Case Study of Acute Gastritis

To be submitted to:

Northeastern College Clinical Instructors

Submitted by:

Bugarin, Kathleen Pia T.

Gaspar, Rhiza Y.

Gunnawa, Dinalyn M.

Hernandez, Bret Heart M.

Jordan, Aldy B.

Landingin, Reslie Ann M.

Manuel, Marilene S

Millan, Lira Kaye E.

Soleto, Revielyn D.

Vargas, Clair N.

March 22, 2023

1
 i. Objectives

ii. Disease Overview

iii. Demographic Data

iv. Patient's History

v. Physical Assessment

vi. Gordon's 11 Functional Health Pattern

vii. Laboratory Results

viii. Anatomy and physiology

ix. Pathophysiology

x. Course in the Ward

xi. Drug Study

xii. Nursing Care Plan

xiii. Discharge Planning

2
 I. Objectives

GENERAL OBJECTIVES

The purpose of a case presentation is to demonstrate the student's

knowledge of a patient's general health and disease condition, as well as to

stimulate theoretical knowledge research on pathology, signs and symptoms,

physical examination techniques related to nursing and its possible complications,

treatment plan, medical and nursing interventions

SPECIFIC OBJECTIVES

 To Provide an accurate general assessment of the client, including

physical examination and family history taking.

 To understand the pathophysiology and etiology of the presented case.

 To understand the role of drug therapy in client management in relation to

the patient's diagnosis.

 To recognize the factors that contributed to the development of the

diagnosis.

 To present the data relevant to the case in a systematic manner.

 Provide appropriate and proper nursing diagnoses in accordance with the

client's medical condition, as well as skillfully formulate nursing care plans

for the problems identified.

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 II. Patient & Disease Overview

OVERVIEW

This study presents the important considerations of diagnosis and

treatment in view of the ongoing study of the admitted patient. Patient BM is a 4 3

years old from Pinaripad Sur, Aglipay, Quirino. He told us that he’s experiencing

abdominal pain for several days. An hour prior to admission, the patient experienced

vomiting and severe abdominal pain before he decided to go to the hospital for

admission and seek for medical help.

The attending physician advised the patient to go through a series of laboratory tests

specially routine blood test, ECG and urine testing. It was then find out that patient

BM is experiencing Acute Gastritis to consider Peptic Ulcer Disease.

DISEASE OVERVIEW

Acute gastritis is a sudden inflammation or swelling in the lining of the

stomach. It can cause severe and nagging pain. However, and usually lasts for short

bursts at a time. Acute gastritis comes on suddenly and can be caused by infection

with helicobacter pylori and use of nonsteroidal anti-inflammatory drugs, injury,

bacteria, viruses, stress or ingesting irritants such as alcohol, steroids or spicy

foods.

Acute gastritis affects about 8 out of every 1,000 people. Chronic, long term gastritis

is less common. It affects approximately 2 out of 10,000 people.

Acute gastritis can cause stomach bleeding and it can lead to serious problems,

such as:

4
Anemia

Red blood cell counts can be decreased by stomach ulcers or gastritis,

both of which are conditions brought on by the bacteria Helicobacter pylori called

anemia

Pernicious anemia

Auto immune gastritis can affect how your body absorbs vitamin B12.

You’re at risk of this illness when you don’t get enough B12 to make healthy red

blood cells

Peritonitis

Gastritis can worsen stomach ulcers. Ulcers that break through the

stomach wall can spill stomach contents into the abdomen.

Stomach cancer

Gastritis caused by helicobacter pylori and autoimmune disease can

cause growths in the stomach lining.

Therefor, the goal of treatment is to control the symptoms of the disease effectively,

to become acquainted with the various conditions that enter into the differential

diagnosis of the patient’s condition and to be able to apply the types of treatment

recommended for the patients.

5
 III. Demographic Data

Name: BM

Age: 43 years old

Address: Pinaripad Sur, Aglipay, Quirino

Sex: Male

Birthdate: March 08, 1980

Civil status: Married

Occupation: Farming

Religion: Roman Catholic

Blood Type: B+

Weight: 65kg

Height: 165.1 cm

BMI: 19. 7

Chief Complaint: Abdominal Pain and Vomiting

Admitting Diagnosis: Acute Gastritis to consider Peptic Ulcer

Date of Admission: March 14, 2023

Time of Admission: 4:30 AM

Date of Discharge: N/A

Time of Discharge: N/A

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 IV. Patient's History

FAMILY HISTORY

Patient BM mother has a heart disease and hypertension other than

that the rest of his family does have no known diseases. The patient has no known

allergy to drugs. However, he is allergic to sea foods

PAST MEDICAL HISTORY

Patient BM used to have head injury before, however, he has no

record for this because he did not consult to doctors. The patient said that he has

not been admitted in hospital before, he said that this is his first time to be admitted

in the hospital because of his current problem which is the severe abdominal pain

and vomiting. But, before he got sick he only go at the barangay health clinic for

consultation, he only take medicine that was prescribed to him. According to him,

week before the admission, he experienced moderate pain in upper portion of his

abdomen.

PRESENT MEDICAL HISTORY

Few hours prior to admission, patient BM experiencing severe

abdominal pain, body weakness and vomiting and has an admitting diagnosis of

Actute Gastritis to consider Peptic Ulcer Disease.

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 V. Physical Assessment

GENERAL APPEARANCE: Upon admission last March 14, 2023, the patient

general appearance is weak and experienced vomiting, conscious and coherent with

vital signs of Blood Pressure: 140/80, Pulse Rate: 76 bpm, Respiratory Rate: 23

cpm and temperature of 36.7°C. But, upon our physical assessment last March 15,

2023 at exactly 1 in the afternoon the patient general appearance is weak and

experiences abdominal pain, conscious and coherent with facial grimace.

PHYSICAL ASSESSMENT:
DATE AND TIME: March 15, 2023, 1:00 pm
VITAL SIGNS: Blood Pressure: 90/70 Respiratory Rate: 19 cpm
Pulse Rate: 88 bpm Oxygen Saturation: 97%
Temperature: 38.5 °C
RANGE OF MOTION: Needs help from significant others
BEHAVIOUR: Cooperative
LANGUAGE: Other than Tagalog: Ilocano-Ifugao

8
AREA METHOD ACTUAL NORMAL INTERPRETA
FINDINGS TION
FINDINGS

SKIN INSPECTIO Pallor palm No unusual ABNORMAL

N and plantar or because of
surface prominent pallor color of
discoloratio the palm.
n

Skin are intact. Skin are ABNORMAL

Skin is dry intact. because of
without lesions There's no decreased
and pus presence fluid in the
lesions and body caused
pus. by vomiting.
PALPATION Skin has no Skin has NORMAL
masses no masses
palpated palpated

Skin is warm to Skin is ABNORMAL

touch with normally because of
temperature of warm in elevated body
38. 5 °C temperatur temperature.
e
Skin is mobile Skin is NORMAL
with elasticity mobile with
and returns to elasticity
original shape and returns
quickly to original
shape
quickly
Skin rebounds Skin NORMAL
and does not rebounds
remain and does
indented when not remain
pressure indented
released when
pressure
released
There is visible No body ABNORMAL
of abdominal pain is because of
pain especially visible severe pain
in the right
upper quadrant
of the patient 9
HAIR INSPECTIO Hair color is Natural NORMAL
N AND black hair color
VI. 11 GORDON’S FUNCTIONAL HEALTH PATTERNS
Date: 03/15/23
FUNCTIONAL Before During Interpretation
HEALTH Hospitalization Hospitalization
PATTERN

Health The patient The patient still The patient’s

Perception/Health verbalized that believed that health perception about
Management health is very is important, and he health remains the
Pattern important. He also also said that he is same.
said that he cannot still experiencing
afford checkups financial problem
due to financial but he cannot Instead of taking
problems. compromise his pain relievers, the
health. patient stated that
he will use
The patient stated ointments instead.
that he often takes He stated that, from
pain reliever now on he will now
whenever he use ointment
experience body instead of taking
pain after work, and pain relievers.
then he also takes
multivitamins.

According to the
patient, he is
allergic to seafood
like crabs, and he
also said that he
had head injury
before.
Nutrition and According to the According to the The patient’s
Metabolic Pattern patient he eats 3x a patient he eats 2-3x nutrition and
day, and he has a day. The patient metabolic pattern
irregular eating usually eats 2 changed, because
pattern. He usually spoons of solid of the patient’s
eats breakfast at food and then hard condition.
8am, then he eats cracker to ease his
lunch at 1pm. hunger. He also
eats fruit like
banana.

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 His diet is usually
more on vegetables
According to him he
and fish. He also
cannot eat properly
said that he likes to
because of his
mix chili in his food.
stomach pain.

The patient drinks

The patient drinks
1L of water a day,
3-4 glasses of
and he also drinks
water a day. And
1 cup of coffee a
he does not drink
day.
coffee anymore.

He does not
smoke, and he
drinks alcohol
occasionally.
Elimination Patient defecates Patient defecated The patients stool
Pattern 2-3x a week, and 2x since he was color and
he verbalized that admitted, with soft consistency
his stool comes out to watery changed because
smoothly with consistency and of the patient’s food
yellow to brown in dark green in color. intake.
color.

He urinates 3x a There is slight

He urinates 3x a day with a dark to difficulty in
day with a dark to light yellow color. defecating noted
light yellow color. because of the pain
he experiences.
The patient
The patient does experiences slight
not experience any difficulty in
difficulty in defecating.
defecating and
urinating.
The patient also
vomited 2x, green
in color.
Activity and The patient is a The patient is not The patient is not
Exercise Pattern farmer so his main able to move freely, able to do his
exercises were and he stays in bed routines due to his
farm work, like because of his condition.
taking care of his

11
 carabao, planting, stomach pain.
spraying
insecticides, and
then he also feed He also said that he
the pigs. gets tired easily.

He does not get

tired easily, but
when he gets home
he feels body pain.
Cognitive – The patient
The patient Due to his
Perceptual Pattern understands understand the condition, he is not
Tagalog, Ilocano,questions being able to respond
and Ifugao. asked, but he properly because of
barely responds the pain he is
He does not have
because of his feeling.
any problem with
stomach pain.
his senses.
Sleep – Rest According to the Patient verbalized The patient is
Pattern patient, he sleeps that he has an homesick, and
usually at 9pm and irregular sleep rest could not sleep
wakes up around pattern and he also properly due to the
3:30 am, he also said that he environment and
verbalized that he experiences due to the
usually have 6-7 difficulty in falling discomfort brought
hours of sleep. asleep because of by the pain he
the environment. experiences.

The patient’s
activity before The patient
going to bed is verbalized that
preparing food for during
his family. hospitalization, he
usually sleeps
around 10 pm then
He also stated that wakes up at 3 am.
his sleep is not
continuous, he
usually wakes up He also said that
and then sleep when he wakes up,
again. he still feel
exhausted.

The patient said

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 that he feels
refreshed upon
waking up.
Self-Perception/ According to the During The patient’s self-
Self Concept patient, he hospitalization, the perception
Pattern considers himself patient felt changed, he felt
healthy. He can do unhealthy, and his unhealthy and
all his work and body feels weak exhausted.
perform all his and exhausted due
duties well. And he to the pain he
does not easily get experiences.
tired.
Role – According to the He cannot fully Due to his
Relationship patient, his family isperform his role condition, he was
Pattern supportive and due to his not able to perform
cooperative. condition. But he his roles and
still communicates responsibilities.
with his family
The patient has a through video call.
good relationship
with his family.
According to the
patient, his family
He is a caring and were supportive
a hardworking and his wife looks
husband to his wife after him, and
and father to his 5 attends to all his
children. needs.

When it comes to
decision-making,
he discusses it first
with his wife, and
then both of them
decides as one.
Sexuality – The patient is The patient is Since the patient
Reproductive sexually active, and sexually inactive was hospitalized,
uses contraceptive due to his he was not able to
Pattern
for family planning. condition. do sexual activities.

Coping/Stress The patient Patient verbalized The patient’s

Tolerance Pattern verbalized that that he is sharing coping and stress
whenever he has a his feelings and tolerance remains
problem, he usually problems with his the same, and he

13
 shares it with his wife and copes up diverts his attention
wife. with stress by not by talking to his
thinking too much family to gain moral
and by talking to his support and
If he is stressed, he wife. prevent himself
manages it by from overthinking.
bonding with his
children and by He also talks to his
meditating or going children through
to quiet and video call to divert
peaceful places to his pain and stress.
relax.
Value-Belief The patient is a According to the The patient values
Pattern Roman Catholic patient, he prays at and beliefs remains
and attends mass night and ask God the same.
once a month. for healing and
guidance.

He usually prays at
night before bed
time and he
verbalized that with
GOD nothing is
impossible.

He uses herbal
medicines like
lagundi and he also
believes in “hilot”

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 VII. LABORATORY AND DIAGNOSTIC PROCEDURES
HEMATOLOGY CBC- 5 PARTS
Date/Time Performed: Tuesday, March 14, 2023/3:39 am

PARAMETERS Results UNIT REF. RANGE INTERPRETATION

WHITE BLOOD 10.78 10^9/L 5.00-10.00 ABNORMAL

CELLS High WBC indicates
that there is an
infectious disease
nad inflammatory
disease.

NEUTROPHILS 9.34 10^9/L 2.00-7.00 ABNORMAL

NUMBER High Neutrophils
number often the
result of a bacterial
infection.

LYMPHOCYTE # 0.73 10^9/L 0.80-4.00 ABNORMAL

Low numbers of
Lymphocyte
indicates higher risk
of infection.

MONOCYTE # 0.68 10^9/L 0.12-1.20 NORMAL

EOSINOPHIL # 0.03 10^9/L 0.02-0.50 NORMAL

BASOPHIL # 0.00 10^9/L 0.00-0.10 NORMAL

NEUTROPHILS % 86.6 % 50.0-70.0 ABNORMAL

Inflammation, and
an infections
mostly caused by
bacteria will
increase the
Neutrophil count in
the blood.

LYMPHOCYTE % 6.8 % 20.0-40.0 ABNORMAL

A low Lymphocyte
indicates of an
infection.

MONOCYTE % 6.3 % 3.0-12.0 NORMAL

EOSINOPHIL % 0.3 % 0.5-5.0 ABNORMAL

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 A low Eosinophil
count can result
intoxication from
alcohol or excessive
production of
cortisol.

BASOPHIL % 0.0 % 0.0-1.0 NORMAL

RBC 3.55 10^9/L 3.50-5.50 NORMAL

HEMOGLOBIN 80 g/L 110-160 ABNORMAL

Hemoglobin that
lower than normal,
means having fewer
red blood cells
doing essential work
that is carrying
oxygen throughout
your body.

HEMATOCRIT 27.0 % 37.0-54.0 ABNORMAL

A lower than normal
Hematocrit can
indicate insufficient
supply of healthy
RBC(anemia).

MCV 76.2 fL 80.0-100.0 ABNORMAL

Low MCV means
that RBC are
smaller than normal
and may indicate
microcytic anemia.
This condition may
be caused by iron
deficiency that
causes the body to
have less
hemoglobin than
normal.

MCH 22.6 pg 27.0-34.0 ABNORMAL

Common causes of
low MCH include
iron deficiency,
which is a condition

16
 in which red blood
cells are abnormally
small, carrying less
hemoglobin.

MCHC 296 g/L 320-360 ABNORMAL

A low MCHC shows
that red blood cells
do not have enough
hemoglobin.

RDW-CV 23.4 % 11.0-16.0 ABNORMAL

A high RDW means
that there’s variation
in the size of red
blood cells beyond
what’s considered
normal. This may be
a sign of anemia or
a related condition.

PLATELET 227 10^9/L 150-140 NORMAL

ELECTROCYTES
Date/Time Performed: Tuesday, March 14, 2023/6:46 am

TEST RESULT REFERENCE VALUE INTERPRETATION

SODIUM 137 135.0-145 mmol/L NORMAL

POTASSIUM 3.6 3.5-5.1 mmol/L NORMAL

CHLORIDE 98-107 mmol/L

CALCIUM 2.10-2.55 mmol/L

(TOTAL)

CALCIUM 1.05-1.25 mmol/L

(IONIZED)

17
 RADIOLOGY RESULT
Date: 03-14-2023
Examination: CHEST PA
The lung fields are clear.
Heart is normal in size.
Aorta is unremarkable.
Both hemidiaphragms, costophrenic sulcus and
visualized bone are intact.
IMPRESSION: ESSENTIALLY NEGATIVE

RADIOLOGY RESULT
Date: 03-14-2023
Examination: WHOLE ABDOMINAL UTZ
The liver is normal in size with homogenous parenchymal
echogenecity.
The intrahepatic ducts are not dilated.
The gallbladder measures 3.3 cm at its widest transverse diameter.
Lumen is echofree.
Wall is tickened measuring 0.6 cm.
Common duct is not dilated.
Pancreas is obscured.
The spleen is within normal in size and echopattern.
The spleenic vessels are not dilated.
The right kidney measures 10 x 4.9 cm.
The left kidney measures 9.9 x 5.5 cm.
Parenchymal echopattern is homogenous.
There is an echogenic structure seen at the lower pole of the

18
 right kidney measuring 0.7 x 0.6 cm.
Pelvocalyces are not dilated.
Urinary bladder is distensible showing smooth contour and outline.
Prostate measures 2.7 x 3.2 x 3.8 cm with prostatic volume of 17.90 ml.
Parencymal echopattern is homogenous.
There is present of intraperitoneal fluid seen at the hepatorenal and pelvic
area.

IMPRESSION:
ACALCULUS CHOLECYSTITIS
NEPHROLITHIASIS, RIGHT
ASCITES
UNREMARKABLE LIVER, GALLBLADDER, SPLEEN, LEFT KIDNEY,
URINARY BLADDER AND PROSTATE.

19
 VIII. Anatomy and Physiology

Stomach

an enlargement of the

gastrointestinal tract. It lies in the upper part

of the abdominal cavity just under the

diaphragm muscle. It has the shape of the

let er J. When it is empty, it is about the size

of a large sau age. However, it can be

stretched to accommodate large amounts

of food.

Divided into four parts:

 the cardiasurrounds the gastroesophageal sphincter.

 the fundus is the rounded portion above and to the left of the cardia.

 below the fundus is the large central portion of the stomach known as the

body.

 the pylorus

or antrum is

the narrow

inferior

20
 region that conects with the duodenum of the small intestine via the

pyloric sphincter.

When there is no food in the stomach, the mucosa lies in large folds called rugae.

The mucosa of the stomach contains many

pits or gastric glands that have three kinds of

secreting cells:

 zymogenic or chief cells secrete

the principal gastric enzyme

pepinogen.

 parietal cells secrete hydrochloric acid, which activates the pepsinogen

to become pepsin, the enzyme that begins to break down proteins.

 mucous cells, which secrete mucus that protects the stomach from

being diested. The secretions of these gastric glands collectively are

referred to as gastric juice.

Muscularis coat of the stomach has uniquely three, not just two, layers

of smooth muscle: an inner oblique, a middle circular, and an outer longitudinal.

These three layers allow the stomach to contract in a variety of ways to break up

food into small pieces, churn it, and mix it with the gastric juice. When the stomach

is empty and this activity occurs, we experience the stomach growling.

21
Main chemical activity of the stomach is to be in the digestion of proteins by the

enzyme pepsin.

The stomach has three phases:

 Cephalic Phase sensations of taste,

the smell of food, stimulation of tactile

receptors during the process of

chewing and swallowing, and

pleasant thoughts of food stimulate centers within the medulla oblongata

that influence gastric secretions. The postganglionic neurons stimulate

secretory activity in the cells of the stomach mucosa, causing the release

of hydrochloric acid, pepsin, mucus, and intrinsic factor.

- Gastrin is a hormone that enters the circulation and is carried back to the

stomach, where it stimulates additional secretory activity.

-Histamine is both a paracrine chemical signal that acts locally and a

hormone that enters the blood to stimulate gastric gland secretory activity.

Histamine is the most potent stimulator of hydrochloric acid secretion. Drugs

that block the actions of histamine can lower acid levels.

22
  Gastric Phase the period during which the greatest volume of gastric

secretion occurs. This phase is

activated by the presence of food

in the stomach. The food in the

stomach is mixed with gastric

secretions. Action potentials

generated by these receptors

activate CNS reflexes and local

reflexes, resulting in the cascade

of events that increases

secretion, as in the cephalic phase. Peptides, produced by the action of

pepsin on proteins, stimulate the secretion of gastrin, which in turn

stimulates additional hydrochloric acid secretion.

 Intestinal Phase primarily inhibits gastric secretions. It is controlled by the

entrance of acidic chyme into the duodenum, which initiates both neural and

hormonal mechanisms. When the

pH of the chyme enteringthe

duodenum drops to 2.0 or below, the

inhibitory influence of the intestinal

phase is greatest. The hormone

secretin, which inhibits gastric

secretions, is released from the

duodenum in response to low pH.

23
Fatty acids and peptides in the duo-denum initiate the release of the hormone

cholecystokinin, which also inhibits gastric secretions. Acidic chyme (pH <

2.0) in the duodenum also inhibits CNS stim-ulation and initiates local

reflexes that inhibit gastric secretion.

24
DIGESTIVE SYSTEM IX. Pathophysiology

25
 X. Course in the Ward

Date In Time Doctor's Order Rationale

3/14/2023 1) Admit under the 1) For specialized

service of medicine treatment given to

4:20 am
at medical ward. the patient that is
VS: BP 140/80
require medical
2) Secure consent
PR 76 care.
3) DAT
RR 23 2) For legal purposes
4) IVF PNSS x
TEMP 36.7 3) For nourishment
100cc/hr x 2 cycles

4) For IV access and

Diagnostic
fluid replacement
5) RAT
5) May help identify if
6) CBC
the patient is

7) Sodium, Potassium infected in covid19

virus.
8) 12L ECG

6) To determined
9) Chest X-ray
patient latest
10)WAB UTZ status of blood

Therapeutic component. Use to

look at overall
11)Omeprazole 40mg
health and find a
now then OD
wide range of

12)HNBB 1amp TIV condition including

1
 X. Course in the Ward

Date In Time Doctor's Order Rationale

3/14/2023 1) Admit under the 1) For specialized

service of medicine treatment given to

4:20 am
at medical ward. the patient that is
VS: BP 140/80
require medical
2) Secure consent
PR 76 care.
3) DAT
RR 23 2) For legal purposes
4) IVF PNSS x
TEMP 36.7 3) For nourishment
100cc/hr x 2 cycles

4) For IV access and

Diagnostic
fluid replacement
5) RAT
5) May help identify if
6) CBC
the patient is

7) Sodium, Potassium infected in covid19

virus.
8) 12L ECG

6) To determined
9) Chest X-ray
patient latest
10)WAB UTZ status of blood

Therapeutic component. Use to

look at overall
11)Omeprazole 40mg
health and find a
now then OD
wide range of

12)HNBB 1amp TIV condition including

1
 or to decrease

production of

gastric juice.

Has some

bacteriostatic activity

against H.pylori

12)For muscle spasm

To help the stomach

muscle to relax

13)Anti-inflammatory

drugs that is useful

in the

management of

short term,

moderate to

severe pain.

14)Pain reliever that

help reduce gastric

secretion and

acidity

15)To monitor for the

improvement and

abnormality of the

3
 patients vital sign.

16)To determine

patients output if

adequate.

3/15/2023 Ceftriaxone 2mg IV now To treat bacterial

then OD ANST infections

10;30 am

Continue medications

Refer accordingly

3/15/2023 Paracetamol 300mg IV q4 Reduce fever

PRN
1:00 pm For patients fluid

TF: PNSS 1L X 12hrs maintenance

VS: Temp 38.5

Refer to Surgeon For further management

and evaluation

3/15/2023 GS Notes For surgery management

5:03 pm Refer to Dr. E For pain management

Give Analgesic RTC Use to kill Helicobacter

Pylori
Metronidazole 500mg TIV

q8 Can help determine the

associated risk of
X-ray of abdomen (supine
pneumoperitonium.
& upright)

3/15/2023 Follow up referral to Daily maintenance of body

4
 surgery service fluids

7:00 pm D5LR 1L x 12hrs for 7

cycles

5
 XI. Drug Study

Drug Name Classificati Mechanism of Indication Contraindicatio Adverse Nursing

on action ns Reaction Responsibili
ty

Generic Name: Proton- Is a selective >decreasin >Contraindicate Headache, >Watch out

Omeprazole pump and irreversible g the d in patients nausea/vomitin for possible

inhibitors proton pump amount of with known g, allergic

Brand Name:
inhibitor. It acid hypersensitivity reaction to
Prilosec Diarrhea,
suppresses produce in to any the
Actual Dose, Abdominal
stomach acid the component of medication.
Frequency and pain, rash,
secretion by stomach the formulation
>Advise
Route: 40 mg dizziness,
specific
>used for >Treatment with patient to
TIV now then
inhibition of the General feeling
the short omeprazole may avoid foods
OD
H/K ATPase of discomfort
term mask the that may
system found at or illness.
treatment symptoms of cause an
the secretory
and other gastric increase in
surface of
symptomat disease GI irritation

1
 heartburn,

flatulence,

abdominal

pain).

Generic Anticholiner its blocks the it helps to Contraindicated Constipation, >Educate the

Name:Hyoscine- gic drug action of ease in patients with patient

Decreased
N-butylbromide acetylcholine on bloating myasthenia regarding
sweating
(HNBB) the receptors and the gravis, desired and
Mouth, skin,
found within the spasm- megacolon, adverse
Brand Name: eye dryness,
smooth muscle type pain glaucoma and effects.
Scopolamine
Blurred feeling,
of the that can be in patients with
butylbromide
gastrointestinal associated known Bloating,
Actual dose,
and urinary tract with hypersensitivity
Dysuria,
Frequency and
and thus irritable to hyoscine
Route: 1 amp Nausea or
reduces the bowel butylbromide
TIV now then
spasms and syndrome

3
every 6 hours contractions this and vomiting,

PRN relaxes the diverticular

Lightheadedne
muscle and thus disease.
ss,
reduced the pain
relieves
Headache,
from the cramps
the pain of
and spasms Weakness
stomach

and bowel

cramps by

helping

your

digestive

system to

relax

Generic Nonsteroidal Anti used for a Contraindicated Headache, >Monitor for

4
Name:Ketorolac anti- inflammatory short term with significant signs and

inflammator and analgesic manageme renal pain relief,

Brand Name: dizziness,
y drug activity inhibits nt of post impairment, such as an
Toradol
drowsiness,
(NSAID) prostaglandin operative aspirin, allergy increase
Actual Dose,
and leukotriene pain after recent GI bleed diarrhea, appetite and
Frequency and
synthesis delivery or perforation activity.
constipation
Route: 1 amp
use cautiously
>Monitor BP
TIV now then
with impaired
upon
every 8 hours for
hearing,
administratio
severe
allergies,
n
abdominal pain
hepatic
>Monitor IV
conditions
site for pain,

swelling, and

irritation.

>Report

5
 prolonged or

excessive

injection site

reactions to

the physician

Generic Opiate Binds to opiate used to Contraindicated Dizziness, >Monitor

Name:Tramadol (narcotic) receptors in the relieve in patients who vital signs

Headache,
analgesics CNS causing moderate have had a
Brand Name: >Assess for
Drowsiness,
inhibition of to hypersensitivity
orthostatic
Ultram
ascending pain moderately reaction to any nausea and
hypotension
Actual Dose, pathways, severe opioid. vomiting,
>Assess for
Frequency and altering the pain.
Patients with a constipation,
level of pain
Route: 1 amp perception of
Manageme history of
lack of energy, relief and
now and response to
nt of pain epilepsy or risk
administer
pain, also
in factors for sweating,
prn dose as
inhibits the
operative

6
 reuptake of site seizures dry mouth, needed

norepinephrine
itching >Instruct
and serotonin,
Client to
which also
report any
modifies the
adverse
ascending pain
reaction to
pathways.
the physician

or nurse.

Generic Analgesic To produce For fever contraindicated Anxiety, >Monitor

Name:Paraceta and analgesia by or pain in patients vital signs

Fatigue,
mol Antipyretic inhibiting hypersensitive every 4
Nausea,
drugs prostaglandin to drug. IV form hours,
Brand Name:
and other is Vomiting, especially
Dymadon
substances that contraindicated the
Tachycardia
Actual Dose, sensitize pain in patients with temperature.

receptors. May severe hepatic

7
Frequency and relieve fever impairment or Pruritus >Check the

Route: 300 mg through central severe active patient’s

IV every 4 hours action in liver disease. medication, if

PRN for fever hypothalamic there is other

heat-regulating medication

center. that contains

paracetamol.

>Evaluate

therapeutic

response

>Make sure

patient are

aware are

they must

not exceed

the

8
 recommende

r dose.

Generic Cephalospo inhibiting the Susceptibl Contraindicated Black or tarry >Always

Name:Ceftriaxo rin mucopeptide e bacterial in patients with stools wash hands

ne antibiotics synthesis in the infections known allergy to thoroughly

Chest pain,
bacterial cell of the the and disinfect
Brand Name:
Cough,
wall. The beta- lower cephalosporin equipment
Rocephin
lactam moiety of respiratory group of Fever,
>Monitor
Actual Dose,
ceftriaxone tract antibiotics
Shortness of signs of
Frequency and
binds to
used to breath, allergic
Route: 2 gm IV
carboxypeptidas
treat reactions
now OD ANST Sore throat
es,
bacterial and
endopeptidases,
infections anaphylaxis
and
in many
>Monitor IV
transpeptidases
different
site for pain,
in the bacterial
parts of the

9
cytoplasmic body swelling, and

membrane. irritation.

These enzymes
>Watch for
are involved in
seizures
cell-wall
>Notify
synthesis and
physician
cell division

10
 XII. Nursing Care Plan

Severe Abdominal Pain

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Severe Abdominal After 1 hour & 30 1) Nurse patient 1) To establish After 1 hour & 30
Pain secondary to minutes of nursing interaction raport minutes of nursing
"sobrang sakit ng inflammation of the intervention the intervention the
tiyan ko” as stomach patient will 2) Assess for the 2) To know patient decreased
verbalized by the decrease severity factors of the what severity of pain
patient of pain in the existing intervention from 8 to 4 out of
abdominal area. problem. is 10. The patient will
Pain scale: 8/10 appropriate know what are the
The patient will
3) Assist to its to give.
know what are the factors causing him
comfortable
factors causing him abdominal pain.
position. 3) To promote
abdominal pain.
comfort and
4) Ensure Safety relief.
Objective
5) Administer 4) To prevent
 VS: BP:
medication as further
150/100
order injury.
 Facial 6) Encourage
Grimace 5) To relieve
patient to severe pain.
 (+) Bloated have
adequate 6) To promote
 Body sleep recovery.
weakness

11
 Fever

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subject: Elevated body After 2 hours 1) Position in comfortable 1) To promote rest and After 2 hours of
temperature of nursing position. comfort. nursing interventions
∅
as evidence of interventions the patient
2) Do tepid sponge bath. 2) To reduce elevated
Objective: 38.5°c the patient temperature
temperature.
temperature 3) Assist the client to decrease from
Vital Signs
will decrease change clothing to lose 3) To have good 38.5°C to 36.8°C.
Temperature: from 38.5°C clothes. circulation and
38.5°C upto normal provide comfort.
4) Advice to have a rest.
range.
4) This helps patient to
5) Administer medication
recover.
as order/prescribed.
5) To medicaly reduce
elevated
temperature.

12
 Body weakness

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Risk for fall Within 3hrs of 1) identify factors that 1) to know the After 3hrs of
“Agkakapsutak" secondary to rendering proper affect safety needs intervention that will rendering proper
as verbalized by body weakness intervention the be established nursing
2) assess the patient
the patient. patient will be intervention the
ability to ambulate 2) it is helpful to
free from patient are safe
OBJECTIVE: safety with or determine the
possible fall. from possible
without assistive client’s functional
>weak in fall as evidenced
devices abilities to plan for
appearance. by ability to
ways of improving
3) thoroughly orient explain the
>decreased the problem areas
the patient to safety
strength in lower
environment 3) for the client precautions
extremeties.
familiarize the
4) tell the significant
surroundings
others to always
stay with the client 4) to ensure clients
safety
5) instruct the patient
to call for 5) to prevent the
assistance when patient from falling

13
 moving. on bed.

6) put side rails up. 6) to reduce the risk of

falling.
7) provide assistive
devices for walking 7) for the client’s
such as cane, support
walker or use
8) to prevent from
wheelchairs.
slippering
8) ensure that the
patient wears
proper shoes

Knowledge Deficit

14
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Knowledge deficit After nursing health 1) Assess for 1) To gain After nursing health
"Madalas akong in NSAID'S drug as teaching the patient history of any history or teaching the patient
uminom ng Alaxan evidence of regular will verbalize its over-the- background verbalized its
lalo na kapag may intake of pain understanding counter on drugs that understanding
masakit sa katawan reliever. interms of NSAID'S medicine that previously interms of NSAID'S
ko kapag galing sa drug specially in too is regularly taken of the drug and that he
bukid" much Ingestion of intake. patient. will use other
ibuprofen. remedy for the
Objective: ∅ 2) Educate the 2) For the
body pain.
patient about patient to
the side understand
effects and what are the
contraindicati possible
ons of the harm that
given/saids this drug/s
drug. can cause.

3) Advice the 3) This aims to

15
 patient to use give enough
other remedy knowledge
such as for the client
ointment to not to take
relieve body any drugs
pain. but rather to
use
4) Encourage
alternatives.
the patient to
have at least 4) Having
8 hrs of sleep enough rest
after going to and water in
work and to the body
take/drink promotes
water muscle
regularly. recovery and
pain relief.

16
 XIII. Discharge Planning

MEDICATION  Advise and instructed the

patient to take his home

medication at a constant time

and at prescribed dosage.

 Reinforce the purpose of taking

medication to prevent

complications and to promote

health for his fully recovery.

EXERCISE  Instructed patient to avoid

strenuous activity.

 Encourage patient to have an

adequate rest and sleep atleast

6 to 8 hours. He can do light

exercises like gradually

walking.

TREATMENT  Advise the patient to comply

medication as prescribed by the

physician.

HEALTH TEACHING  Advise patient to increase fluid

intake to prevent fluid loss.

 Encourage to do tepid Sponge

17
 bath if fever occurs.

 Advise to wash his hand and

cook foods properly before

eating.

OUT PATIENT  Encourage to visit the Doctor at

given time and date.

 Advise patient to report any

signs and symptoms of

abdominal disturbances like

nausea and vomiting and

recurrence of pain.

DIET  Advise patient to avoid spicy

food because it may triger
abdominal irritation.

 Avoid drinking cola's, coffee

and alcohol or any beverages
when stomach is empty.

SPIRITUAL  Encourage patient to have a

strong faith in God and keep
praying.

18