Angeles University Foundation

College of Nursing

A. Y. 2015-2016

CASE STUDY:
GASTROINTESTINAL BLEEDING
SECONDARY TO BLEEDING PEPTIC
ULCER, ANEMIA
Submitted by:

Group 2 BSN III-A

Fajardo, Vannicar

Garcia, Veronica

Guiao, Grace

Magdangal, Kalvin

Sanchez, Levy Anne

Submitted to:

Rhocette Sn. Agustin, R.N, M.N

July 01, 2015

TABLE OF CONTENTS

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 I. INTRODUCTION ………………………………………………………………… 3
A. OBJECTIVES …………………………………………………………14
II. NURSING ASSESSMENT……………………………………………………….17
A. PERSONAL HISTORY…………………………………………….....17
B. FAMILY HEALTH ILLNESS HISTORY…………………………….19
C. HISTORY OF PAST ILLNESS ………………………………………21
D. HISTORY OF PRESENT ILLNES ……………………………...….21
E. PHYSICAL EXAMINATION (CEPHALOCAUDAL APPROACH) 23
F. DIAGNOSTIC LABORATORY
PROCEDURES………………………………………………………..37
III. ANATOMY AND PHYSIOLOGY………………………………………………..48
IV. THE PATIENT AND HIS ILLNESS……………………………………….…….72
A. PATHOPHYSIOLOGY Book-Centered……………………………….72
B. PATHOPHYSIOLOGY Client-Centered………………………………87.
V. THE PATIENT AND HIS CARE
A. MEDICAL MANAGEMENT
a. IVFS………………………………………………………………. 99
b. DRUGS……………………………………………………………103
c. DIET……………………………………………………………....108
B. NURSING MANAGEMENT………………………………………....110
a. NURSING CARE PLANS……………………………………….110
b. SOAPIERS……………………………………………………….135
VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL………………………...144
VII. SUMMARY OF FINDINGS……………………………………………………...147
VIII. CONCLUSION……………………………………………………………………151
IX. RECOMMENDATION……………………………………………………………153
X. LEARNING DERIVED…………………………………………………………..154
XI. BIBLIOGRAPHY………………………………………………………………...157

I. INTRODUCTION

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 “No man can be wise on an empty stomach;

No man can worship God or love his neighbor on an empty stomach”

–George Eliot and Winston Churchill

The digestive system is like an energy machine, receiving all the food which is the
body’s primary source of energy. “We are what we eat”, as the famous saying goes; but a
person can’t think well when a stomach is empty, for the reason that the digestive system is the
one delivering the nutrients in the brain. A person with an empty stomach can’t also perform
different physical activities due to lack of energy. Indeed, the digestive system is a critical part of
man’s daily life. As based on Abraham Maslow’s hierarchy of needs, man must prioritize his
physiologic needs because these predispose the fulfillment of higher needs. So abusing the
digestive system like eating with dirty hands would mean trouble just like Peptic Ulcer Disease.

Peptic Ulcer Disease (PUD) is a term used to describe a group of ulcerative disorders that
occur in areas of the upper gastrointestinal tract that are expose to acid-pepsin secretions. The
most common forms of peptic ulcer ate duodenal and gastric ulcers. Peptic ulcer disease, with
its remissions and exacerbations, represents a chronic health problem. Duodenal ulcers occur
five times more commonly than gastric ulcers. Ulcers in the duodenum occur at any age and
frequently are seen in early group, with a peak incidence between 55 and 70 years of age. Both
types of ulcers affect men three to four times more frequently than women.

A peptic ulcer can affect one or all layers of the stomach or duodenum. The ulcer may
penetrate only the mucosal surface, or it may extend into the smooth muscle layers.
Occasionally, an ulcer penetrates the outer wall of the stomach or duodenum. Spontaneous
remissions and exacerbations are common. Healing of the mascularis layer involves
replacement with scar tissue; although the mucosal layers that cover the scarred muscle layer
regenerate, the regeneration often less than perfect, which contributes to repeated episodes of
ulceration.

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 Since the early 1980’s, there has been a radical shift in thinking regarding the cause of
peptic ulcer. No longer is peptic ulcer though to result from a genetic predisposition, stress, or
dietary indiscretions. Most cases of peptic ulcer are caused by Helicobacter pylori infection. The
second most common cause of peptic ulcer is aspirin and other Non Steroidal Anti Inflammatory
drugs (NSAIDs). Aspirin appears to be the most ulcerogenic of the NSAIDs. In contrast to peptic
ulcer from other causes, NSAIDs-induced gastric injury often is without symptoms, and life-
threatening complications can occur without warning. (Carol Mattson Porth, page 610-611)

Anemia is clinical condition that results from an insufficient supply of healthy red blood cells
(RBCs), the volume of packed RBCs, and/or the quantity of hemoglobin. Hypoxia results
because the body’s tissues are not adequately oxygenated. Not a disease in itself, anemia
reflects a number of underlying pathologic processes leading to an abnormality in RBC number,
structure, or function. When anemia is identified, further testing must be done to determine its
cause.

Anemia can arise from primary hematologic problems or can occur as a secondary
consequence of defects in other body systems. Those at risk for developing anemia differ with
the various etiologies. Because the prevalence of anemia increases with age, adults 65 and
older are at particular risk; the estimated prevalence in this age-group is 20%. Aging cannot be
assumed to be the cause of anemia, however, without excluding other reversible causes.
Hereditary anemia have several cultural and ethnic considerations.

The prevalence of sickle cell disease and thalassemia is high in African Americans.
Thalassemia is also high in people of Mediterranean origin. Pernicious anemia rates are high in
Scandinavanians and African Americans. (JOYCE M. BLACK, page 2005)

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 According to World Health Organization PUD remains a relatively common condition
worldwide, with annual incidence ranging from 0.10% to 0.19% for physician-diagnosed PUD
and from 0.03% to 0.17% for PUD diagnosed during hospitalization. The 1-year prevalence of
physician diagnosed PUD was 0.12–1.5%, and the 1-year prevalence of PUD diagnosed during
hospitalizations was 0.10–0.19%.

The incidence of PUD has decreased over recent decades in many countries, most likely as
a result of the decrease in H. pylori infection, particularly in Western populations. However, it is
possible that the situation may be different in Asian countries; a recent study in Korea revealed
that the prevalence of H. pylori infection in association with Gastric Ulcer was increasing with
time, whereas H. pylori infection in Duodenal Ulcer was decreasing. Further work is required to
confirm if the results of this study can be extrapolated to the Asian population in general. The
most reliable study of physician-diagnosed prevalence was from Sweden, reporting cross-
sectional data representative of the general population; the study thus included both
symptomatic and asymptomatic PUD. The overall prevalence of PUD observed in this study
was 4.1%; 19.5% of all PUD cases identified were asymptomatic. Comparing this prevalence
with the lower rates obtained from other studies of physician-diagnosed PUD in primary care
suggests that a proportion of individuals with PUD remain undiagnosed. In individuals with
asymptomatic PUD, severe complications, such as gastrointestinal hemorrhage, may be the first
signs of the disease. Hemorrhage is associated with mortality approaching 10% and high
recurrence. This is particularly relevant for elderly patients who are less likely to have
symptoms, possibly because of the analgesic effects of Acetylsalicylic Acid (ASA) and Non-
steroidal Inflammatory Drugs) NSAIDs.

Overall, the review of the literature shows that the reported incidence and prevalence of PUD
have decreased over time in recent decades. However, temporal trends in the rate of
hospitalizations for complications of PUD varied in studies included in our review, remaining
unchanged or increasing in recent decades in two studies in Finland and the Netherlands, but
declining over time in one study in Scotland.

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 Management of PUD has improved substantially following the introduction of Proton-pump
inhibitor and therapy for H. pylori eradication. This is reflected in the decrease in prevalence of
H. pylori-associated PUD, the change in the proportion of H. pylori-positive PUD, and the lower
proportion of H. pylori infection, particularly in complicated PUD. The continued occurrence of
PUD is probably due, at least in part, to the widespread use of low-dose ASA and NSAIDs,
especially in Western countries and among older patients and those with comorbidities. Use of
these medications may also explain why the rate of hospitalizations for PUD complications has
not decreased in some studies and the general lack in reduction of mortality from PUD bleeding.
Use of traditional NSAIDs in Western countries has increased since the withdrawal of some
cyclooxygenase-2-selective inhibitors and Proton-pump inhibitor have been shown to produce a
marked and consistent reduction in the risk of gastrointestinal symptoms in patients receiving
NSAIDs and non-ASA anti-platelet agents. The common occurrence of PUD in users of NSAID
or low-dose ASA, despite wide availability of guidelines on the use of gastro protective agents in
NSAID users, is likely to be due to incomplete application of these guidelines in clinical practice
and incomplete adherence of patients to prescribed gastro protective medication.

Our review has several strengths, including the wide and comprehensive set of data
identified and the focus on publications from the last decade or so, which provides an update on
current status. Limitations include a lack of capture in most studies of asymptomatic patients
with PUD and the range of methodologies used in the publications identified, including the
different definitions of peptic ulcer used by the different studies. Also, the secondary care
studies may miss a large number of PUD patients, especially if they only counted the number of
inpatients.

In terms of future work, an estimate of the global population prevalence of symptomatic as

well as asymptomatic PUD, including the associated risk symptoms and potential risk factors,
would yield important information on burden of the disease and aid its management. Such data,
although scarce, are available from Europe, whereas similar data from Asia are still lacking.

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 According to the latest World Health Organization data published in April 2011 Peptic Ulcer
Disease Deaths in Philippines reached 7,423 or 1.76% of total deaths. The age adjusted Death
Rate is 14.83 per 100,000 of population ranks Philippines #2 in the world.

REASONS FOR CHOOSING THE CASE FOR PRESENTATION

In the process of learning, we as student nurses are entailed to be knowledgeable with the
different kinds of diseases that do harm to the human body. As we render holistic care we are
enriched with concepts, theories and necessary information to fully deliver ourselves in the
service of promoting life. For me, this case study will cater us good comprehension about the
mechanics of the disease condition. I chose this because I want to be acquainted with the
factors that cause such condition. I want to have an extensive view of the processes that can
lead to ulcer. I want to be conscious of this disease condition for me to be effective in
preventing and helping other people primarily the future patients. This case study will be
conducive to aid in halting the disease. I want to be mindful of every circumstance that will
attribute to this, hence, choosing this case study will be relevant not only for us but for all the
people needing our care.

-Veronica S. Garcia

The group has chosen this topic because we wanted to learn more about the
pathophysiology and the course of Upper Gastro Intestinal Bleeding in general. The group
believes that this case will enable us to broaden our knowledge regarding this case and be able
to provide each member sufficient data regarding the case, its sign and symptoms and
treatment process; this will also enable us to familiarize ourselves with different nursing
intervention related to this disease in order to enhance our skills as future nurses. With the aid
of this case study, the student does not only accomplish one requirement but gain knowledge
about this condition as well, thus making it more beneficial to the students. As the student
nurses discover more about this condition, they gain more of what they can impart to others to
be able to make the society become aware of it.

- Sanchez, Levy Anne G.

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 The group chose this case because a simple stomachache a man knows can
actually be aggravated and eventually lead to death. The group chose this case study
because it arouses the critical mind of the group regarding the unidentified process of
the occurrence of Peptic Ulcer Disease and how patients take action to emotionally deal
with this kind of situation. Through the course of the study, the group would also want to
familiarize themselves on the different causative factors and treatment for the disease;
for them to become more efficient in rendering proper care and service to their patient.
In addition, as student nurses and as part of the health care team in the future, they
may equip themselves with the proper knowledge regarding the disease and its
processes, enhance their skills with the proper management of the patient's condition
and provide interventions to prevent the disease from occurring or reoccur. Different
nursing roles would be also applied while being exposed with the patient in various test
and laboratory procedures. Lastly, this study by the group would serve as a future
reference for upcoming studies with the same condition.

- Fajardo, Vannicar, S.

"The group have considered the said study to enhance the knowledge regarding
it's scope. It has a purpose of training us how to be mindful of a patient's history in
contrast to his/her diagnosis. It will help not only the group but the individuals as well in
developing collaboration and team work developing it throughout the making of the case
study.

- Magdangal, Kalvin Paul

The group chose this case study because it arouses the critical mind of the group
regarding the disease condition and how patient/significant others take action to
emotionally deal with this kind of situation. Through the course of the study, the group
would also want to familiarize themselves on the different causative factors and
treatment for the disease; for them to become more efficient in rendering proper care
and service to their patient.

- Guaio,Grace

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A. CURRENT TRENDS ON PEPTIC ULCER DISEASE

In a new study published in the journalStem Cell Reports, biologists and

physicists at the University of Oregon (UO) in the US reveal how a protein in H.
pylori, the acid receptor TlpB (Helicobacter pylori chemotaxis receptor), grabs a small
molecule called urea that helps it to sense and navigate away from highly acidic
environments. They write about their findings in the 14 June online issue of the
journal Structure.

An important feature of the study is that the researchers found TlpB has a small
platform that protrudes from the bacterium cell, which they identified as a "PAS
domain". A PAS domain is a part of a protein that senses signals. Normally it resides
inside cells, but in the case of TlpB in H. pylori it sticks out of the cell, reaching
outwards, and binds to urea, giving it the ability to sense the external environment.

The researchers say this is the first time that crystallography has been used to
show that a bacterial chemoreceptor contains a PAS domain that is outside the cell. Co-
author James Remington is professor of physics and member of the UO Institute of
Molecular Biology. He told the press: "It is a beautiful structure, and this domain has
never been seen before in this class of proteins. Captured at the atomic resolution of
1.38 angstroms, it is the first new, significant structural view in 20 years of the class of
receptors used by bacteria to navigate their chemical environment," he added.

He and his colleagues managed to manipulate the atomic structure of the protein
and disrupt its ability to bind to urea, and showed urea was the key to helping H. pylori
sense and avoid acid. Co-author Karen Guillemin, professor of biology and also a
member of UO's Institute of Molecular Biology, said when the receptor is not able to
bind to urea, the bacterium gets "confused" and can't navigate away from high acid:
"We found that this urea binding is absolutely crucial for this protein to act as an acid
sensor."

Guillemin explained they now have "significant new insights into how acid sensing
works at the atomic level which is important for H. pylori's life in the stomach. The health

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implications are this: If we disrupt the binding of urea, we can confuse the bacteria and
potentially block their ability to reach the stomach lining where they cause damage," she
added.

Remington said so far they only have "snapshots along the way" of how H. pylori's
signals work. He said more work is now needed to understand the underlying
mechanisms. But, he said, the structure they have revealed, allows researchers see the
location of about 3,000 individual atoms in the urea-binding protein domain. H. pylori is
a Gram-negative bacterium that was first identified in 1982 and shown to be linked with
stomach ulcers and stomach cancer. While we know little about how it spreads, it is
present in the stomachs of half of the people in the world, 80% of whom will have no
symptoms. Grants from the National Institutes of Health and the National Science
Foundation helped support some of the researchers on the study. (Catharine Paddock
PhD Medical News Today)

Researchers from Southern Medical University in Guangdong, Guangzhou, China, have

developed an oral vaccine against Helicobacter pylori, the bacteria responsible for peptic ulcers
and some forms of gastric cancer, and have successfully tested it in mice. The research is
published ahead of print in the journal Clinical and Vaccine Immunology. The investigators
constructed a live recombinant bacterial vaccine, expressing the H. pylori antigen, adhesin
Hp0410, in the food-grade bacterium, Lactobacillus acidophilus. They then used it to orally
vaccinate the mice. The vaccine elicited specific anti-Hp0410 IgG antibodies in serum, and
showed "a significant increase" in the level of protection against gastric Helicobacter infection,
according to the report. When assayed, following challenge with H. pylori, immunized mice had
significantly lower bacterial loads than non-immunized mice.

H. pylori is a class 1 human carcinogen, according to the World Health Organization. It

causes gastritis, peptic ulcers, stomach cancer, and mucosa-associated lymphoid tissue
lymphoma. Antibiotic therapy is complex, unsuccessful in some patients (particularly in
developing countries) and relapse is common. A vaccine against H. pylori could circumvent
these difficulties.

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 L. acidophilus, a bacterium which is common in yogurt cultures, has distinct advantages as
an oral vaccine antigen delivery vehicle. It is safe and nontoxic. It resists the stomach's acidity
and tolerates bile, all of which aids in enabling it to survive in the gastrointestinal (GI) tract for
more than 72 hours. Additionally, it adheres to, and elicits an immune response from the GI tract
mucosa.

The current first-line treatment option for H. pylori infection includes two antibiotics and a
proton pump inhibitor, but is ineffective in roughly 20 percent of patients. "The high cost of
treatment, noncompliance, and antibiotic resistance are the most important reasons," says first
author Fan Hongying. Roughly 15-30 percent of patients relapse quickly, she says, noting that
after treatment, H. pylori may be resupplied to the stomach from a reservoir in the mouth. A
vaccine would circumvent these problems. "Our results collectively indicate that adhesin
Hp0410 is a promising candidate vaccine antigen and recombinant Lactobacillus acidophilus
expressing Hp0410 is likely to constitute an effective, low-cost live bacterial vaccine against H.
pylori," says Hongying. (www.sciencedaily.com)

The ulcer-causing bacterium Helicobacter pylori can directly interact with stomach stem cells,
causing the cells to divide more rapidly, according to a new study by researchers at the Stanford
University School of Medicine. The increased cell division was observed in mice, but the
findings could explain why H. pylori is a risk factor for gastric cancer in humans, the researchers
said. They used 3-D microscopy to identified colonies of the bacteria deep within human
stomach glands, where stem cells and precursor cells that replenish the stomach's lining reside.

One of every two people has H. pylori in their stomachs. It's one of the few organisms
capable of surviving the harsh acidic environment. While the majority of people remain
asymptomatic, in about 15 percent of those infected the bacteria causes painful ulcers, and in
another 1 percent the bacteria contribute to stomach cancer, the third-most lethal cancer
worldwide. Although the infection can be successfully treated with antibiotics, those who
develop cancer are often unaware of their condition until the tumor is large enough to interfere
with stomach functions. "The bacteria will be brewing for many years, and when the cancer
starts to cause symptoms it may be too late," said Manuel Amieva, MD, PhD, associate

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professor of pediatrics and of microbiology and immunology. Amieva is the senior author of the
paper describing the findings. The paper was published online May 1 in Gastroenterology. The
lead author is Michael Sigal, MD, PhD, a former postdoctoral scholar. H. pylori has long been
known to evade stomach acid by taking shelter in the protective mucus that covers the organ's
epithelial cell lining. The bacteria grow directly on the surface of the epithelial cells, injecting a
signaling protein, called CagA, to trick the cells into delivering nutrients to where the bacteria
are. The signaling protein also stimulates stem cells to divide faster, the researchers found.
Epithelial cells are short-lived and constantly replaced by new ones that originate from stem
cells residing in tiny glands throughout the stomach: The stem cells divide into precursor cells,
which populate the middle of the glands. Then precursor cells give rise to the mature epithelial
cells. The passage into and out of the gland is narrow: Its diameter is only about four times
wider than a single H. pylori cell, and filled with mucus. Earlier research in mice by Sigal and
Amieva showed that some H. pylori swam into the glands, but it wasn't known if the bacteria
actively grew there, or if this behavior occurred in humans. A more systematic study was
necessary, but the difficulty lay in finding appropriate human stomach samples to image. While
stomach biopsies are plentiful, they provide shallow samples from the top layer of the stomach
and omit the deeper tissues the researchers needed. "You don't want to go all the way through
-- it would be like giving the patient a big ulcer," Amieva said.

The researchers came up with the idea of sampling stomach tissues removed during weight-
loss surgery. These samples came from healthy stomachs, in which H. pylori was not actively
causing ulcers or cancer. After identifying tissue infected with particular strains of H. pylori, they
used confocal microscopy to reconstruct 3-D images of the glands from four stomachs with H.
pylori. All four showed colonies of the spiral-shaped bacteria clustered about two-thirds of the
way into the gland, where fast-dividing precursor cells reside. Unexpectedly, the researchers
found a smaller number of bacterial colonies at the base of the glands, where the stem cells
reside. When they went back to their mouse models, they discovered about 30 percent of the
glands colonized by H. pylori had bacteria at the base of the glands.

This unanticipated finding shed light on how H. pylori could influence cells to turn cancerous.
Cancer is thought to develop slowly as the cell acquires mutations in the DNA that override
cellular controls and increase cell proliferation. Even though H. pylori had been shown to

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manipulate cellular controls, the mature stomach's epithelial cells don't live long enough to
acquire mutations. "Once they reach the surface of the stomach, the cells live for about 24
hours," Amieva said. "It's hard to imagine H. pylori doing something to those cells that would
lead to cancer." But the stem cells are extremely long-lived, and H. pylori infections often start in
childhood. So there would be plenty of time for the bacteria to interact and change the stem
cells. To observe how H. pylori might modify stem cell behavior, the researchers turned to a
mouse strain used in developmental biology. The stem cells of the mouse express fluorescent
markers, which allowed the scientists to identify the stem cells and track their daughter cells.

Two weeks after infection with H. pylori, the mice's glands were noticeably longer and more
inflamed than those of uninfected mice. The stem cells in the glands of infected mice were also
dividing more actively. The researchers suspected CagA might be involved. To confirm this
hypothesis, they infected mice with H. pylori that can't inject CagA, and while the bacteria still
colonized the glands, they observed less inflammation and stem cell growth. Richard Peek, MD,
a professor of medicine and cancer biology at Vanderbilt University who was not involved in the
study, said the paper was "beautiful, almost artistic" and that by "using cutting-edge technology
to identify a subpopulation niche in the stomach, the research has opened up a new field of
investigation." (www.sciencedaily.com)

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OBJECTIVES:

The study aims to improve the present condition of the patient and is conducted
to gain a thorough understanding concerning the case of the patient. This was done to
the purpose of applying knowledge on nursing assessment, problem identification,
nursing interventions and evaluation that is related to the disease condition of the
patient. Furthermore, by gathering the subjective and objective regarding the case, it will
allow the researchers to have a proper and appropriate nursing care towards the
condition of an actual patient.

This study also aims to improve the skills of the student nurses in the clinical
area, their interpersonal relationships with other health care givers and to gain more
confidence towards what is tasked to them.

General Objectives:

After the completion of this study, the nurse researchers shall be able to have a
firm background on the health condition of the patient and his needs associated to
Peptic Ulcer Disease so that proper planning, management and intervention will be
given to meet basic needs, alleviate sufferings and prevent complications.

The group has formulated the following specific objectives to guide them towards
the completions of this case study.

Student-Nurse Centered:

After the conduction of this study, the nurse researchers shall be able to:

 Short Term Objectives:

• Establish a good interpersonal and professional relationship with the patient and his
accompanying family member;

• Select a relevant subject for the case study;

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• Collect data regarding the past and present health history of the patient;

• Assess the patient in a cephalocaudal approach which will serve as their baseline
data in determining the changes in patient’s body;

• Identify the modifiable and non-modifiable factors that contribute to the onset of the
disease;

• List the actual and possible symptoms that the patient may manifest;

• Study and relate the significance of the diagnostic examinations done;

• Share knowledge and skills to the chosen patient;

• Work together with the health team providing continuous care and;

• Provide significant health teachings that would promote patient’s health and
wellness.

 Long Term Objectives:

• Formulate an introduction that can present a concise overview of the case study;

• Identify its contribution in the fields of nursing education, practice, and research;

• Formulate specific, measurable, attainable, realistic and time bounded objectives

that will serve as a guide for the accomplishment of the study;

• Determine and discuss the anatomy and physiology of the body systems involved;

• Trace the pathophysiology of the disease process;

• Research on the drug study of the medications given to the patient and;

• Formulate effective nursing care plan with at least three actual problems and two
risk problems.

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Patient-Centered:

After the conduction of this study, the patient/family shall be able to:

 Short-term Objectives:

• Established therapeutic relationship with the student nurses and will trust and
cooperate with them;

• Understood the purpose of the Student nurse purpose for acquiring related
information about the patient with regards to his condition;

• Assessed by the student nurses and the family’s level of understanding about the
disease condition;

• Maintained sound communication during the interview;

• Participated during the assessment phase and in the interview and;

• Demonstrated interest during the course of nursing process.

 Long-term Objectives:

• Enumerated the underlying cause of the disease and its occurrence;

• Participated in the modality of the treatment given to the patient;

• Obtained pharmacological and non-pharmacological treatment to alleviate

disease condition and;

• Acquired palliative care and management of pain as well as reducing the

occurrence of complication from disease condition.

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II. Nursing Assessment

A. Personal History.

1. Demographic Data

In order to protect the patient and his significant others, the group purposely
concealed the patient’s identity and instead referred to him as Patient A throughout the
course of this study.

This is a case of Patient A, 56 years old, male, who has been married for twenty
three years and a father who makes the decisions for the family together with his wife.
He is residing in Dau Homeside, Angeles city, born at May 14, 1959 in Roxas City. He is
a natural born Filipino and a devout of the Roman Catholic.

Patient A was admitted in one of the hospitals in San Fernando, Pampanga on June
20, 2015 at 8:10 am with a chief complaint of epigastric pain and dizziness. He was
then initially diagnosed with upper gastro intestinal bleeding secondary to bleeding
peptic ulcer disease, Anemia.

2. Socio-Economic & Cultural Factors

The family of patient A is classified as a nuclear type of family. It is composed of

seven members, five of which pertains to their children. Patient A was a former
electrician in a call center company for almost eight years. Patient A is unemployed for
almost nine months due to the closing of the company he worked for. Meanwhile, His
wife works as a dealer of retailed rags to different vendors that sell in stores and
individually, she approximately earns 3,000 php in a week.The family’s main source of
income comes from the business of his wife. The family’s estimated income is 14,000
php per month that includes the extra pay whenever the wife accepts sideline jobs such
as seaming clothes. The family is classified under the poor category. According to
NEDA 2004, a family must have a total income of 13. 543 per member or 2,768.6 per
family member. Although patient A’s sibling helps in financing for the education of his
daughters, they are still in full responsibility for other fees and important expenses that

17
are sometimes inadequate for the family. According to Patient A’s wife, they usually
allot5,600 php for their monthly food expense, 5,000 php for the allowance and school
expense of the children, 1,000 php for the electricity, 300 php for the water expense,
200 php for the transportation and other fees for emergency situations.

The family’s typical diet consists of three meals per day, it is usually
accompanied with rice, vegetables (kangkong, pinakbet, ampalaya), meat (fried pork,
sinigang) and fish (tilapia, bangus) which is bought in the wet market and is cooked
either by his wife or Patient A himself.

Patient A’s lifestyle begins by sleeping at around 10:00pm to 5:00am, he wakes

up and exercises in the morning by biking and then usually does the household chores
since he lost his job and his wife takes over with the management of their income in the
family. He can do simple daily activities like cleaning their house. Patient A reported
difficulty in elimination of his waste. He only defecates twice in a week. He has been
smoking three sticks a day for almost twenty-five years. He is also fond of drinking soda
or soft drinks about 500ml everyday especially when he was still working for the
company as an electrician because the company used to cater their foods. He also
drinks beer but only during special occasions, usually twice or thrice in a year.

Patient A observes superstitious beliefs like the use of herbs like bayabas for
some wounds, tawas- tawas and hilots when he is not feeling well or has a fever The
wife of Patient A comply to medical practices such as bringing their children and Patient
A to the hospital when they are ill and they avail the services of the health center like
immunizations and check-ups during prenatal period and check- ups for the kids. They
also use over the counter drugs such as biogesic, biofit, paracetamol and the like when
some of the family members experience headaches, and other conditions that can be
tolerated.
As a Roman Catholic, Patient A seeks to attend mass every Sunday or if not,
every other Sunday. He celebrates special occasions like abstinence from meat during
Lent or by preparing delicious foods especially during Christmas season.

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 Patient A spent his elementary and highschool days in a public school
somewhere in Roxas City. After that, they moved to Pampanga because the
occupation of the father was to be transferred. He then studied his vocational course as
an electrician in Pampanga where they resided.

3. Environmental Factors

Patient A lives with his family. They live in a one-story house originally owned by
the parents of his wife. Their house is made up of concrete materials. The house has
three bedrooms, a comfort room with water carriage, a living room, and a garden. The
house has three windows which gives them adequate ventilation and make up an over
all of approximately 200sqm2for the lot area and approximately 90-100sqm 2 for the lot of
the house as recalled by the wife of Patient A. Their appliances consist of a refrigerator;
three electric fans, stove and some furniture that includes the dining table, sofa and
three beds. Their house is immediately surrounded by open canals in both sides of the
road, sari-sari store and other houses from their neighbors.

B. Family Health Illness History

The Family’s genogram shows the hereditary conditions or the illnesses that the
patient can develop. The genogram illustrates possible heart disease that is linked from
his deceased mother. Furthermore, it also presents the likelihood of some condition like
asthma which is an illness of his sister. The diagram also shows the relationship, type
and size of the family. It shows the conditions that are most likely develop in their
relations like diabetes mellitus and ulcer that was also a condition of the siblings of his
wife. Based from the genogram, there are no visible factors of the family which led to
the development of his disease.

19
20
C. History of Past Illness

Patient A did not encounter any problems at birth. However, as he grew up, he
was able to encounter childhood illnesses such as chicken pox, mumps and measles
when he was around seven to ten years old. All childhood immunizations were given to
him as recalled by patient A. He had an unknown allergic reaction to any drug, food,
animals, insects and other environmental agents. Furthermore, the patient had several
accidents and injury. During the 1980’s he had a motor vehicle accident where he was
hit on the left leg and caused a fracture which was casted. He was also hospitalized in
2011, at one of the hospitals in Angeles City where he underwent surgical removal of
two cysts that was a size of a centavo in his forehead and in the right hypochondriac

21
region of the abdomen. In the same year he also underwent removal of the cataract in
both eyes through laser. In 2013, he underwent knee joint aspiration and injection to
remove accumulated fluid due to arthritis. In February 2015, he had a deep abrasion
over his right leg which exposed a part of his tibia and was treated using laser
technology.

D. History of Present Illness

Last February 17, 2015Patient A was diagnosed of having ulcer in a clinic near
the intercession in Angeles City. The patient was said to experience epigastric pain,
burning in character, on and off and precipitated by food. On the same day, patient A
was conflicted whether to go to the hospital to get himself checked or not due to
practicality reasons such as saving money however, the physician instructed him to take
omeprazole 40mg tablet to relieve the pain which he did. He was also advised to
purchase biofit teas to help in his difficulty of defecation. Due to the known history of
fondness in drinking soft drinks which he verbalized, he was advised to limit intake of
acidic substances including sodas and alcohol, he was instructed to increase the intake
of water so as to limit the burning sensation of the patient. After his initial check-up, He
abided with the use of omeprazole to gain his relief. Despite the persistence of the pain,
he can still continue with his daily activities such as doing the household chores.

After a month (March,2015), the patient,despite his occasional intake of soft

drinks, continued his use of omeprazole for reliefbut can still feel the pain that would
sometimes last the whole day, because of this the patient lessened his chores and often
takes a rest to limit extraneous fatigue. Furthermore, after another month (April,2015),
Patient A’s epigastric pain was still persistent and it worsens when he is not taking
his meals, when he suddenly takes in food or when he eats too much. Omeprazole
provided relief for some time but the pain was still recurrent which made him feel even
weaker and which restrained him from doing the activities of daily living. At first, He was
not convinced of having another check-up because he feels that he can still tolerate

22
the pain with the help of the drug, so Patient A continued with his regimen, he
lessened his intake of acidic foods and he continued to have adequate rest.

It was in the month of May when Patient A started to feel generalized weakness
and dizziness. Amidst temporary relief of omeprazole, Patient A felt irritated with the
sustained pain in his stomach. As much as he would strive to feel better, he
progressively feels weak and often gets dizzy especially when standing up or
walking. An incident of fainting was reported while he was doing his household chores.

Two weeks prior to his admission, the patient had episodes of black tarry stool
approximately ¼ cup, persistence of epigastric pain, burning and radiating pain
from the epigastric area to the hypogastric region. The patient also experienced
dizziness, and vomiting which made it hard for him to continue other activities such as
doing simple household chores and other daily activities because of possible fainting or
collapse.

On June 20, 2015, 7:00am, patient A felt persistent epigastric pain as well as
dizziness, and black tarry stool. His wife decided to bring him to one of the tertiary
hospitals in San Fernando, Pampanga. At exactly 8:10 am he was admitted and
diagnosed with upper gastrointestinal bleeding secondary to bleeding peptic ulcer
disease, anemia.

E. Physical Examination

Date of Admission: June 20, 2015

(Data were lifted from the patient’s chart)

VITAL SIGNS:

23
 Blood Pressure: 100/70mmHg

Respiratory Rate: 20 breaths per minute

Pulse Rate: 85 beats per minute

Temperature: 36.3 degree celsius

Chief complaint: Epigastric pain

Manifestations: (+) Epigastric Pain

(+) recurrence of epigastric pain

(+) melena

(+) dizziness

(+) Nausea and Vomiting

Skin:(+) pallor, (-) rashes, (+) dry lips, (-) dryness of mucous membrane (-) jaundice
HEAD: (-) headache (+) dizziness (-) head injury
Ears: (-) tinnitus, (-) discharge, (-) decreased hearing
Nose: (-) colds, (-) nasal stuffiness (-) discharge
Mouth and Throat: (-) bleeding, (-)sorethroat (-) hoarseness
Respiratory: (-) hemoptysis, (-) sputum production (-) dyspnea

Lymph nodes: (-) cervical lymphadenopathy

Chest:

Lungs: Symmetrical chest expansion, (-)wheezes, (-) rales

Cardiovascular: (-) chest discomfort (-) irregular heart beat (–) murmurs

Breast: (-) palpable mass

Abdomen: soft, tender, flat abdomen, (+) epigastric pain

24
Rectum: (+) melena

Musculoskeletal: (-) edema, (+) weakness

Neurological: (-) convulsion (-) seizures (+) fainting (-) tremors

Sunday (June 21, 2015)

(Data were lifted from the patient’s chart)
GENERAL APPEARANCE:

Received patient on bed in supine position, awake and coherent with an ongoing
IVF of D5W 1L x 31-30gtts/min infusing well on the left hand. Patient has weakness
noted, pallor, slightly pale palpebral conjunctiva, poor skin turgor. With Vital signs
taken as follows: T- 36.6 P- 80bpm R- 24 cpm BP- 100/70mmHg

First day of student nurse-patient interaction (June 22,2015)

GENERAL APPEARANCE:

Received patient on bed in supine position, awake and coherent with an ongoing
IVF of 0.9Nacl IL x 30-31 gtts/min with a side drip of 1u PRBC properly typed and cross
matched with serial number # 4227 type A + Rhb infusing well on the left hand. Patient
has weakness noted, pallor, slightly pale palpebral conjunctiva, decreased skin
turgor, capillary time of four seconds, loss of appetiteand constipation noted; With
Vital signs taken as follows: T- 36.6 P- 63bpm R- 17cpm BP- 120/60mmHg

CEPHALOCAUDAL ASSESSMENT:

SKIN:

Upon inspection, patient A had a tan complexion that was uniform except in the
areas of lighter pigmentation such as the palms, and nail beds. The patient has a scar
on both lower extremities. The skin was cool and clammy to touch and had tenting
when skin is pinched.

25
HAIR:
The patient’s hair was of medium length, black-colored, smooth and evenly
distributed upon inspection. Patient has thin and silky hair strands. There were no signs
of hair loss and infestations such as pediculosis or dandruff.

NAILS:

The patient’s nails were pale and had normal shape. His nail texture was smooth
and the tissue surrounding the nail is intact on the epidermis. His nail bed capillaries
blanched when they were pressed but slowly returned into their usual color about
four seconds when the pressure was released after two seconds. His finger and toe
nails are dirty and untrimmed. There was no presence of clubbing.

HEAD AND FACE:

The patient had a normocephalic skull with frontal, parietal and occipital
prominences and with a smooth skull contour. There was absence of nodules and
masses upon palpation. However, the patient had a scar on the forehead. There were
no abnormal elevations or depressions of the face. His face was symmetrical in shape.
All of the sinuses were non tender upon palpation.

NECK:

His neck muscles were equal in size and centered. There were no masses or
lesions noted upon inspection and palpation. Patient A was able to move his head
smoothly and in a coordinated pace when instructed.

EYES:

26
 His eyebrows were symmetrically aligned with hair evenly distributed. There was
normal movement of his eyebrows. His eyelashes were also evenly distributed and
curled slightly outward. Patient A has a pale palpebral conjunctiva, pupils are equally
round and reactive to light and accommodation. The eyes are able to move in cardinal
direction and with blinking reflex.

EARS:

Upon inspection the patient’s auricles were 15-20 degrees adjacent to the outer
canthus of his eyes. Auricles has the same color with the facial skin, non-tender upon
palpation and returned after pinna was folded. No discharges noted.

MOUTH, THROAT, and SINUSES:

The patient’s lips were pale and dry. Mucous membranes of the mouth are
pale. The patient’s teeth are incomplete, yellowish. There were no deviations
observed upon inspection and palpation of the shape, size and color of the external
nose. All of the sinuses were not tender upon palpation.

TRACHEA:

The patient’s trachea was centrally aligned. There was no swelling or tenderness
upon inspection and palpation. His lymph nodes were non tender.

THORAX and LUNGS:

The patient’s chest was symmetrical, equal in expansion during ventilation. No

retractions or any use of accessory muscles. No adventitious sound heard upon
auscultation. Respiratory rate of 20 breaths per minute.

HEART:

27
 The patient’s skin color over the heart area has the same shade all over the skin.
There is normal symmetry of movement and no retractions noted. There are no thrills or
fine vibrations noted upon palpation. The patient has normal heart rate and rhythm upon
auscultation and no presence of adventitious heart sounds. Pulse rate of 85 breaths per
minute.

BREAST AND AXILLAE:

The patient’s skin has uniformity in color and breasts sizes are generally
symmetric upon inspection. There is absence of tenderness or edema. Upon inspection
of the axillae there are no rashes, redness nor unusual pigmentation noted. There were
no palpable lymph nodes upon palpation.

ABDOMEN

The patient’s skin is uniform in color and smooth upon inspection. There are
hypoactive bowel sounds upon auscultation. Presence of on and off burning pain in
epigastric area. With constipation noted

UPPER and LOWER EXTREMITIES

The patient has non tender purplish scar on the left and right leg, presence of
small mass located in the index finger in his left hand. All joints of both upper and lower
extremities are within normal limits and non-tender upon palpation.

MUSCULOSKELETAL:

The patient’s muscles are equal on both sides of the body with no contractures,
no fasciculation, no tremors and muscle are firm. Muscles have normal full movement
against gravity and against resistance,

NEUROLOGIC EXAMINATION:

28
 Level of consciousness: conscious and coherent, oriented with time place and
person. Patient A was cooperative throughout the assessment. Patient was able to
distinguish and perceive dull and sharp sensations. With generalized weakness noted

Neurologic Assessment:

a. Olfactory:

The patient was able to sense smell through identification of the odor of an
alcohol and perfume and the patient has intact sense of smell.

b.Optic:

For vision, Patient A was able to read the reading material such as newspaper

c. Oculomotor:

The Patient’s pupils constricted when passed using a penlight from inner to outer
cantus and was able track the object without difficulty.

d. Trochlear:

The Patient has coordinated ocular movements and can move his eyes upward
and downward.

e. Trigeminal:

The patient can elicit blink reflex when his eyes were touched with cotton, he can
also identify sharp objects from dull.

f. Abducens:

29
 The patient is able to track the object without difficulty. He can follow directed
cardinal fields.

g. Facial:

The patient can raise his eyebrows, smile, puff out cheeks, and close eyes
tightly.

h. Vestibulocochlear:

The patient can hear the tick of the watch when the other ear is occluded.

I.Glossopharyngeal:

The patient can move his tongue form side to side and up and down.

j. Vagus:

The patient elicited gag reflex after the introduction of tongue depressor and
spoke without hoarseness

k. Accessory:

The patient was able to shrug shoulders against resistance from hands and to
turn head to the side against resistance from your hand.

l. Hypoglossal:

30
 The patient can moved his tongue from side to side and up and down

Physical Examination:

Second day of student nurse-patient interaction (June 23,2015)

GENERAL APPEARANCE:

31
 Received patient on bed in sitting position, awake and coherent. With
generalized weakness noted, slightly pale palpebral conjunctiva, decreased skin
turgor and capillary refill of four seconds. With Vital signs taken as follows: T- 36.6
P- 82 bpm R- 28 cpm BP- 120/90mmHg

CEPHALOCAUDAL ASSESSMENT:

SKIN:

Upon inspection, patient A had a tan complexion that was uniform except in the
areas of lighter pigmentation such as the palms, and nail beds. The patient has a scar
on both lower extremities.

HAIR:
The patient’s hair was of medium length, black-colored, smooth and evenly
distributed upon inspection. Patient has thin and silky hair strands. There were no signs
of hair loss and infestations such as pediculosis or dandruff.

NAILS:

The patient’s nails were pale and had normal shape. His nail texture was smooth
and the tissue surrounding the nail is intact on the epidermis. His nail bed capillaries
blanched when they were pressed but slowly returned into their usual color about
four seconds when the pressure was released after two seconds. His finger and toe
nails are trimmed. There was no presence of clubbing.

HEAD AND FACE:

32
 The patient had a normocephalic skull with frontal, parietal and occipital
prominences and with a smooth skull contour. There was absence of nodules and
masses upon palpation. However, the patient had a scar on the forehead. There were
no abnormal elevations or depressions of the face. His face was symmetrical in shape.
All of the sinuses were not tender upon palpation.

NECK:

The Patient’sneck muscles were equal in size and centered. There were no
masses or lesions noted upon inspection and palpation. Patient A was able to move his
head smoothly and in a coordinated pace when instructed.

EYES:

His eyebrows were symmetrically aligned with hair evenly distributed. There was
normal movement of his eyebrows. His eyelashes were also evenly distributed and
curled slightly outward. Patient A has slightly pale palpebral conjunctiva, pupils are
equally round and reactive to light and accommodation. The eyes are able to move in
cardinal direction and with blinking reflex.

EARS:

Upon inspection the patient’s auricles were 15-20 degrees adjacent to the outer
canthus of his eyes. Auricles has the same color with the facial skin, non-tender upon
palpation and returned after pinna was folded. No discharges noted.

MOUTH, THROAT, and SINUSES:

The patient’s lips were pale and dry. Mucous membranes of the mouth are
pale. The patient’s teeth are incomplete, yellowish. There were no deviations

33
observed upon inspection and palpation of the shape, size and color of the external
nose. All of the sinuses were not tender upon palpation.

TRACHEA:

The patient’s trachea was centrally aligned. There was no swelling or tenderness
upon inspection and palpation. His lymph nodes were non tender.

THORAX and LUNGS:

The patient’s chest was symmetrical, equal in expansion during ventilation. No

retractions or any use of accessory muscles. No adventitious sound heard upon
auscultation. Respiratory rate of 28 breaths per minute.

HEART:

The skin color over the heart area has the same shade all over the skin. There is
normal symmetry of movement and no retractions noted. There are no thrills or fine
vibrations noted upon palpation. The patient has normal heart rate and rhythm upon
auscultation and no presence of adventitious heart sounds. Pulse rate of 85 breaths per
minute.

BREAST AND AXILLAE:

The patient’s skin has uniformity in color and breasts sizes are generally
symmetric upon inspection. There are no presence of tenderness or edema. Upon
inspection of the axillae there are no rashes, redness nor unusual pigmentation noted.
There were no palpable lymph nodes upon palpation.

ABDOMEN

34
 The patient’s skin is uniform in color and smooth upon inspection. There are
hypoactive bowel sounds upon auscultation.

UPPER and LOWER EXTREMITIES

The patient has non tender purplish scar on the left and right leg, presence of
small mass located in the index finger in his left hand. All joints of both upper and lower
extremities are within normal limits and non-tender upon palpation.

MUSCULOSKELETAL:

The patient’s muscles are equal on both sides of the body with no contractures,
no fasciculation, no tremors and muscle are firm. Muscles have normal full movement
against gravity and against resistance,

NEUROLOGIC EXAMINATION:

Level of consciousness: conscious and coherent, oriented with time place and
person. Patient A was cooperative throughout the assessment. Patient was able to
distinguish and perceive dull and sharp sensations. With weakness noted

Neurologic Assessment:

a. Olfactory:

The patient was able to sense smell through identification of the odor of an
alcohol and perfume and the patient has intact sense of smell.

b.Optic: For vision, Patient A was able to read the reading material such as newspaper

35
c. Oculomotor:

The patient’s pupils constricted when passed using a penlight from inner to outer
cantus and was able track the object without difficulty.

d. Trochlear:

The patient has coordinated ocular movements and can move his eyes upward
and downward.

e. Trigeminal:

The patient can elicit blink reflex when his eyes were touched with cotton, he can
also identify sharp objects from dull.

f. Abducens:

The patient is able to track the object without difficulty. He can follow directed
cardinal fields.

g. Facial:

The patient can raise his eyebrows, smile, puff out cheeks, and close eyes
tightly.

h. Vestibulocochlear:

The patient can hear the tick of the watch when the other ear is occluded.

I.Glossopharyngeal:

The patient can move his tongue form side to side and up and down.

36
j. Vagus:

The patient elicited gag reflex after the introduction of tongue depressor and
spoke without hoarseness

k. Accessory:

The patient was able to shrug shoulders against resistance from hands and to
turn head to the side against resistance from your hand.

l. Hypoglossal:

The patient can moved his tongue from side to side and up and down

37
F. Diagnostic and Laboratory Procedures

DIAGNOSTIC/LABO DATE INDICATION or RESULTS NORMAL ANALYSIS AND

INTERPRETATION
RATORY ORDERED PURPOSE VALUES(UNITS
OF RESULTS
PROCEDURES DATE USES IN THE
RESULT(S) IN HOSPITAL)
SERUM Date Ordered: BUN BUN The patient’s result
showed the number
ELECTROLYTES 06/20/2015 8.12 8-20mg/dl
of BUN within
(Hepatic, Renal Date of Results: This is indicated to normal range. This
indicatesnormal
Function) 06/21/2015 measure amount
functioning of liver
of urea in the and kidney.
blood. This is
determined by a
blood test directly
related to the
metabolic function
of the liver and
The patient’s results
excretory function
showed creatinine
of the kidney. within normal range
that indicates
Patient-centered:
normal functioning
This is indicated Creatinine of kidney.
for patient A to 1.0 0.6-1.2 mg/dL
detect a renal

38
 disorder or
The patient’s result
dehydration
showed Sodium
associated with levels within normal
rangeand indicates
BUN level
acid base balance,
CREATININE SODIUM water balance,
transmission of
Date Ordered: This is indicated to 140.5 135-145 mEq/L
nerve impulse and
Electrolyte Panel 06/20/2015 measure adequate contraction of
muscles.
Date of Results: kidney function. It
06/21/2015 measures the rate
at which creatinine
is cleared from the
blood by the
The patient’s results
kidney. showed normal
levels of potassium
POTASSIUM and keep
SODIUM 3.73 3.5-5mEq/L electrolyte balance
of the body
This is indicated to
resulting to good
determineelectrolyt functioning of the
nerves and
e and mineral. It
muscles.
helps keep the
water (the amount
Date Ordered: of fluid inside and Light brown,
FECALYSIS with 06/20/2015 outside the body's soft in

39
 Occult Blood Date of Results: cells) and consistency
06/21/2015 electrolyte balance Pus cells : 0-2
of the body. Empty Rectal
POTASSIUM occult
This is indicated to
determine
predominant
intracellular cation
helping to regulate
neuromuscular
excitability and
muscle contraction

DIAGNOSTIC/LABOR DATE INDICATION or RESULTS NORMAL ANALYSIS AND

INTERPRETATIO
ATORY ORDERED PURPOSE VALUES(UNI
N OF RESULTS
PROCEDURES DATE TS USES IN
RESULT(S) IN THE
HOSPITAL)
COMPLETE BLOOD Date Ordered: HEMOGLOBIN HEMOGLOBIN The patient’s result
COUNT (CBC) OR 06/20/2015 (Hgb) showed a
HEMATOLOGY Date of Results: General: 95 g m/L 140-174g m/L decrease in the
A complete blood count 06/22/2015 This is indicated to quality of
(CBC) is a series of subject the patient hemoglobin in the

40
tests used to evaluate to test number of blood to the levels
the composition and hemoglobin in below normal
concentration of the production of range.This
cellular components of erythropoietin. The connotes decrease
blood. It measures the findings in the in the production of
number of red blood Date Ordered: CBC give valuable erythrocytes or
cells (RBCs), The 06/20/2015 diagnostic loss of blood and is
number of white blood Date of Results: information about at risk of having
cells (WBCs), the total 06/22/2015 hematologic and ineffective tissue
amount of hemoglobin other body perfusion and lack
in the blood, the systems, of adequate
fraction of the blood prognosis, oxygen.Results
composed of red blood response to indicate anemia
cells (hematocrit), the treatment, and that occur due to
mean corpuscular recovery. bleeding of the
volume (MCV) – the Patient- digestive tract
size of the red blood Centered:
cells. This is indicated HEMATOCRIT
for patient A to
subject adequate 0.28 0.40-0.54 L/L
Date Ordered: oxygen carrying
06/20/2015 capacity,homeosta

41
Date of Results: sis and diagnose
06/22/2015 anemia.

HEMATOCRIT
(Hct)
General:
The patient’s
This is indicated to
results showed
identify measures
decrease in the
of concentration of
quality of
the red blood cells
hematocrit in the
and the total blood
blood to the levels
volume.
below normal
Patient-
below normal
Date Ordered: Centered: WBC
range. This
06/20/2015 This is indicated 11.4 x 109g/L 5-10x109 g/L
connotes decrease
Date of Results: for Patient A to aid
percentage of the
06/22/2015 in the diagnosis of
total blood volume
abnormal states of
regarding active
hydration, anemia
fluid loss in the
and current RBC
body that affects
mass
the nourishment of
cells as well.

42
 0.45-0.65
WBC NEUTROPHILS
COUNTGeneral: 0.72
This is indicated to
Date Ordered: detect infection or The patient’s result
06/20/2015 inflammation. showed an
Date of Results: Patient- centered: increase in number
06/22/2015 This is indicated of WBC above
for patient A to normal range due
determine to increased
presence of production of
infection affecting leukocyte to fight
0.20-0.35
the tissues of the an underlying
gastrointestinal infection and
are. LYMPHOCYTES increased as a to
0.22 any tissue damage
NEUTROPHILS in the
This is indicated to gastrointestinal
0.02-0.06
determine most area.
Date Ordered: numerous

43
 06/20/2015 circulating WBC in The patient’s
Date of Results: response to MONOCYTES resultshowed an
06/22/2015 inflammatory and 0.06 increase of
tissue injury sites. neutrophils above
This protects body normal range that
againstdisease connotes
and infections by opposition of
removing and infection in the
destroying some 150-400×109/L body such as
types of bacteria, tissue damage in
wastes, foreign PLATELET the gastrointestinal
substances, and COUNT area
othercells. 207 x 109g/L

Date Ordered: LYMPHOCYTES

06/20/2015 This is indicated to
Date of Results: determine cells
06/22/2015 that are important The patient’s result
part of the immune 4.5-6.0×1012/L showed a number
system. They help of lymphocytes
fight off diseases, within normal
after an infection range.

44
 RBC
3.26 x 1012/L
MONOCYTES
This is indicated to The patient’s result
determine the type showed a number
of white blood cell of monocytes
that fights off within normal
bacteria, viruses range.
and fungi.
Monocytes are
biggest type of
white blood cell in
the immune
system. The patient’s
PLATELET results are within
This is indicated to normal range that
determine special may indicate
fragments that normal clotting
play an important time and can
role in blood prevent risk of
clotting. If the excessive bleeding
patient doesn’t

45
 have enough
platelets, the
patient will have
an increased risk
of excessive
bleeding and The patient’s
bruising. results showed
RBC below the
RBC normal range that
This is indicated may indicate
for patient A to decrease in the
determine production of
calculated values erythropoietin or
of size and Hb loss of blood
content of RBCs;
important in
evaluating anemia.

46
Nursing Responsibilities:
Prior:
 Check the doctor’s order.
 Determine the prescribed test and other restrictions prior to the test.
 Get the laboratory requisition slip.
 Explain to the patient what the procedure to be done is.
 Inform the patient how the procedure is performed, the equipment to be used.
 Explain to the patient that the HCT test detects anemia and other abnormal blood
conditions.
 Advise the patient that the test require blood samples. Explain that she may feel
slight discomfort from the torniquet and the needle puncture.
 Note any recent procedures that can interfere with test results. (CBC)

During:
 Prepare all the equipment to be used.
 Tell the patient when to insert the needle for her to be prepared.
 Encourage the patient to remain calm during the test.
 Instruct the patient to cooperate fully and to follow directions. Direct the patient to
breathe normally and to avoid unnecessary movement.
 Observe/assess venipuncture site for bleeding or hematoma formation and
secure gauze with adhesive bandage. (CBC) Explain to the patient what test

should be done.
 Ensure a sterile blood sample from the patient.
 Send the sample to the laboratory immediately

After:

 A report of the results will be sent to the requesting HCP, who will discuss the
results with the patient.
 Monitor the puncture site for hematoma formation. (CBC)
 Proper documentation

47
III. ANATOMY AND PHYSIOLOGY

DIGESTIVE TRACT

The digestive tract is a 23 to 26 foot long

pathway that extends from the mouth to the
esophagus, stomach, small and large intestines,
and rectum to the terminal structure, the anus. It is
a hollow tube that passes through the body
providing an isolated environment for digestion
and absorption of the nutrients. The GI system
isolates ingested food and provides an
environment for digestion and absorption of
nutrients. The major functions of the GI tract are
motility, secretion, digestion and absorption.

ORAL CAVITY, PHARYNX, and ESOPHAGUS

The oral cavity, or mouth, is the first part of the digestive

tract. It is bounded by the lips and cheeks and contains the teeth
and tongue.

The lips are muscular structures, formed mostly by the

orbicularis oris muscle. The outer surfaces of the lips are covered

48
by skin. The keratinized stratified epithelium of the skin becomes thin at the margin of
the lips. The color from the underlying blood vessels can be seen through the thin,
transparent epithelium, giving the lips a reddish-pink appearance. At the internal margin
of the lips, the epithelium is continuous with the moist stratified squamous epithelium of
the mucosa in the oral cavity. The cheeks form the lateral walls of the oral cavity.

The buccinators muscles are located within the cheeks and flatten the cheeks
against teeth. The lips and cheeks are important in the process of mastication, or
chewing. They help manipulate the food within the mouth and hold the food in place
while the teeth crush or tear it. Mastication begins the process of mechanical digestion,
in which large food particles are broken down into smaller ones. The cheeks also help
form words during the speech process.

The tongue is a large, muscular organ that occupies most of the oral cavity. The
major attachment of the tongue is in the posterior part of the oral cavity. The anterior
part of the tongue is relatively free. There is an anterior attachment to the floor of the
mouth by a thin fold of tissue called the frenulum.

The tongue moves food in the mouth and, in cooperation with the lips and
cheeks, holds the food in place during mastication. It also plays a major role in the
process of swallowing. The tongue is a major sensory organ for taste, as well as being
one of the major organs of speech.

TEETH

There are 32 teeth in the

normal adult mouth, located in the

49
mandible and maxillae. The teeth can be divided into quadrants: right upper, left upper,
right lower, and left lower. In adults, each quadrant contains one central and one lateral
incisor; one canine; first and second premolars; and first, second, and third molars. The
third molars are called wisdom teeth because they usually appear in a persons late
teens or early twenties, when the person is old enough to have acquired some degree
of wisdom.

The teeth of adults are permanent, or secondary, teeth. Most of them are
replacements of the 20 primary, or deciduous, teeth.

Each tooth consists of a crown with one or more cusps, a neck and a root. The
center of the tooth is a pulp cavity, which is filled with blood vessels, nerves and
connective tissue, called pulp. The pulp cavity is surrounded by a living, cellular,
bonelike tissue called dentin. The dentin of the tooth crown is covered by an extremely
hard, acellular substance called enamel, which protects the tooth against abrasion and
acids produced by bacteria in the mouth. The surface of the dentin in the root is covered
with cementum, which helps anchor the tooth in the jaw.

The teeth are rooted within alveoli along the alveolar processes of the mandible
and maxillae. The alveolar processes are covered by dense fibrous connective tissue
and moist stratified squamous epithelium, referred to as the gingival, or gums. The teeth
are held in place by periodontal ligaments, which are connective tissue fibers that
extend from the alveolar walls and are embedded into the cementum.

PALATE AND TONSILS

50
 The palate, or roof of the oral cavity, consists of two parts. The anterior part
contains bone and is called the hard palate, whereas the posterior portion consists of
skeletal muscle and connective tissue and is called the soft palate. The uvula is a
posterior extension of the soft palate. The palate separates the oral cavity from the
nasal cavity and prevents food from passing into the nasal cavity during chewing and
swallowing.

The tonsils are located in the lateral posterior walls of the oral cavity, in the
nasopharynx, and in the posterior surface of the tongue.

SALIVARY GLANDS

There are three pairs of salivary glands the parotid, submandibular, and sublingual
glands. They produce saliva, which is a mixture of serous and mucous fluids. Saliva
helps keep the oral cavity moist and contains enzymes that begin the process of
chemical digestion. The salivary glands are compound alveolar glands. They have
branching ducts with clusters of alveoli, resembling grapes, at the ends of the ducts.

The largest of the salivary glands, the parotid glands, are serous glands located
just anterior to each ear. Parotid ducts enter the oral cavity adjacent to the second
upper molars.

The submandibular glands produce more serous than mucous secretions. Each
gland can be felt as a soft lump along the inferior border of the mandible. The
submandibular ducts open into the oral cavity on each side of the frenulum of the
tongue. In certain people, if the mouth is opened and the tip of the tongue is elevated,
saliva can squirt out of the mouth from the ducts of these glands.

51
 The sublingual glands, the smallest of the three paired salivary glands, produce
primarily mucous secretions. They lie immediately below the mucous membrane in the
floor of the oral cavity. Each sublingual gland has 10-12 small ducts opening onto the
floor of the oral cavity.

PHARYNX

The pharynx, or throat, which connects the mouth with the esophagus, consists of
three parts: the nasopharynx, oropharynx, and laryngopharynx. Normally only the
oropharynx and laryngopharynx transmit food. The posterior walls of the oropharynx
and laryngopharynx are formed by the superior, middle, and inferior pharyngeal
constrictor muscles.

ESOPHAGUS

The esophagus is a muscular tube, lined with moist stratified squamous epithelium
that extends from the pharynx to the stomach. It is about 25 centimeters long and lies
anterior to the vertebrae and posterior to the trachea within the mediastinum. It passes
through the diaphragm and ends at the stomach. Upper and lower esophageal
sphincters, located at the upper and lower ends of the esophagus, respectively, regulate
the movement of food into and out of the esophagus. The lower esophageal sphincter is
sometimes called the cardiac sphincter. Numerous mucous glands produce thick,
lubricating mucus that coats the inner surface of the esophagus.

STOMACH

52
 Stomach is an enlarged segment of the
digestive tract in the left superior part of the
abdomen. The opening from the esophagus into
the stomach is called the cardiac opening
because it is near the heart. The region of the
stomach around the cardiac opening is called the
cardiac region. The most superior part of the
stomach is the fundus. The largest part of the
stomach is the body, which turns to the right,
forming a greater curvature on the left, and a
lesser curvature on the right. The opening from
the stomach into the small intestine is the pyloric opening, which is surrounded by a
relatively thick ring of smooth muscle called pyloric sphincter. The region of the stomach
near the pyloric opening is the pyloric region.

The muscular layer of the stomach is different from other regions of the digestive
tract in that it consists of three layers: an outer longitudinal layer, a middle circular layer
and an inner oblique layer. These muscular layers produce a churning action in the
stomach, important in the digestive process. The submucosa and mucosa of the
stomach are thrown into larger folds called rugae when the stomach is empty. These
folds allow the mucosa and submucosa to stretch, and the folds disappear as the
stomach is filled.

The stomach is lined with simple columnar epithelium. The mucosal surface
forms numerous tube-like gastric pits, which are the openings for the gastric glands.
The epithelial cells of the stomach can be divided into five groups. The first group
consists of surface mucous cells on the inner surface of the stomach and lining the
gastric pits. Those cells produce mucus, which coats and protects the stomach lining.

53
The remaining four cell types are in the gastric glands. They are mucous neck cells,
which produce mucus; parietal cells, which produce hydrochloric acid and intrinsic
factor; endocrine cells, which produce regulatory hormones; and chief cells, which
produce pepsinogen, a precursor of the protein-digesting enzyme pepsin.

Three phases of Stomach Secretions

Cephalic Phase

The smell, taste of food, tactile sensations of food in the mouth, or even thought of food
stimulates the medulla oblongata.

Parasympathetic action potentials are carried by the vagus nerves to the stomach.

Preganglionic parasympathetic vagus nerve fibers stimulate postganglionic neurons in

the enteric plexus of the stomach.

Postganglionic neurons stimulate secretion by parietal and chief cells and stimulate
gastrin secretion by endocrine cells

Gastrin is carried through the circulation back to the stomach, where it stimulates
secretion by parietal and chief cells.

54
 Gastric Phase

Distention of the stomach stimulates mechanoreceptors and activates a

parasympathetic reflex. Action potentials are carried by the vagus nerves to the medulla
oblongata.

The medulla oblongata increases action potentials in the vagus nerves that stimulate
stomach secretions.

Distention of the stomach also activates local reflexes that increase stomach secretions

Intestinal Phase

Chyme in the duodenum with pH less than 2 or containing fatty acids and other lipids
inhibits gastric secretions by three mechanisms.

Chemoreceptors in the duodenum are stimulated by H + (low pH) or lipids. Action

potentials generated by the chemoreceptors are carried by the vagus nerves to
themedulla oblongata where they inhibit parasympathetic action potentials.

Local reflexes inhibit secretions of the stomach mucosa.

55
Secretin, gastric inhibitory polypeptide, and cholecystokinin produced by the duodenum
inhibit secretions of the stomach mucosa.

Movements in the Stomach

A mixing wave initiated in the body of the stomach progresses toward the pyloric
sphincter.

A more fluid part of the chime is pushed toward the pyloric sphincter, whereas the more
solid center of the chime squeezes past the peristaltic constriction back toward the body
of the stomach.

Peristaltic waves move in the same direction and in the same way as the mixing waves
but are stronger.

Again, the more fluid part of the chime is pushed toward the pyloric region whereas the
more solid center of the chime squeezes past the peristaltic constriction back toward the
body of the stomach.

Peristaltic contractions force a few milliliters of the most fluid chime through the pyloric
opening into the duodenum. Most of the chime, including the more solid portion, is
forced back toward the body of the stomach for further mixing.

56
 SMALL INTESTINE

The small intestine is about 6 meters

long and consists of three parts the
duodenum, jejunum, and ileum. The
duodenum is about 25 centimeter. The
jejunum is about 2.5 meter long and makes
up two-fifths of the total length of the small
intestine. The ileum is about 3.5 meter long and makes up three-fifths of the small
intestine.

The duodenum nearly completes a 180-degree arc as it curves within the

abdominal cavity. Part of the pancreas lies within this arc. The common bile duct from
the liver and the pancreatic duct from the pancreas join each other and empty into the
duodenum.

The small intestine is the major site of digestion and absorption of food, which
are accomplished by the presence of a large surface area. The surface of the small
intestine has three modifications that increase surface area about 600-fold: circular
folds, villi, and microvilli. The mucosa and submucosa form a series of circular folds that
run perpendicular to the long axis of the digestive tract. Tiny finger like projections of the
mucosa forms numerous villi, which are 0.5-1.5 mm long. Most of the cells composing
the surface of the villi have numerous cytoplasmic extensions, called microvilli. Each
villus is covered by simple columnar epithelium. Within the loose connective tissue core
of each villus is a blood capillary called lacteal. The blood capillary network and the
lacteal are very important in transporting absorbed nutrients.

57
 The mucosa of the small intestine is simple columnar epithelium with four major
cell types: (1) absorptive cells, which have microvilli, produce digestive enzymes, and
absorb digested food; (2) goblet cells, which produce a protective mucus;(3) granular
cells, (Paneths cells), which may help protect the intestinal epithelium from bacteria;
and (4) endocrine cells, which produce regulatory hormones.

The epithelial cells are produce within tubular glands of the mucosa, called
intestinal glands, at the base of the villi. Granular and endocrine cells are located in the
bottom of the glands. The sub mucosa of the duodenum contains mucous glands, called
duodenal glands, which open into the base of the intestinal glands.

The duodenum, jejunum, and ileum are similar in structure except that there is a
granular decrease in the diameter of the small intestine, in the thickness of the intestinal
wall, in the number of circular folds, and in the number of villi as one progress through
the small intestine. Lymph nodules are common along the entire length of the digestive
tract. Clusters of lymph nodules, called Peyer’s patches, are numerous in the ileum.
These lymphatic tissues in the intestine help protect the intestinal tract from harmful
microorganisms.

The junction between the ileum and the large intestine is the ileocecal junction. It
has a ring of smooth muscle, the ileocecal sphincter, and an ileocecal valve, which
allows material contained in the intestine to move from the ileum to the large intestine,
but not in the opposite direction.

Secretions of the Small Intestines

58
 Secretions from the mucosa of the small intestine mainly contain mucus, ions
and water. Intestinal secretions lubricate and protect the intestinal wall from the acidic
chime and the action of the digestive enzymes. They also keep the chime in the small
intestine in a liquid form to facilitate the digestive process. Most of the secretions
entering the small intestine are produced by the intestinal mucosa, but the secretions of
the liver and the pancreas also enter the small intestine and play important roles in the
process of digestion.

The epithelial cells in the walls of the small intestine have enzymes bound to their
free surfaces that play a significant role in the final steps of digestion. Peptidases break
the peptide bonds in proteins to form amino acids. Disaccharidases break down
dissacharides, such as maltose and isomaltose, into monosaccharide. The amino acids
and monosaccharides can be absorbed by the intestinal epithelium.

Mucus is produced by duodenal glands and by goblet cells, which are dispersed
throughout the epithelial lining of the entire small intestine and within intestinal glands.
Hormones released from the intestinal mucosa stimulate liver and pancreatic
secretions. Secretion by duodenal glands is stimulated by the vagus nerve, secretin
release, and chemical or tactile irritation of the duodenal mucosa.

Movement of Small Intestines

Mixing and propulsion of chime are the primary mechanical events that occur in
the small intestine. Peristaltic contractions proceed along the length of the intestine for
variable distances and cause the chime to move along the small intestine. Segmental
contractions are propagated for only short distances and function to mix intestinal
contents.

59
 The ileocecal sphincter at the juncture of the ileum and the large intestine
remains mildly contracted most of the time, but peristaltic contractions reaching the
ileocecal sphincter from the small intestine cause the sphincter to relax and allow
movement of chime from the small intestine into the cecum. The ileocecal valve allows
chime to move from the ileum into the large intestine, but tends to prevent movement
from the large intestine back into the ileum.

Absorption in the Small Intestines

A major function of the small

intestine is the absorption of nutrients.
Most absorption occurs in the
duodenum and jejunum, although
some absorption also occurs in the
ileum.

LIVER

The liver weighs about 1.36 kilograms and is located in the right upper quadrant of
the abdomen, tucked against the inferior surface of the diaphragm. The posterior
surface of the liver is in contact with the right ribs 5-12. It is divided into two major lobes,
the right and left lobes, separated by a connective tissue septum, the falciform ligament.
Two smaller lobes, the caudate and quadrate, can be seen from an inferior view. Also
seen from the inferior view is the porta, which is the “gate” through which blood vessels,
ducts and nerves enter or exit the liver.

60
 The liver receives blood from two sources. The hepatic artery brings oxygen-rich
blood to the liver, which supplies liver cells with oxygen. The hepatic portal vein carries
blood that is oxygen-poor but rich in absorbed nutrients and other substances from the
digestive tract to the liver. Liver cells process nutrients and detoxify harmful substance
from the blood. Blood exits the liver through hepatic veins, which empty into the inferior
vena cava.

Many delicate connective tissue septa divide the liver into lobules with portal triads
at the corners of the lobules. The portal triads contain three structures: the hepatic
artery, hepatic portal vein, and hepatic duct. Hepatic cords, formed by platelike groups
of cells called hepatocytes, are located between the center and the margins of each
lobule. The hepatic cords are separated from one another by blood channels called
hepatic sinusoids. The sinusoid epithelium contains phagocytic cells that help remove
foreign particles from the blood. Blood from the hepatic portal vein and the hepatic
artery flows into the sinusoids and becomes mixed. The mixed blood flows towards the
center of each lobule into a central vein. The central veins from all the lobes unite to
form the hepatic veins, which carry blood out of the liver to the inferior vena cava.

A cleft-like lumen, the bile canaliculus, is between the cells of each hepatic cord.
Bile, produced by the hepatocytes, flows through the bile canaliculi to the hepatic ducts
in the portal triads. The hepatic ducts converge and empty into the right and left hepatic
ducts, which transport bile out of the liver. The right and left hepatic ducts unite to form
a single common hepatic duct. The common hepatic ducts is joined by the cystic duct
from the gallbladder is a small sac on the inferior surface of the liver that stores and
concentrates bile. The common bile duct joins the pancreatic duct and opens into the
duodenum at the duodenal papilla. The opening into the duodenum is regulated by a
sphincter.

61
 The liver performs important digestive and excretory functions, store and
processes nutrients, synthesizes new molecules, and detoxifies harmful chemicals.

The liver secretes about 70mL of bile each day. Bile contains no digestive
enzymes, but it plays an important role in digestion by diluting and neutralizing stomach
acid and by dramatically increasing the efficiency of fat digestion and absorption.
Digestive enzyme cannot act efficient on large fat globules. Bile salts emulsify fats,
breaking the fat globules into smaller droplets, much like the action of detergent in dish-
water. The small droplets are more easily digested by the digestive enzymes. Bile also
contains excretory products such as bile pigments, cholesterol and fats. Bilirubin is a
bile pigment that results from the breakdown of hemoglobin.

Bile excretion by the liver is stimulated by secretin, which is released from the
duodenum. Cholecystokinin stimulates the gall bladder to contract and release bile into
the duodenum. Parasympathetic stimulation through the vagus nerve also stimulates
bile secretion and release.

Most (90%) bile salts are reabsorbed in the ileum, and the blood carries them back
to the liver, where they stimulate additional bile salts secretion and are once again
secreted into the bile. The loss of bile salts in the feces is reduced by this recycling
process.

The liver can remove sugar from the blood and store it in the form of glycogen. It
can also store fat, vitamins, copper and iron. This storage function is usually short term.

62
 Foods are not always ingested in the proportion needed by the tissues. If this is the
case, the liver can convert some nutrients into others.

The liver also transforms some nutrients into more readily usable substances.
Many ingested substances are harmful to the cells of the body. In addition, the body
itself produces many by-products of metabolism that, if accumulated, are toxic. The liver
is an important line of defense against many of those harmful substances. It detoxifies
them by altering their structure, making their excretion easier.

The liver can also produce its own unique new compounds. Many of the blood
proteins, such as albumin, fibrinogen, globulins, and clotting factors, are synthesized in
the liver and released into the circulation.

PANCREAS

The pancreas is located retroperitoneal, posterior to the stomach in the inferior

part of the left upper quadrant. It has a head near the midline of the body and a tail that
extends to the left where it touches the spleen. It is a complex organ composed of both
endocrine and exocrine tissues that perform several functions. The endocrine part of the
pancreas consists of pancreatic islets (islets of Langerhans). The islet cells produce
hormones insulin and glucagons, which enter the blood. These hormones are very
important in controlling blood vessels of nutrients such as glucose and amino acids.

The exocrine part of the pancreas is a compound acinar gland. The acini produce
digestive enzymes. Clusters of acini are connected by small ducts, which join to form
larger ducts, and larger ducts join to form the pancreatic duct. The pancreatic duct joins
the common bile duct an empties in the duodenum.

63
Functions of the Pancreas

The exocrine secretions of the pancreas include HCO 3, which neutralizes the
acidic chime that enters the small intestine from the stomach. The increased pH
resulting from the secretion of HCO3 stops the pepsin digestion but provides the proper
environment for the pancreatic enzymes. Pancreatic enzymes are also present in the
exocrine secretions and are important for the digestion of all major classes of food.
Without enzymes produced by the pancreas, lipids, proteins, and carbohydrates are not
adequately digested.

The major proteolytic enzymes are trypsin, chymotrypsin and carboxypeptidase.

These enzymes continue the protein digestion that started in the stomach, and
pancreatic amylase continues the polysaccharide digestion that began in the oral cavity.
The pancreatic enzymes also include a group of lipid-digesting enzymes called
pancreatic lipases. Nucleases are pancreatic enzymes that reduce DNA and ribonucleic
acid to their component nucleotides.

The exocrine secretory activity of the pancreas is controlled by both hormonal

and neural mechanisms. Secretin initiates the release of a watery pancreatic solution
that contains a large amount of HCO3. The primary stimulus for secretin release is the
presence of the acidic chyme in the duodenum. Cholecystokinin stimulates the
pancreas to release an enzyme rich solution. The primary stimulus for cholecystokinin
release is the presence of fatty acids and amino acids in the duodenum, and enzymes
secreted by the pancreas digest fatty acids and amino acids. Parasympathetic
stimulation through the vagus nerves also stimulates the secretion of the pancreatic
juices rich in pancreatic enzymes. Sympathetic action potentials inhibit pancreatic
secretion.

LARGE INTESTINE

64
 The large intestine consists of the cecum, colon, rectum, and anal canal.

Cecum

The cecum is the proximal end of the large intestine and is where the large and
small intestines meet at the ileocecal junction. The cecum is located in the right lower
quadrant of the abdomen near the iliac fossa. The cecum is a sac that extends inferiorly
about 6 cm past the ileocecal junction. Attached to the cecum is a tube about 9 cm long
called the appendix.

Colon

The colon is about 1.5 – 1.8 m long and consists of long parts: the ascending
colon, the transverse colon, the descending colon, and the sigmoid colon. The
ascending colon extends superiorly from the cecum to the right colic flexure, near the
liver, where it turns to the left. The transverse colon extends from the right colic flexure
to the left colic flexure near the spleen, where the colon turns inferiorly; and the
descending colon extends from the left colic flexure to the pelvis, where it becomes the
sigmoid colon. The sigmoid colon forms an S-shaped tube that extends medially and
then inferiorly into the pelvic cavity and ends at the rectum.

The mucosal lining of the colon contains numerous straight tubular glands called
crypts, which contain many mucus-producing goblet cells. The longitudinal smooth
muscle layer of the colon does not completely envelope the intestinal wall but forms
three bands called teniae coli.

RECTUM

65
 The rectum is straight, muscular tube
that begins at the termination of the sigmoid
colon and ends at the anal canal. The
muscular tunic is smooth muscle and it is
relatively thick in the rectum compared with
the rest of the digestive tract.

Anal Canal

The last 2-3 cm of the digestive tract is the anal canal. It begins at the inferior end of the
rectum and ends at the anus. The smooth muscle layer of the anal canal is even thicker
than that of the rectum and forms the internal anal sphincter at the superior end of the
anal canal. The external anal sphincter at the inferior end of the anal canal is formed by
skeletal sphincter.

Functions of the Large Intestine

The function of the large intestine is feces production and water absorption. It
takes much longer for material to move through the large intestine than the small
intestine. While in the colon, chime is converted to feces. Absorption of water and salts,
the secretion of mucus, and extensive action of microorganisms are involved in the
formation of feces. The colon stores the feces until they are eliminated by the process of
defecation. Mass movements occur for every 8-12 hours. Each mass movement
contraction extends over 20 or more centimeters of the large intestine, which is a much
longer part of the digestive tract than that covered by a peristaltic contraction. Reflex

66
 activity moves feces through the internal anal sphincter. Voluntary activity regulates
movement through the external anal sphincter.

DIGESTION, ABSORPTION, AND TRANSPORT

Digestion id the breakdown of food to molecules that are small enough to be

absorbed into the circulation. Mechanical digestion breaks large food particles down into
smaller ones. Chemical digestion involves the breaking of covalent chemical bonds in
organic molecules by digestive enzymes. Absorption begins in the stomach, where
some small, lipid-soluble molecules, such as alcohol and aspirin, can diffuse through
the stomach epithelium into the circulation. Transport requires carrier molecules and
includes facilitated diffusion, cotransport, and active transport. Cotransport and active
transport require energy to move the transported molecules across the intestinal wall.
(SEELEY’S ESSENTIALS OF ANATOMY AND PHYSIOLOGY, EIGHT EDITION,
International Edition 2013)

Blood has always fascinated humans, and throughout

history they have speculated about its function. Some
societies consider blood the “essence of life” because
the uncontrolled loss of it can result in death. Blood
performs many functions essential to life and can
reveal much about our health. The heart pumps blood
through blood vessels that extend throughout the body.

Blood is a type of connective tissue that consists of a

liquid matrix containing cells and cell fragments. The
liquid matrix is the plasma, the cells and cell fragments
are the formed elements. The plasma accounts for
slightly more than half of the total blood volume, and
Blood components 67
http://www.learningl.com
the formed elements account for slightly less than half. The total blood volume in the
average adult is about 4-5 liters in females and 5-6 in males . Blood makes up about 8%
of total body weight.

Plasma

Plasma is a pale yellow fluid that consists of about 91% water, 7% proteins, and 2%
other components, such as ins, nutrients, gases, waste products, and regulatory
substances . (SEELEY’S ESSENTIALS OF ANATOMY AND PHYSIOLOGY, EIGHT
EDITION, International Edition 2013)

Formed Elements

About 955 of the volume of the formed elements consists of red blood cells (RBCs), or
erythrocytes. The remaining 5% of the volume of the formed elements consists of white
blood cells (WBCs), or leukocytes and cell fragments called platelets or
thrombocytes. The process of blood cell production is called hematopoiesis.
(SEELEY’S ESSENTIALS OF ANATOMY AND PHYSIOLOGY, EIGHT EDITION,
International Edition 2013)

Red Blood Cells

Normal red blood cells are disk-shaped, with edges that are thicker than the center of
the cell. The biconcave shape increases the cell’s surface area compared to a flat disk
of the same size. The greater surface area makes it easier for gases to move into and
out of the red blood cell. The primary function of the red blood cells is to transport
oxygen from the lungs to the various tissues of the body and to help transport carbon
dioxide from the tissues to the lungs. (SEELEY’S ESSENTIALS OF ANATOMY AND
PHYSIOLOGY, EIGHT EDITION, International Edition 2013)

68
White Blood Cells

White blood cells are spherical cells that lack hemoglobin. White blood cells are thin,
white layer of cells between plasma and red blood cells when the components of blood
are separated from each other. They are larger than red blood cells, and each has a
nucleus. The two functions of white blood cells are (1) to protect the body against
invading microorganisms and (2) to remove dead cells and debris from the tissues by
phagocytosis. (SEELEY’S ESSENTIALS OF ANATOMY AND PHYSIOLOGY, EIGHT
EDITION, International Edition 2013)

Platelets

Platelets are minute fragments of cells, each consisting of a small amount of cytoplasm
surrounded by a cell membrane. They are produced in the redbone marrow from
megakaryocytes, which are large cells. Smalls fragments of these cells break off and
enter the blood as platelets, which play an important role in preventing blood loss.
(SEELEY’S ESSENTIALS OF ANATOMY AND PHYSIOLOGY, EIGHT EDITION,
International Edition 2013)

The blood vessels of the body form a network more complex than an interstate highway
system. The blood vessels carry blood to within two or three cell diameters of nearly all
the trillions of cells that make up the body. Blood flow through them is regulated, so that
cells receive adequate nutrients and so that waste products are removed. Blood vessels
remain functional, in the most
cases, in excess of 7- years,
when they are damaged, they
repair themselves. (SEELEY’S
ESSENTIALS OF ANATOMY
AND PHYSIOLOGY, EIGHT
EDITION, International Edition
2013)

69
Arteries

Elastic arteries are the largest-diameter arteries and have the thickest walls. Compared
to other arteries, a greater proportion of their walls is composed of elastic tissue, and a
smaller proportion is smooth muscle. The aorta and pulmonary trunk are examples of
elastic arteries. Elastic arteries stretch when the ventricles of the heart pump blood into
them. The elastic recoil of these arteries prevents blood pressure from falling rapidly
and maintains blood flow while ventricles are relaxed. (SEELEY’S ESSENTIALS OF
ANATOMY AND PHYSIOLOGY, EIGHT EDITION, International Edition 2013)

Muscular arteries include medium-sized and small arteries. The walls of medium-sized
arteries are relatively thick compared to their diameter. Most of the wall’s thickness
results from the smooth muscle cells of the tunica media. Medium-sized arteries are
frequently called distributing arteries because the smooth muscle tissue enables
these vessels to control blood flow to different body regions. Medium sized arteries
supply blood to small arteries. Small arteries have about the same structure as the
medium-sized arteries, except for a smaller diameter and thinner walls. The smallest of
the small arteries have only three or four layers of smooth muscle in their walls

Arterioles transport blood from the small arteries to capillaries. Arterioles are the
smallest arteries in which the three tunics can be identified; the tunica media consists of
only one or two layers of circular smooth muscle cells. Small arteries and arterioles are
adapted for vasodilation and vasoconstriction. (SEELEY’S ESSENTIALS OF
ANATOMY AND PHYSIOLOGY, EIGHT EDITION, International Edition 2013)

Capillaries

Blood flows from arterioles into capillaries, which branch form networks. Blood flow
through capillaries is regulated by smooth muscle cells called precapillary sphincters
located at the origin of branches. Capillary walls consists of endothelium, which is a
layer of simple squamous epithelium surrounded by delicate loose connective tissue.
The thin walls of capillaries facilitate diffusion between the capillaries and surrounding
cells, each capillary is 0.5-1 mm long. (SEELEY’S ESSENTIALS OF ANATOMY AND
PHYSIOLOGY, EIGHT EDITION, International Edition 2013)
70
Veins

Blood flows from capillaries into venules and from venules into small veins. Venules
have a diameter slightly larger than that of capillaries and are composed of endothelium
resting on a delicate connective tissue layer. Medium sized veins collect blood from the
small veins and deliver it to large veins. Veins having diameters greater than 2mm
contain valves, which allow blood to flow toward the heart but not in the opposite
direction. There are many valves in the medium-sized veins and more valves in veins of
the lower limbs than in veins of the upper limbs. This prevents blood from flowing
toward the feet in response to the pull of gravity. (SEELEY’S ESSENTIALS OF
ANATOMY AND PHYSIOLOGY, EIGHT EDITION, International Edition 2013)

71
 The Patient and His Illness
A. PATHOPHYSIOLOGY Book-Centered

Modifiable Risk Factors

Non-Modifiable Risk Factors
 Ages: 35 y/o and above
 Sex: Male
 Type A blood
 Familial Tendency/Heredity
 Helicobacter Pylori
 NSAIDs and Aspirin Medications
 Smoking
 Diet – Caffeine, Acidic Foods,
Spices/Highly-seasoned Foods
 Lifestyle

Diffusion of substances to Increased autonomic nervous

Decreased resistance of
lipid layer system effects on gastric
mucosa
mucosa

Increased stimulation of HCl

Increased permeability of the acid secretion by parietal cells
mucosal/gastric lining

Disruption of action of enzyme cyclooxygenase

by substances significantly aspirin

Reduced response or suppressed prostaglandin Adherence to mucus

release to support bicarbonate production secreting cells of the stomach

Decreased production of bicarbonate ions in

response to HCl acid secretion

Unequal bicarbonate secretion to

hydrogen ion secretion

Increased concentration of
72 gastric acid
 Stripping away of surface
mucus

H. pylori produces enzymes

Toxin release
Interruption of the mucosal that decrease efficiency of
barrier mucus secretions in protecting
the mucosal lining

Suppression of mucus
secretion

Local damage to the gastric

mucosa
Weakness
Release of histamine anemia
Fatigue

Further increase in HCl acid production Continuous bleeding

Dizziness

Further injury to gastric lining Orthostatic Erosion of small

hypotension blood vessels

Ulceration/formation of Pallor Slow and insidious

gastriv/duodenal ulcer
blood loss

Increase in gastric pressure Ulceration in the pylorus and antrum Erosion of the blood vessels Occult blood in stool
caused by ulceration

Spasm or local reflex mechanism from Obstruction of the pylorus canal erosion or perforation of ulcer
contact of lesion with acid through gastric serosa into
peritoneal cavity
Erosion of large
blood vessels
 Immediate severe
Leakage of the gastric Sudden severe
Epigastric pain Acute swelling Muscular Mechanical upper abdominal Passage to
contents over the bleeding with
of the spasm of the obstruction from pain stool
peritoneum hematemesis
inflamed pylorus scarring
Anorexia mucus
membrane melena
Bacterial proliferation
adjacent to in sterile peritoneum
Weight loss the ulcer cavity

Rapid
hematochezia
Increased intragastric Activation of inflammatory and absorption of
pressure immune defense mechanisms bacterial toxins
into the blood
Hypovolemic
Elimination of small Edema of affected Shock
Action potentials travel through numbers of bacteria tissues Bacterial septicemia
viscera sensory neurons/visceral
afferent pathways

Elevation of
Overwhelming/ massive
white blood fever
contamination
Stimulation of cells
vomiting center in
the medulla
oblangata Release of histamine and other Irritation of the
vasoactive substances by mast diaphragm and
cells the phrenic
nerve

Nausea and vomiting

Pain during
inhalation
Increased CHON, WBC, cellular
debris and blood in the peritoneal
Loss of HCl acid, Sodium, cavity Shallow respiration
Potassium
 Reflux muscle
Phagocytosis of
Metabolic guarding
Fluid and electrolyte imbalance bacteria and
alkalosis foreign matter
Board-like rigidity
of abdomen
Development of hypovolemia Fibrinogen-rich
plasma exudate

Compensatory sympathetic Promotion of bacterial

nervous system stimulation destruction and formation
of fibrin clot to seal off and
segregate the bacteria

Hypertension Tachypnea Tachycardia

21

Continued Localization of
contamination infection

Limitation of Diminished
intestinal or absent
motility peristalsis Generalized inflammation of
peritoneal cavity/peritonitis

Accumulation
of air and
fluid in the Fluid shifting to
bowel peritoneal space

Depletion of
circulating blood
volume
 A. Synthesis of the Disease (book-centered – based on the pathophysiology;
indicate sources)

a.1 Definition of the Disease

Peptic Ulcer disease (PUD) results when mucosal defences become impaired
and no longer protect the columnar epithelial cells from the effect of acid and
pepsin. PUD involves a disruption in the continuity of the lower esophageal, gastric,
duodenal mucosa, leading to a local defect resulting from inflammation. An ulcer
may occur in any part of the gastrointestinal (GI) tract that comes into contact with
gastric juices such as hydrochloric acid and pepsin. The ulcer may be found in the
esophagus, stomach, duodenum or the jejunum after gastroenterostomy.

Peptic ulcers are fairly common in the united states, occurring in 4 million
individuals yearly with an estimated cost of treatment exceeding 10 billion dollars
yearly. A lifetime prevalence of PUD in the united states is a approximately 12% in
men and 10% in women. An estimated 15,000 deaths occur per year as a result of
complications of PUD such as hemorrhage. Gastric ulcers are more likely to occur
during the fifth and sixth decades of life; duodenal ulcers more commonly occur
during the fourth and fifth decades for men. For women, the occurrence is about ten
years later in life. Men are more likely to have both gastric and duodenal ulcers.
(Black & Saunders, 2010)

Three types of ulcers are commonly seen (1) gastric ulcer, (2) duodenal ulcer,
and (3) stress ulcers. Acid, pepsin, and H. Pylori infection play an important role in
the development of gastric ulcers. The gastric mucosal barrier overlies the
epithelium. The secretion of mucus and bicarbonate provides the first line of defense
in maintaining a near-normal pH on the gastric epithelium and protects the mucosal
barrier against acid. Gastromucosal prostaglandins increase the barrier’s resistance
to ulceration. The integrity of the barrier is enhanced by the rich blood supply of the
mucosa of the stomach and duodenum. When a break in the mucosal barrier occurs,

76
 hydrochloric acid injures the epithelium. Gastric ulcers may then result from back-
diffusion of acid or dysfunction of the pyloric sphincter. (Black & Saunders, 2010)

Anemia is a clinical condition that results from an insufficient supply of health red
blood cells (RBCs), the volume of packed RBCs, and/or the quantity if haemoglobin.
Hypoxia results because the body’s tissues are not adequately oxygenated. Not a
disease in intseld, anemia reflects a number of underlying pathologic processes
leading to an abnormality in RBC number, structure, or function. When anemia is
identified, further testing must be done to determine its cause. (Black, 2010)

Anemia can arise from primary hematologic problems it can occur as a

secondary consequence of defects in other body systems. Those at risk for
developing anemia differ with the various etiologies. Because the prevalence of
anemia increases with age, adults 65 and older are at particular risk; the estimated
prevalence in this age-group is 20%. Aging cannot be assumed to be the cause of
anemia, however, without excluding other reversible causes. (Black, 2010)

77
 a.2 Risk Factors/ Contributing Factors
Non-Modifiable Risk Factors
Age:
Peptic ulcer disease is more common to people aging 35 years old and above.
Epithelial tissue provides a covering for deeper body layers. The skin and the
linings of the passages inside the body, such as the gastrointestinal system, are
made of epithelial tissue. As aging continues, waste products build up in tissue. The
tissues become stiffer making the organ and blood vessels of the GI tract more rigid.
Cell membranes change therefore having difficulty in getting oxygen, nutrients, and
removing carbon dioxide and wastes. This in turn, slows the GI system’s function
specifically the peristalsis. The decreased peristalsis may add to the ulcer formation
of an individual.

Sex: Male:

Lifetime prevalence of PUD is approximately 12% in men. An estimated 15,000

deaths occur per year as a result of complications of PUD. Gastric ulcers are more likely
to occur during the fifth and sixth decades of life; duodenal ulcers more commonly occur
during the fourth and fifth decades for men.  Ulcers form as a result of stress, a genetic
predisposition to excessive stomach acid secretion, and poor lifestyle habits such as
smoking and drinking. Men are more exposed to such poor lifestyle more than women.
Studies suggest that males are more likely to keep to themselves their problems
causing stress due to social stigma that men should be less expressive and tough.

Type A blood:

Patients with blood type A are more likely to develop gastric ulcers. Helicobacter
pylori  is closely associated with type B antral gastritis and peptic ulceration in
humans. Early epidemiologic studies carried out before H. pylori was identified found

78
 that non-secretors of the glycoprotein form of their ABO blood group antigens and
persons of blood group O were overrepresented among patients with peptic ulcers.
Although H. pylori is associated with development of gastric carcinoma, a
significantly higher proportion of persons of group A has been reported among these
patients.

Familial Tendency/Heredity:

Work done on the genetic factors in peptic ulcer has shown that it occurs 2 to 3
times more frequently in the first degree relatives of the individuals with peptic ulcer
as in the relatives of the controls or in general population.  For first degree relatives
of duodenal ulcer patients and controls, the endoscopy showed the presence of
ulceration in 13% and 3.9%, respectively. In another study, the frequency of a
positive family history in the controls and in the families of positive duodenal ulcer
patients was found to be 13.0% and 52.5%, respectively. In studies of twins, one
study showed that monozygotic twins showed concordance in half the cases and 3
times more frequently than dizygotic pairs, leading to the conclusion that hereditary
factors are involved in ulcerogenesis. To establish the role of the genetic factors in
the peptic ulcer, different markers have been studied. These include the studies on
blood groups, secretor status, alkaline phosphatase and pepsinogen in ulcer
patients. The results of studies on the genetic markers indicate the importance of
genetic factors in the aetiology of the peptic ulcer

Modifiable Risk Factors

NSAIDs and Aspirin Medications:

Non-steroidal anti-inflammatory drugs are the most commonly prescribed drugs
for arthritis, inflammation, and cardiovascular protection. However, they cause
gastrointestinal complications. The pathophysiology of these complications has mostly
been ascribed to non-steroidal anti-inflammatory drugs’ action on the cyclooxygenase

79
inhibition and the subsequent prostaglandin deficiency. When this happens, there is
decreased production of bicarbonate ions which protects the gastric mucosa therefore
the acid secretion overwhelms the protective layer causing damages on the epithelial
cells leading to affectation of the stomach wall.

Smoking:

Tobacco causes vasoconstriction with the GI tract which then contributes to the
buildup of stomach acids that erode the protective lining of the stomach, duodenum, or
esophagus.

Diet – Caffeine, Acidic Foods,

Spices/Highly-seasoned Foods:

Caffeine is a stimulant and is present in coffee, tea, cocoa, soda, and some
medications. It increases alertness, revs up metabolism and enhances mood. Caffeine
reaches its peak level in your body within one hour of consumption and can stay at peak
levels for up to six hours. Caffeine increases the production of stress hormones. Stress
hormones such as cortisol, adrenaline and norepinephrine which causes the heart to
beat faster and give you a boost of energy. Blood supply to the intestines is decreased.
As a result, digestion can be slowed. Peppery foods are also believed to stimulate the
appetite by setting off the flow of saliva and gastric juices. Spicy and highly seasoned
foods produce a burning sensation on the skin and mucous membranes, including the
inside of the mouth which travels up to the stomach area as well.

Lifestyle:

A sedentary lifestyle slows down the digestive process. There are signicant risks
due to sedentary lifestyle. Furthermore, an outdoor stroll is a beneficial way of taking in
much needed sunlight that is often lacking in our daily lives. Exercise and movement

80
promotes peristalsis. Impaired peristalsis may cause dyspepsia on the upper
gastrointestinal area. Decreased peristalsis may contribute to ulceration

Stress:

Chronic stress and negative thinking can literally “upset” the digestive system.
Over time, stress can cause serious damage to the digestive system, in the form of
ulcers.

Type A personality:

Type A individuals tend to be very competitive and self-critical. They strive

toward goals without feeling a sense of joy in their efforts or accomplishments. Type
A individuals tend to be easily aroused to anger or hostility, which they may or may
not express overtly. Such individuals tend to see the worse in others, displaying
anger, envy and a lack of compassion. Type A individuals stress themselves more
compared to other personalities. This in turn results to negative effects such as
producing stomach acid contributing to the overall amount of stomach acid.

a.3 Signs and Symptoms

Acute Pain

The principal manifestation of ulcers is an aching, burning, cramp-like, gnawing

pain. The pain has a definite relationship to eating. With gastric ulcers, food may
cause the pain and the vomiting may relieve it. Clients with duodenal ulcers have pain
with an empty stomach, and discomfort may be relieved by ingestion of food or antacids
whereby patients will continue eating to relieve pain therefore gaining weight. Gastric
ulcer pain often occurs in the epigastrium, with localization to the left midline, whereas
duodenal pain is in the right epigastrium. Ulcer pain also varies with the site, size, or
penetration of the ulcer or amount of surrounding fibrotic tissue.

81
In duodenal ulcers, steady pain near the midline of the back between the sixth and tenth
thoracic vertebrae with radiation to the right upper quadrant may increase perforation of
the posterior duodenal wall. Fullness or hunger may also be present. Distention of the
duodenal bulb produces epigastric pain, which may radiate to the back and thorax.
Hydrochloric acid secretion may produce edema and inflammation. With resultant pain,
or may activate motor changes with increased spasm, intragastric pressure, and
increased motility, also with resultant pain. (Black, 2010)

Nausea and Vomitiong

Clients with a duodenal ulcer usually have a normal appetite unless pyloric
obstruction is present. Carcinoma, gastric ulcers, or gastritis may be associated with
anorexia, weight loss, and dysphagia. Vomiting occurs more often with gastric ulcer
than with duodenal ulcer. It also occurs more frequently when the ulcer is in the pylorus
or antrum of the stomach. Vomiting results from gastric stasis or pyloric obstruction, and
the client typically vomits undigested food. Severe retching and vomiting may suggest
an esophageal tear.
Bleeding

Clients with ulcers often bleed when the ulcer erodes through a blood vessel.
Bleeding may occur as massive hemorrhage or may be occult, with slow oozing.
Approximately 25% of clients with gastric ulcers may experience bleeding.
The diagnosis of ulcers is confirmed on the basis of manifestations, radiographic
evidence, and endoscopy. The history and physical examination do not yield much
significant information in a client with uncomplicated peptic ulcer. A complete blood cell
count with decreased hematocrit and haemoglobin values may indicate bleeding. Stool
testing for occult blood will usually be positive if bleeding is present. Testing for the
presence of H. Pylori can be done via urea breath tests or identification of H. Pylori
serum antibodies in addition to esophagogastroduodenoscopy (EGD) with biopsy.
Monoclonal stool antigen testing may also be used to diagnose the presence of H.

82
Pylori as well as to evaluate the client for cure after the uses of pharmacologic
eradication measures have been instituted.
The major diagnostic tests include EGD and an upper GI tract x-ray series. The
EGD has several advantages. It allows the physician to take tissue specimens and to
treat the ulcer with either multipolar electrocoagulation (MPEC) or heat-probe therapy.
(Black, 2010)

Hemorrhage

Hemorrhage varies in degree from minimal, manifested by the presence of occult

blood in the stool (melena), to massive, manifested by vomitus containing red blood cell
(hematemesis). The usual manifestation of the GI tract bleeding is either vomiting of
coffee ground like material or passing of tarry stools. Acid digestions of blood in the
stomach results in a granular dark emesis, whereas digestion in the duodenum or below
may result in a black stool. Hemorrhage tends to occur more often with gastric ulcers,
especially in the older adult population. Although the onset of hemorrhage may be
associated with fatigue, nervous tension, upper respiratory infection, dietary
indiscretion, alcoholism, or irritating drug, there may be no known precipitating factor.
(Black, 2010)
Manifestations depend on the severity of the hemorrhage. With mild bleeding
(<500 ml), the client may experience only sight weakness and diaphoresis. Severe loss
of more than 1L of blood in 24 hours may cause manifestation of shock. (Black, 2010)

Shock
Intervention for massive bleeding aims treats hypovolemic shock, prevent
dehydration and electrolyte imbalance, and stop the bleeding. The client, who should be
fasting, receives intravenous fluids until the bleeding subsides. The nurse or the
physician may insert an NG tube in the presence or absence of blood in the stomach to
assess the rate of bleeding and prevent gastric dilation; subsequent administration of
room the stomach. The room temperature saline is cooler saline is cooler than the body

83
temperature, which creates mild vasoconstriction. Gastric cooling may also be promoted
by cool saline lavage, which although controversial, further curtails hemarrhage through
its vasoconstrictive effect. Iced saline is rarely used because it may lead to more
mucosal damage by decreasing perfusion to the gastric mucosa and may cause a vagal
response, decreasing systemic perfusion. (Black, 2010)

Weakness
Anemia occurs when the number of healthy red blood cells in the body is too low.
Red cells carry oxygen to all the body’s tissues, so a low red blood cell count indicates
that the amount of oxygen in the blood is lower than it should be. The impaired
oxygenation of tissues and cells may cause the weakness. (Black, 2010)

Orthostatic Hypotension
Orthostatic hypotension is a decrease in systolic blood pressure of 20 mm
Hg or a decrease in diastolic blood pressure of 10 mm Hg within three
minutes of standing when compared with blood pressure from the sitting or
supine position. A patient with anemia and blood loss may experience
orthostatic hypotension due to the decrease in blood volume. (Black, 2010)

Pallor
Anemia is strictly defined as a decrease in red blood cell mass. The function of
the RBC is to deliver oxygen from the lungs to the tissues and carbon dioxide from the
tissues to the lungs. This is accomplished by using hemoglobin, a tetramer protein
composed of heme and globin. Anemia impairs the body’s ability for gas exchange by
decreasing the number of RBCs transporting oxygen and carbon dioxide. The most
serious complications of severe anemia arise from tissue hypoxia. The decreased tissue
oxygenation or perfusion may lead to whitish discoloration of mucous membranes.
(Black, 2010)

Hematemesis, Melena, and Hematochezia

84
 Hematemesis is the vomiting of blood, which may be obviously red or have an
appearance similar to coffee grounds.Melena is the passage of black, tarry
stools. Hematochezia is the passage of fresh blood per anus, usually in or with stools.
Hematemesis, melena, and hematochezia are symptoms of acute gastrointestinal
bleeding. Bleeding that brings the patient to the physician is a potential emergency and
must be considered as such until its seriousness can be evaluated. The goals in
managing a major acute gastrointestinal hemorrhage are to treat hypovolemia by
restoring the blood volume to normal, to make a diagnosis of the bleeding site and its
underlying cause, and to treat the cause of the bleeding as definitively as possible.
(Black, 2010)

Epigastric Pain
Epigastric pain is pain that is localized to the region of the upper abdomen
immediately below the ribs. Epigastric pain may also occur with conditions that cause
inflammation of the digestive organs, such as gastritis. Epigastric pain can also arise
from conditions that impair the normal digestive process, such as peptic ulcers. Some
people have mild epigastric pain that occurs after eating and subsides quickly, while
others may have a severe burning feeling in the abdomen, chest and neck that prevents
sleep. (Black, 2010)

Anorexia
Anorexia or loss of appetite could be a protective mechanism of patients with
peptic ulcers in preventing foreign substances from entering. It reduces the passage of
chyme through diseased parts of the upper gut, thereby minimizing pain. The relief of
not eating with pain will be registered to the patient’s mind therefore it is considered
hazardous. (Black, 2010)

Weight Loss
An individual suffering from peptic ulcer disease experiences epigastric pain
depending on what type. There may be persistent pain before meals or after meals.

85
This may affect the patients choice of not eating, to avoid pain which can lead to
prolonged anorexia leading to weight loss (Black, 2010)

86
 The Patient and His Illness
B. PATHOPHYSIOLOGY Patient-Centered

Modifiable Risk Factors

Non-Modifiable Risk Factors
 Smoking
 Ages: 35 y/o and above  Diet – Soda and occasional
 Sex: Male alcohol consumption
 Type A blood  Lifestyle
 Stress

Diffusion of substances to Increased autonomic nervous

Decreased resistance of
lipid layer system effects on gastric
mucosa
mucosa

Increased stimulation of HCl

Increased permeability of the acid secretion by parietal cells
mucosal/gastric lining

Disruption of action of enzyme cyclooxygenase

by substances significantly aspirin

Reduced response or suppressed prostaglandin

release to support bicarbonate production

Decreased production of bicarbonate ions in

response to HCl acid secretion

Unequal bicarbonate secretion to

hydrogen ion secretion

87
 Increased concentration of
Strippinggastric
away acid
of surface
mucus

Interruption of the mucosal

barrier

Suppression of mucus
secretion

Local damage to the gastric

mucosa Weakness

>June 20,21 &22,2015

anemia
Release of histamine Fatigue >June 20,2015

Further increase in HCl acid production Dizziness >June 20,21 Continuous bleeding
&22, 2015

Orthostatic hypotension
Further injury to gastric lining Erosion of small
>June 20,2015 blood vessels

Ulceration/formation of Pallor >June 20 ,21 &22,

2015 Slow and insidious
gastriv/duodenal ulcer
blood loss

>Hematocrit level (0.40-

0.54)
Increase in gastric pressure Ulceration in the pylorus and antrum Erosion of the blood vessels
caused by ulceration 0.38 (06-22-15)

Spasm or local reflex mechanism from Obstruction of the pylorus canal Erosion or perforation of ulcer
contact of lesion with acid through gastric serosa into
88
peritoneal cavity
 Erosion of large
blood vessels
Immediate severe
Leakage of the gastric Sudden severe
Epigastric pain Acute swelling Muscular Mechanical upper abdominal Passage to
contents over the bleeding with
of the spasm of the obstruction from pain stool
>recurrent from Feb. peritoneum hematemesis
inflamed pylorus scarring
17,2015 up to June 20, mucus
21, & 22,2015
membrane Melena
Bacterial proliferation
Anorexia adjacent to in sterile peritoneum >two
the ulcer cavity weeks
>June
prior,
Rapid >June
Activation of inflammatory and absorption of 20,2015
Increased intragastric immune defense mechanisms bacterial toxins
pressure into the blood

Action potentials travel through
viscera sensory neurons/visceral
afferent pathways
Stimulation of
vomiting center in
the medulla
oblangata
Elimination of small
numbers of bacteria Bacterial septicemia
Elevation of
Overwhelming/ massive white blood
contamination cells >June
22,2015
Release of histamine and other
vasoactive substances by mast
cells

Nausea and vomiting

>two weeks prior to admission

Increased, WBC
89
>June 22,2015
90
 B. Synthesis of the Disease (patient-centered – based on the
pathophysiology; indicate sources)

a.1 Definition of the Disease

Peptic Ulcer disease (PUD) results when mucosal defences become impaired
and no longer protect the columnar epithelial cells from the effect of acid and
pepsin. PUD involves a disruption in the continuity of the lower esophageal, gastric,
duodenal mucosa, leading to a local defect resulting from inflammation. An ulcer
may occur in any part of the gastrointestinal (GI) tract that comes into contact with
gastric juices such as hydrochloric acid and pepsin. The ulcer may be found in the
esophagus, stomach, duodenum or the jejunum after gastroenterostomy.

Peptic ulcers are fairly common in the united states, occurring in 4 million
individuals yearly with an estimated cost of treatment exceeding 10 billion dollars
yearly. A lifetime prevalence of PUD in the united states is a approximately 12% in
men and 10% in women. An estimated 15,000 deaths occur per year as a result of
complications of PUD such as hemorrhage. Gastric ulcers are more likely to occur
during the fifth and sixth decades of life; duodenal ulcers more commonly occur
during the fourth and fifth decades for men. For women, the occurrence is about ten
years later in life. Men are more likely to have both gastric and duodenal ulcers.
(Black & Saunders, 2010)

Three types of ulcers are commonly seen (1) gastric ulcer, (2) duodenal ulcer,
and (3) stress ulcers. Acid, pepsin, and H. Pylori infection play an important role in
the development of gastric ulcers. The gastric mucosal barrier overlies the
epithelium. The secretion of mucus and bicarbonate provides the first line of defense
in maintaining a near-normal pH on the gastric epithelium and protects the mucosal
barrier against acid. Gastromucosal prostaglandins increase the barrier’s resistance
to ulceration. The integrity of the barrier is enhanced by the rich blood supply of the
mucosa of the stomach and duodenum. When a break in the mucosal barrier occurs,

91
 hydrochloric acid injures the epithelium. Gastric ulcers may then result from back-
diffusion of acid or dysfunction of the pyloric sphincter. (Black & Saunders, 2010)

Anemia is a clinical condition that results from an insufficient supply of health red
blood cells (RBCs), the volume of packed RBCs, and/or the quantity if haemoglobin.
Hypoxia results because the body’s tissues are not adequately oxygenated. Not a
disease in intseld, anemia reflects a number of underlying pathologic processes
leading to an abnormality in RBC number, structure, or function. When anemia is
identified, further testing must be done to determine its cause. (Black, 2010)

Anemia can arise from primary hematologic problems it can occur as a

secondary consequence of defects in other body systems. Those at risk for
developing anemia differ with the various etiologies. Because the prevalence of
anemia increases with age, adults 65 and older are at particular risk; the estimated
prevalence in this age-group is 20%. Aging cannot be assumed to be the cause of
anemia, however, without excluding other reversible causes. (Black, 2010)

a.2 Risk Factors/ Contributing Factors

Non-Modifiable Risk Factors
Age:

Peptic ulcer disease is more common to people aging 35 years old and above.
Epithelial tissue provides a covering for deeper body layers. The skin and the linings
of the passages inside the body, such as the gastrointestinal system, are made
of epithelial tissue. As aging continues, waste products build up in tissue. The
tissues become stiffer making the organ and blood vessels of the GI tract more rigid.
Cell membranes change therefore having difficulty in getting oxygen, nutrients, and
removing carbon dioxide and wastes. This in turn, slows the GI system’s function
specifically the peristalsis. The decreased peristalsis may add to the ulcer formation
of an individual.

92
 Sex: Male:

Lifetime prevalence of PUD is approximately 12% in men. An estimated 15,000

deaths occur per year as a result of complications of PUD. Gastric ulcers are more likely
to occur during the fifth and sixth decades of life; duodenal ulcers more commonly occur
during the fourth and fifth decades for men.  Ulcers form as a result of stress, a genetic
predisposition to excessive stomach acid secretion, and poor lifestyle habits such as
smoking and drinking. Men are more exposed to such poor lifestyle more than women.
Studies suggest that males are more likely to keep to themselves their problems
causing stress due to social stigma that men should be less expressive and tough.

Type A blood:

Patients with blood type A are more likely to develop gastric ulcers. Helicobacter
pylori  is closely associated with type B antral gastritis and peptic ulceration in
humans. Early epidemiologic studies carried out before H. pylori was identified found
that non-secretors of the glycoprotein form of their ABO blood group antigens and
persons of blood group O were overrepresented among patients with peptic ulcers.
Although H. pylori is associated with development of gastric carcinoma, a
significantly higher proportion of persons of group A has been reported among these
patients.

Modifiable Risk Factors

Smoking:

Tobacco causes vasoconstriction with the GI tract which causes vasoconstriction

of the blood vessels in the GI tract causing an increased stimulation of HCl acid
secretion by parietal cell resulting to decreased production of bicarbonate ions in
response to HCl acid secretion then increasing the concentration of gastric acid in the
stomach acid that erode the protective lining of the stomach, duodenum, or esophagus .

93
 Diet – Alcoholic Beverages, alcohol
The secretory response of gastric acid to pure ethanol and alcoholic beverages may
be different because the action of the non-ethanolic contents of the beverage may
overwhelm that of ethanol. Drinks containg these substances may trigger acid secretion
from the stomach.

Lifestyle:

A sedentary lifestyle slows down the digestive process. There are signicant risks
due to sedentary lifestyle. Furthermore, an outdoor stroll is a beneficial way of taking in
much needed sunlight that is often lacking in our daily lives. Exercise and movement
promotes peristalsis. Impaired peristalsis may cause dyspepsia on the upper
gastrointestinal area. Decreased peristalsis may contribute to ulceration

Stress:

Chronic stress and negative thinking can literally “upset” the digestive system.
Over time, stress can cause serious damage to the digestive system, in the form of
ulcers.

a.3 Signs and Symptoms

Acute Pain

The principal manifestation of ulcers is an aching, burning, cramp-like, gnawing

pain. The pain has a definite relationship to eating. With gastric ulcers, food may
cause the pain and the vomiting may relieve it. Clients with duodenal ulcers have pain
with an empty stomach, and discomfort may be relieved by ingestion of food or antacids
whereby patients will continue eating to relieve pain therefore gaining weight. Gastric
94
ulcer pain often occurs in the epigastrium, with localization to the left midline, whereas
duodenal pain is in the right epigastrium. Ulcer pain also varies with the site, size, or
penetration of the ulcer or amount of surrounding fibrotic tissue.

In duodenal ulcers, steady pain near the midline of the back between the sixth and tenth
thoracic vertebrae with radiation to the right upper quadrant may increase perforation of
the posterior duodenal wall. Fullness or hunger may also be present. Distention of the
duodenal bulb produces epigastric pain, which may radiate to the back and thorax.
Hydrochloric acid secretion may produce edema and inflammation. With resultant pain,
or may activate motor changes with increased spasm, intragastric pressure, and
increased motility, also with resultant pain.

Nausea and Vomitiong

Clients with a duodenal ulcer usually have a normal appetite unless pyloric
obstruction is present. Carcinoma, gastric ulcers, or gastritis may be associated with
anorexia, weight loss, and dysphagia. Vomiting occurs more often with gastric ulcer
than with duodenal ulcer. It also occurs more frequently when the ulcer is in the pylorus
or antrum of the stomach. Vomiting results from gastric stasis or pyloric obstruction, and
the client typically vomits undigested food. Severe retching and vomiting may suggest
an esophageal tear.

Bleeding

Clients with ulcers often bleed when the ulcer erodes through a blood vessel.
Bleeding may occur as massive hemorrhage or may be occult, with slow oozing.
Approximately 25% of clients with gastric ulcers may experience bleeding.
The diagnosis of ulcers is confirmed on the basis of manifestations, radiographic
evidence, and endoscopy. The history and physical examination do not yield much
significant information in a client with uncomplicated peptic ulcer. A complete blood cell

95
count with decreased hematocrit and haemoglobin values may indicate bleeding. Stool
testing for occult blood will usually be positive if bleeding is present. Testing for the
presence of H. Pylori can be done via urea breath tests or identification of H. Pylori
serum antibodies in addition to esophagogastroduodenoscopy (EGD) with biopsy.
Monoclonal stool antigen testing may also be used to diagnose the presence of H.
Pylori as well as to evaluate the client for cure after the uses of pharmacologic
eradication measures have been instituted.
The major diagnostic tests include EGD and an upper GI tract x-ray series. The
EGD has several advantages. It allows the physician to take tissue specimens and to
treat the ulcer with either multipolar electrocoagulation (MPEC) or heat-probe therapy.

Hemorrhage

Hemorrhage varies in degree from minimal, manifested by the presence of occult

blood in the stool (melena), to massive, manifested by vomitus containing red blood cell
(hematemesis). The usual manifestation of the GI tract bleeding is either vomiting of
coffee ground like material or passing of tarry stools. Acid digestions of blood in the
stomach results in a granular dark emesis, whereas digestion in the duodenum or below
may result in a black stool. Hemorrhage tends to occur more often with gastric ulcers,
especially in the older adult population. Although the onset of hemorrhage may be
associated with fatigue, nervous tension, upper respiratory infection, dietary
indiscretion, alcoholism, or irritating drug, there may be no known precipitating factor.
Manifestations depend on the severity of the hemorrhage. With mild bleeding
(<500 ml), the client may experience only sight weakness and diaphoresis. Severe loss
of more than 1L of blood in 24 hours may cause manifestation of shock.

Shock
Intervention for massive bleeding aims treats hypovolemic shock, prevent
dehydration and electrolyte imbalance, and stop the bleeding. The client, who should be

96
fasting, receives intravenous fluids until the bleeding subsides. The nurse or the
physician may insert an NG tube in the presence or absence of blood in the stomach to
assess the rate of bleeding and prevent gastric dilation; subsequent administration of
room the stomach. The room temperature saline is cooler saline is cooler than the body
temperature, which creates mild vasoconstriction. Gastric cooling may also be promoted
by cool saline lavage, which although controversial, further curtails hemarrhage through
its vasoconstrictive effect. Iced saline is rarely used because it may lead to more
mucosal damage by decreasing perfusion to the gastric mucosa and may cause a vagal
response, decreasing systemic perfusion.

Weakness
Anemia occurs when the number of healthy red blood cells in the body is too low.
Red cells carry oxygen to all the body’s tissues, so a low red blood cell count indicates
that the amount of oxygen in the blood is lower than it should be. The impaired
oxygenation of tissues and cells may cause the weakness. (Black, 2010)

Orthostatic Hypotension
Orthostatic hypotension is a decrease in systolic blood pressure of 20 mm
Hg or a decrease in diastolic blood pressure of 10 mm Hg within three
minutes of standing when compared with blood pressure from the sitting or
supine position. A patient with anemia and blood loss may experience
orthostatic hypotension due to the decrease in blood volume. (Black, 2010)

Pallor
Anemia is strictly defined as a decrease in red blood cell mass. The function of
the RBC is to deliver oxygen from the lungs to the tissues and carbon dioxide from the
tissues to the lungs. This is accomplished by using hemoglobin, a tetramer protein
composed of heme and globin. Anemia impairs the body’s ability for gas exchange by
decreasing the number of RBCs transporting oxygen and carbon dioxide. The most

97
serious complications of severe anemia arise from tissue hypoxia. The decreased tissue
oxygenation or perfusion may lead to whitish discoloration of mucous membranes.
(Black, 2010)

Melena
Melena is the passage of black, tarry stools. Melena is a symptom of acute
gastrointestinal bleeding. Bleeding that brings the patient to the physician is a potential
emergency and must be considered as such until its seriousness can be evaluated. The
goals in managing a major acute gastrointestinal hemorrhage are to treat hypovolemia
by restoring the blood volume to normal, to make a diagnosis of the bleeding site and its
underlying cause, and to treat the cause of the bleeding as definitively as possible

Slow and Insidioud Blood Loss

Gastrointestinal bleeding is a common clinical problem frequently requiring
hospitalization. It can vary in degrees, from massive life threatening hemorrhage to a
slow, insidious chronic blood loss. Peptic ulcer disease itself causes the bleeding since
it is a wound.

Epigastric Pain
Epigastric pain is pain that is localized to the region of the upper abdomen
immediately below the ribs. Epigastric pain may also occur with conditions that cause
inflammation of the digestive organs, such as gastritis. Epigastric pain can also arise
from conditions that impair the normal digestive process, such as peptic ulcers. Some
people have mild epigastric pain that occurs after eating and subsides quickly, while
others may have a severe burning feeling in the abdomen, chest and neck that prevents
sleep. (Black, 2010)

Anorexia
Anorexia or loss of appetite could be a protective mechanism of patients with
peptic ulcers in preventing foreign substances from entering. It reduces the passage of
chyme through diseased parts of the upper gut, thereby minimizing pain. The relief of

98
not eating with pain will be registered to the patient’s mind therefore it is considered
hazardous. (Black, 2015

99
. THE PATIENT AND HIS CARE
A. Medical Management
a. IVF

Medical Date ordered General Indication/Purpos Client’s

Management Dates disruption e response to
performed the treatment
IVF Date Ordered Plain normal Ordered to correct The patient did
#1 PNSS(plain 06/20/15 saline solution is mild to moderate not manifest
normal saline an isotonic dehydration any sign of
solution)1L x Date Performed solution with resulting from the dehydration as
30 gtts/min osmolarity of 308 patients with evidence by
06/20/15
mOsm/ L. It has a inadequate fluid normal skin
06/22/15
pH of 4.5 to 7.0. It and electrolyte turgor. The
contains 154 intake and blood patient did not
mmol/ L of loss or low blood manifest any
Sodium and 154 volume. PNSS was undesirable
mmol/ L of given to patient A, side
chloride. Each because he will effect/adverse
100 ml contains undergo blood reactions such
0.90 g of NaCl transfusion, and as allergy,
and 100 ml of also the PNSS are water
water for the only fluid that intoxication,
injections are compatible in and phlebitis
blood transfusion. and there were
Moreover, it was no signs of
primarily given infiltration.
because it has no
dextrose
component that
could increase
further the patient’s

100
 blood glucose level

#2 D5W Date Ordered 5% Dextrose in 5% dextrose in Patient A

(Dextrose in 06/20/15 water is a water is given to the maintained
Water) 1L + carbohydrate patient as a route adequate fluid
90cc solution that uses for administration of status as
Date Performed
omeprazole glucose (sugar) intravenous evidenced by
06/20/15
80mg x 8 as the solute medicines. D5W normal skin
uggts/min dissolved in sterile was the fluid of turgor. And
water. Five patient A because, also patient A
percent dextrose he have an order of is not having
in water is packed 80mg omeprazole any
as an isotonic side drip, since reactions/side
solution but D5W only contain effect from the
becomes glucose and does drug in the
hypotonic once in not have any fluid.
the body because chemical
the glucose component it was
(solute) dissolved compatible for
in sterile water is administering
metabolized medication such as
rapidly by the omeprazole.
body’s cells.

#3 D5W Date Ordered Dextrose in water 5% dextrose in Patient A

(Dextrose in 06/20/15 is a carbohydrate water is given to the responded well
Water)1L x solution that uses patient as a route to the given
30gtts/min Date Performed glucose (sugar) for administration of IVF as he did
as the solute intravenous not manifest
06/20/15
dissolved in sterile medicines, and to any signs and
06/21/15
water. Five correct mild to symptoms of
06/22/15

101
 06/23/15 percent dextrose moderate dehydration
in water is packed dehydration, and and water
as an isotonic also D5W was intoxication as
solution but given to patient A to evidenced by
becomes keep his vein open good skin
hypotonic once in for another turgor and no
the body because administration of sign of edema
the glucose medication such as or
(solute) dissolved omeprazole. inflammation.
in sterile water is
metabolized
rapidly by the
body’s cells.

Nursing Responsibilities:
Before:
 Check for doctor’s order
 Prepare IVF
 Check amount to be used
 Clean the injection site
 Locate vein
 Insert the needle
During:
 Regulate the solution
 Check for any backflow of blood
 Check for swelling on the injection site
After:
 Assess the therapeutic effect of the drug
 Document the action done

102
 b. Blood transfusion

Medical Date ordered General Indication/purposes Client’s

management Date performed description response to
the treatment
Blood Date ordered Blood transfusion Patient A was The patient
transfusion 06/21/15 is a medical ordered to have a did not
Date performed treatment that blood transfusion,to manifest any
replaces blood replace the blood transfusion
06/22/15
lost through loss cause by the reaction such
injury, surgery, or gastrointestinal as
disease. The bleeding. hypotension
blood goes and chills as
through a tube evidence by
from a bag to an normal vital
intravenous (IV) signs.
catheter and into
your vein.

Nursing Responsibilities
Before:
 Check for doctor’s order
 Explain the procedures to the patient/So with its purpose and importance
 Consent for BT must be secured first.
 Always check the corrected typed of blood, serial number, expiration date.
 Give the pre-meds 30 minutes transfusion as prescribe
 Wash hands and observe other appropriate infection control procedures.
During:
 Set up infusion equipment.
 Open the saline to the intravenous catheter
 Run the blood transfusion for 4 hours

103
  Check the flow of the blood
 Watched for blood transfusion reaction
 Check for swelling on the injection site
After:
 Document relevant data
 Monitor the client
 Assess the client, including the vital sign, every 30 minutes or more often.
 Stop the blood
 Remove the blood and Hooked the main line if ordered
 Terminate the blood bag
 Document the action done

c. Drug

Name of drug Date ordered Route of General action Client’s

Generic and Date taken or administration and response to
Brand name give/ Dosage and indication/purpos medication
Date change frequency e with actual side
effects
Date ordered 80mgIV (side Therapeutic: Upon the
Omeprazole
06/20/15 drip) Proton pump administration of
(Apo
Date taken inhibitor. the drug to
-omemprazole,
06/20/15 patient A did not
Losec,
Pharmacological: manifest any
Prilosec, Date change
side effects or
Prilosec OTC) 06/23/15 Increases gastric
allergic
ph, reduces gastric
reactions.
acid production.

Omeprazole was
administered to

104
 patient A to reduce
the acid from peptic
ulcer.

Nursing Responsibilities
Prior
 Check the doctor’s order.
 Identify the patient
 Explain the procedures and the time o give the medication
 Make sure it is the right drug, right dosage, and right time to give
 Check for the expiration date
 Identify the right patient, by the checking patient name on the chart
 Explain the medication to the significant other

During
 Check IV tubing for patency
 Check if there is presence of edema or infiltration
 Observe the proper administration of the medication
 Make sure the medication is taken already

After
 Assess the therapeutic effect of the drug
 Monitor IV injection site
 Tell the patient that he may be experience some effect of the drug.
 Document the action done

c. Drug

Name of drug Date ordered Route of General action Client’s

Generic and Date taken or administration and response to

105
Brand name give/ Dosage and indication/purpos medication
Date change frequency e with actual side
effects
Lactulose Date ordered 30cc Therapeutic: Patient A
(Acilac, Apo – 06/22/15 Hyperosmotic responded well
Lactulose, Date taken OD (1 a day) laxative, ammonia to the
Constulose, 06/22/15 detixicant. medication as
Enulos, evidence by
Date change
Generlac, Pharmacological: having normal
06/23/15
Kristalose, bowel
Increased
laxilos) movement and
peristalsis, bowel
being able to
evacuation;
defecate.
decreases serum
ammonia
concentration.

Lactulose indicated
to patient A,
because it can
increased the
peristaltic
movement of the
bowel
(maka tae)
Folic acid (Apo Date ordered 1 tab Therapeutic: The desired
– folic, Folicin – 06/23/15 BID (2x a day) Nutritional effect of this
800, Folvite) Date taken supplement, and drug was

06/23/15 stimulates achieved as

production of evidence by
platelets, RBCs, normal RBC,
WBCs. and Platelets

106
 Pharmacological: result on June
Essential for 22 2015.
nucleoprotein
synthesis,
maintenance of
normal
erythropoiesis.

Folic acid was

administer to
patient A because it
will help in the
production of RBC,
WBC, and Platelet
since patient An
experience having
anemia and UGIB.

Omeprazole Date ordered 40mg 1tab Therapeutic: Patient respond

(Apo 06/23/15 OD (1 a day) Proton pump well on the
-omeprazole, Date taken inhibitor. medication AEB
Losec, 06/23/15 by the absence
Prilosec, Pharmacological: of the side effect
Prilosec OTC) of the drug
Increases gastric
ph, reduces gastric
acid production.

Omeprazole was
administered to
patient A to reduce

107
 the acid from peptic
ulcer
Nursing Responsibilities
Prior
 Verify doctors order
 Identify patient
 Check the drug three times before administration
 Check for the expiration date
 Ensure that it is the right drug, right dosage, and right time to give drug
 Explain the action and importance of the drug
 Prepare the medication and check the level
 Assessed patient general condition
 Monitor vital sign

During
 Observe the proper administration of the medication
 Make sure the medication is taken already

After
 Assess the therapeutic effect of the drug
 Document the action done

d. Diet

Type of Date ordered General Indication/purp Specific food Client’s

Diet Date started description ose taken response and
Date change reaction to the
diet
NPO Date ordered A medical To avoid Patient A

108
(Nothing 06/20/15 instruction aspiration of None verbalize the
Per Orem) Date started meaning to gastric content felling of hunger
06/20/15 withhold oral due to vomiting, and desire to eat
food and fluids and to allow food.
from a patient gastrointestinal
for various system to rest.
reasons.
Soft diet Date ordered A medical To avoid irritation None The patient feels
06/22/15 instruction on the relive and
Date stated meaning to gastrointestinal satisfied with his

06/22/15 give food that tract and to give diet as evidence

are easily to some rest prior by showing
chew, swallow to re – improvement and
and digest. introducing high able to answer
fiber, raw food the question that
which are harder the student
to break down nurses ask.
and absorb.

NURSING RESPONSIBILITIES:
BEFORE:
 Check the Doctors order for the type of diet prescribe.
 Assess patient’s condition.
 Explain to the patient and significant other about the prescribe diet ordered by
the physician
 Explain the purpose and importance of the diet

DURING:
 Assist in patient’s meal-taking.
 Monitor the reaction of the patient to the diet
 Provide safety measures.

109
AFTER:
 Observe patient’s response to the diet. Monitor patient’s condition.

110
 Nursing Problem #1: Acute pain

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE

DIAGNOSIS EXPLANATION EVALUATION

S=“ Masakit yung Acute pain Pain sensation Short Term: 1. Establish 1. To gain patients
bandang itaas ng begins to end rapport trust
tiyan ko. Six/ ten ang points of After 4 hours
sakit” as verbalized by afferent nerve After 4 hours of of nursing
the patient endings, and nursing interventions,
interventions, the 2. Monitor Vital 2. To obtain base the patient
are activated
patient will report Sign line data shall have
due to damage
of the skin. pain is relieved. reported pain
0= The patient When is relieved.
manifested: terminals are 3. Provide 3. To promote non
stimulated, comfort pharmacologic
 facial grimace Long Term:
chemical measures such management
upon as stretching
movement
mediators are
released linens. After 2 days of
 Positioning to After 2 days of nursing
avoid to other particularly the nursing
histamine, 4. To have sound intervention
side to avoid interventions, the 4. Determine
bradykinins assessment of the patient
pain. patient will follow presence of
and cause and shall have
 Provocation of pathophysiolog
prescribed possible followed
pain prostalglandin ical cause of
pharmacological treatment
precipitated by that could elicit pain. prescribed
regimen. regimen.
food sensation of pharmacologic
 Intermittent pain related to al regimen.
burning pain ulceration of
noted. the mucosa or
 Radiation from damage of
epigastric to
tissues in the 5. Assess for
hypogastric 5. Help determine
gastrointestinal referred pain,

111
 region tract. as appopriate. possibility of
 Pain scale of underlying
6/10 condition or
 Recurring pain organ
from time to dysfuntion
time. requiring
 With Vital Sign treatment
taken as
followed:
6. Obtain
T=36.6°C
assessment of 6. To rule out
PR= 63 bpm pain including worsening of
provocation, underlying
RR= 17 cpm quality, condition or
radiation, development of
BP= 120/60 mmHg
severity and complications.
time
= The patient may
manifest: 7. Use pain rating
scale 7. To determine
 Guarding
severity felt by
behavior
the patient.
 Sleep
disturbance 8. Observe non
verbal cues 8. Some
 Restlessness and pain observation
 Distraction behaviors may not be
behavior congruent with
 Change in verbal reports
muscle tone or may be only
 diaphoresis indicator
present when
client is unable
to verbalize
9. Ascertain

112
 knowledge 9. To be informed of
oand treatment regimen.
expectation
about pain
management

10. Note when 10. To medicate

pain occurs prophylactically
as appopriate.

11. Assist in
thorough 11. To aid in the
evaluation management of
including pain.
neurological
and
psychological
factors

12. Administer
analgesic as 12. To maintain
indicated acceptable level
of pain.

13. Evaluate
patient’s 13. Indicated for
response to increasing or
analgesia and decreasing
assist in dosage
transitioning or program to help
altering drug in management
regimen based of pain.
on individual

113
 needs and
protocol.

14. collaborate in
treatment of
underlying 14. To facilitate in
condition faster recovery
causing pain with the help of
and proactive the health care
management team.

Nursing Problem #2: Impaired gas exchange related to altered oxygen-carrying capacity of the blood as evidenced by decreased level of
hemoglobin

114
 Assessment Nursing Scientific Objectives Nursing Rationale Objectives
Diagnosis Explanation Interventions
S= Impaired gas Short Term: 1.Establish 1. To gain Short Term:
Patient may Impaired gas exchange is a After 4-5 therapeutic patient’s trust After 4-5
verbalize: exchange state in which hours of relationship hours of
>Dyspnea related to an individual nurse-patient 2. To obtain nurse-patient
>Visual altered experiences interventions, 2.Monitor and baseline data interventions,
Disturbances oxygen- an excess or the patient record vital signs 3. To provide the patient
>Headache upon carrying deficit in will 3. Provide comfort shall have
wakening capacity of the oxygenation demonstrate comfort demonstrated
>Sense of blood as and/or carbon non measures such non
impending doom evidenced by dioxide pharmacologi as stretching bed pharmacologi
decreased elimination at c linens, cleaning c
O= level of the alveolar management bed side and 4.To promote management
Patient hemoglobin capillary as evidenced providing am optimum as evidenced
manifested: membrane. by patient care. expansion of by patient
>Hematocrit level Transport of doing deep 4. Encourage the lungs and doing deep
(0.40-0.54) oxygen is breathing, frequent position drainageof the breathing,
-0.38 (06-22-15) impaired in coughing and changes and secretion coughing and
anemia. turning deep breathing turning
>hemoglobin Haemoglobin exercises or coughing 5. to help limit exercises
level(140-174) is lacking or exercises oxygen needs
-95(06-22-15) the number of Long Term: or consumption Long Term:
RBCs is too After 1-2 5. Encourage After 1-2 days
low to carry days of adequate rest 6. to mobilize of nurse-
>pale bulbar and adequate nurse-patient and limit secretions patient
palpebral oxygen to interventions, activities within interventions,
conjunctiva tissues and the patient client tolerance 7. to reduce the patient
>diaphoresis hypoxia will 6. Maintain anxiety shall have
>restlessness develops. demonstrate adequate intake demonstrated
>vital signs were The body adequate and output adequate
taken and as attempts to oxygenation 7. Provide 8. to limit oxygenation
follows: compensate of tissue by psychological adverse effects of tissue by

115
 T=36.6°C for tissues haemoglobin support, active- of anemia haemoglobin
PR= 63 bpm hypoxia by result within listen 9. To reduce result within
RR= 17 cpm increasing client’s questions/concer irritant effect of client’s normal
BP= 120/60 the rate of normal limits ns dust and limits and
mmHg RBC and absence 8. Minimize chemicals on absence of
Patient may production, of respiratory blood loss from airways respiratory
manifest: increasing distress procedure 10. to treat distress
>Confusion cardiac 9. Keep underlying
>Somnolence output by environment condition; to
>Abnormal increasing allergen free or increase red
ABGs/arterial pH; stroke pollutant free blood cells
hypoxia/hypoxemi volume or 10. Administer 11. to improve
a heart rate, medication as respiratory
>Abnormal redistributing indicated such as function/oxyge
Breathing blood from recombinant n carrying
>Tachycardia tissues of low human capacity
>polycythemia oxygen erythropoietin- 12. to decrease
needs to beta dyspnea and
tissues with 11.Assist with improve quality
high oxygen procedures as of life
needs, and individually
shifting of indicated
oxygen- 12.Reinforce
hemoglobin need for
dissociation adequate rest,
curve to the while
right to encouraging
facilitate the activities such as
removal of deep breathing
more oxygen exercises and
by the tissues coughing
at the same exercises
partial

116
 pressure of
oxygen
making the
ability of
blood to carry
oxygen
decreased.
Even though
there will be
enough
oxygen
coming from
the lungs,
there is a
lesser
carrying
capacity of
oxygen to the
blood hence
there is
inadequate
distribution of
oxygen in the
different parts
of the body
giving rise to
the problem
impaired gas
exchange.

117
Nursing Problem #3: Ineffective tissue perfusion related to decreased oxygen – carrying capacity of the blood
secondary to anemia.

Assessment Nursing Scientific Objectives Nursing Rationale Evaluation

diagnosis explanation intervention
S= ∅ Ineffective Loss of blood Short term 1. Monitor vital 1. this is to Short term
tissue perfusion from the signs established
related to gastrointestinal After 5 hours baseline data After 5
decreased tract is most of nursing 2.Assess 2. To gain the hours of
O = The Patient oxygen – often the result interventions nursing
patient’s knowledge of
manifested: carrying of erosion or , the patient intervention
 pale capacity of the ulceration of the will be able general the patient’s s, the
palpebral blood secondary mucosa but may to patient shall
condition general
conjunctiva to anemia. be the result of demonstrate have
 delayed arteriovenousfor increases 3.Monitor and condition demonstrat
capillary mation.Alcohol tissue ed
record vital 3. To obtain
refill time of abuse is a major perfusion as increases
4 etiological factor individually signs baseline data tissue
 weakness in GI bleeding. appropriate. perfusion as
for future
 Hemoglobi Gastrointestinal individually
n bleeding, may reference appropriate.
result from the 4. Review
95 g m/L (140- laboratory 4. It determines
lack of RBC in
174g m/L result for extent of
our body
hemoglobin anemia and its
) especially Long term: Long term:
and hematocrit. effect on
hematocrit and
 Hematocrit energy output
hemoglobin in After 1 day After 1 day
5. Monitor for appropriate
0.28 (0.40-0.54 our body which of nursing of nursing
mental status measures
is important in interventions intervention
L/L changes, 5. These are
carrying oxygen the patient s the patient
in our body. will verbalize detoriation level other cues that shall have
) of may be

118
  WBC Once a understandin consciousness, affected with verbalized
hemoglobin g of restlessness, decreased understandi
11.4 x 109g/L (5- molecule is condition, irritability, easy tissue ng of
10x109 g/L) glycated, it therapy fatigability. perfusion. condition,
remains that regimen, and 6. Determine therapy
 RBC way. A buildup of side effect of the presence 6. This may regimen,
12
3.26 x 10 /L (4.5- glycated medication. and character indicate and side
hemoglobin of peripheral decreased effect of
6.0×1012/L) within the red pulse, capillary perfusion medication.

With initial cell, therefore, refill time, skin resulting from
vital sign reflects the color impaired
as follow: average level of temperature. coronary blood
T=36.6°C glucose to which 7. Maintain flow
PR= 85bpm the cell has been some bed rest. 7. This is to
RR=20cpm exposed during decreases
BP= its lifecycle. energy
100/70mmHg Because of the 8. Encourage consumption
higher amounts and assist and demand.
of glycosylated gradually
hemoglobin, that increasing 8. It helps in
indicates poorer periods of promoting
The patient may control of blood exercise. circulation and
manifest: glucose levels. prevents
 fatigue The oxygen 9. Assist in muscle
 tachycardia supply that performing wasting.
should be carried activities of
 dyshythmia
by the red blood daily living as 9. This is to
s
cell is replaced to feeding, help the patient
 hypotensio
by the glucose, toileting and in attaining the
n
so there is a bathing. optimum level
 lethargy decreased of functioning.
 seizure oxygen supply 10. Provide
going to health teaching

119
 systemic on maintaining 10. This is to
circulation. a schedule that provide rest
contains and enough
adequate time sleep which
rest and sleep decreases the
should be demand on the
considered. kidneys to
function.
11. Administer
medication as 11. This is to
ordered pharmacologic
ally treat the
12. Refer to client.
medical social
services as 12. This is to
necessary. counsel in
about the
impact of
having such
disease.

Nursing Problem #4: Anxiety related to coping with an acute diasease

ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION
S: Anxiety Peptic ulcer is Short term: 1. Establish 1.To avoid the Client shall
related to common After 2-3 therapeutic contagious effect or have
O: The patient coping with gastrointestinal hours of communication, transmission of identified
may manifest: an acute complaint. nurse conveying anxiety. healthy ways
>worried diasease Disordered patient empathy and to deal with
autonomic interventions unconditional and express
>fearful nervous system client will positive regard. 2. Alternation can anxiety.

120
 function also able to be a sign of
>hopelessness occurs in longer identify 2. Monitor and problems. Client shall
lasting anxiety healthy record Vital sign. have
>scared with such ways to deal appeared
physiologic with and 3.Observe 3.Which can point relaxed and
>feelings of changes as express behaviors to the level of report anxiety
inadequacy increased anxiety. anxiety. is reduced to
production of 4.Encourage to a manageable
>shakiness gastric acid, Long Term: express problems 4.Open level.
rapid emptying After 1-2 and fears and ask communication
>dry mouth of the stomach, days of questions as helps develop
diarrhea or nurse needed. trusting relationship
>heart constipation, patient that help reduce
pounding increased or interventions 5. Explain the anxiety and stress.
decreased client will reasons for the
>weakness appetite. able to planned 5.Knowledge
appear treatment reduce anxiety
>difficulty in relaxed and schedule such as appears to be
breathing report pharmacotherapy sense of fear due to
anxiety is , dietary ignorance.
>anorexia reduced to a restrictions, Knowledge can
>diarrhea manageable modification of have a positive
level. activity levels, effect on behavior
reduce or stop change
smoking.
6.Teach stress 6.Decrease anxiety
management decreases the
strategies; secretion of
example drugs, hydrochloric acid.
distraction and
Imagination
Nursing Problem #5: Ineffective protection related to abnormal blood profiles as evidenced by deficient immunity, restlessness and
perspiration

121
 Assessmen Nursing Scientific Objectives Nursing Rationale EVALUATIO
t diagnosis explanation intervention N
s
S= Pt Ineffective Short Term: 1. Establish 1. to gain .Short Term:
verbalized: Ineffective protection is After 4-5 hours therapeutic patient’s trust After 4-5 hours
“walaakongga protection the decrease of nurse- relationship and of nurse-
nangkumainm related to in the ability to patient 2. Monitor and cooperation patient
asakitangtiya abnormal guard self from interventions, record vital 2. to acquire interventions,
nko” blood profiles internal and the patient will signs baseline data the patient
(ANOREXIA) as evidenced external identify 3. Provide 3. to provide shall have
Patient may by deficient threats such as interventions to comfort comfort identified
verbalize: immunity, illness or prevent or measures such interventions to
>Neurosensor restlessness injury. A reduce risk of as stretching prevent or
y alterations and decrease in infection or bed linens, reduce risk of
>chilling perspiration. RBC level may external cleaning infection or
>itching cause hypoxia threats such as bedside and 4. reduce risk external
>insomnia and to injury providing am of existing risk threats such as
O= compensate, care factors injury
Patient the body Long term: 4. stress
manifested: increases the >After 2-3 days proper hand 5. to limit Long term:
>deficient rate of RBC of nurse- hygiene by all exposures, >After 2-3 days
immunity production patient caregivers thus reducing of nurse-
-Hematocrit increasing intervention, between cross- patient
level (0.40- cardiac output the patient will therapies and contamination intervention,
0.54) by increasing demonstrate clients the patient
0.38 (06-22- stroke volume techniques, 5. Offer masks shall have
15) or heart rate, lifestyle tissues to 6. to avoid demonstrated
>hemoglobin redistributing changes to client or bladder techniques,
level(140-174) blood from promote safe visitors who distention and lifestyle
95(06-22-15) tissues of low environment are coughing urinary stasis changes to
>WBC level (5- oxygen needs or sneezing promote safe
10x109) to tissues with 7. to reduce environment

122
11.4 x 109(06- high oxygen 6. Maintain risk of
22-15) needs, and adequate ascending tract
>restlessness shifting of hydration, infection
>perspiration oxygen- stand or sit to 8. to determine
>vital signs hemoglobin void, effectiveness
were taken dissociation catheterize, if of therapy or
and as follows: curve to the necessary presence of
T=36.6°C right to 7. Provide side effects
PR= 63 facilitate the urinary 9. to promote
bpm removal of catheter and wellness
RR= 17 more oxygen perineal care
cpm by the tissues 8.
BP= 120/60 at the same Administer/mo
mmHg partial nitor
Pt may pressure of medication
manifest: oxygen making regimen and
>impaired the ability of note client’s 10. to increase
healing; blood to carry response awareness and
altered clotting oxygen 9.Instruct client prevention of
>maladaptive decreased. A or significant communicable
stress decrease in others in diseases
response tissue oxygen techniques to
>dyspnes;coug perfusion may protect the
h lead the integrity of
>disorientation patient to skin, care for
>pressure susceptibility to lesions, and
sores health threats prevention of
> immobility internal and spread of
external, such infection
as bruising and 10. provide
poor healing. information
and and
involve in

123
 appropriate
community and
national
community and
national
education
programs

Nursing Problem #6: Imbalanced Nutrition: less than body requirements related to pain

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE

DIAGNOSIS EXPLANATION EVALUATION

S=”Wala akong Imbalanced Gastric ulcers SHORT TERM: 1. Establish 1. To gain SHORT
ganang kumaen, Nutrition: are defined as rapport patient’s trust TERM:
sumasakit and tiyan a break in After 1-2 Hours of 2. To obtain
less than nursing After 1-2
ko” as verbalized by mucosal 2. Monitor vital baseline data
body surface which interventions, the signs hours of
the patient.
requirement allows patient will be 3. To assess nursing
O= Patient manifested s related to hydrochloric able to verbalize causative and interventions,
the following on 06//15: pain acid to be understanding of 3. Assess contributing the patient
secreted into causative factors general factors shall have
>Lack of interest of the stomach and necessary condition verbalized
food which may interventions understanding
cause injury, 4. All factors that of causative
>Pallor LONG TERM:
which makes can affect factors and
>Capillary refill of 4 the stomach ingestion necessary
irritable when After 2-3 days of 4. Determine and/or interventions
made contact nursing client’s ability digestion of
>weakness
with food that interventions, the to chew, nutrients LONG TERM:
>With Vital Sign taken results to pain patient will be swallow and

124
as followed: able to taste After 2-3 days
demonstrate Food of nursing
T=36.6°C behaviors to 5. To determine interventions,
regain or maintain informational the patient
PR= 63 bpm needs of
appropriate 5. Ascertain shall have
weight. understanding client/ SO. demonstrate
RR= 17 bpm
BP= 120/60 of individuals behaviors to
nutritional regain or
Patient may manifest: needs maintain
appropriate
weight..
-Abnormal laboratory
studies
6. Discuss eating
habits, 6. To appeal to
including food client’s tastes
preferences,
intolerances or
aversions
7. Auscultate
bowel sounds 7. To evaluate
8. Note age, degree of
body built, deficit.
strength, 8. Helps
activity and determine
rest level nutritional
needs
9. Evaluate total
daily food
intake 9. To reveal
possible
cause of
malnutrition

125
 and changes
that could be
made in
client’s intake
10. Instruct to 10. To establish
avoid foods nutritional plan
that cause that meets the
intolerances or patient’s
increase needs.
gastric motility

11. Emphasize the 11.To promote

importance of well wellness.
balanced, nutritious
intake

Nursing Problem #7: Constipation related to ulcer and irregular defecation habits as evidence by decreased
frequency

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE

DIAGNOSIS EXPLANATION EVALUATION

S= “Sa isang linggo, Constipation Little fluid, little Short Term: 1. Establish 1.To gain patient After 4 hours of
dalawang beses lang related to fiber, inactivity therapeutic and patient’s SO nursing
ako nakakatae.” As or immobility relationship trust and comfort interventions,
ulcer and
verbalized by the and disruption the patient shall
irregular After 4 hours of
patient. in the daily have
defecation nursing 2. To obtain
routine. A established or
habits as interventions, the 2. Monitor and baseline data
manifestation regain normal
is decrease of patient will record vital signs
evidence by pattern of bowel

126
O = The patient decreased blood establish or functioning.
manifested: frequency (anemia) in the regain normal
body primarily pattern of bowel 3. Determine fluid 3. To evaluate
 Hypoactive the hemoglobin intake. hydration
functioning.
bowel sounds status
and hematocrit
After 2 days of
 Presence of of the patient
4. Note energy and nursing
pastelike stool that 4. Sedentary
in rectum; Long Term: activity levels and interventions,
compromise lifestyle may affect
blood in stool transport o f exercise pattern the patient shall
o

elimination pattern
 With Vital oxygen and red have verbalized
After 2 days of understanding
Signs taken as blood cells into
nursing of etiology and
follows: the mass and
interventions, the appropriate
T: 36 ° C is a factor for
decrease in patient will 5.Identify areas of interventions or
PR:82bpm metabolic verbalize stress 5. Individuals solution for
understanding of may fail to
demands, individual
RR: 28cpm etiology and allow time for
thereby result good bowel situation
to decrease in appropriate
BP: 120/90mmHg habits or suffer
normal interventions or from
frequency of solution for gastrointestinal
defecation individual effects from
The patient may accompanied situation stress
manifest: by difficulty or
 Straining with incomplete 6. Identify
defecation passage of elements that 6. Help in
 Severe flatus; identifying
stool and usually stimulate
anorexia factors in
passage of bowel activity and alleviating
excessively interfering factors condition
Palpable abdominal or hard, dry stool.
rectal mass
7.Investigate 7. To provide
preventive/
reports of pain with
prophylactic
defecation.

127
 measures

8.Determine usual
defecation habits 8. To determine
usual pattern
of elimination

9. Note color,
odor, 9. Provides a
coconsistency, baseline for
amount and comparison
frequency of promotes
stool. recognition of
changes

10. Administer stool

softeners or 10. To aid in
bulk forming better
agent as excretion.
indicated.

128
Nursing Problem #8: Dysfunctional gastrointestinal motility related to sedentary lifestyle secondary to upper GI
bleeding, and peptic ulcer.

Assessment Nursing Scientific Objectives Nursing Rationale Evaluation

diagnosis explanation interventions
S= ∅ Dysfunctional Gastrointestinal Short term: 1 .Establish 1. To gain Short term:
gastrointestin bleed (GI After 2-3 After 2-3
rapport trust of the
O = The patient al motility bleed), is all hours of hours of
manifested: related to forms nursing patient and nursing
 Absence of sedentary of blood loss interventions interventions
SO to elicit
flatus lifestyle from the patient the patient
 Pain secondary to the gastrointest will quality shall have
 With an upper GI inal tract. GI verbalizes verbalized
2 .Assess patient’s exchange of
initial vital bleeding, and bleeding is understandin understandin
sign of; peptic ulcer. most commonly g of general condition information. g of
T:36.6° C, identified by the causative causative
2. To gain the
R: 85bpm, presence of factors and factors and
R:20bpm, blood in the rationale for 3. Monitor and knowledge of rationale for
BP: vomit or stool. treatment treatment
record vital signs the patient’s
100/70mmh Blood in the regimen. regimen.
g vomit and general
stools can
4. Note presence condition
129
 present as of condition 3. To obtain Long term:
bright red affecting systemic After 4-5
baseline data
mixed in the Long term: circulation/perfusio hours of
The patient my matter, in the After 4-5 n. for future nursing
manifest: toilet bowl or on hours of intervention
reference
toilet paper, but nursing the patient
 Diarrhea it can also intervention 4. That can shall have
 Nausea appear black. the patient result in GI demonstrate
 Abdominal Small amounts will hypoperfusio d
distortion of bleeding demonstrate 5. Assess vital n, and short- appropriate
 Abdominal over a long appropriate sign, noting and/or long behaviors to
cramping period may behaviors to presence of low term GI assist with
 Vomiting cause iron assist with blood pressure, dysfunction. resolution of
 Dry stool deficiency resolution of elevated heart 5. May causative
anemia. causative rate, and fever. suggest agent.
Anemia can agent. hypoperfusio
result in the n or
lack of developing
hemoglobin 6. Ascertain sepsis. Fever
and hematocrit presence and in presence
in the body of characteristics of of bright red
patient. abdominal pain blood in stool
Hemoglobin may indicate
and Hematocrit ischemic
is responsible 7. Auscultate the colitis.
in the abdomen 6. Pain is a
transporting of common
oxygen and red symptoms of
blood cells into GI disorder
the body. If and can vary
there is lack of in location,
hemoglobin duration, and
and hematocrit intensity.

130
 in the body it 8. Measure 7.
can be a factor abdominal girth Hypoactive
for decrease in and compare with bowel sound
metabolic patient customary my indicate
demands, waist belt length. ileus.
thereby result Hyperactive
in decreasing 9. Note frequency bowel sound
peristaltic and characteristics may indicate
movement and of bowel early
also it can movement. intestinal
decreasethe obstruction
normal or irritable
frequency of bowel, or GI
defecation bleeding
accompanied 10. Maintain GI 8. To monitor
by difficulty or rest when development
incomplete indicated. or
passage of progression
stool.Thereby it of distention.
can result from
the absence of
flatus or stool. 9. bowel
movements
need to be
considered in
total
assessment
as they may
reveal
underlying
problem.
10. To
reduce

131
 intestinal
bloating and
risk for
vomiting.

132
SOAPIES

1. S= “ Masakit yung bandang itaas ng tiyan ko. Six/ ten ang sakit” as
verbalized by the patient

O= Received patient on bed in supine position, awake and coherent with an ongoing
IVF of 0.9Nacl IL x 30-31 gtts/min with a side drip of 1u PRBC properly typed and cross
matched with serial number # 4227 type A + Rhb infusing well on the left hand. Noted
facial grimace upon movement. positioning to avoid other side to pain. Provocation of
pain precipitated by food, Intermittent burning pain noted.Radiation from epigastric to
hypogastric region.Pain scale of 6/10. Recurring pain from time to time.With Vital Sign
taken as followed:

T=36.6°C PR= 63 bpm RR= 17 cpm BP= 120/60 mmHg

A= Acute Pain

P= After 4 hours of nursing interventions, the patient will report pain is relieved

I= Established therapeutic relationship

= Monitored Vital Sign

= Assessed patient’s condition

= Provided comfort measures such as stretching linens.

= Determined presence of pathophysiological cause of pain.

= Asessed for referred pain, as appopriate.

= Obtain assessment of pain including provocation, quality, radiation, severity and time

= Observed non verbal cues and pain behaviors

133
= Ascertained knowledge of and expectation about pain management

= Noted occurrence of pain

E= Goal not met as evidenced by recurrent pain however, the patient maintained
comfortable measures

2. S= ∅

O= Received patient on bed in supine position, awake and coherent with an ongoing
IVF of 0.9Nacl IL x 30-31 gtts/min with a side drip of 1u PRBC properly typed and cross
matched with serial number # 4227 type A + Rhb infusing well on the left hand.
Hematocrit level (0.40-0.54)

-0.38 (06-22-15), hemoglobin level(140-174)

-95(06-22-15), pale bulbar and palpebral conjunctiva, diaphoresis, restlessness

.With Vital Sign taken as followed:

T=36.6°C PR= 63 bpm RR= 17 cpm BP= 120/60 mmHg

A= Impaired gas exchange related to altered oxygen-carrying capacity of the blood as

evidenced by decreased level of hemoglobin

P= After 4-5 hours of nurse-patient interventions, the patient will demonstrate non
pharmacologic management as evidenced by patient doing deep breathing, coughing
and turning exercises

I= 1.Established therapeutic relationship

2.Monitored and record vital signs

3. Provided comfort measures such as stretching bed linens, cleaning bed side and
providing am care.

4. Encouraged frequent position changes and deep breathing or coughing exercises

134
5. Encouraged adequate rest and limit activities within client tolerance

6. Maintained adequate intake and output

7. Provided psychological support, active-listen questions/concerns

8. Minimized blood loss from procedure

9. Keeped environment allergen free or pollutant free

10. Administered medication as indicated such as recombinant human erythropoietin-

beta

11.Assisted with procedures as individually indicated

12.Reinforced need for adequate rest, while encouraging activities such as deep
breathing exercises and coughing exercises

E= Goal met as evidenced by patient demonstrating nonpharmacologic management

3. S= ∅
 O> Received on bed in supine position with an IVF 0.9 NACL 1Lx 30-31gtts/min.
and with ongoing blood transfusion of 1u prbc properly typed and crossmatched
with serial # 4227, with pale palpebral conjunctiva noted, delayed capillary refill
time of 4, weakness, with labresult as follows:
Hemoglobin 95 g m/L (140-174g m/L)
Hematocrit 0.28 (0.40-0.54 L/L)
WBC (11.4 x 109g/L (5-10x109 g/L)
RBC (3.26 x 1012/L (4.5-6.0×1012/L)
>Vital Sign taken as followed:

T=36.6°C

PR= 85bpm

RR=20cpm
BP= 100/70mmHg

135
A= Ineffective tissue perfusion

P= after 5 hours of nursing interventions, the patient will be able to demonstrate

increases tissue perfusion as individually appropriate

I>Established therapeutic relationship

>Monitored Vital Sign

>Assessed patient’s condition

>Review laboratory result for hemoglobin and hematocrit.

> Monitor for mental status changes, detoriation level of consciousness, restlessness,
irritability, easy fatigability.

>Determine the presence and character of peripheral pulse, capillary refill time, skin
color temperature.

>Maintain some bed rest.

>Encourage and assist gradually increasing periods of exercise.

>Assist in performing activities of daily living as to feeding, toileting and bathing.

E= Goal NOT met AEB patient’s was unable to able to demonstrated increases tissue
perfusion as individually appropriate

4. S= ∅
 O> Received on bed in supine position with an IVF 0.9 NACL 1Lx 30-31gtts/min.
and with ongoing blood transfusion of 1u prbc properly typed and crossmatched
with serial # 4227, with pale palpebral conjunctiva noted, delayed capillary refill
time of 4, weakness, with labresult as follows:
Hemoglobin 95 g m/L (140-174g m/L)
Hematocrit 0.28 (0.40-0.54 L/L)
WBC (11.4 x 109g/L (5-10x109 g/L)
RBC (3.26 x 1012/L (4.5-6.0×1012/L)
>Vital Sign taken as followed:

T=36.6°C

PR= 85bpm

136
 RR=20cpm
BP= 100/70mmHg

A= Anxiety related to coping with an acute diasease

P= after 5 hours of nursing interventions, the patient will be able to demonstrate

increases tissue perfusion as individually appropriate

I>Established therapeutic relationship

>Monitored Vital Sign

>Assessed patient’s condition

>Review laboratory result for hemoglobin and hematocrit.

> Monitor for mental status changes, detoriation level of consciousness, restlessness,
irritability, easy fatigability.

>Determine the presence and character of peripheral pulse, capillary refill time, skin
color temperature.

>Maintain some bed rest.

>Encourage and assist gradually increasing periods of exercise.

>Assist in performing activities of daily living as to feeding, toileting and bathing.

E= Goal NOT met AEB patient’s was unable to able to demonstrated increases tissue
perfusion as individually appropriate

5. S= ∅

O= Received patient on bed in supine position, awake and coherent with an ongoing
IVF of 0.9Nacl IL x 30-31 gtts/min with a side drip of 1u PRBC properly typed and cross
matched with serial number # 4227 type A + Rhb infusing well on the left hand.
Hematocrit level (0.40-0.54)

-0.38 (06-22-15), hemoglobin level(140-174), 95(06-22-15), pale bulbar and palpebral

conjunctiva, WBC level (5-10x109)

11.4 x 109(06-22-15), diaphoresis, restlessness, itching, perspiration , With Vital Sign

taken as followed:

137
T=36.6°C PR= 63 bpm RR= 17 cpm BP= 120/60 mmHg

A= Ineffective protection related to abnormal blood profiles as evidenced by deficient

immunity, restlessness and perspiration.

P= After 4-5 hours of nurse-patient interventions, the patient will identify interventions to
prevent or reduce risk of infection or external threats such as injury

I=

1. Establish therapeutic relationship

2. Monitor and record vital signs

3. Provide comfort measures such as stretching bed linens, cleaning bedside and
providing am care

4. stressed proper hand hygiene by all caregivers between therapies and clients

5. Offers masks tissues to client or visitors who are coughing or sneezing

6. Maintained adequate hydration, stand or sit to void, catheterize, if necessary

7. Provided urinary catheter and perineal care

8. Administered/monitored medication regimen and note client’s response

9.Instructed client or significant others in techniques to protect the integrity of skin, care
for lesions, and prevention of spread of infection

E= Goal met as evidenced by increased immunity showing normal blood profile

138
 6.

S= “Wala akong ganang kumaen, sumasakit ang tiyan ko” as verbalized by the
patient.

0= Received patient lying in bed, conscious and coherent, with ongoing IVF of 0.9
NaCl 1L x 8 gtts/min at 940 cc level, pallor, Pale conjunctiva, Lack of interest
of food, with an initial vital signs of: T=36.6°C, PR= 63 bpm, RR= 17 bpm, BP=
120/90 mmHg

A= Imbalanced Nutrition: less than body requirements related to pain

P= After 1-2 Hours of nursing interventions, the patient will be able to verbalize
understanding of causative factors and necessary interventions.

I=

1. Establish rapport
2. Monitor vital signs
3. Assess general condition
4. Determine client’s ability to chew, swallow and taste food
5. Ascertain understanding of individuals nutritional needs
6. Discuss eating habits, including food preferences, intolerances or aversions
7. Auscultate bowel sounds
8. Note age, body built, strength, activity and rest level
9. Evaluate total daily food intake
10. Instruct to avoid foods that cause intolerances or increase gastric motility

E= Goal met as evidence as evidence by verbalization of causative factors and

necessary interventions.

139
 7. Constipation
General appearance: Received patient on bed awake in a sitting position.
Coherent to time place and person with weakness noted .

S = “Sa isang linggo, dalawang beses lang ako nakakatae.” As verbalized by the
patient.

O = Received patient on bed in sitting position, awake and coherent. with an ongoing
IVF of 0.9Nacl IL x 30-31 gtts/min with a side drip of 1u PRBC properly typed and cross
matched with serial number # 4227 type A + Rhb infusing well on the left hand.
Hypoactive bowel sounds noted, Presence of pastelike stool in rectum; blood in stool
with Vital Signs taken as follows:
T: 36 ° C PR: 82bpmRR: 28cpm BP: 120/90mmHg

A = Constipation related to ulcer and irregular defecation habits as evidence by

decreased frequency

P = After 4 hours of nursing interventions, the patient will establish or regain normal
pattern of bowel functioning.

I = Established therapeutic relationship

= Monitored and recorded vital signs

= Assessed patient’s general condition

= Provided AM care

=Determined fluid intake.

= Noted energy and activity levels and exercise pattern

= Identified areas of stress

= Determined usual defecation habits

= Noted color, odor, coconsistency, amount and frequency of stool

140
 E = Goal met as evidenced by patient’s regained normal bowel function/ pattern.

8.
S= ∅
O= Received patient lying on bed with an IVF D5W 1L x 31-30gtts/min. and with
absence of flatus, pain, and vital signs of T:36.6° C, R: 85bpm, R:20bpm, BP:
100/70mmhg

A= Dysfunctional gastrointestinal motility

P= After 2-3 hours of nursing interventions the patient will verbalizes

understanding of causative factors and rationale for treatment regimen.

I>Established therapeutic relationship

>Monitored Vital Sign

>Assessed patient’s condition

>Note presence of condition affecting systemic circulation/perfusion.

>Assess vital sign, noting presence of low blood pressure, elevated heart rate,
and fever.

>Ascertain presence and characteristics of abdominal pain

>Auscultate the abdomen

>Measure abdominal girth and compare with patient customary waist belt length.

E= Goal met AEB patient verbalized understanding of causative factors and

rationale for treatment regimen.

141
VI. CLIENTS DAILY PROGRESS CHART’
1. Clients Daily Progress Chart
*Note: Discharge day not included, the student-nurses only handled patient A twice.

DAYS ADMISSION DAY 2 DAY 3 DAY 4

June 20, 2015 June June 22, June 23,
21,2015 2015 2015
st nd
1 nurse- 2 nurse-
patient patient
interaction interaction
Nursing
Problems
#1 Acute Pain * * *
#2 Impaired Gas * *
Exchange
#3 Ineffective *
Tissue Perfusion
#4 Anxiety
#5 Ineffective * *
Protection
#6 Imbalanced * *
Nutrition: less
than body
requirements
#7 Constipation *
#8 Dysfunctional *
gastrointestinal
motility
Vital Signs
Temperature 36.6°c 36.6°c 36.4°c 36.6°c
Pulse Rate 85 bpm 80 bpm 80 bpm 82 bpm
Respiratory Rate 20 cpm 24 cpm 27 cpm 28 cpm
Blood Pressure 100/70 mmHg 100/70mmH 100/70mmH 120/90mmHg
g g
Laboratory
Procedures
Hematology
ABO blood-typing A
RH Typing Positive
Hemoglobin 95
Hematocrit 0.28
WBC 11.4x109L
Neutrophils 0.72
Lymphocytes 0.22

142
Monocytes 0.06
Platelet count 207
RBC 3.26x1012L
Electrolytes
BUN 8.12
Creatinine 1.0
Sodium 140.5
Potassium 3.73
Digital rectal
exam
Color: Light Brown *
Consistency: Soft
Pus cell =
0-2
Empty occult blood
melena
Medical
Management
IVF
#1 PNSS (plain * *
normal saline
solution)1L x 30
gtts/min
#2 D5W (Dextrose *
in Water) 1L + 90cc
omeprazole 80mg
x 8 uggts/min
#3 D5W (Dextrose *
in Water)1L x
30gtts/min
#4 & 5 D5W 1L x * *
31-30gtts/min
Blood
Transfusion
PRBC # 4227 *
Time started :
4:30am
Time consumed:
8:30am
Drugs
Omeprazole80mg *
IV
Lactulose 30cc *
Once daily at hours

143
 of sleep
- Omeprazole 40 *
mg tab Once daily,
30 minutes before
breakfast
- Folic acid *
FeSO4 tablet BID *
(twice a day)
Diet
NPO * *
Soft Diet * *
Activity/exercise
Activity as tolerated * * * *

144
VII. SUMMARY OF FINDINGS

This is the case of Patient A, 56 years old, male, who has been married for twenty
three years and a father who makes the decisions for the family together with his wife.
He is residing in Dau Homeside, Angeles city, born at May 14, 1959 in Roxas City. He is
a natural born Filipino and a devout of the Roman Catholic. Patient A was admitted in
one of the hospitals in San Fernando, Pampanga on June 20, 2015 at 8:10 am with a
chief complaint of epigastric pain and dizziness. He was then initially diagnosed with
upper gastro intestinal bleeding secondary to bleeding peptic ulcer disease, Anemia.

The family of patient A is classified as a nuclear type of family. It is composed of

seven members, five of which pertains to their children. Patient A was a former
electrician in a call center company for almost eight years. Patient A reported difficulty in
elimination of his waste. He only defecates twice in a week. He has been smoking three
sticks a day for almost twenty-five years. He is also fond of drinking soda or soft drinks
about 500ml everyday especially when he was still working for the company as an
electrician because the company used to cater their foods. He also drinks beer but only
during special occasions, usually twice or thrice in a year. Patient A observes
superstitious beliefs like the use of herbs like bayabas for some wounds, tawas- tawas
and hilots when he is not feeling well or has a fever The wife of Patient A comply to
medical practices such as bringing their children and Patient A to the hospital when they
are ill and they avail the services of the health center like immunizations and check-ups
during prenatal period and check- ups for the kids. They also use over the counter
drugs such as biogesic, biofit, paracetamol and the like when some of the family
members experience headaches, and other conditions that can be tolerated.

Peptic Ulcer Disease (PUD) is a term used to describe a group of ulcerative

disorders that occur in areas of the upper gastrointestinal tract that are expose to acid-
pepsin secretions. The most common forms of peptic ulcer ate duodenal and gastric

145
ulcers. Peptic ulcer disease, with its remissions and exacerbations, represents a chronic
health problem. Duodenal ulcers occur five times more commonly than gastric ulcers.
Ulcers in the duodenum occur at any age and frequently are seen in early group, with a
peak incidence between 55 and 70 years of age. Both types of ulcers affect men three
to four times more frequently than women. A peptic ulcer can affect one or all layers of
the stomach or duodenum. The ulcer may penetrate only the mucosal surface, or it may
extend into the smooth muscle layers. Occasionally, an ulcer penetrates the outer wall
of the stomach or duodenum. Spontaneous remissions and exacerbations are common.

Anemia is clinical condition that results from an insufficient supply of healthy red
blood cells (RBCs), the volume of packed RBCs, and/or the quantity of hemoglobin.
Hypoxia results because the body’s tissues are not adequately oxygenated. Not a
disease in itself, anemia reflects a number of underlying pathologic processes leading to
an abnormality in RBC number, structure, or function. When anemia is identified, further
testing must be done to determine its cause. Anemia can arise from primary
hematologic problems or can occur as a secondary consequence of defects in other
body systems. Those at risk for developing anemia differ with the various etiologies.
Because the prevalence of anemia increases with age, adults 65 and older are at
particular risk; the estimated prevalence in this age-group is 20%. Aging cannot be
assumed to be the cause of anemia, however, without excluding other reversible
causes. Hereditary anemias have several cultural and ethnic considerations.

Management of PUD has improved substantially following the introduction of

Proton-pump inhibitor and therapy for H. pylori eradication. This is reflected in the
decrease in prevalence of H. pylori-associated PUD, the change in the proportion of H.
pylori-positive PUD, and the lower proportion of H. pylori infection, particularly in
complicated PUD. The continued occurrence of PUD is probably due, at least in part, to
the widespread use of low-dose ASA and NSAIDs, especially in Western countries and
among older patients and those with comorbidities. Use of these medications may also
explain why the rate of hospitalizations for PUD complications has not decreased in
some studies and the general lack in reduction of mortality from PUD bleeding. Use of
traditional NSAIDs in Western countries has increased since the withdrawal of some

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cyclooxygenase-2-selective inhibitors and Proton-pump inhibitor have been shown to
produce a marked and consistent reduction in the risk of gastrointestinal symptoms in
patients receiving NSAIDs and non-ASA anti-platelet agents. The common occurrence
of PUD in users of NSAID or low-dose ASA, despite wide availability of guidelines on
the use of gastro protective agents in NSAID users, is likely to be due to incomplete
application of these guidelines in clinical practice and incomplete adherence of patients
to prescribed gastro protective medication.

Last February 17, 2015Patient A was diagnosed of having ulcer in a clinic near
the intercession in Angeles City. The patient was said to experience epigastric pain,
burning in character, on and off and precipitated by food. On the same day, patient A
was conflicted whether to go to the hospital to get himself checked or not due to
practicality reasons such as saving money however, the physician instructed him to take
omeprazole 40mg tablet to relieve the pain which he did. He was also advised to
purchase biofit teas to help in his difficulty of defecation. Due to the known history of
fondness in drinking softdrinks which he verbalized, he was advised to limit intake of
acidic substances including sodas and alcohol, he was instructed to increase the intake
of water so as to limit the burning sensation of the patient. After his initial check-up, He
abided with the use of omeprazole to gain his relief. Despite the persistence of the pain,
he can still continue with his daily activities such as doing the household chores.

After a month (March,2015), the patient,despite his occasional intake of soft

drinks, continued his use of omeprazole for reliefbut can still feel the pain that would
sometimes last the whole day, because of this the patient lessened his chores and often
takes a rest to limit extraneous fatigue. Furthermore, after another month (April,2015),
Patient A’s epigastric pain was still persistent and it worsens when he is not taking his
meals, when he suddenly takes in food or when he eats too much. Omeprazole
provided relief for some time but the pain was still recurrent which made him feel even
weaker and which restrained him from doing the activities of daily living.At first, He was
not convinced of having another check-up because he feels that he can still tolerate the

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pain with the help of the drug, so Patient A continued with his regimen, he lessened his
intake of acidic foods and he continued to have adequate rest.

It was in the month of May when Patient A started to feel generalized weakness
and dizziness. Amidst temporary relief of omeprazole, Patient A felt irritated with the
sustained pain in his stomach. As much as he would strive to feel better, he
progressively feels weak and often gets dizzy especially when standing up or
walking.An incident of fainting was reported while he was doing his household chores.

Two weeks prior to his admission, the patient had episodes of black tarry stool
approximately ¼ cup, persistence of epigastric pain, burning and radiating pain from the
epigastric area to the hypogastric region. The patient also experienced dizziness, and
vomiting which made it hard for him to continue other activities such as doing simple
household chores and other daily activities because of possible fainting or collapse.

On June 20, 2015, 7:00am, patient A felt persistent epigastric pain as well as
dizziness, and black tarry stool. His wife decided to bring him to one of the tertiary
hospitals in San Fernando, Pampanga. At exactly 8:10 am he was admitted and
diagnosed with upper gastrointestinal bleeding secondary to bleeding peptic ulcer
disease, anemia.

The nursing care plans that were identified are numbered based on priority.
These are: 1. Acute pain, 2. Impaired gas exchange related to altered oxygen-carrying
capacity of the blood as evidenced by decreased level of hemoglobin, 3. = Ineffective
tissue perfusion, 4. Anxiety related to coping with an acute disease, 5. = Ineffective
protection related to abnormal blood profiles as evidenced by deficient immunity,
restlessness and perspiration, 6. Imbalanced Nutrition: less than body requirements
related to pain, 7. Constipation related to ulcer and irregular defecation habits as
evidence by decreased frequency, 8. Dysfunctional gastrointestinal motility.

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VIII. CONCLUSIONS

Upper gastrointestinal bleeding (sometimes upper GI, UGI bleed, Upper gastrointestinal

hemorrhage, gastrorrhagia) refers to bleeding in the upper gastrointestinal tract,
commonly defined as bleeding arising from theesophagus, stomach, or duodenum.
Blood may be observed in vomit(hematemesis) or in altered form in the stool (melena).
Depending on the severity of the blood loss, there may be symptoms of insufficient
circulating blood volume and shock. As a result, upper gastrointestinal bleeding is
considered a medical emergency and typically requires hospital care for urgent
diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic
ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric
cancer.

The initial assessment includes measurement of the blood pressure and heart rate, as

well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid
replacement is often required, as well as blood transfusion, before the source of
bleeding can be determined by endoscopy of the upper digestive tract with
an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can
be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump
inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal
hemorrhage) may be used. Recurrent or refractory bleeding may lead to need
for surgery, although this has become uncommon as a result of improved endoscopic
and medical treatment.Persons with upper GI hemorrhage often present
with hematemesis, coffee ground vomiting, melena, or hematochezia(maroon coloured
stool) if the hemorrhage is severe. The presentation of bleeding depends on the amount
and location of hemorrhage.A person with an upper GI hemorrhage may also present
with complications of anemia, including chest pain, syncope,fatigue and shortness of
breath.

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 A number of medications increase the risk of bleeding
including NSAIDs and SSRIs.SSRIs double the rate of upper gastrointestinal bleedinG
There are many causes for upper GI hemorrhage. Causes are usually anatomically
divided into their location in the upper gastrointestinal tract.People are usually stratified
into having either variceal or non-variceal sources of upper GI hemorrhage, as the two
have different treatment algorithms and prognosis.

The diagnosis of upper GI bleeding is assumed when hematemesis is

documented. In the absence of hematemesis, an upper source for GI bleeding is likely
in the presence of at least two factors among: black stool, age < 50 years, and blood
urea nitrogen/creatinine ratio 30 or more. In the absence of these findings, consider a
nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an
upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is
negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is
improved by using the Gastro Occult test.

The initial focus is on resuscitation beginning with airway management and fluid

resuscitation using either intravenous fluids and or blood. A number of medications may
improve outcomes depending on the source of the bleeding. Although proton pump
inhibitors are often given in the emergent setting, there is no evidence that these
medications decreases death rates, re-bleeding events, or needs for surgical
interventions. After the initial resuscitation has been completed, treatment is instigated
to limit the likelihood of rebleeds and correct any anemia that the bleeding may have
caused.

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RECOMMENDATION

With this study presented regarding Upper Gastro Intestinal Bleeding Secondary
to Bleeding Peptic Ulcer Disease, Anemia, the group came up with several
recommendations:

The student nurses would like to recommend this case study for presentation to
their colleagues, for them to acquire ideas and information regarding the contributing
factors of Upper Gastro Intestinal Bleeding. Through this, the student nurses believe
that their colleagues would be able to foster awareness not only to themselves, but to
their families and to the community as well. In line with this, student would like to
recommend working relationship with other health professions in advocating the
prevention of the disease.

This study is also recommended for health care providers for the modification of
the medical procedures and treatment, as well as the interventions appropriate for the
condition, since there are new discoveries on the disease process itself and on the
interventions necessary for it.

Lastly, the student nurses would like to recommend to the Department of Health
in offering their support, and to make available resources necessary in promoting
lifestyle changes to the people. With this, the community would be able to take initial
steps in preventing disease and its complications.

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X. LEARNING DERIVED

Being assigned in the Medicine Ward is one of the hardest, toughest,

complicated yet fulfilling experiences for me as a student nurse. Charting which makes
it hard. Toughest in the manner like being in a situation where we have patients with life
threatening and complicated diseases or conditions. Complicated in a point when you
encounter different cases which makes you wonder how it had turned out. One major
requirement a student nurse have is the Case study. In doing the Case study, we
should not look at the patient as the means to finish our requirement but we make our
requirement as a help for a patient because with this we able to understand deeply the
condition of our patient and be more knowledgeable of the interventions our patient
needs.

This Case study is another way of showing concern and care for our patient
because bring into actions the feelings we have and work hard in order to bring good
results. As of this we are able to impart knowledge to our patient to enhance their
awareness about the importance of having a healthy lifestyle and good health
management. Thus, reducing the number of victims and also eradicating the disease.
During the nurse-patient interaction I have learned to establish rapport and build a
foundation of trust to gain information to the patient’s Significant Others that would aid in
this study. With this case study conducted by our group, that acquired bits of knowledge
that would be useful in our pursued course and hopefully with our future work as
registered nurses. Having a background about the disease condition, we, as nursing
students can disseminate knowledge about the disease and safety precautions that may
decrease the incidence of this illness. Through this conducted study, I have learned the

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disease pattern or flow or the pathophysiology of the above condition. By knowing this,
interventions would be given earlier before complications may arise. With this basic
knowledge, we can render smart nursing service to our patients who need comfort and
support.

- Levy Anne G. Sanchez

I was able to handle patient A, and able to know his condition. Despite that I
cannot give any knowledge to him or to his SO. Because even I, don’t what kind of
disease he had, I only know that he have bleeding in GI and peptic ulcer disease. And
because of this I feel a bit a shamed to him because I cannot give him any further
knowledge about his condition. Throughout the course of this study, we gained
knowledge about the disease. We learned of the mechanisms it does to the body and in
turn oversee and control or prevent it. This study also enhanced not only our actual
skills but also our communication skills. It made us aware of the factors that contribute
to the illness and the management that we are to provide for the patient.

Being involved in this case study made me learn lots of things and gain
experiences. It also enhanced our skills as student nurses. Our critical thinking, our
rational judgment were very much enhanced. We had our clinical instructor in our side
so nothing to be worry about.

- Guiao, Grace, AUFSN

Learning is a continuous process which we gain not only through books but also with
the situations we encounter around us in our day to day life. While we were interviewing
our patient, I felt how he suffers from his disease condition. Our profession as future
nurses is not easy as what other people think considering that curing and healing our
patients is our main priority. One of the most important things I learned is to change my
notion about doing a case study. I admit that I thought it would be a burden for us since
it is too laborious. However, I realized that this case study is not conducted for us to
complete our requirements but for us to learn a little about our profession compare to
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the vast knowledge that lies ahead of us. It is a method of widening the horizon of
learning as it is an essential part of students especially nursing students who are
aspiring to handle life of their patients.

In this case study, I was able to learn more about Peptic Ulcer Disease. I learned
about its causes, complications, manifestations and reasons why these manifestations
appeared. I was able to connect and rationalize the manifestations of our patient with
the disease condition. It made the nursing care I am rendering more appropriate for the
patient.
Fajardo, Vannicar, S.

“Some days you must learn a great deal. But you should also have days when
you allow what is already in you to swell up and touch everything. If you never let that
happen, then you just accumulate facts, and they begin to rattle around inside of you.” –
E.L Konigsburg. For me, this case study served as good tool for us to be acquainted
with the disease of the gastrointestinal tract primarily ulcer. It awakened our minds to be
more conscious of the condition and the anticipated effect and treatment. I believe that
learning is never ending as cliché as it may sound and throughout the course of this
study I allowed myself to embrace the work not only because we want to finish it but
because we know that as we accomplished, we learned. As the saying goes, We must
learn and we must act and let it touch everyone that we can possibly touch.

I learned that every part of our body is truly significant in especially in maintain
homeostasis and one of the problems that we take hold will be how to handle it through
our respective lifestyles. Having a problem in the gastrointestinal area is an indication of
how we should be more conscious of how we take food- how we take care of ourselves
for that matter. This case study embodies the life as we take it and how we will handle it
as we are, it may define us but I know that there is always a choice. As a student, I find
this very helpful and I am glad to be a part of this learning process.

Veronica S. Garcia

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XI. BIBLIOGRAPHY

Black, J. L (2010) Medical-Surgical Nursing: Clinical Management for Positive

Outcomes

Kee, J.L (2011) Laboratory and Diagnostic Test with Nursing Implication: Pearson
Education, Inc.

Lipincott W. &Lipincott W. (2011) Nursing Diagnosis: Application to Clinical Practice,

Eleventh Edition

Jones and Barlett (2011). Nurse’s Handbook of IV Drugs. Third Edition. Malloy, Inc.

Doenges M. Moorhouse M. &Murr A. (2010). Nurse’spocketguide: diagnosis,

prioritized, intervention, and rationale (12th Ed). Bangkok: I group press CO., Ltd.

Deglin J. &Vallerand A. (2011). Davis drug guide for nurses (11th Ed.) Bangkok,I
group press CO., Ltd.

Sounders. (2014). Sounders Nursing Drug Handbook 2014. Philadelphia, PA:

Elsevier, Inc

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