ulcers.
● Eating foods that are rich in fiber and probiotics. Fibers and probiotics also play an
important role in the treatment of peptic ulcer, because they reduce the side effects of
antibiotics and help reduce treatment time.
● Avoid eating foods that are fried, greasy, acidic and spicy. This may irritate the
stomach lining and aggravate the ulcer.

Nursing Management

1. Providing Pain Relief and Comfort. Assess the patient’s pain, including the location,
characteristics, precipitating factors, onset, duration, frequency, quality, intensity, and
severity.
 2. Instruct the patient to avoid NSAIDs such as aspirin. These medications may cause
irritation of the gastric mucosa.
3. Instruct the patient that meals should be eaten at regularly paced intervals in a
relaxed setting. An irregular schedule of meals may interfere with the regular
administration of medications.
4. Encourage the importance of smoking cessation. Smoking decreases the secretion of
bicarbonate from the pancreas into the duodenum, resulting in increased acidity of the
duodenum.
5. Assist the patient with identifying foods that cause gastric irritation. patients need to
learn what foods they can tolerate without gastric pain. Soft, bland, non-acidic foods
cause less gastric irritation. The patient is more likely to increase food intake if the foods
are not associated with pain. Foods that may contribute to mucosal irritation include spicy
foods, pepper, and raw fruits and vegetables.
6. Instruct on the importance of abstaining from excessive alcohol. Alcohol causes
gastric irritation and increases gastric pain.
7. Encourage the patient to limit the intake of caffeinated beverages such as tea and
coffee. Caffeine stimulates the secretion of gastric acid. Coffee, even if decaffeinated,
contains a peptide that stimulates the release of gastrin and increases acid production.
8. Assess for the signs of hematemesis or melena. The patient with a bleeding ulcer may
vomit bright red blood or coffee grounds emesis. Melena occurs when there is bleeding in
the upper GI tract.
9. Monitor the patient’s fluid intake and urine output. The kidney will reabsorb water
into circulation to support a decrease in blood volume. This compensatory mechanism
results in decreased urine output. A decrease in circulatory blood volume leads to
decreased renal perfusion and decreased urine output.
10. Monitor the patient’s vital signs, and observe BP and HR for signs of orthostatic
changes. The erosion of an ulcer through the gastric or duodenal mucosal layer may
cause GI bleeding. The patient may develop anemia. If bleeding is brisk, changes in vital
signs and physical symptoms of hypovolemia may develop rapidly. A decrease in BP and
an increase in HR with changes in position is an early indicator of decreased circulatory
volume.

Complications

Complications of peptic ulcer disease (PUD) include:

● Hemorrhage (excessive bleeding)

● Perforation/penetration, due to the ulcer burning through the stomach wall.
● Gastric outlet obstruction, or pyloric stenosis, occurs when the pylorus narrows.
III. Anatomy and Physiology

A. Gastrointestinal Tract

The GI tract consists of the oral cavity, pharynx, esophagus, stomach, small intestine, large
intestine, and anus. The main functions of the GI system include ingestion and digestion of food,
nutrient absorption, secretion of water and enzymes, and excretion of waste products.

The upper GI tract is generally considered to be the mouth, esophagus, stomach, and finally the
first part of the small intestine (duodenum). The lower GI tract runs from the small intestine to
the large intestine (colon) to the anus.
Mouth

The oral cavity has four

main functions. First, it
provides sensory analysis of
food material before
swallowing and mechanical
processing via the action of the teeth,
tongue, and palatal surfaces. The oral
cavity also provides lubrication by
mixing food material with mucus
and salivary gland secretions and
limited digestion of carbohydrates
and lipids.

Esophagus

The esophagus is a passageway that conducts food by

peristalsis to the stomach. It is about 25 cm or 10 inches
long. The esophagus contains four layers: mucosa,
submucosa, muscularis externa, and serosa.

The pharynx serves as a passageway of food material to

the esophagus. During swallowing, closure of the
nasopharynx and larynx occurs to maintain the proper
direction of food; a process achieved by cranial nerves IX
and X. From the pharynx, food material goes to the
esophagus.

The primary function of the esophagus is to transport food

materials into the stomach via waves of contraction of its
longitudinal and circular muscle, known as peristalsis. The
skeletal muscles in the pharynx and upper esophagus are
controlled by the swallow reflex; hence the pharyngeal
and esophageal phases of swallowing are under involuntary control via afferent and efferent
fibers of glossopharyngeal
and vagus nerves. The smooth muscles of the esophagus are arranged circularly and
longitudinally and aid in peristaltic movement during swallowing.

Stomach

The C-shaped stomach is on the left side of the abdominal cavity, nearly hidden by the liver and
the diaphragm. The stomach acts as a temporary “storage tank” for food as well as a site for food
breakdown.

The stomach has five distinct sections:

● The cardia is the top part of your stomach. It contains the cardiac sphincter, which
prevents food from traveling back up your esophagus.
● The fundus is a rounded section next to the cardia. It's below your diaphragm (the dome-
shaped muscle that helps you breathe).
● The body (corpus) is the largest section
of your stomach. In the body, your
stomach contracts and begins to mix
food.
 ● The antrum lies below the body. It holds food until your stomach is ready to send it to
your small intestine.
● The pylorus is the bottom part of your stomach. It includes the pyloric sphincter. This
ring of tissue controls when and how your stomach contents move to your small intestine.

Once the food material arrives in the stomach, it can be temporarily stored and mechanically and
chemically broken down by the actions of stomach acids and enzymes. The secretion of intrinsic
factors produced by the stomach helps appropriately absorb vitamin B12. The ability of the
stomach to store food stems from its compliance and ability to change size. On average, the
lesser curvature of the stomach has a length of approximately 10 cm, and the larger curvature has
a length of roughly 40 cm. The stomach typically spans from vertebrae T7 to L3, giving it the
ultimate ability to hold on to a large amount of food.

The ability of the stomach to mechanically break down food materials is due to its sophisticated
muscular dimensions. The stomach has three muscular layers: an inner oblique layer, a middle
circular layer, and an external longitudinal layer. The contraction and relaxation of these three
muscular layers of the stomach assist in the mixing and churning activities essential in the
formation of chyme. Then the chemical breakdown of food material in the stomach is propagated
by the gastric glands, produced majorly by the parietal cells, chief cells, G-cells, foveolar cells,
and mucous neck cells.

Several layers of muscle and other tissues that make up the stomach:

● Mucosa is your stomach’s inner lining. When your stomach is empty, the mucosa has
small ridges (rugae). When your stomach is full, the mucosa expands, and the ridges
flatten.
● Submucosa contains connective tissue, blood vessels, lymph vessels (part of your
lymphatic system) and nerve cells. It covers and protects the mucosa.
● Muscularis externa is the primary muscle of your stomach. It has three layers that
contract and relax to break down food.
● Serosa is a layer of membrane that covers your stomach

The parietal cells secrete intrinsic factors and hydrochloric acid. The hydrochloric acid produced
by the parietal cell keeps the stomach pH between 1.5 to 2.0. The stomach acidity brought on by
hydrochloric acid destroys most of the microorganisms ingested with food, denatures protein,
breaks down plant cell walls, and is essential for the activation and function of pepsin, a protein-
digesting enzyme secreted by chief cells. The chief cells produce a zymogen called pepsinogen,
which gets activated at a pH between 1.5 to 2 to become pepsin. The foveolar and mucous neck
cells produce mucus, protecting the gastric epithelium from acidic corrosion. The G cells are
abundant within the pyloric section of the stomach. They produce gastrin which stimulates
secretions from the parietal and chief cells. Within the pyloric glands of the stomach, D cells
produce somatostatin, which inhibits gastrin release.

Duodenum

The small intestine is the body’s major digestive organ.

Chyme is directed to the small intestine, where digestion

continues. Unlike the stomach, which has minor absorptive
properties, 90% of food absorption occurs in the small intestine.
The small intestine has three segments: the duodenum, the
jejunum, and the ileum. The duodenum receives chyme from the
stomach and digestive material from the pancreas and the liver.
The enzymes produced by the small intestine include lipase for fats digestion, peptidase for
peptide breakdown, and sucrase, maltase, and lactase for sucrose, maltose, and lactose
breakdown, respectively. Brunner glands, primarily found in the duodenum, produce bicarbonate
for acid neutralization.

Within the duodenum, accessory digestive organs such as the liver and the pancreas release
digestive secretions. The liver is the largest internal organ and gland in the human body. It has
numerous functions, but as an accessory organ of the digestive system, it produces bile which
emulsifies fats and various lipids for optimal digestion. Bile produced in the liver is stored in the
gallbladder. The gallbladder contracts to release bile into the duodenum when fat-containing
food is present

A. Functions and composition of Blood

Blood is a connective tissue consisting of plasma and formed elements. It is the body’s only fluid
tissue and accounts for approximately 8% of body weight. Blood is composed of liquid plasma
and formed elements. These formed elements include: erythrocytes (red blood cells), leukocytes
(white blood cells), and platelets.

Blood is a sticky, opaque fluid with a metallic taste and the color varies from scarlet red to dark
red. The pH of blood is 7.35-7.45. Temperature is 38 degrees celsius and the average volume is
5-6 L for males, and 4-5 L for females.

Blood helps maintain homeostasis in several ways:

1. Transport of gases, nutrients, waste products
2. Transport of processed molecules
3. Transport of regulatory molecules
4. Regulation of pH and osmosis
5. Maintenance of body temperature
6. Protects against foreign substances such as microorganisms and toxins
7. Blood clotting prevents fluid and cell loss and is part of tissue repair

Red Blood Cells

Red blood cells are biconcave discs, anucleate,

essentially no organelles. RBCs are an example of how
structure fits function. Biconcave shape has a huge
surface area relative to volume. Its structural
characteristics contribute to its gas transport function.
The shape and its flexible membrane also allows RBCs
to bend or fold around their thin center which give
erythrocytes their flexibility and allow them to change
shape as necessary.

RBCs are dedicated to respiratory gas transport. It is filled with hemoglobin (Hb), a protein that
functions in gas transport. Hemoglobin (Hb) accounts for about a third of the cell’s volume. This
consists of the protein globin, made up of two alpha and two beta chains, each bound to a heme
group. Each heme group bears an atom of iron, which can bind to one oxygen molecule.
• Heme molecules transport oxygen (Iron is required)
– Oxygen content determines blood color
• Oxygenated: bright red
• Deoxygenated: darker red
• Globin molecules transport carbon dioxide
Red Blood Cells Production
Erythropoiesis is the production of red blood cells. Erythropoiesis takes place in people’s bone
marrow.

Process:
1. A hemocytoblast is transformed into a proerythroblast
2. Proerythroblasts develop into early erythroblasts The
developmental pathway consists of three phases
1. Ribosome synthesis in early erythroblasts
2. Hb accumulation in intermediate erythroblasts and
late erythroblasts
3. Ejection of the nucleus from late erythroblasts and
formation of reticulocytes
– Reticulocytes are released from the red bone
marrow into the circulating blood, which
contains ~1-3% reticulocytes
3. Reticulocytes then become mature erythrocytes

The lifespan of an erythrocyte is 100–120 days. Old RBCs become rigid

and fragile, and their Hb begins to degenerate. Dying RBCs are engulfed by macrophages
located in the spleen or liver. Heme and globin are
separated and the iron is salvaged for reuse
– Globin chains are broken down to individual amino acids and are metabolized or
used to build new proteins
– Iron released from heme is transported to the red bone marrow and is used to
produce new hemoglobin
– Heme becomes bilirubin that is secreted in bile
• In the intestines bilirubin is converted by bacteria into other pigments
– Gives feces its brown color
– Gives urine its yellow color
IV. Pathophysiology

V. Laboratory Results and Diagnostic Studies

Blood Chemistry (09/16/2023, 2:51PM)

Examination Result Normal Value Pathophysiological

Basis

Glucose (FBS) 3.60-6.10mmol/L

Glucose (HBS) 90-140 mmol/L

Uric Acid M- 214-448 umol/L

F- 137-363 umol/L

Cholesterol 0.00-5.20 mmol/L

Triglyceride 0.00-2.30 mmol/L

Creatinine 83 M(0-50y/o)- 74-110 Significance:

umol/L Creatinine is a
M(51-100y/o)72-127 waste product that
umol/L F(0-100y/o)- is significant in
58-96 determining
umol/L possible kidney
problems as it is
being excreted from
the blood to the
kidneys.
Indication:
NORMAL

BUN 10.56 2.2-7.1mmol/L Significance:

Blood Urea
Nitrogen (BUN) is
significant in
determining the
nitrogen present in
blood that is
produced when
liver breaks down
protein Indication:
ABNORMAL
Interpretation:
The patient has an
elevated BUN
result.

ALP 30-120 u/L

SGOT/AST 18 M- <35 u/L Significance: This

F- <31 u/L determines if the
liver is functioning
well as this is
produced by the
liver, but this is also
present in the heart,
kidneys, muscles,
and brain that’s
why elevated result

may suggest
problems in
 the said body
parts. Indication:
NORMAL

SGPT/ALT 17 M- <45 u/L Significance: This

F- <35 u/L evaluates the health
of the liver as this
is an enzyme found
in the liver.
Indication:
NORMAL

HDL M- >0.9 mmol/L

F- >1.15 mmol/L

LDL 0.63 <2.9 mmol/L Significance: LDL

(bad cholesterol) is
significant in
determining a
possible heart
problem.
Determining the
level of LDL may
help the patient
prevent heart
diseases and be
knowledgeable
about his
current heart
health. Indication:
NORMAL

Total Protein 64.83 g/L

Albumin 35-62 g/L

Globulin 23.0-35.0 g/L

A/G Ratio
Hematology (CBC)

Parameter Result Result Result Unit Reference Pathophysiological

(09/16/20 (09/17/20 (09/19/20 Range Basis
23, 23, 23,
2:50PM) 12:51PM 3:00AM)
) Post-BT

HGB 83 84 99 g/L 110-160 Significance:

Hemoglobin is
significant in
transporting
oxygen and
nutrients in the
 body. Abnormal
results may cause
O2 deprivation.
Indication:
ABNORMAL
Interpretation:
The patient has
lower than normal
hgb count.

HCT 26.9 26.6 32.6 % 37.0-54.0 Significance:

Hematocrit is
significant in
determining the
red blood cell
count of a patient.
Indication:
ABNORMAL
Interpretation:
The patient’s hct
results were
consistently low.

RBC 3.26 3.26 3.90 10^12/L 3.50-5.50 Significance: Red

blood cells are the
oxygen carrying
component of the
blood.
Indication:
ABNORMAL
Interpretation:
During the first
and second
laboratory test of
the patient, his red
blood cells were
lower than
normal. On the
third day,
Post-BT, his rbc
result went back
to normal.

PLT 267 215 198 10^9/L 150-350 Significance:

Platelets are
important in
clotting the blood
to prevent
bleeding. This test
is used to
determine if the
clotting factor of
 the blood is
functioning well
Indication:
NORMAL

WBC 17.43 14.65 10.19 10^9/L 4.00-10.00 Significance:

White blood cells
are responsible
for the
inflammatory
response of
the body.
These cells fight
diseases,
bacteria, and
viruses by
increasing in
number.
Indication:
ABNORMAL
Interpretation:
The patient has a
consistent
elevated result.

Neu# 12.76 9.89 6.29 10^9/L 2.00-7.00 significance:

Neutrophils are a
type of
white blood
cells that
protect the
body from
infection,
and other
diseases.
Indication:
ABNORMAL
Interpretation:
The patient has a
consistent
elevation in his
neutrophil count.

Lym# 3.63 2.55 2.09 10^9/L 0.80-4.00 Significance:

Lymphocytes are
also a type of
white blood cells
that protects the
body by fighting
off infections and
diseases that are
transmitted
 bacteria,
viruses, and
other foreign
objects. This test
is used to
determine the
lymphocyte count
in the blood.
Indication:
NORMAL

Mon# 0.78 0.91 0.73 10^9/L 0.12-1.20 Significance:

Monocytes are
responsible for
the inflammatory
response of the
body once
bacteria or germs
invade the body.
Abnormal results
may indicate
presence of
inflammation or
infection. This
test is used to
determine the
monocyte number
in the blood.
Indication:
NORMAL

Eos# 0.23 1.26 1.06 10^9/L 0.02-0.50 Significance:

Eosinophils are
part of the defense
mechanism of the
body to fight
against bacteria,
germs, and
viruses. This test
is used to
determine
eosinophil
count in the
blood.
Indication:
ABNORMAL
Interpretation:
The patient’s
results were
elevated during
the second and
third test.
Bas# 0.03 0.04 0.02 10^9/L 0.00-0.10 Significance:
Basophils are also
part of the WBC
which fights off
allergens,
pathogens, and
parasites. They

also prevent blood

clots and improve
blood flow in the
body. Abnormal
results may
indicate infection
or more
complicated
disorders such as
leukemia and
hyperthyroidism.
This test is used to
determine
the basophil count
in the blood.
Indication:
NORMAL

MCH 25.5 25.8 25.4 pg 27.0-34.0 Significance:

Mean Corpuscular
Hemoglobin
shows the amount
of hgb present in
the rbc. Abnormal
results may
indicate anemia if
low, and lung or
kidney disease if
high. Indication:
NORMAL

MCV 82.6 81.7 83.7 fL 80.0-100.0 Significance:

Mean Corpus
Volume shows the
size and volume
of the rbc.
Abnormal
results may
indicate
microcytic anemia
or macrocytic
anemia.
Indication:
NORMAL
MCHC 309 316 304 g/L 320-360 Significance:
Mean Corpuscular
Hemoglobin
Concentration
servesas an
evaluation of the
blood's oxygen-
carrying capacity
and can be used to
identify and
categorize
blood-related

illnesses, such as
anemia.
Indication:
ABNORMAL
Interpretation:
The patient’s
results were
consistently low.

RDW-CV 16.3 19.1 17.7 % 11.0-16.0 Significance: Red

Cell Distribution
Width-Coefficient
of Variation
shows if sufficient
amount of rbc is
normal in size.
Indication:
ABNORMAL
Interpretation:
Consistent
elevation of
RDW-CV was
seen in the
patient’s result.

RDW-SD 50.7 57.9 54.9 fL 35.0-56.0 Significance: Red

Cell Distribution
Width- Standard
Deviation shows
the width of rbc.
Indication:
ABNORMAL
Interpretation: On
the second
laboratory test,
the patient’s result
was elevated.
Neu% 73.2 67.5 61.7 % 50.0-70.0 Significance:
Neutrophils are a
type of
white blood
cells that
protect the
body from
diseases,
illnesses, and
infections.
Indication:
ABNORMAL
Interpretation:
The patient’s
neutrophil
percentage was
higher than
normal when he
was admitted.

Lym% 20.8 20.4 20.5 % 20.0-40.0 Significance:

Lymphocytes are

also a type of
white blood cells
that protects the
body by fighting
off infections and
diseases that are
transmitted
bacteria, viruses,
and other foreign
objects. This test
is used to

determine the
lymphocyte
percentage in
blood,
Indication:
NORMAL
Mon% 4.5 6.2 7.2 % 3.0-12.0 Significance:
Monocytes are
responsible for

the inflammatory
response of the
body once
bacteria or germs
invade the body.
Abnormal results
may indicate
presence of
 inflammation or
infection. This
test is used to
determine the

monocyte the
percentage in
blood.
Indication:
NORMAL
Eos% 1.3 8.6 10.4 % 0.5-5.0 Significance:
Eosinophils are
part of the defense
mechanism of the
body to fight
against bacteria,
germs, and
viruses. This test
is used to
determine
eosinophil count
in the blood.
Indication:
ABNORMAL
Interpretation:
The patient’s
result elevated
during the second
and third test.

Bas% 0.2 0.3 0.2 % 0.0-1.00 Significance:

Basophils are also
part of the WBC
which fights off
allergens,
pathogens, and
parasites. They
also prevent blood
clots and improve
blood flow in the
body. Abnormal
results may
indicate infection
or more
complicated
disorders such as
leukemia and
hyperthyroidism.
This test is used
to determine the
basophil
percentage in the
blood.
 Indication:
NORMAL
MPV 7.9 7.8 8.2 fL 6.5-12.0 Significance:
Mean Platelet
Volume shows the
size of the
platelet. This test
is used to
determine if there
is any problem
regarding blood
clotting.
Abnormal results
may indicate
bleeding
disorders.
Indication:
NORMAL
PDW 15.8 15.7 15.8 9.0-17.0 Significance:
Platelet
Distribution
Width shows the
size of the

platelet.
Abnormal
results may
indicate
destruction of
platelets.
Indication:
NORMAL
PCT 0.211 0.168 0.162 % 0.108-0.28 Significance:
2 Procalcitonin is a
defense
mechanism of
the body against
infections and
inflammation. This
test is used to
determine the
presence of sepsis
in the body.
Abnormal results
may
indicate infection.
Indication:
NORMAL
Crossmatching (09/16/2023, 10:17AM)
Patient’s Blood Group B

Rh (Anti-D) Positive
 Blood Component PRBC (closed system)
Blood Bag Segment Number P58Y7346

PRBC Extraction Date August 26, 2023

PRBC Expiration Date September 30, 2023

PRBC Expiration Time 11:59 PM

Donor’s Number NV-6186

Blood Group B

Rh (Anti-D) Positive

CROSSMATCHING COMPATIBLE
Blood Typing (09/16/2023, 10:17AM)

Examination Result

Blood Type B

Rh Type Positive
Serum Electrolyte (09/16/23, 2:52PM)

Test Sodium Potassium Chloride

Result 141.4 4.05 100.2

Normal Value 135-145 mmol/L 3.5-5.5 mmol/L 96.0-110.0 mmol/L

Pathophysiological Significance: Significance: Significance:

Basis This test determines This test determines This test determines
if the fluid in the if the cell, if the body’s fluid is
body and the blood nerve and maintained and the
volume are muscle of the body acid-base is
well-maintained. are balanced. Indication:
Indication: functioning well as it NORMAL
NORMAL carries small
electrical charges.
Indication:
NORMAL
Nursing Consideration
Before:
1. Verify the patient's identification to ensure the correct patient is being tested.
2. Explain the procedure and the purpose of the test to the patient.
3. Ask the patient to disclose any medications, supplements, or herbal remedies they have
taken that may affect the test results.
4. Check the patient's medical history for any previous blood disorders or bleeding
tendencies.
5. Assess the patient's vital signs, including blood pressure, pulse, and respiratory rate.
During:
1. Collect a blood sample from the patient using a needle and syringe or by pricking the
finger with a lancet, depending on the specific test being performed.
2. Use appropriate aseptic techniques to minimize the risk of infection.
 3. Monitor the patient's vital signs and comfort level during the procedure.
4. Provide emotional support as needed.
After:
1. Label the blood sample with the patient's information and send it to the laboratory for
testing.
2. Monitor the patient for any signs of adverse reactions or complications, such as bleeding
or infection.
3. Document the procedure and the results of the test in the patient's medical record. If the
test result is abnormal, inform the healthcare provider and provide
appropriate interventions as ordered.
4. Provide the patient with information on how and when to expect the test results, and how
to follow up with the healthcare provider if necessary.
5. Dispose of any supplies and equipment properly to minimize the risk of infection.

NVPH Radiographic Report (09/16/2023, 10:06AM)

Exam- Chest PA
Examination shows clear lungs
Heart and great vessels are of normal size and configuration
Other chest structures are remarkable
Impression- Normal Chest Radiograph

Nursing Considerations
Before:
1. Remove everything metallic.
2. Inform the patient that unless prescribed by a healthcare professional, fasting or
medication restriction are not necessary.
3. Make sure the patient is not suspected of being pregnant or pregnant.
4. Evaluate the patient’s capacity for breath holding.
5. Give the patient instructions on how to take off all clothing up to the waist and put on an
X-ray gown for the procedure.
During:
1. When feasible, leave the room during an X-ray exposure.
2. As little time as possible should be spent when exposing patient to X-rays.
3. Use protective lead shielding while within the X-ray room by donning a lead apron or
standing behind a lead screen.
After:
1. Reassure the patient that after the procedure, no additional care is needed.
2. Make sure that the patient is comfortable after the procedure.
 CHAPTER VI
PERSON ASSESSMENT

PSYCHOSOCIAL

Assessment Pre-Assessment Post-Assessment

Date & Time: Date & Time:

September 18, 2023 September 19, 2023

Family Type Nuclear

Significant Others Name: Mrs. LT

Age: 38 years old

Sex: Female

Educational Attainment: Elementary (Grade 6)

Relationship to the patient: Wife

Coping Mechanism The patient stated that he does The patient stated that he does
gardening when he is stressed. gardening when he is stressed.

Religion Roman Catholic Roman Catholic

Primary Language Ilocano Ilocano

Primary Source Nueva Vizcaya Provincial Hospital Nueva Vizcaya Provincial Hospital
Healthcare (NVPH) (NVPH)

Financial Resources PhilHealth PhilHealth

Related to Healthcare

Occupation Farmer Farmer

Educational Grade 6 Grade 6

Attainment

General Appearance The patient was dressed properly; The patient was dressed properly;
he was wearing a shirt and pants. he was wearing a shirt and shorts.
His hair was short, and his nails His hair was short, and his nails
were neat and well-trimmed. were neat and well-trimmed.

The patient cannot maintain a fully The patient cannot maintain a fully
upright position due to body upright position due to body
 weakness.
Level of The patient is conscious. He was
Consciousness compliant and cooperative. His
responses to the interview questions
were unclear; he was confused.
Orientation The patient is fully oriented. He
recognizes what the date is and
where he is.
Time - The patient is able to tell time
by saying, "10:15 am ma'am."
Date - The patient determines the
date as he verbalizes, "September
18, ma'am."
Place - The patient is aware of where
the incident happened.
Event - the patient is aware that he is
being interviewed at NVPH.
Memory - The patient is able to recall
immediate and remote
memories but he is not able
to recall recent memories.
Immediate - Memory is intact
- the patient was able to repeat
“5,10,15,20” and
“10,20,30,40”
Recent - Memory is not intact
- When I asked what he had
eaten for breakfast, the
patient stated, "nalipatak
ma’am"
Remote - Memory is intact
- The patient verbalized that
their anniversary was on July
23, 1988.
Speech The patient speaks in a normal tone
and is easily understandable.
The patient was able to respond to
weakness.
onscious. He was
The patient is c
cooperative. His
compliant and
the interview
responses to
unclear; he was
questions were
confused.
The patient is fully oriented. He
recognizes what the date is and
where he is.
Time - The patient is able to tell time
by saying, "9:45 am ma'am."
Date - The patient determines the
date as he verbalizes, "September
19, ma'am."
Place - The patient is aware of where
the incident happened.
Event - the patient is aware that he is
being interviewed at NVPH.
- The patient is able to recall
immediate, recent, and remote
memories
Immediate - Memory is intact
- the patient was able to repeat
“red, blue, green” and
“yellow, pink, white”
Recent - Memory is intact
- He remembered how the
incident happened.
Remote - Memory is intact
- The patient remembered that
he was hospitalized at the age
of three for dengue fever.
The patient speaks in a normal tone
and is easily understandable.
The patient was able to respond to
 questions and explain them. The questions and explain them. The
responses were also specific. responses were also specific.

Nonverbal Behavior The patient smiles and maintains eye The patient smiles and maintains eye
contact during pre-assessment. contact during post-assessment.

ELIMINATION

Stool Frequency: 1x Frequency: 1x

Consistency and Shape: Consistency and Shape:Solid,

soft, and well formed Color:
Watery, no solid pieces.
Yellow Amount: Moderate
Color: Yellow and dark red
Odor: No unusual odor.
Amount: Moderate

Odor: The odor is foul-smelling; it's

an iron-like smell.

Urine Patient has no difficulty urinating Patient has no difficulty urinating

Amount: approx. 500ml per Amount: approx. 500ml per

urination urination

Frequency: urinates 9x times a day Frequency: urinates 6x times a day

Color: light yellow Color: light yellow

Smell: no unusual odor Smell: no unusual odor

Clarity: Clear Clarity: Clear

Pattern: usually every 2 hours Pattern: usually every 2 hours

Toileting Ability
The patient can ambulate and can The patient can ambulate and can
go to the toilet with assistance. go to the toilet with assistance.

REST AND ACTIVITY

Current Activity The patient can sit, stand, and walk The patient can sit, stand, and walk
Level carefully with assistance. carefully with assistance.
ADL’s Grooming: bathes once a day, and Grooming: bathes once a day, and
he can groom himself with he can groom himself with
assistance. assistance.

Feeding: Patient is able to feed Feeding: Patient is able to feed

himself with assistance. himself with assistance.

Ambulating: The patient needs Ambulating: The patient needs

assistance when moving and uses assistance when moving and uses
assistive devices. assistive devices.

Toileting: The patient can go to the Toileting: The patient can go to the
toilet with assistance. toilet with assistance.

Communicate: patient is clear and Communicate: patient is clear and

comprehensive and can comprehensive and can
communicate properly. communicate properly.

Sleep Sleep History: The patient is Sleep History: Patient is able to

unable to sleep properly. sleep properly.

Duration: He sleeps for 7 hours, Duration: He sleeps for 8 hours,

from 11 p.m. to 6 a.m from 10 p.m. to 6 a.m

Quality and Characteristics: Quality and Characteristics:

Aside from nurses coming in at
night to administer medications, the
patient can't sleep peacefully due to
epigastric pain, and his sleep is
interrupted.
Aside from nurses coming in at
night to administer medications, the
patient can't sleep peacefully due to
epigastric pain, and his sleep is
interrupted.

Body Frame Body Type: Mesomorph Body Type: Mesomorph

Weight: 55kg Weight: 55kg

Height: 5’4 Height:5’4

BMI: 20.8 (NORMAL) BMI: 20.8 (NORMAL)

Posture The patient cannot maintain a fully The patient cannot maintain a fully
upright position due to body upright position due to body
weakness. weakness.

Coordination Able to do the finger nose test Able to do the finger nose test
properly. properly.

Gait The patient can walk with The patient can walk with
assistance. assistance.

Balance The patient cannot maintain his The patient cannot maintain his
balance; he does balance; he does
experience dizziness when experience dizziness when
 standing. standing.

Muscle
Strength: 5/5 Strength: 5/5

Size: Normal Size: Normal

Movements: No involuntary Movements: No involuntary

movements. movements.

Motor Function Fine: the patient can grasp his Fine: the patient can hold his water
phone bottle
Gross: the patient can flex and Gross: the patient can flex and
extend extremities extend extremities

Range of Motion Arms: can extend arms and can do Arms: can extend arms and can do
pronation and supination of arms pronation and supination of arms
with no difficulty with no difficulty

Elbows: can flex and extend elbow Elbows: can flex and extend elbow

Wrists: can consistently twist his Wrists: can consistently twist his
wrist wrist

Hands and fingers: can flex and Hands and fingers: can flex and
extend his hand and his fingers extend his hand and his fingers

Leg: Can do pronation, neutral and Leg: Can do pronation, neutral and
supination of arms with no supination of arms with no
difficulty difficulty

Pain Relief Measures Sleep, rest, and deep breathing Sleep, rest, and deep breathing

Mobility and The patient needs assistance when The patient needs assistance when
Assistive Devices: moving and uses assistive devices. moving and uses assistive devices.

SAFETY AND ENVIRONMENT

Allergies
No allergies to food, medication, and No allergies to food, medication, and
environment. environment.

Eyes/Vision Glasses: The patient does not use Glasses: The patient does not use
glasses. glasses

PERRLA: PERRLA all assessed as PERRLA: PERRLA all assessed

normal (pupils are equally round as normal (pupils are equally round
and react to light and and react to light and
accommodation) accommodation)

P- The pupil is about 4-5mm. P- The pupil is about 4-5mm.

 E- The patient's pupils are the same E- The patient's pupils are the same
size and shape. size and shape.

R- The patient's pupils are round. R- The patient's pupils are round.

R- Pupils react smaller in response to R- Pupils react smaller in response to

light. light.

L- Pupils are constricted when L- Pupils are constricted when

exposed to light. exposed to light.

A- The patient's pupils dilate when he A- The patient's pupils dilate when he
looks at something far away and looks at something far away and
shrink when he looks near. shrink when he looks near.

Vision: The patient states that he has Vision: The patient states that he has
no problem seeing things afar no problem seeing things afar
Color
Skin: Brown Skin: Brown

Nail Beds: Pale Nail Beds: Pale

Peripheral pulse Location: Radial Location: Radial

Rate: 90 bpm Rate: 84 bpm

Rhythm: Regular Rhythm: Regular

Strength: Strong, and consistent Strength: Strong, and consistent

Blood Pressure 130/90mmHg 130/90 mmHg

Edema None None

Hearing/Ears
The patient had no The patient had no
difficulty hearing us. difficulty hearing us.

The patient also does not have any The patient also does not have any
hearing aids. hearing aids.

Skin Integrity
Upon pinching, the skin elasticity is Upon pinching, the skin elasticity is
good. good.

The patient had no jaundice or The patient had no jaundice or

cyanosis, but he had pallor. He also cyanosis, but he had pallor. He also
had no rashes or lesions. had no rashes or lesions.

Temperature 36.8 C 36.4 C

 OXYGENATION

Activity Intolerance The patient performs tasks with The patient performs tasks with
difficulty and needs assistance. difficulty and needs assistance.

Airway Clearance During the assessment, the patient’'s During the assessment, the
airway clearance in his nose patient’s airway clearance in his
maintains clear and open airways. nose maintains clear and open
airways.

Respiration Rate: 22cpm Rate: 20cpm

Rhythm: Regular Rhythm: Regular

Character: depth is normal. Character: depth is normal.

Lung Sounds During auscultation, a vesicular lung During auscultation, a vesicular lung
sound and a soft blowing sound hav e sound and a soft blowing sound have
been noted. been noted.

Capillary refill Pressure is applied to the nail bed

Pressure is applied to the nail bed
until it turns to white. Color returns
until it turns to white. Color
to normal for less than 2 seconds.
returns to normal for less than 2
seconds.
It is used to monitor dehydration and
the amount of blood flow to tissue.
It is used to monitor dehydration and
the amount of blood flow to tissue.

Oxygen Saturation 98% 97%

NUTRITION

Diet restrictions Diet as tolerated, except for dark Diet as tolerated, except for dark
foods, because it may affect the foods, because it may affect the
color of the stool and may affect color of the stool and may affect the
the accuracy of the assessment. accuracy of the assessment.

Fluid Intake 8 glasses 10 glasses

Height 5’4 5’4

Weight 55kg 55kg

BMI 20.8 (NORMAL) 20.8 (NORMAL)

Skin Turgor Patient is hydrated. Skin returns to Patient is hydrated. Skin returns to
normal for less than 2 seconds. normal for less than 2 seconds.

Ability Chew: Patient is able chew Chew: Patient is able chew

Swallow: Patient is able swallow Swallow: Patient is able swallow

Feed Self: Patient is able to feed Feed Self: Patient is able to feed
himself with assistance himself with assistance

Tolerate Food: Diet as tolerated Tolerate Food: Diet as tolerated

except dark foods except dark foods
 CHAPTER VII
Drug Study
DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS/ADVERSE NURSING CONSIDERATION
EFFECTS
Generic Name: Treatment of peptic - Hypersensitivity to Side Effects: Baseline assessment:
- Omeprazole ulcers and reduces Omeprazole. - Headaches T: 36
stomach acid - Nausea PR: 120
Stock Dose: production for healing - Vomiting BP: 130/70 mm Hg
- 40mg and preventing - Stomach pain RR: 21
recurrence. - Constipation O2 Sat: 96
Therapeutic - Flatulence
Classification: Intervention/evaluation:
- Antiulcer Adverse Effects: - Conduct thorough assessment
drugs - Asthenia of the patient’s medical
- Abdominal pain history (allergies and current
- Acid regurgitation medications).
Date Started: - Check vital signs for baseline
- Back pain
- September data.
- Cough
16, 2023 - Examine and palpate the
- URI
abdomen to rule out any
Doctor’s order: - Rash
underlying medical issues;
Dosage: 80mg note any changes in bowel
Route: Intravenous movements and GI distress to
rule out any side effects.
- Monitor the patient’s
nutritional status; use of small
 frequent meals may be

helpful if GI upset is a
problem.
- Monitor patient in case
adverse effects occur.

Patient/family teaching:
- Educate patient or family on
potential side effects.
- Instruct patient to report any
side effects or adverse effects.
- Observe how well the
comfort and safety
precautions are working and
how well the regimen is
being followed.

DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS/ADVERSE NURSING CONSIDERATION

EFFECTS
 Generic Name: To promote the healing of peptic ulcer in the stomach or small Contraindicated in Side Effects: Baseline assessment:
- Rebamipid intestine. patients with: - Nausea T: 36
e - hypersensitivit - Diarrhea PR: 120
y to drug, and - Abdominal BP: 130/70 mm Hg
Stock Dose: - severe renal pain RR: 21
- 100mg impairment. - Headache O2 Sat: 96
- Dizziness
Therapeutic Intervention/
Classification: Adverse Effects: evaluation:
- Antiulcer - Rash - Conduct
drugs - Itching thorough
- Swelling assessment of the
Date Started: patient’s medical
- Severe
- September history (allergies
dizziness
16, 2023 and current
- Difficulty
breathing medications).
Doctor’s order:
- Liver - Assess patient’s
Dosage: renal function
dysfunctio
100mg - Check vital signs
n
Frequency: for baseline data.
3x a day - Provide health
Route: Oral teaching about
the medication.
- Monitor patient
in case adverse
effects occur.

Patient/family teaching:
- Educate patient
or family on
potential side
effects.
- Instruct patient to
report any side
effects or adverse
effects.
- Observe how
well the comfort
and safety
precautions are working and
how well the regimen is
being followed.
DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS/ADVERSE NURSING CONSIDERATION
EFFECTS
Generic To promote regular bowel movements and Contraindicated in Side Effects: Baseline assessment:
Name: facilitate elimination of stool. patients with: - Bloating T: 36
- Lactulose - Galactosemia - Abdominal PR: 120
- Intestinal cramps BP: 130/70 mm Hg
Stock Dose: Obstruction, - Diarrhea RR: 21
- 10g/15mL and; - Nausea O2 Sat: 96
- Severe - Vomiting
Therapeutic dehydration Intervention/evaluation:
Classification: Adverse Effects: - Check Doctor’s
- Osmotic - Severe order.
laxatives diarrhea - Conduct thorough
- Dehydration assessment of the
Date Started: - Electrolyte patient’s medical
- September imbalances history (allergies
16, 2023 and current
medications).
Doctor’s - Check vital signs
order: for baseline data.
Dosage: 30mL - Monitor patient’s
Frequency: hydration status.
Once daily - Provide health
Route: Oral teaching about the
medication.
- Monitor patient in
case adverse
effects occur.

Patient/family teaching:
- Educate patient or
family on potential
side effects.
- Instruct patient to
report any side
effects or adverse
effects.
- Observe how well the
comfort and safety
precautions are working and
how well the regimen is
being followed.
DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS/ADVERSE NURSING CONSIDERATION
EFFECTS
Generic Name: To treat nausea and Contraindicated in patients Side Effects: Baseline assessment:
- Metroclopra vomiting. with: - Muscle spasms T: 36
mide - Hypersensitivity to - Drowsiness PR: 120
drug - Diarrhea BP: 130/70 mm Hg
Stock dose: - Mechanical - Weakness RR: 21
- 10 mg Obstruction - Hypotension O2 Sat: 96
(5mg/mL) - Perforation
- Pheochromocytoma Adverse Effects: Intervention/evaluation:
Therapeutic - Seizure disorders - Seizure - Conduct thorough
Classification: assessment of the patient’s
- Antiemetic, medical history (allergies and
GI stimulant current medications).
- Check vital signs for baseline
Date Started: data.
- September - Assess GI condition
16, 2023 - Monitor the patient's
hydration status.
Doctor’s order:
Dosage: 10mg Patient/family teaching:
Frequency: Every 8 - Educate patient or family on
hours, as needed potential side effects.
Route: Intravenous
- Instruct patient to report any
side effects or adverse
effects.
- Observe how well the
comfort and safety
precautions are working and
how well the regimen is
being followed.
 Nursing Care Plan

Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
SUBJECTIVE: Disturbed ShortTerm: Independent: Independent: Short Term:
sleeping
- “Madalas pattern After 1 hour - Assess - Assessing After 8 hours
paputol nursing of the a patient's of nursing
related to
-putol the intervention patient’s sleep intervention,
epigastric
yung patient , sleep pattern goal was met
pain to:
tulog will be able patterns. helps in as evidenced
secondary
ko - Identify providing by the
dahil to - health
upper comparati patient being able to:
minsan Identify condition
gastrointesti individually ve
sumasa s
nal appropriate baseline - Verbalize
kit contribut
bleeding interventions data. understand
yung ing to
AEB that - Acute and ing on
tiyan disturbed
difficulty sleeping chronic individuall
ko kaya y
daily promote sleep patterns. diseases
nagigisi - appropriat
functioning such as - Identify conditions
ng ako” e
, music and dim poor must
be interventio
OBJECTIVES lights. sleep
identifi ns
: Identify hygiene
ed first that
factors behavior
- Inability as promote
contributing s.
to to poor - Educate these sleep AEB
concentrat - sleep the cannot being able
e patterns patient to identify
always
- Confusion such as on basic and/or
be
- Dark environmen sleep state it
adjuste
circle tal stimuli hygiene accurately.
d.
 under eye like noise behavior - The use He plays
- Frequent and light. s. of music
yawning Report - Suggest electronic when he
- Lack of improvement ways to s wants to
energy in sleep improve before sleep and
pattern. the uses a
bed,
environme blanket to
napping
nt or block the
during
provide a hospital
the
calm lights.
day,
and - Verbalize
irregul
quiet understand
ar
bedtim ing onthe
es,
caffein factors
e
intake too
late
in the
day, and
sedentary
 - Report an - environment - lifestyles - contributing to
increase in to achieve contribute poor sleep
energy level optimum to patterns
and feeling amount inadequate AEB
rested. of sleep. showing
- Verbalize resting time. Room-darken
signs
understanding Educate ing curtains
of adherence to
on the proper the can keep out health
use of sleep patient on the bright light if teachings. He
aids and sleep proper food the patient does not use
hygiene and fluid needs to sleep cell phone
behaviors. - intake such as during the day, before going to
while bed.
avoiding quiet is Report an
heavy meals, usually -
Long Term: improvement in
alcohol, recommended sleeping pattern
caffeine, , if
After 6 weeks of as evidenced by
or background
nursing intervention smoking an increased
the patient will be able noise is energy level and
before -
to: needed, a feeling
bedtime.
white noise rested. The client
Encourage
- Report an machine
daytime is able to do
optimal or other
physical self
amount of sleep soothing sounds
activities but care
as evidenced by can
instruct activities such as
a help.
the grooming,
rested These foods
patient to bathing,
appearance, and
avoid toileting
strenuous substances and
activities inhibit sleep feeding.
before and Verbalize
bedtime. understanding
avoiding
verbalization - Introduce - heavy meals on the
of feeling rested, relaxing during the night proper use of
and activities reduces sleeping aids
improvement such as warm the need and compliance
in sleep baths, calm for on sleep
pattern. music, night-time hygiene
reading a book, elimination. behaviors AEB
and Stress is showing
-
relaxation reduced signs of
exercises through adherence
before therapeutic towards the
- bedtime. activities and it instructions
Render also given.
bedtime care promotes
such as back sleep. Long term:
rub and other - Activities that
relaxation provide - To be followed
- techniques. relaxation and
Educate the distraction
patient about prepare the
sleep mind and
requirements body for
and help him sleep.
understand Bedtime
the main cause
nursing
of care
sleeping facilitates
difficulties. relaxation and
promotes
the
onset of sleep.
Dependent: - Part of a
healthy bedtime
- Review routine is
medications signaling to the
being taken mind and body
and their that it’s time to
effect on shut down.
sleep and - Misconceptions
suggest and myths
modification
about sleep
in regimen.
exist, thus,
- Administer
wrong notions
pain
about sleep
medication if
disturbances
required 1 hour
before sleep may cause fear
and anxiety.
Collaborative:

- Refer to
a sleep Dependent:
specialist/
- Some
laboratory for
medications
treatment
cause sleep
when
disturbances,
indicated.
hence,
reviewing the
patient’s
medications
 enables us to
assess and
report if any
modification
is needed.
- To relieve
discomfort
and to allow
the patient to
sleep
adequately
and
comfortably.

Collaborative:

- To promote
faster sleep
development
of the patient

Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
SUBJECTIVE: Fatigue r/t Short term: Independent: Independent: Short Term:
decreased
- “Nakakara hemoglobin After1 hour of 1. Establish - To gain trust from Goal Met:
mdam ako ng and nursing rapport the patient the patient and be
diminished intervention, the will After1 hour of
pagod through: able to get the
oxygen patient be able nursing
madalas at needed
carrying to: a) Proper intervention, the
nanghihina information in patient was able
ako, akala ko capacity of the communication connection to her
- Verbalize to:
e dahil lang blood concern.
secondary to understandin b) Non – -
to sa - To obtain basic Verbalize
anemia as g of the use violent
trabaho ko” indicators of a his
evidenced by of approach
- “Konting patient's health understand
galaw ko lethargy, status. ing in the
- energy 2. Monitor
palang drowsiness, use of
conservation physiologic - To promote rest to
nakakaramd difficulty the patient. energy
principles. response to
am na ako concentrating, - To know what is conservati
Verbalize activities.
ng pagod. yawning, and on
the 3. Assistthe patient the cause of
Minsan disinterest in - principles.
reduction of to a fatigue.
maglakad-la the Identify
fatigue, comfortable position - To know how we the
kad lang surrounding
as for rest and sleep. can help our causative
napapagod evidenced 4. Assess the specific patient in terms of factors of
pa ako kaya by reports of cause of fatigue. his daily living. his
madalas na increased 5. Assess the - Since the patient is disease.
lang akong -
energy and patient’s ability weak it is very
na upo ” ability to to perform important to
- “Madalas perform Assess patients in
activities of
paputol-put desired
 activities. risk of falling to
Identify avoid future
causative problems.
- You need to assess
patients' emotional
ol yung response to
limitations in
physical activity
because the patient
may be surprised
by the
 tulog ko Long factors of his 6. daily living change in his Partially Met:
dahil disease. (ADLs) and the daily routine.
minsan After demands of - Educating a patient After1 hour of
sumasakit nursingTerm: about his daily activity nursing
daily living.
yung tiyan Assess the risk will help him to have intervention, the
patient 6 weeks of 7. patient was able
ko kaya of falling and knowledge about
to: to:
nagigising enforce working and resting
ako” intervention, the will
- applicable periods. -
be able Verbalize
strategies. - So that the body of the
OBJECTIVES: the
Assess patient will not be reduction
Identify 8. emotional startled.
- Lethargy of fatigue,
methods to response to - Promoting nutritional as
- Drowsiness - - reduce limitations in status will help the evidenced
activity physical patient to be more by reports
Difficulty
intolerance. activity. healthy and have enough of
Concentrati ng
Feel Educate energy for daily living. increased
- Yawning
comfortable 9. the energy
- Disinterest
in his patient in Dependent: and ability
in the
surroundings developing a to perform
surrounding - To look at overall
- , get rid of schedule desired
dizziness for daily health of the patient activities.
Vital Signs:
and activity and find a wide range
- yawning. of conditions,
- RR - and rest.
Have including anemia. Long
22 cpm Educate Term:
adequate
- PR - rest. the
109 Collaborative:
Report the patient about
bpm gradual increase
ability to
 of activities
to
tolerance as the
patient’s

The laboratory - perform strength - To assist and help the - Undetermi

findings are as the progresses. 10. patient for his daily ned e
follows: required Promote living and fast recovery.
activities Nutritional Status
- Hgb: 83g/L of
- Hct: 26.9% Dependent:
daily living.
Have 1. Monitor
laboratory
stable Hgb studies, such
and as CBC.
Hct.
Collaborative:

1. Discuss to the
family about
the patient's
condition.
Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation
Explanation
SUBJECTIVE: Fatigue r/t Short term: Independent: Independent: Short term:
activity
- “Hindi ko intolerance After 1 hour of 1. Determine - To provide a After 1 hour of
nagagawa secondary to nursingintervention, the level baseline nursing intervention,
yung mga the to:patient will able of the comparison the goal was met. The
anemia AEB
gusto kong verbalization of and track the patient was able to:
- patient’s
gawin mag decreased activity
report progress - report progressive
isa dahil tolerance in intolerance
progressive - To
nanghihina daily activities, of development and
development
ako at madali physical the patient increase in
and increase in promote
akong assessments, activity 2. Determine activity
mapagod.” higher than mobility tolerance
tolerance the need for
- “Hindi na normal vital ambulation of the AEB by gradually
such as
gaya ng dati signs, and aids if patient if walking to
bathing,
yung pag decreased patient needed the
grooming,
galaw ko. laboratory cannot walk - To identify bathroom,
ambulating, deficiencies
Kailangan ko findings 3. Monitor bathing,
toileting, that may be
ng tutulong - the grooming,
and affecting his
sa akin.” patient’s ambulating,
feeding activity
hemoglobin toileting, and
OBJECTIVES: with tolerance
level feeding with
minimal to - To promote
4. Encourage minimal to no
- Shortness of no proper
the patient to assistance
breath assistance
try breathing and - identify the factors
- Body weakness identify the performing help stabilize that
- Dizziness factors that vital signs
activities aggravate
- Difficulty in aggravate - To help
slowly such
 decreased as sitting,
tolerance to standing,
activities walking to the
such as the patient decreased
bathroom, gradually tolerance to activity
performing and lying on increase his AEB by not
concentrating unnecessary his own tolerance doing

- easy activities, 5. Assess - To identify if - unnecessary

fatigability not complying for there’s pain activities to
- needs with the regimens patient’s that is promote
assistance that can increase degree of contributing to rest,complying
when doing his hgb and rbc, comfort the activity with intervention
ADLs such disturbed sleeping 6. Monitor the intolerance of to correct
ambulating, pattern, and sleep pattern the patient disturbed sleeping
bathing, not of the patient pattern, being
- To check if the
grooming, cooperating compliant with
sleeping
feeding, during the Dependent: the regimen that
pattern of the patient
and interventions. increases his hgb
is affecting
V/S toileting 1. Provide
- identify methods his activity and rbc, and
supplemental
and techniques level cooperating
- oxygen as
to reduce ordered. during the
- Dependent:
RR: 22 cpm activity intervention.
Laboratory PR: 109 bpm intolerance such Collaborative: identify methods
as gradual - To promote and techniques to
- findings: increase in 1. Refer to the balance reduce activity
- activities by laboratory between intolerance AEB
Hgb: 83g/L walking to the when ordered. cooperating with
oxygen supply
RBC: 3.26 bathroom, 2. Encourage the given
and demand.
grooming, the SO to interventions such
Collaborative:
toileting, and support the as displaying
feeding patient - To monitor proper deep
the breathing
Long Term: hemoglobin technique and
level and trying to
RBC

After 6 weeks of - To give the gradually increase

nursing intervention, patient a activities
the patient will be motivation - demonstrate
able to: to cooperate methods of
with the controlled
- display a stable interventions breathing
laboratory techniques to conserve
value energy
specifically AEB by
hgb, hct, rbc, cooperating during the
wbc, neu, eos, health teaching of
mchc, rdw-cv, proper deep
rdw-sd, and breathing
BUN
technique
 - report -
maximum
tolerance Long Term:
in
activities - for further
of daily evaluation
living
such as
ambulating,
bathing,
grooming,
feeding,
and
toileting

Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
 SUBJECTIVE:

- “Biglang sumakit ang tiyan ko, banda dito (pointing at his

epigastric
region”
- PQRST:

Provoking factor:
The pain is triggered by
overeating

Q: Throbbing pain is experienced

Region/Radiation: The pain is situated on his epigastric region.

Severity: 7/10 pain

scale
Acute pain r/t epigastric pain secondary UGIB As evidenced by verbalization of pain, PQRST
assessment,
increased
respiratory and heart rate, and
physical assessment
 Disruption of
mucous protective
layer
Gastric
mucosa
inflammation
Adherence on the
superficial mucosal
layer
Tissue
damage

Short term:

After 30 minutes of nursing intervention, the patient will be able to:

- Demonstrate
self-relaxation
techniques to relieve pain such as proper positioning and massage as well as deep
breathing exercise.

- Understand non-pharmacol ogical pain management such as deep

breathing
exercise which will be
Independent:

1. Assess the patient’s vital signs specifically

RR and PR since it
increases
when the client is in pain. .
2. Educate the patient about his condition, including
 what triggers it such as acidic food and spicy
foods, medications, and laboratory procedures.
Independent:

- To have comparison data regarding the patient's condition.

- This reduces the risk of a

patient's
condition to reoccur, and helps him to be more aware about
his condition.
Short Term:

After 30 minutes of nursing intervention, the goal patient was met.The patient:

- Demonstrated
self-relaxation
techniques AEB deep breathing and progressive movement and is able to position himself properly when in pain and use deep
breathing technique.
- Understand non-pharmacolo
gi cal pain
management, dietary changes, and proper
positioning and deep breathing. He verbalized

Time: pain started on September 15 and on September

16 he was
immediately
admitted to NVPH with chief complaints of epigastric pain

OBJECTIVES:
 - weakness
- grimace
- decreased
activity
tolerance
- guarding behavior

V/S

- RR: 22 cpm
- PR: 109 bpm

Acute
pain
Epigastric pain

Gastric ulcer

-
 measured by observing the client’s action. Receive patient
teaching regarding the
condition,
including its triggers such as eating acidic
foods,
treatments
such as use of analgesics , and procedures that need to be done and
verbalize
understanding regarding the treatments and procedures as well as dietary changes.
3. Advise the patient about non-pharmac ological techniques to relieve pain such as
proper
positioning
and massage
.
4. Instruct the patient to modify diet such as high fiber and non acidic foods. Avoid carbonated, alcoholic,
and spicy foods.

Dependent:

1. Take
prescribed medication
for pain
- This will helpin
alleviating patient’s comfort without the need to take medications.

- This
prevents triggering the condition which causes acute pain.
 Dependent

- To relieve acute epigastric

-

-
that he uses these techniques and reported decreased pain.

Received education about

his condition AEB
understanding how to properly position himself when having an acid reflux, diet modification,
and what he should avoid to prevent
recurrence of condition. Verbalize understanding of dietary changes to prevent furthertriggers. He stated that he will avoid
Long Term: management pain that the patient alcoholic
such as proton is drinks and
After 6 weeks of pump currently soft drinks as
nursing inhibitors experiencing well as spicy
intervention, the (e.g. - To foods
patient will be able Omeprazole
to: 2. Consult the further
doctor if pain examine and
- Report absence persists. Long Term
treat the
of pain 3. Administer patient. - To be followed
- Experience analgesic as - To
increase in prescribed
food tolerance relieve pain
Collaborative
Collaborative
1. Advise the
SO ( if - This will help
available ) to help the patient be
the more
patient encouraged
modify their to eat
diet. healthier food
2. Refer to options.
community - To
resources. continuously
have
healthcare
access outside
 the
hospital.

Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation

SUBJECTIVE:

- “Natatakot
ako pag nakikita ko yung dugo na isasalin sakin baka kasi may makuha akong sakit jan”

OBJECTIVES:

- weakness
 - difficulty concentrating
- tachycardia

V/S

- RR: 22
- PR: 109 bpm
Mild Anxiety r/t fear of blood secondary to blood transfusion
AEB feeling
nervous, weakness tachycardia and
difficulty concentrating.

The amygdala
releases stress
hormones that
prepare the body
to fight the threat
or flee from
danger.
 Hypothalamus
relays signals

Blood transfusion
scares the patient.

Short

After nursing

patient to:

-
term:

1 hour of
 interventions, the will be able

Patient’s vital signs will return to a stable baseline state.

Verbalize
awareness of feelings of anxiety.
Identify healthy ways to deal with anxiety.
Appear relaxed and report that anxiety is reduced to a
manageable level.
Independent

1. Establish rapport and

therapeutic relationship, conveying empathy and
positive regard.
2. Recognize awareness of
patient's anxiety.
3. Encourage the patient to acknowledge and express feelings.
4. Actively listen to the
patient's
feelings and concerns, and observe for non-verbal communicati on.
Independent

- To promote comfort and allow patient to begin looking at feelings and dealing with
situation
- To promote self awareness that helps in
controlling
actions and beginning to deal with issues that are causing anxiety.
- To clarify and understand a
patient's
thoughts and
feelings
- To help the patient
 identify what
Short term:

After 1 hour of nursing interventions, the patient was met. The patient was
able to:

- Stabilize his vital signs to a stable baseline state AEB by PR of 86 bpm and
20 cpm RR
- Verbalize awareness of feelings of anxiety AEB by openly communicating his feelings and telling about his fear in blood
- Identify healthy ways to deal anxiety AEB
meditation,
resting, deep breathing, and

Nervous,
tachycardia,
increased PR,
difficulty of
concentrating
 Body - Use resources/ support systems effectively.

Long Term:
Mild anxiety
After 6 weeks of nursing interventions, the patient will be able to:

- Develop and practice effective

coping skills
- Develop and demonstrate problem-solving techniques.
5. Provide honest and
respectful feedback
6. Provide
relaxation techniques
such as
resting,medit
ation, positive
visualization, reassuring or positive self
-statement,
and deep breathing.

Dependent

1. Administer medications such as anti

-anxiety
agents or sedatives if needed.
2. Drug management
is reality based.
- To help her recognize unrealistic
thinking
- To provide choices and help her make informed decisions on developing coping strategies

Dependent
 - To reduce and relax a
patient's anxiety.
- As some drugs may
cause
symptoms of anxiety.

Collaborative
positive
visualization
- Appear relaxed and reported that anxiety is reduced to a
manageable level AEB by his posture and verbalization of understanding that BT is a part of his treatment.
- Use resources/ support systems effectively AEB by active
collaboration
with the nurse and SO.

Long Term:

- Undetermined

alteration - To further
of the evaluate and
prescription counsel the
regimen. patient’s
Collaborative anxiety and if
drug man
1. Refer to the
physician for
consultation
 CHAPTER VIII
COURSE IN THE
WARD

DATE & TIME PROGRESS DOCTOR’S FDAR

NOTES ORDER

SEPTEMBER 16, 2023: Admission Date

@ 9:45am ASSESSMENT - Please F: admission
admit to medical
Chief Complaint: ward D: admitted a
Body weakness - Secure 44-year-old male with
consent for bouts of vomiting,
History of Present blood on stool, T –
admission
Illness: One-day 36,
history of epigastric Cd – 120, BP –
pain with body IVF: 130/70, O2 – 97%
weakness and - PNSS 1L x
melena; no other 8hrs x 3 cycles
@ 11:30am F: client was
accompanying - Omeprazole
transferred into the
signs and Drip: 80mg IV +
ward from the ER via
symptoms. 90cc PNSS TRF
wheelchair (post
Persistence 10hrs. x 72hrs.
admission care)
prompt
consultation.
D: wear as seen
Pertinent Past
A: assisted to bed
Medical History:
comfortably, regulated
with history of
IVF accordingly, V/S
BPUD
monitored and
PHYSICAL recorded, due meds
EXAMINATION given, needs
attended.
HEENT: Pale
conjunctivae R: endorsed for
further care
Chest/Lungs:
Normal

CVS: Tachycardic

Abdomen: Normal

GU (IE): Normal

Skin/Extremities:
Weak pulses, pale
nail beds
@ 4pm – 12am Neuro Exam: F: blood transfusion
Normal
D: with low Hgb count
of 83mg/dl with
available unit of PRBC
type B+

A: consent
taken,
procedure
explained,
blood hooked, adverse
reaction was
monitored.

R: no reaction noted

SEPTEMBER 17, 2023: Day 1

@ 8am – 4pm Hgb: 83 - Continue F: blood transfusion
present
meds to D: “ano po and mabuti
managem kong kainin?”
ent
A: advised to eat iron-
- Repeat
riched and vit. C rich
CBC 6hrs
foods to hasten Hgb
post BT
production,
- Refer
lab compliance noted.
results
R: endorsed for further
once
care
available
@ 4pm – 12am - Secure
and
F: health teaching
transfuse
2unit D: with ongoing
PRBC
regimen
properly
typed and A: encourage
cross-mat adherence to regimen,
ched oral rehydration, due
medications
IVF: PNSS 1L x
8hrs x 3 cycles R: for further care
@ 12am – 8am F: blood transfusion

D: with low Hgb count

of 83mg/dl with
available blood with
serial no. 6175

A: conset secured,
checked patency of
blood with NOD and
SNOD, hooked 3rd unit
of PRBC properly
typed and cross-
matched with an
expiration date of
September 30, 2023 at
11:59pm. Instructed to
report any untoward
signs and symptoms of
BT, monitored v/s
above.

R: no reaction noted

SEPTEMBER 18, 2023: Day 2

@ 12mn – 8am Hgb: 84 - Facilitate F: continuity of care
transfusio
Pale palpebral n of 1 D: with ongoing
conjunctiva more unit regimen
PRBC
(-) n/v, melena, A: encourage
then
hematuria adherence to regimen,
repeat
oral rehydration, due
BP: 120/80 CBC after
6hrs medications
HR: 87 - Continue
R: for further care
meds
@ 8am – 4pm managem F: continuity of care
ent
- Facilitate D: with ongoing
FOBT - regimen
Refer
A: adequate rest
advised, instructed to
IVF: PNSS 1L x eat nutritious foods;
due medications
8hrs x 3 cycles
given, instructed
accordingly R: for
further care
 @ 4pm – 12am F: health teaching

D: appears weak

A: instructed diet
modifications and
adequate rest period,
instructed to report any
ill feelings monitored

R: verbalized
understanding

SEPTEMBER 19, 2023: Day 3 (Last Day)

@ 8am – 4pm (-) melena - Please
facilitate FUBT F: continuity of care
(-) hematochezia and H.pylori test
D: with ongoing
(-) dizziness - To regimen
consume
(-) hematemesis
omeprazole drip A: FUBT facilitated,
vital signs monitored
- IVF TF: and recorded, due
PNSS 1L x meds given, instructed
12hrs (2 accordingly.
cycles)
- Refer R: for further care
VITAL SIGNS MONITORING

On September 16, 2023, the patient was admitted at NVPH with initial vital signs
of BP: 130/70mmHg, PR: 120bpm, RR: 21cpm, T: 36 oC, O2 sat: 96%. As observed, all
vital signs are normal except for the pulse rate and it remained elevated up until 8pm
and recorded as follows – 2pm: 126bpm, 6pm: 120bpm, 8pm: 110bpm. With the
patient's present condition which is anemia, his heart needs to work faster in order to
compensate for the low oxygen level in his circulation.

On the following day, September 17, 2023, the patient's vital signs were all
normal, however his blood pressure slightly deviated for three consecutive hours which
are recorded as follows – 12mn:140/80mmHg, 1am: 140/80mmHg. 2am: 130/80mmHg.
Also, at 6pm, an elevation on his pulse rate was again observed as evidenced by
105bpm.

Meanwhile, on September 18, the patient's heart rate along with his respiratory
rate were slightly elevated and recorded as 109bpm and 22cpm, respectively. Aside
from that, all vital signs were normally obtained and recorded and it stayed normal up
until the next day.

DATE/TIME IV FLUIDS
September 16, 2023 1L of PNSS inserted @ 900cc consumed @
10am 10:20am
(Admission Date)

8am – 4pm SD: PNSS – 800cc + 80mg Omeprazole

4pm – 12am 300cc consumed @ 6pm 1L of PNSS inserted @

6pm

12am – 8am 300cc of PNSS 1L of PNSS inserted @

consumed @ 2am 2am

September 17, 2023: Day 1

8am – 4pm 600cc of PNSS 1L of PNSS inserted @

consumed @ 2pm 2pm

8pm – 12am 700cc of PNSS 1L of PNSS inserted @

consumed @ 10pm 10pm

12mn – 8am 800cc of PNSS 1L of PNSS inserted @

consumed @ 6am 6am

September 18, 2023: Day 2

8am – 4pm 500cc of PNSS 1L of PNSS inserted @

consumed @ 3pm 3pm

4pm – 12am 800cc of PNSS 1L of PNSS inserted @

consumed @ 10pm 10pm

September 19, 2023: Day 3 (Last day)

8am – 4pm 660cc of PNSS 1L of PNSS inserted @

consumed @ 2pm 2pm

INTAKE AND OUTPUT RECORD

TIME INTAKE OUTPUT

September 16, 2023: Admission Date

8am – 4pm IVF – 200 Urine – 1

H20 – 200 Stool – 0

Others – 0

TOTAL – 400
4pm – 12am IVF – 600 Urine – 2

H20 – 400 Stool – 0

Others – 450

TOTAL – 1450

12am – 8am IVF – 400 Urine – 1

H20 – 500 Stool – 0

Others – 0

TOTAL – 900

September 17, 2023: Day 1

8am – 4pm IVF – 500 Urine – 2

H20 – 300 Stool – 0

Others – 450

TOTAL – 1250

4pm – 12am IVF – 1000 Urine – 2

H20 – 500 Stool – 1

Others – 0

TOTAL – 1500

12am – 8am IVF – 900 Urine – 2

H20 – 400 Stool – 0

Others – 0

TOTAL – 1300

September 18, 2023: Day 2

8am – 4pm IVF – 1000 Urine – 3

H20 – 400 Stool – 1

Others – 0

TOTAL – 1400

4pm – 12am IVF – 1000 Urine – 3

H20 – 500 Stool – 0

Others – 300

TOTAL – 1800

12am – 8am IVF – 1000 Urine – 3

H20 – 400 Stool – 0

Others – 0

TOTAL – 1400

September 19, 2023: Day 3 (Last Day)

8am – 4pm IVF – 800 Urine – 4

H20 – 500 Stool – 1

Others – 0

TOTAL – 1300

4pm – 12am IVF – 1000 N/A

H20 – 300

Others – 0

TOTAL – 1300

12am – 8am N/A N/A

DISCHARGE SUMMARY

Patient’s Name S.T.

Age 44

Gender Male
 Admitting Physician Dra. S.J.B.

Admitting Diagnosis Anemia secondary to UGIB probably

secondary to bleeding peptic ulcer disease
Medications in the ward:
1. Omeprazole 80 mg IV drip: 80 mg omep + 90cc PNSS to run for 10hrs x 72hrs
2. Rebamipide 100mg tab TID
3. Lactulose 30cc ODHS
4. Metoclopramide 10mg IV q8 PRN x N/V
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