TABLE OF CONTENTS

I. Introduction

a. Overview of the case

b. Objective of the study

c. Scope and Limitation of the study

II. Health History

III. Developmental Data

IV. Medical Management

a. Medical orders with rationale

b. Drug Study

c. Laboratory results

V. Anatomy and Physiology with Pathophysiology

VI. Nursing Assessment

VII. Nursing Management

a. Ideal Nursing Management

b. Actual Nursing Management (SOAPIE)

VIII. Referrals and Follow-up

IX. Evaluation and Implications

X. Bibliography
I. INTRODUCTION
a. Overview of the Case

Gastritis is inflammation of the lining of the stomach and has many possible

causes. Common causes of gastritis are excessive alcohol consumption or
prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs)
such as aspirin or ibuprofen. Gastritis may also develop after major surgery,
traumatic injury, burns, or severe infections. Gastritis may also occur in those who
have had weight loss surgery resulting in the banding or reconstruction of the
digestive tract. Chronic causes are infection with bacteria, primarily Helicobacter
pylori, chronicbile reflux, and stress; certain autoimmune disorders can cause
gastritis as well. The most common symptom is abdominal upset or pain. Other
symptoms are indigestion, abdominal bloating, nausea, and vomiting
and pernicious anemia. Some may have a feeling of fullness or burning in the
upper abdomen. An esophagogastroduodenoscopy, blood test, complete blood
count test, or a stool test may be used to diagnose gastritis. Treatment includes
taking antacids or other medicines, such as proton pump inhibitors or antibiotics,
and avoiding hot or spicy foods. For those with pernicious anemia, B12 injections
are given, but more often oral B12 supplements are recommended.

Many people with gastritis experience no symptoms at all. However, upper

central abdominal pain is the most common symptom; the pain may be dull, vague,
burning, aching, gnawing, sore, or sharp. Pain is usually located in the upper
central portion of the abdomen, but it may occur anywhere from the upper left
portion of the abdomen around to the back.

Other signs and symptoms may include:Nausea,Vomiting (if present, may be clear,

green or yellow, blood-streaked, or completely bloody, depending on the severity
of the stomach inflammation),belching (if present, usually does not relieve the pain
much)Bloating.Early signs are loss appetite,unexplained weight loss.

Acute gastritis is a gastric mucosal erosion caused by damage to mucosal

defenses. Alcohol consumption does not cause chronic gastritis. It does, however,
erode the mucosal lining of the stomach; low doses of alcohol
 stimulate hydrochloric acid secretion. High doses of alcohol do not stimulate
secretion of acid. NSAIDs inhibit cyclooxygenase-1, or COX-1, an enzyme
responsible for the biosynthesis of eicosanoids in the stomach, which increases
the possibility of peptic ulcers forming. Also, NSAIDs, such as aspirin, reduce a
substance that protects the stomach called prostaglandin. These drugs used in a
short period are not typically dangerous. However, regular use can lead to gastritis.

b.General Objective

The objective of making this case study is to identify the problem of our patient
and to determine the factors that contribute to this kind of disease so that specific
actions should be done and rendered to our patient. I have selected this patient having
this kind of disease because the primary concept that should fit our study is all about
abnormalities pertaining a child with physiologic disorders. Having this kind of case
study is a privilege for me because it would be a good learning process by adding new
knowledge and concept about different kinds of diseases that may be present in some
patients. By making this case study I can identify the disease step by step, its nature on
how this disease occur, and nursing actions that would be appropriate for the patient.

This study aims to convey familiarity and to provide an effective nursing care to a
patient diagnosed with Acute Gastritis through understanding the patient history,
disease process and management.

c.Specific Objectives

At the end of this study, we will be able to:

1. Define Acute Gastritis

2. Identify the development theory of the patient
3. Discuss the health history of the patient
4. Identify the history of the patient
5. Discuss the medical management of the disease
6. Show the physical assessment of the patient
 7. Discuss the pathophysiology of the disease
8. Enumerate and discuss the nursing management
9. Identify the drugs administered to the patient
10. Discuss the health teachings which includes the referral and follow-up

d. Scope and Limitations

The scope of this study covers from the patient’s health history, developmental
data, and as well as with her medical and nursing management. Based upon the
assessment done, appropriate interventions were implemented to have a proper care
for the client’s health.

The study is limited from the information being collected from the patient. The
data gathering through objective and subjective assessment was limited based upon my
interview to Ms.RFE and nursing assessment. The patient was being assessed for 1
day from the time we had our ward duty exposure.
II. HEALTH HISTORY
a. Profile of Patient

Patient’s Name : Ms. RFE

Address : Yacapin Burgos CDOC
Age : 28 y.o
Sex : Male
Birth Date : 10-11-86
Religion : Roman Catholic
Nationality : Filipino
Civil Status : Single
Family Income : 10,000/month
Occupation : Nurse
Date of Admission : 2-714 – 3:25 PM
Admitting Diagnosis : T/C Acute Gastrtis
Attending Physician : Dr. Tan

b. Personal Health History

According to Ms. RFE, they don’t had history of acute gastrtis in her
mother side and DM in her father side. She also admits drinking of alcoholic
beverage for socialization purposes. She even claims to have known the
negative effect of these products but would always associate it with enjoying
life and some sort of relaxation. Patient has no allergy to foods. She loves to
eat fatty and acidic foods and on her teenage days she mentioned that she
had stop drinking.

c. History of Present Illness

One day prior to admission patient had onset of abdominal pain radiating to
right epigastric region. Four days prior to admission pain at the epigastric
region is frequently occuring.
 d. Chief Complaint

10/10 pain scale of abdomen.

III. DEVELOPMENTAL DATA

As part of understanding our client’s totality, we as nurses should understand

their developmental aspects and compare them with that of the well-known

theories formulated by Erikson, Freud, and Havighurst.

A. Erikson's Stages of Psychosocial Development

Psychosocial development as articulated by Erikson describes eight

developmental stages through which a healthy developing human should pass from
infancy to late adulthood. In each stage the person confronts, and hopefully masters
new challenges. Each stage builds on the successful completion of earlier stages. The
challenges of stages not successfully completed may be expected to reappear as
problems in the future.

Young Adulthood (19-40 yrs)

Intimacy vs. Isolation:

According to Erikson, this stage is characterized by increasing importance of

human closeness and sexual fulfillment: gradually, the acquisition of love.

Implication:

Based on our assessment the patient was able to participate easily and able to
build trust with others and accepts the chosen lifestyle and might do changes relating to
health.
B.Sigmund Freud's Psychosexual Development

The concept of psychosexual development as envisioned by Freud at the end of

the nineteenth and the beginning of the twentieth century is a central element in the
theory of psychology. It consists of five separate phases' oral, anal, phallic, latency, and
genital. In the development of his theories, Freud's main concern was with sexual
desire, defined in terms of formative drives, instinct and appetites that result in the
formation of an adult personality.

Genital (Puberty and after)

Energy is directed toward full sexual maturity and function and development of
skills, needed to cope with the environment.

Implication:

Based on our assessment, patient was able to have her own income as
evidenced of being independent for her self from her parents and do his own decision
making.

C.JEAN PIAGET’S COGNITIVE THEORY

Piaget refers to the adulthood stage as the formal operational stage.The formal
operational stage is the fourth and final of the stages of cognitive development of
Piaget's theory. This stage, which follows the Concrete Operational stage, commences
at around 11 years of age (puberty) and continues into adulthood. It is characterized by
acquisition of the ability to think abstractly and draw conclusions from the information
available. During this stage the young adult functions in a cognitively normal manner
and therefore is able to understand such things as love, "shades of gray", and values.
Lucidly, biological factors may be traced to this stage as it occurs during puberty and
marking the entry to adulthood in Physiology, cognition, moral judgments (Kohlberg),
Psychosexual development (Freud), and social development (Erikson). Some two-thirds
of people do not successfully complete this stage, and "fixate" at the concrete
operational stage.
 In case of Ms. RFE, she is on this stage since she has social groups and he has
sound judgments on problems that she may encounter.

PHASE AND STAGE AGE SIGNIFICANT

BEHAVIOR

Formal Operational 11-adulthood Uses rational thinking

Phase
Reasoning is deductive
and futuristic

D.ROBERT HAVIGHURST’S DEVELOPMENTAL TASK THEORY

Robert Havighurst believes that learning is basic to life and that people continue
to learn throughout life. He describe growth and development as occurring during six
stages each associated with from six to ten tasks to be learned.

In the middle years, from about thirty to about fifty-five, men and women reach
the peak of their influence upon society, and at the same time the society makes its
maximum demands upon them for social and civic responsibility. It is the period of life to
which they have looked forward during their adolescence and early adulthood. And the
time passes so quickly during these full and active middle years that most people arrive
at the end of middle age and the beginning of later maturity with surprise and a sense of
having finished the journey while they were still preparing to commence it.

The biological changes of ageing, which commence unseen and unfelt during the
twenties, make themselves known during the middle years. Especially for the woman,
the latter years of middle age are full of profound physiologically-based psychological
change.
 The developmental tasks of the middle years arise from changes within the
organism, from environmental pressure, and above all from demands or obligations laid
upon the individual by his own values and aspirations.

Since most middle-aged people are members of families, with teen-age children,
it is useful to look at the tasks of husband, wife, and children as these people live and
grow in relation to one another. Each family member has several functions or roles.

The Man of the Family     The Woman of the Family      The Teenager

   a man                              a woman                      a person

   a husband                         a wife                            a family member

   a father                              a mother    

   a provider                          a homemaker &

   a homemaker                       family manager

Unless the man performs well as a provider, it will be difficult for the woman to
perform well as a homemaker. Unless the woman performs well as a mother, it will be
difficult for the teen-age child to meet the tasks of adolescence. The developmental
tasks of family members then, are reciprocal; they react upon one another.

IV. MEDICAL MANAGEMENT

 A. Doctor’s Order

Date Order Rationale

2/7//2014 -For constant monitoring by
 Pls. Admit to ROC under Dr. hospital staff and for
4:35PM
Tan prompt rendering of nursing
care
 Secure consent to care and
mgt. -For legal purposes which
provides and protects
patients with his due right
 DAT diet
-To maintain nutritional
supplementation

 IVF: PNSS iiL @ 25gtts

-To provide a quick route to
supply body with fluids and
electrolytes.

 Monitor V/S q4, O2 sat q4

-For constant monitoring of
cardinal measurements,
especially patient’s RR
 Labs: CBC, U/A,
 -CBC is ordered to
determine blood
component levels
including platelet, the
clotting factor of the
blood. U/A is ordered To
evaluate renal function

 Meds:
Omeprazol 40mg IV now -Symptomatic
then OD Iin AM gastroesophageal reflux
disease (GERD) without
esophageal lesions

 I and O q shift -Measure fluid intake and

loss
  Pls. Inform AP
-For medical mgt.
 Refer accordingly
-For referral concerning
unusualities.

2/8/14  Give Tramadol 50mg IV now - To relieve acute/

severe pain
10AM
 For UTZ of upper abdomen -to evaluate the condition of
the digestive system

 For CXL
 - To evaluate lung
condition

 Tramadol 50mg q8h (6am-  - To relieve acute/

2pm-10pm) severe pain

 D/C Omeprazol

 IVF TF: D5NM IL @20gtts/min - To provide fluids

x 3 bottles glucose and
electrolytes

- Skin and skin structure

 Cefuroxime ( Kefox ) 75mg
infections, infections of the
IVTT ANST then q8h
urinary and lower
respiratory tract
 D/C Tramadol

- Short term management

 Ketorolac 15mg IVTT ANST of moderately severe acute
then q8h pain for single dose
treatment

 IVF TF: D5NM IL @ - - To provide fluids glucose

20gtts/min and electrolytes
 A.Classification Dose/ Mechanism Specific Contraindica Side Nsg
N frequen of Actions Indication tion effects Precautions
cy
Omep GIT drugs 40mg IV Inhibits Symptom Contraindicat CNS: 1. Administer
razole (Anti-ulcer now activity of atic ed in patients headache, drug before
drugs) & then OD acid (proton) gastroeso with known dizziness, meals.
(Proton Pump Iin AM pump and phageal hypersensitivi asthenia
Inhibitors) binds to reflux ty to drug or 2. Provide
hydrogen- disease its GI: appropriate
potassium (GERD) components diarrhea, safety and
adenosine without abdominal comfort
triuphosphat esophage Use pain, measures if CNS
e at al lesions cautiously in nausea, effects occur to
secretory pregnant or vomiting, prevent injury.
surface of lactating constipati
gastric women on, 3. Make sure
parietal cells flatulence patient swallow
to block the tablets or
formation of Musculosk capsules whole
gastric acid eletal: and not to open,
back pain chew or crush.

B.Drug Study
 A.Classification Dose/ Mechanism Specific Contraindica Side Nsg Precautions
N frequen of Actions Indicatio tion effects
cy n

Tram GIT drugs 50mg Centrally Used for Hypersensitiv Vasodila Assess patientpain( location
adol (Anti-ulcer q8h acting tion,
moderate ity, acute andtypes)
drugs) & (6am- analgesic not dizzines
(Proton Pump 2pm- chemically to severe intoxication with s/vertigo, - Assess for hypersensitivity
Inhibitors) 10pm) related to headache
pain alcohol, reaction: rash and pruritus
opioids but ,
binds to mu- hypnotics stimulatio -Monitor for possible drug
opioid n,
,centrally induced adverse reaction
receptors anxiety ,
and inhibits acting confusio CNS; stimulation dizziness,
reuptake n and
analgesics vertigo, headache,
of norepinep sleep
hrine and disorder CV: vasodilation
serotonin
GI: nausea
 A.Classification Dose/ Mechanism Specific Contraindica Side effects Nsg Precautions
N frequen of Actions Indication tion
cy
Ketor Analgesic 15mg Unknown. Short term Short term CNS: drowsiness Correct hypovolemia
olac IVTT May inhibit managem management CV: edema, before giving
ANST prostaglandi ent of of moderately Hypertension ketorolac
then q8h n synthesis, moderatel severe acute GI: nausea,
to produce y severe pain for dyspepsia Carefully observe
anti acute pain single dose Hematologic: patient’s with
inflammatory for single treatment decreased platelet coagulopathies and
, analgesic, dose absorption those taking
and treatment Skin: pruritus coagulants drug
antipyretic Other: pain at the inhibit platelet
effects injection site aggregation and
can prolong
bleeding time
 A.Classification Dose/ Mechanism Specific Contrain Side Nsg
N frequen of Actions Indicatio dication effects Precautions
cy n
Cefur Cephalosporin 75mg Second Skin and Contraindi CNS: Fever, Before
oxime s IVTT generation skin cated in headache administration,
now cephalospori structure patient’s CV: ask the patient
then q8h ns that infections, hypersens Diarrhea if he is allergic
inhibits cell infections itive to GI: genital to penicillins or
wall of the drug or pruritus cephalosporins
synthesis, urinary other Hematologi
osmotic and lower cephalosp c: Monitor PT and
instability, respirator orin thrombocyto INR in patient
usually y tract penia with impaired
bactericidal Skin: pain in vitamin K
Duration synthesis or
Other: low vitamin k
hypersensiti store. Vitamin
vity reaction K may be
needed
 A. Laboratory Results

X-RAY REPORT

Name:Ms. RFE Date: Febuary 8, 2014

Age/Sex: 28/F Examination: CXR PA
Requested by: Dr. Tan

Chest X-ray PA:

The lungs are clear

Heart is not enlarged
Aorta is not dilated
Diaphragm and both cotosphrenic sulci are intact
The rest of the visualized chest structures are unremarkable

Impression: No significant chest findings

HEMATOLOGY
Test Result References Implications
Ranges
Total WBC 10.0 x 10 ^9/L 5.0 – 10.0 Normal
Total RBC 3.3 x 10 ^12/L 3.69 – 5.90
Hemoglobin 9.0 g/dL 13.70 – 16.70 *Low Hgb suggests
anemia
Hematocrit 29.9 % 40.00 – 49.70 *
MCV 89.5 fL 70.00 – 97.00 Normal
MCH 29.3 pg 26.10 – 33.30 Normal
MCHC 32.0 g/dL 32.0 – 35.0 Normal
Platelet Count 400 x 10^9/L 150.0 – 390.0 Normal
Differential Count
 Neutrophils 77.50 % 54.0 - 62.0 * Increased due to
infection and stress
response – PTB
and emotional
stress
Lymphocytes 19.20 % 20.0 - 40.0 * Decreased due to
advanced
tuberculosis cp
Monocytes 7.10 % 4.0 – 10.0 Normal
Eosinophils 2.10 % 1.0 – 6.0 Normal
Basophils 0.10 % 0.00 – 1.00 Normal
RDW - CV 11.6 % 11.5 – 14.5 Normal

Name: Ms. RFE Date done: 2/8/14

Age: 28/F Clinician: Dr. Tan

URINALYSIS
Test Result
Macroscopic
Color Yellow
Appearance Clear
Glucose Negative
Protein Negative
Reaction 6.0 pH
Specific Gravity 1.020
Microscopic
WBC 0-1
RBC 0-2
Epithelial Cells Few
Mucous Threads Rare
Urates None Seen
Bacteria Few
Name: Ms. RFE Date done: 2/8/14
Age: 28/F Clinician: Dr. Tan

Ultrasound report

Ultrasound of the Upper Abdomen

MEASUREMENTS

R Liver Lobe =14.73cm R Kidney =10.51 x 4.12 x 4.19 cm C-T = 0.97cm

L Liver Lobe= 12.82cm L Kidney=11.7 x 5.13 x 5.44 cm C-T =1.39cm

Gallbladder= 6.25 x 2.26 x 1.69cm Spleen = 9.40cm

The liver is normal in size and parenchymal echogenecity. No focal mass lesion seen.

The intrahepatic ducts and extrahepatic ducts are not dilated.

The gallbladder is normal in size and configuration with smooth and not thickened wall.

No intraluminal intense echo seen.

Pancreas and spleen are unremarkable.

Both kidneys are normal in size and echopattern. No pelvocallectasia nor lithiasis seen.

Impression: NEGATIVE ULTRASOUND OF THE LIVER , INTRAHEPATIC DUCTS,

EXTRAHEPATIC DUCTS, GALLBLADDER, PANCREAS, SPLEEN AND BOTH
KIDNEYS.
 V. ANATOMY & PHYSIOLOGY with PATHOPHYSIOLOGY

The stomach is an expanded section of the digestive tube between the esophagus and
small intestine. Its characteristic shape is
shown, along with terms used to describe the
major regions of the stomach. The right side of the
stomach is called the greater curvature and the left
the lesser curvature. The most distal and
narrow section of the stomach is termed the
pylorus - as food is liquefied in the stomach it
passes through the pyloric canal into the small
intestine.

The wall of the stomach is structurally similar to other parts of the digestive tube, with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer, which aids in performance of complex grinding motions.

In the empty state, the stomach is contracted and its mucosa and submucosa are
thrown up into distinct folds called rugae; when distended with food, the rugae are
"ironed out" and flat. The image below shows rugae on the surface of a dog's stomach.

Within the stomach there is an abrupt

transition from stratified squamous
epithelium extending from the esophagus
to a columnar epithelium dedicated to
secretion. In most species, this transition is very close to the esophageal orifice, but in
some, particular horses and rodents, stratified squamous cells line much of the fundus
and part of the body.

The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom). The creatures attached to the
surface are bots, larval forms of Gasterophilus.

If the lining of the stomach is examined with a hand lens, one can
see that it is covered with numerous small holes. These are the
openings of gastric pits which extend into the mucosa as straight
and branched tubules, forming gastric glands.

Types of Secretory Epithelial Cells

Four major types of secretory epithelial cells cover the surface of

the stomach and extend down into gastric pits and glands:

Mucous cells: secrete an alkaline mucus that protects the

epithelium against shear stress and acid

Parietal cells: secrete hydrochloric acid!

Chief cells: secrete pepsin, a proteolytic enzyme

G cells: secrete the hormone gastrin

There are differences in the distribution of these cell types among regions of the
stomach - for example, parietal cells are abundant in the glands of the body, but virtually
absent in pyloric glands. The micrograph to the right shows a gastric pit invaginating
into the mucosa (fundic region of a raccoon stomach). Notice that all the surface cells
and the cells in the neck of the pit are foamy in appearance - these are the mucous
cells. The other cell types are farther down in the pit and, in this image, difficult to
distinguish.

Mouth

Is the first portion of the alimentary canal that receives food and begins digestion by
mechanically breaking up the solid food particles into smaller pieces and mixing them
with saliva. The oral mucosa is the mucous membrane epithelium lining the inside of the
mouth.

Pharynx

The section of the alimentary canal that extends from the mouth and nasal cavities to
the larynx, where it becomes continuous with the esophagus.

Esophagus

The esophagus is a tube that carries swallowed foods to the stomach.

Stomach

Is a muscular organ of the digestive tract. It is located between the esophagus and the
small intestine. The stomach is hollow and sac-shaped. It is involved in the second
phase of digestion, following mastication (chewing).The stomach produces protease
enzymes and hydrochloric acid which kills bacteria and gives the right pH for the
protease enzyme to work.
Small Intestine

The part of the gastrointestinal tract (GI tract) that extends from the pyloric sphincter to
the ileocecal valve, where it empties into the large intestine. The small intestine finishes
the process of digestion, absorbs the nutrients, and passes the residue on to the large
intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive
system that are closely associated with the small intestine.

Large Intestine

The part of the gastrointestinal tract (GI tract) that extends from the pyloric sphincter to
the ileocecal valve, where it empties into the large intestine. The small intestine finishes
the process of digestion, absorbs the nutrients, and passes the residue on to the large
intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive
system that are closely associated with the small intestine
 VI. NURSING ASSESSMENT TOOL

Name of Patient: Ms. RFE

VII. NURSING SYSTEM REVIEW CHART

Temp: PR: RR: 22cpm BP: Height: Weight: Date:
36˚C 90bpm 110/70mmHg 5’2’ 60kg 2/9/14
EENT
[]impaired []blind []pain
vision
[]reddened []drainage []gums sunken eyeballs
[]hard []deaf []burning Cough
hearing Vomiting
[]edema []lesion []teeth
Assess eyes, ears, nose, throat for any Moderate diarrhea
abnormalities [x]no problem Cough
RESPIRATORY Vomiting
[]asymmetric []tachypnea []apnea
[]rales [x]cough []barrel chest Abdominal Pain
5/10
[]bradypnea []shallow []rhonchi Abdominal Pain
3/10
[]sputum []diminished []dyspnea
[]orthopnea []labored []wheezing
[]pain []cyanotic
Assess respiration, rate, rhythm, depth,
pattern, breath sounds, comfort [x]no
problem
CARDIOVASCULAR
[]arrhythmia []tachycardia []numbness
[]diminished []edema []fatigue
pulses
[]irregular []bradycardi []murmur
a
[]tingling []absent []pain
pulses
Assess heart sound, rate, rhythm, pulse,
blood pressure, circulation, fluid retention,
comfort
[x]no problem
GASTROINTESTINAL TRACT
[]obese []distention []mass
[]dysphagia []rigidity [x]pain
Assess abdomen, bowel habits,
swallowing, bowel sound, comfort []no
problem
GENITO-URINARY & GYNE
[]pain []urine color []vaginal
bleeding
[]hematuria []discharges []nocturia
Assess urine frequency, control, color,
odor, comfort, gyne bleeding, discharges
[x]no problem
NEURO
[]paralysis []stuporous []unsteady
[]seizures []lethargic []comatose
[]vertigo []tremors []confused
[]vision []grip
Assess motor function, sensation, Loc,
strength, grip, gait, coordination,
orientation, speech [x]no problem
MUSCULOSKELETAL & SKIN
[]appliance []stiffness []itching
[]petechiae []hot []drainage
[]prosthesis []swelling []lesion
[]poor turgor []cool []deformity
[]wound []rash []skin color
[]flushed []atrophy []pain (back)
[]ecchymosis []diaphoretic []moist
Assess mobility, motion, gait, alignment,
joint, function, skin color, texture, turgor,
integrity [x]no problem
NURSING ASSESSMENT II
SUBJECTIVE DATA OBJECTIVE DATA
COMMUNICATIO Comments: Maayo []Glasses []Languages
N man ako
[]Hearing Loss panan.aw og []Contact Lens []Hearing Aide
[]Visual Changes pandungog as Pupil L3mm R3m []Speech difficulties
verbalized. size m
[x]Denied Reaction PERRLA
OXYGENATION Comments: giubo Respiration []Regular [x]Irregular
[]Dyspnea ko pero wla man Describe: Respiration is regular in rate
[]Smoking History noon plema as
verbalized.
[x]Cough
[]Sputum R full chest expansion, symmetric to Left lung
[]Denied L full chest expansion, symmetric to right lung
CIRCULATION Comments: dili Heart Rhythm [x]Regular []Irregular
[]Chest Pain man sakit ako Ankle Edema: No ankle edema noted.
dughan og wala Pulse Car Rad AP Fem*
[]Numbness of man sad R + 90bpm + Refuse
extremities naminhod ako d
kalawasan as L + 90bpm + Refuse
verbalized. d
[x]Denied Comments
NUTRITION Comments: Maayo []Dentures [x]None
Diet: DAT diet man ako ako
pagkaon . Complete Incomplete
[]Recent change Upper [] []
in weight and Lower [] []
appetite
[]Swallowing
Difficulty
[x]Denied
ELIMINATION Urinary frequency Comments: Bowel Bowel Sounds
Usual bowel 4-6 times a day sounds are hard as NORMOACTIVE
pattern gargles, prominent on
Once daily []Urgency RLQ of abdomen. Abdominal Distention
Constipation []Dysuria []Yes [x]No
Remedy
Eats Papaya []Hematuria Urine color,
Date of last BM []Incontinence consistency, odor
2/9/14 []Polyuria Pale yellow,
Diarrhea []Foley in place moderate, aromatic
Character
[]Denied
MANAGEMENT OF HEALTH AND Briefly describe patient’s ability to follow
ILLNESS treatments (diets, medications, etc.)
Patient is able to comply with prescribed diet,
medications and treatment.
[x]Alcohol []Denied
“gainom ko usahay pag nay mga
okasyon
[]SBE Last Pap Smear
LMP 2/1/14

SUBJECTIVE DATA OBJECTIVE DATA

SKIN INTEGRITY Comments: ok []Dry []Cold Pale
[]Dry raman ako pamanit []Flushed []Warm
wala man sad
[]Itching katol2x og dili pud []Moist []Cyanotic
[x]Denied dry as verbalized.. Rashes, ulcers, decubitus (describe size,
location, drainage, color, odor No rashes
 noted
ACTIVITY & SLEEP Comments: LOC & Orientation Patient is conscious and
[]Convulsion makalakaw man is oriented to time, place, and date
noon ko og
[]Dizziness Gait: []Walker []Cane
makaligo na ako ra
[]Limited Motion of as verbalized. [x]Steady []Unsteady
Joints []Sensory & motor losses in face and
Limitation in ability extremities No sensory and motor losses in
to face and extremities
[]Ambulate
[]Bathe self ROM Limitations: No ROM limitations
[x]Denied
COMFORT/SLEEP/AWAKE []Facial Grimace
[x]Pain(location, Comments: Magsakit []Guarding
frequency & lang ako ako tiyan []Other signs of pain: no other signs of pain
remedy usahay mao dili kayu noted
abdomen,pain ko makatulog as
reliever verbalized.

[]Nocturia
[]Sleep Difficulty
[x]Denied
COPING Observed non-verbal behaviour: Patient is
Occupation: Nurse typically quiet but very responsive when
asked
Members of household: 5 members Person and phone number that can be
Most supportive person: mother reached at any time: 09067302815
 VIII. NURSING MANAGEMENT
A. IDEAL NURSING MANAGEMENT

NURSING DIAGNOSIS: Airway Clearance, ineffective

May be related to
 Thick, viscous, or bloody secretions
 Fatigue, poor cough effort
 Tracheal/pharyngeal edema
Possibly evidenced by
 Abnormal respiratory rate, rhythm, depth
 Abnormal breath sounds (rhonchi, wheezes), stridor
 Dyspnea
Desired Outcomes
 Maintain patent airway.
 Expectorate secretions without assistance.
 Demonstrate behaviors to improve/maintain airway clearance.
 Participate in treatment regimen, within the level of ability/situation.
 Identify potential complications and initiate appropriate actions.
Nursing Interventions
 Assess respiratory function, e.g.,
breath sounds, rate, rhythm, and
depth, and use of accessory muscles.
Note ability to expectorate
mucus/cough effectively; document
character, amount of sputum, presence
of hemoptysis.
Place patient in semi- or high-Fowler’s
position. Assist patient with coughing
and deep-breathing exercises.
Clear secretions from mouth and
trachea; suction as necessary.
Maintain fluid intake of at least 2500
mL/day unless contraindicated.
 Humidify inspired air/oxygen.
Administer medications as
indicated:Mucolytic agents, e.g.,
acetylcysteine
(Mucomyst);Bronchodilators, e.g.,
oxtriphylline (Choledyl), theophylline
(Theo-Dur);
 
 
Corticosteroids (prednisone).
Rationale
 Diminished breath sounds may reflect
atelectasis. Rhonchi, wheezes indicate
accumulation of secretions/inability to clear
airways that may lead to use of accessory
muscles and increased work of breathing
 Expectoration may be difficult when
secretions are very thick as a result of
infection and/or inadequate hydration.
Blood-tinged or frankly bloody sputum
results from tissue breakdown (cavitation)
in the lungs or from bronchial ulceration
and may require further evaluation/
intervention.
 Positioning helps maximize lung
expansion and decreases respiratory effort.
Maximal ventilation may open atelectatic
areas and promote movement of
secretions into larger airways for
expectoration.
 Prevents obstruction/aspiration. Suctioning
may be necessary if patient is unable to
expectorate secretions.
 High fluid intake helps thin secretions,
making them easier to expectorate.
 Prevents drying of mucous membranes;
helps thin secretions.
Reduces the thickness and stickiness of
pulmonary secretions to facilitate
clearance.Increases lumen size of the
tracheobronchial tree, thus decreasing
resistance to airflow and improving oxygen
delivery.May be useful in presence of
extensive involvement with profound
hypoxemia and when inflammatory
response is life-threatening.
  Intubation may be necessary in rare cases
 Be prepared for/assist with emergency of bronchogenic TB accompanied by
intubation. laryngeal edema or acute pulmonary
bleeding.

NURSING DIAGNOSIS: Altered Sleep Pattern

Risk factors may include
 Ambient temperature, humidity, lighting , noise
 Caregiving responsibilities
 Lack of sleep privacy
 Interruptions
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes
 Report improve sleep
 Report increased sense of well-being and feeling rested
 Identify individually appopriate interventions to promote sleep

Nursing Interventions Rationale

 Sleep problems can arise form internal and

Identify presence of factors known to interefere
external factors, and may require
with sleep, including current illness,
assessment over time to differentiate
hospitalization
specific causes

 Ascertain presence of short term alteration in

 Hepls identify circumstances thatare known
sleep patterns, suach as can occur with travel,
to interrupt sleep acutely, but not necessary
sharing bed with new sleep partner, crisis at
long term
work

 Note environmental factors, such as unfamiliar

 These factors can reduce client’s ability to
or uncomfortable room; excessive noise and
rest and sleep at a time when more rest is
light; frequent medical and monitoring
needed
interventions
  Helps clarify client’s perception of sleep
Listen to report of sleep quality quantity and quality response to inadequate
sleep

 Turn on soft music, calm TV program, or quite

 To enhance relaxation
environment

 To promote readiness of sleep, improve

 Minimize sleep-disrupting factors
sleep duration and quality
 Nursing Diagnosis Intervention Rationale

Fluid volume deficient related to  Monitor intake and output,  Provide information about
excessive losses through normal note number, character and over all fluid balance, renal
routes amount of stools. function and bowel diseases
 Assess vital signs changes. control as well as guidelines
 Observe for excessively dry for fluid replacement.
skin and mucous  Hypotension, tachycardia and
membrane, dry skin turgor. fever can indicate response of
 Weigh daily. fluid loss.
 Administer parenteral as  Indicates dehydration.
indicated.  Indicator of overall fluid and
nutritional status.
 Maintenance of bowel rest
that will require alternate fluid
replacement to correct losses.
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis  Note non-verbal cues.  Non-verbal cues may be used
prolonged diarrhea, skin/tissue  Permit patient to assume in conjunction with verbal cues
irritation, peri rectal fissures, fistulas position of comfort. to identify extent of the
 Cleans rectal area with mild problem.
soap and water wipes after  Reduce abdominal tension
defecating. and sense of control.
 Record abdominal distention  Protect skin from undigested
increase temperature and bowel contents preventing
decrease blood pressure. excoriation.
 Implement prescribe dietary  May indicate developing
modifications, administer intestinal obstruction from
medication as indicated. inflammation.
 Complete bowel rest can
reduce pain and cramping.
b. Actual Nursing Management (SOAPIE)

S “giubo ko pero wala man noon plema” as verbalized by the patient.

 Non-productive cough
O  Use of accessory muscles for breathing
 RR: 22 cpm

A Ineffective Airway Clearance related to excessive mucous production

Short Term: At the end of 1hr, I will be able to maintain patent airway
P

I Independent
 Placed patient in a semi-fowlers position to facilitate full lung
expansion.
 Assisted patient with coughing and deep-breathing exercises.
 Maintained fluid intake of at least 2500 mL/day unless
contraindicated.
 Encoraged patient to eat foods rich in vit.c like orange, lemon

Objectives met. At the end of nursing exposure, patient was able to maintain
E patent airway and cough out secretions w/out assistance.

S “sakit ako tiyan ” as verbalized.

 Abdominal pain (5/10)

O  Facial grimace
 PR= 90bpm
 Acute pain r/t inflammation of gastric mucosa
A

At the end of 30mins patient will be able to reduce pain in a tolerable

level
P

I Independent
 Placed client in a comfortable position.
 Encouraged patient in a diversional activities lik watching TV, reading
magazines
 Encouraged deep breathing exercise and relaxation technique
 Provide quite environment free from distractions
Collaborative
 Administer pain reliever as ordered by the physician
E Objectives met. At the end of 30mins patient was be able to reduced pain in
a tolerable level

S “basa akong tae usahay ” as verbalized.

 sleepy
O  moderate diarrhea
 :sunken eyeballs

A
Risk for fluid volume deficient r/t excessive loss though vomiting and
diarrhea
At the end of 15-30 min of nursing interventions, patient’s will be able to
P verbalize a normal pattern of bowel functioning.

I  >Monitor intake and output and compare to the normal variation, to
assess the level of dehydration
 >Increase fluid intake to regain the fluid lose in the body.
 >Monitor the vital signs every hour, to detect any alteration or to
identify any variation from normal values
 >Monitor laboratory values, reflects hydration and identifies NA return
and protein deficient
 Provide IVF Fluids and electrolytes for maintain hydration and
electrolytes balance.
E At the end of the 30 minutes the patient verbalized effectiveness of the
intervention given and would able to maintain normal bowel pattern.

S “baspermi ko ga-mata kay gasakit ako tiyan” as verbalized.

 >Irritable
O  >Restless
 >Weak
 >Crying

A
Sleep pattern disturbance related to abdominal discomfort
 At the end of 8 hour the patient will able to have an adequate sleep.
P
 >Organized nursing care. (to promote minimal interruption in sleep.)
I  >Instructed the mother of the patient to limit the fluid of the patient
before bedtime. ( to reduce voiding during sleeping hours.)
 >Back rub, comfortable position done to the patient. ( to promote rest)
 >Maintained environment conducive to sleep. ( to promote sleep)
 E At the end of 8 hours patient achieved optimal amount of sleep as evidence
by rested appearance

Health Teachings

Before the patient is discharge, She was instructed to comply all of her
MEDICATION
medication regimen as prescribe by the attending physician,(Dr.Tan)..

Encouraged to engage in light exercises or exercises he can tolerate

like brisk walking, jogging, or slow running. However, patient is
EXERCISE
instructed to observe rest periods and consume oral fluids to replace
water lost through perspiration.

Patient is also instructed to maintain adequate rest period. Instructed to

increase fluid intake to 3 liters per day. Taught preventive measures
TREATMENT
including: role of nutrition and fluids; avoiding respiratory iiritants, vand
balance between activity and rest.
 Instructed patient to return one week after discharge at CPGH for
OUTPATIENT
evaluation of overall physical condition.
(FOLLOW-UP)

Instructed to eat small frequent feedings – DAT diet. Patient is also

DIET encouraged to maintain adequate fluid intake and to consume fruits and
vegetable to supply necessary vitamins and minerals.

VIII. REFERRALS AND FOLLOW-UP

To allow continuous monitoring of the patient’s condition, she should visit the
doctor a week after discharge for follow-up checkup for OPD as scheduled. This will
ensure through follow up of his condition and prevention of potential complications.
Always apply the universal precaution which is the hand washing and improve
environmental sanitation. She was also advised to have proper personal hygiene. With
regard to his medications, she is advised to maintain a compliant behaviour as well as
to stick to his diet modification and lifestyle changes. And for any unusualities that the
patient may encounter always consult to the doctor for further assessment, test and etc.

IX. EVALUATION and IMPLICATION

My assessment for two successive days showed that the patient’s status has
slightly been stable and had improved the patient’s view towards promoting health. I
had established rapport and harmonious communication during the whole course of the
study, reviewed patient’s chart and had carried out doctor’s orders.

Moreover, I had understood the Anatomy, Physiology and Pathophysiology of the

disease condition of the patient which is Acute Gatritis. I had identified Patient’s Clinical
Manifestations as basis for the Actual and Ideal Nursing Care Plans and had intervened
identified problems through patient-based nursing care.

As a nursing student, the knowledge that I had gained during the 2 days
assessing and caring of the patient had enhanced my understanding about the patient’s
condition.

This exposure had helped me improved and developed my interpersonal

relationship to people whom I worked with.

X. BIBLIOGRAPHY

A. Books

Deglin, Judith Hopfer and Vallerand, April Hazard. Davis’s Drug Guide for Nurses. 10th
Edition. F. A. Davis Company. Philadelphia, Pennsylvania. 2009

Doenges, Marilyn. et.al., Nursing Care Plans-Guidelines for Individualizing Client Care
across the Life Span. F.A. Davis Company. Philadelphia, Pennsylvania. 2006.

Kozier, Barbara. et.al., Fundamentals of Nursing. 8th Edition. Pearson Prentice Hall.
Upper Saddle River, New Jersey. 2008.

Smeltzer, Suzanne. et.al., Textbook of Medical-Surgical Nursing. 11th Edition. Volume 2.

Lippincott Williams & Wilkins. Philadelphia. 2008

Source: Snell, Richard S. Clinical Anatomy by Regions. 8th Edition.Lipincott Williams &
Wilkins. 530 Walnut Street, PA. 2008.

Saxton Nugent, Pelikan. Comphrehensive Review of Nursing for NCLEX – RN. 16th
edition. Mosby’s A Harcourt health sciences company, 1999.
B. Electronic Links

Medline Plus. Hypertension. Retrieved from http://www.nlm.nih.gov/medlineplus

/ency/article/000468.htm. Last accessed on February 25, 2013.

Nurse’sLabs. Allopurinol Drug Study. Retrieved from http://nurseslabs.com/allopurinol-

aloprim-drug-study/#_. Last accessed on February 27, 2013.

Ivabradine (Coralan) Drug Information - Indications, Dosage, Side Effects and

PrecautionsMedindia http://www.medindia.net/doctors/drug_information/ivabradine.htm
#ixzz2sStsc4n