CHRIST THE KING COLLEGE

COLLEGE OF NURSING
CALBAYOG CITY

CASE # 1

1. Leo 47 y.o. was admitted to the hospital for an executive check-up. He had
previously been complaining of chest pains, generalized abdominal pains,
belching and vomiting with altered bowel elimination patterns. He was
prescribed a soft diet with no activity restrictions. Initial Vital signs were T:
37.1 degrees Centigrade, P- 87 beats/min, RR: 21cycles/mins, BP:140/90.
He was advised to remain in the hospital for further management after
having the following diagnostic lab results:
CBC Cardiac Enzymes/Lipid Panel

FBS 95mg/dl WBC 15,000/ mm3* CPK 60 units/L

BUN 16 mg/dl RBC 5 x 10 6/uL CPK-MB 0
Creatinine 0.8 mg/dl Hgb 15 g/dl LDH 150 units/L
Hct 45 % Troponin T 0.2 ng/ml
WBC Differential
Sodium 138 mEq/L Neutrophils 75%*
Potassium 3.0 mEq/L* Lymphocytes 30% Total Cholesterol 300 mg/dl*
Chloride 99 mEq/L Monocytes 7% HDL 40 mg/dl*
Calcium 10 mg/dl Eosinophils 19%* LDL 250 mg/dl*
Basophils 1% Triglycerides 180 mg/dl*
PlateletCount 200,000/mm3

Hepatic Function Tests

Urinalysis
Fecalysis
Albumin 5 g/dl Billirubin Indirect 0.6 mg/dl
Direct 1.0 mg/dl*
Total 2.0 mg/dl*
AST/SGOT 45 units/L*
ALT/ SGPT 48 units/L*
Appearance clear
Color dark orange
Odor aromatic
pH 5.0
Protein negative
Sp. Gravity 1.005
Glucose negative
Casts none
WBC 1-2
RBC 0-1
Color pale
Consistency soft- formed
Blood negative
Pus negative
Ova and Parasites

Positive for ascaris lumbricoides

 Ultrasound of Abdomen
Chest X-Ray
EGD and Colonoscopy
Calcifications of RUQ suggestive of GB stones
Normal Lung findings
Heart midline with normal size
Normal gastric mucosa except for mild strictures at duodenal area with inflammation.

Colon normal with slight erythematous areas suggestive of injuries

1. What will be your focused physical assessment priorities before you start
your care for Leo.

- First, due to the presence of chest pain, ask the patient to rate the pain
using scale of 1-10 and also the location, when it occurs, intensity, type,
duration, with or without exertion, radiation, and etc. Next is assess for skin
turgor, capillary refill, mucous membranes, and amount and character of
urine and determine if there is a history of vomiting of the pt to help know
the possible cause of the discomfort the patient is experiencing. And after
performing physical assessment of the patient, the plan of care will follow.

2. Interpret the diagnostic lab test results for case Correlate the significant
diagnostic tests and PA findings with the pathophysiology of the
condition.

- All lab results are within the normal value. Except for HDL and LDL for
possible cause of the chest pain. If LDL is elevated, it is known as bad
cholesterol, and it can build up on the walls of the arteries. The buildup is
knows as cholesterol plaque. This plaque can narrow the arteries, limit the
blood flow, and raise the risk of having a blood clot. With the SGOT also
elevated, it is part of cardiac enzymes, and may be correlated with the
chest pain. And lastly the possible cause of the abdominal pain is the
parasitic infection which causes the Eosinophil to elevate.

3. Assuming that Leo was given Omeprazole 40 mgs. 2 times a day for
GERD, what is the role of this drug and nursing responsibilities for its
administration? What position and diet modifications will be advised for
 him to help manage his symptoms?

Role of the drug (Omeprazole)

-it is a proton pump inhibitor that decreases the amount of acid produced in the
stomach. And it is used to treat symptoms of  gastroesophageal reflux disease
(GERD) and other conditions caused by excess stomach acid.

Nursing Responsiblities

- Advise patient to avoid alcohol and foods that may cause an increase in GI
irritation. pain)

Instruct patient to report bothersome or prolonged side effects, including skin

problems (itching, rash) or GI effects (nausea, diarrhea, vomiting, constipation,
heartburn, flatulence, abdominal

Diet Modifications for the PT.

-The foods you eat affect the amount of acid your stomach produces. Eating the
right kinds of food is key to controlling acid reflux