Case Analysis Medicine Nursing

SOUTHERN LUZON STATE UNIVERSITY
COLLEGE OF ALLIED MEDICINE
NCM116 (CARE OF THE CLIENTS WITH PROBLEMS IN NUTRITION & GI, METABOLISM
AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC-RLE)
MENDOZA, MARIA ALESSANDRA A. 02-26-2022

BSN-IIIA NCM116 (RLE)
WEEK #1
PEPTIC ULCER DISEASE
Patient’s Chief Complaints

Abdominal pain
History of Present Illness

M.S. is a 56-year-old, male who presents with complaints of a four-week history of gradually
increasing upper abdominal pain. He describes the pain as “burning” in nature, localized to the
epigastrium, and that previously it had been relieved by drinking milk or Mylanta. The pain is much
worse now and milk or antacids do not provide any relief. He scores the pain as a “7” on a scale of 1–
10. The patient does not feel the pain radiating into his back and has not noticed any blood in his
stools. He denies any nausea, vomiting, weight loss, shortness of breath, neurologic symptoms, or
chest pain with exercise. He maintains that his appetite is excellent.
He has been taking 400 mg ibuprofen almost daily for knee pain for the last 18 months. He injured his
right knee in a car accident 15 years ago. He also takes daily doses of 81 mg aspirin “for his heart,”
although this has not been prescribed. He does not take any other prescribed or OTC medications.
The patient smokes 11⁄2 packs of cigarettes every day and has done so for 5 years since his wife passed
away. He does not drink alcohol or use illegal drugs. The patient is allergic to meperidine and develops
a skin rash when he is treated with it.
He admits to feeling “stressed out” as he recently lost his job of 20 years as an insurance salesman and
has had difficulty finding another. Furthermore, his unemployment compensation recently lapsed.
M.S. has been feeling a bit tired lately. He was diagnosed with HTN (stage 1) three years ago and has
been managing his elevated BP with diet and regular workouts at the gym. His younger brother also
has HTN and both his parents suffered acute MI at a young age. M.S. has a history of gallstones and
laparoscopic removal of his gallbladder six years ago. He also has a history of migraine headaches.
PE and Lab Tests

The patient is a heavy Hispanic male in mild acute distress. He is rubbing his chest and upper
abdomen. Height 510-, weight 206 lbs, T 37.1oC, P 90 and regular, RR 18 and unlabored, BP 156/98
left arm sitting.
Laboratory Test Results

 All blood chemistries including Na, K, Ca, BUN, and Cr normal
 WBC 7500/mm3 w/ normal WBC Diff
 Hct 37% Hgb. Hgb 10 g/dl
 ALT, AST, total bilirubin normal
 Amylase 90 IU/L
 ECG normal sinus rhythm w/o evidence of ischemic changes
 Stool heme-positive
 Urinalysis normal
 H. pylori testing positive.
Endoscopy Results
• Normal appearing esophagus
• 1-cm gastric ulcer w/evidence of recent bleeding but no signs of acute hemorrhage in the ulcer crater
• Rapid urease test negative
Doctor’s Order
9/18/21 - Admit patient under the service of Dr. O.
- Secure consent
1
- DAT
- V/S q 40
- IVF : D5 LR x 80
- Labs: CBC pt ct., Urinalysis Fealysis, Serum Electrolytes Na,K,BUN,Crea, ALT AST, Total Bili
Serum Amylase, Hpylori test
- ECG,
- Medications:
- Maalox 10 – 20 ml taken 20 minutes to one hour pc and HS prn for epigastric pain
- Ranitidine 150 mg 1 tab q6o
- Omeprazole 40mg. I tab OD
-Bed rest
2
3
PLANNED ACTIVITIES (MORNING SHIFT)

DATE: February 28, 2022
AREA OF ROTATION: MEDICINE 1
CLINICAL INSTRUCTOR: Prof. Maria Rowena S. Oracion
SHIFT: 6:00 AM – 2:00 PM
GOALS: Peptic ulcer disease is suspected in a client who was admitted and received with a chief complaint of abdominal pain. Throughout the shift, the nursing student's goal is to offer
patient care as directed by the doctor, monitor the patient's overall improvement, and cater to the patient's needs as outlined in the nursing care plan.
TIME ACTIVITIES OBJECTIVES

5:00 am Preparation of equipment and requirements To prepare self prior to handling the patient assigned.
Requirements are important and should not be forgotten
as the guidelines provided, no requirements, no duty.
5:30 am Receive patient for duty Proper endorsement is important to collect the important
details as needed throughout the shift.
5:35 am Pre-conference w/ Team Leader, CI, and groupmates To assess the knowledge of the student nurse regarding
the case of the patient and provide self-assessment with
how the student nurse thinks the whole shift will come
though
5:45 am Perform initial vital signs To establish baseline data of patient
6:00 am Conduct Nurse-Patient Interaction To establish rapport and good communication, as well as
to gather important data about the patient; reporting to
the Clinical Instructor assures them that the case of the
patient can be handled by the student nurse
6:15 am Carry out doctor’s order To avoid delays in providing care to patient
7:15 am Check for results of laboratory To see underlying conditions of patient
7:45 am Administer Maalox To help decrease gastric acidity
9:00 am Recheck vital signs of patient To check if patient has improving situation
12:00 noon LUNCH TIME
1:45 pm Monitor client vital signs To recheck state of vital signs
1:50 pm Endorse properly To endorse to next nurse on duty

1:55 pm Post conference To have time for reflecting and contemplating together as
a group
2:00 pm End of shift
DRUG STUDY
DRUG NAME SPECIFIC MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE/SIDE EFFECTS NURSING RESPONSIBILITY
ACTION ACTION
Generic Name:  Antacid This medication has the  For  Renal insufficiency  Immune system disorders: Preparation:
Aluminum  Adsorbent power of the relief/sympto  Severe abdominal pain hypersensitivity reactions 1. Check doctor’s order for dosage.
hydroxide +  Saline combination of matic relief of  Possibility of bowel  GI disorders: diarrhea, 2. Make sure the container is stored at
magnesium Cathartic Aluminum hydroxide hyperacidity obstructions constipation (uncommon) temperatures not exceeding 30°C.
hydroxide  GIT and Magnesium  Can also be  Hypersensitivity to  Metabolic: 3. Once container is unsealed or open,
Regulators hydroxide. Both used as active substances Hypermagnesemia (very check the date when opened and
Brand Name: components are antacid  Severely debilitated rare); hyperaluminemia make sure it is still within 28 days of
Maalox inorganic salts that are therapy for patients or in those (frequency not known); opening.
utilized as antacids and gastric and suffering from kidney Hypophosphatemia 4. Make sure to shake the oral
10 – 20 ml taken are called basic duodenal failure  Used in caution with suspension well prior to measuring
20 minutes to one compounds. ulcer, dehydrated or fluid the dosage.
hour pc and HS gastritis, and restriction 5. Place medicine cup on flat surface
prn for epigastric The Al(OH)3 acts by heartburn and measure suspension on eye level.
pain neutralizing the Administration:
hydrochloric acid in 1. Provide 20 minutes to 1 hour after
gastric secretions by meals and at bedtime, or as required.
inhibiting pepsin, which 2. Prepare water or milk as it can be
is a proteolytic enzyme. taken with such, if required. This
Mg(OH)3 acts by helps ensure passage of medication to
reducing stomach acid as stomach.
well, and increases water Assessment:
in the intestines, 1. Assess for possible hypersensitivity to
inducing bowel medication.
movements. 2. Assess vital signs and physical
examination to establish baseline
data.
3. Monitor intake and output. Noting
signs of diarrhea or constipation.
4. Inspect abdomen. Auscultate bowel

sounds ensuring GI motility.
5. Monitor number and consistency of
stools.
6. Monitor periodic serum calcium and
phosphorus levels with prolonged
high-dose therapy or impaired renal
function.
Patient and Family Education:
1. Increase phosphorus in diet when
medication will be used in prolonged
periods.
2. Stools may appear speckled or
whitish.
3. Report epigastric or abdominal pain.
When pain persists for 72 hrs, it may
signify serious complications.
4. Seek medical help if indigestion is
accompanied by shortness of breath,
sweating, or chest pain, if stools are
dark or tarry, or if symptoms are
recurrent when taking this
medication.
Generic Name:  Histamine H2- Ranitidine is a  Used for  History of acute  Significant: Rarely, mental Preparation:
ranitidine receptor competitive histamine NSAID- porphyria confusion, depression, 1. Check doctor’s order for dosage.
inhibitor H-2 receptor inhibitor associated  Hypersensitivity to hallucinations. 2. Make sure container is stored in light-
Brand Name:  Gastrointestina which reversibly inhibits ulceration ranitidine  Blood and lymphatic resistant, tightly capped container at
Zantac l Agent histamine action at H-2 and heartburn  Used in caution with system disorders: Rarely, 15°–30° C (59°–86° F) in a dry place.
receptor sites on parietal  Can also be hypersensitivity to H-2 agranulocytosis, aplastic Administration:
Dosage: cells, blocking gastric used in blockers anaemia, 1. Can be provided with or without
150mg 1 tab q6h secretion. This indirectly hypersecretor granulocytopenia, food.
reduces pepsin secretion y conditions, haemolytic anaemia,
but appears to have prophylaxis leucopenia, pancytopenia 2. Administer adjunctive antacid

minimal effects on of (sometimes with marrow treatment 2hrs before or after giving
secretion of gastric gastrointestin hypoplasia or marrow drug.
intrinsic factor or al aplasia), Assessment:
mucus. hemorrhage thrombocytopenia. 1. Monitor intake and output. Potential
from stress  Cardiac disorders: toxicity may result from decreased
ulceration, Dyspnoea, rarely, asystole, elimination, which prolongs action.
dyspepsia, atrioventricular block, 2. Assess HR, ECG, and heart sounds.
GERD, bradycardia (rapid IV 3. Report signs of agranulocytosis and
duodenal administration), neutropenia, aplastic anemia, or
ulcers tachycardia, ventricular thrombocytopenia.
associated premature contractions. 4. Assess dizziness and drowsiness.
with H.  Eye disorders: Rarely, Monitor other CNS symptoms, such
pylori reversible blurred vision. as confusion, hallucinations, and
infections,  Gastrointestinal headache.
acid disorders: Abdominal 5. Monitor signs of hypersensitivity
aspiration pain, constipation, nausea, reactions, including pulmonary
during abdominal distress, symptoms, or skin reactions.
general diarrhoea, vomiting. 6. Monitor periodic liver functions, such
anesthesia  General disorders and as creatinine clearance if renal
admin site conditions: dysfunction is present or suspected.
Rarely, malaise. 7. Be alert for early signs of
 Hepatobiliary disorders: hepatotoxicity, jaundice, and elevated
Rarely, pancreatitis, transaminases.
cholestatic hepatitis, Patient & Family Education:
hepatic failure, hepatitis, 1. Note that the long duration of action
jaundice. provides ulcer pain relief that is
 Immune system disorders: maintained through the night as well
Hypersensitivity reactions as the day.
(e.g. fever, rash, 2. Be aware that even with symptomatic
bronchospasm, relief, this should not be interpreted as
eosinophilia), anaphylaxis, absence of gastric malignancy.
angioneurotic oedema). 3. Adhere to scheduled periodic

Rarely, erythema laboratory checkups.
multiforme. 4. Do not supplement therapy with OTC
 Infections and remedies, such as aspirin.
infestations: Pneumonia. 5. Do not smoke; this decreases the
 Injury, poisoning and efficacy of the medication, and
procedural complications: adversely affects ulcer healing.
Pain, burning sensation,
pruritus at injection site
(IV/IM inj).
 Investigations: Reversible
changes in LFTs, elevated
plasma creatinine,
increased serum prolactin.
 Metabolism and nutrition
disorders: Rarely, acute
porphyria.
 Musculoskeletal and
connective tissue
disorders: Rarely,
arthralgia, myalgia.
 Nervous system disorders:
Headache (sometimes
severe), rarely, involuntary
motor activity, dizziness,
drowsiness, vertigo,
agitation.
 Psychiatric disorders:
Rarely, insomnia.
 Renal and urinary
disorders: Rarely, acute
interstitial nephritis.
 Reproductive system and

breast disorders: Rarely,
reversible impotence.
 Skin and subcutaneous
tissue disorders: Rash,
rarely, alopecia.
 Vascular disorders:
Rarely, vasculitis.
Generic Name:  Proton pump As a proton pump  Used for the  Long-term use for  CNS: Headache, dizziness, Preparation:
omeprazole inhibitors inhibitor, it inhibits the peptic ulcer GERD, duodenal ulcers fatigue. 1. Check doctor’s order.
 Antacids secretion of gastric acid case of  Proton pump inhibitor  GI: Diarrhea, abdominal 2. Must be placed in a tight container
Brand Name:  Antireflux by irreversibly blocking patient hypersensitivity pain, nausea, mild protected from light and moisture.
Prilosec Agents & the enzyme system of  Also used for  Concomitant use transient increases in liver Administration:
Antiulcerants hydrogen/potassium duodenal nelfinavir function tests. 1. Antacids may be administered with
Dosage: adenosine gastric ulcer,  Used in cation with  Urogenital: Hematuria, omeprazole.
40 mg 1 tab OD triphosphatase (proton GERD, long dysphagia, metabolic or proteinuria. 2. Must be given before meals,
pump) of the gastric term respiratory alkalosis  Skin: Rash. preferably breakfast.
parietal cell. treatment of Assessment:
pathologic 1. Monitor improvements in GI
hypersecretor symptoms to help efficacy of
y conditions, medication.
multiple 2. Assess dizziness. Report balance
endocrine problems and functional limitations to
carcinomas, physician.
and systemic 3. Monitor other CNS side effects.
mastocytosis. 4. Monitor any chest pain and attempt
to determine if pain is drug induced or
caused by cardiovascular dysfunction.
5. Monitor urinalysis for hematuria and
proteinuria.
Patient & Family Education:
1. Report any changes to urinary

elimination, such as pain or
discomfort associated with urination,
or blood in urine.
2. Report severe diarrhea; discontinue if
needed.
LABORATORY ANALYSIS
BLOOD CHEMISTRY
ELECTROLYTE METABOLIC PANEL NURSING RESPONSIBILITY
TEST VALUE NORMAL RANGE INTERPRETATION Pre-test:
Calcium 4.00mmol/day 2.50-7.50mmol/day NORMAL 1. Check doctor’s orders for verification.
Potassium 5.0mEq/L 3.5-5.3mEq/L NORMAL 2. Explain to the client the procedure to be done and answer all questions as
Sodium 136mEq/L 135-145mEq/L NORMAL possible.
KIDNEY FUNCTION TEST 3. Explain what to expect with the procedure, how long it will take and what
Blood Urea Nitrogen 12mg/dL 7-18mg/dL NORMAL are the necessary preparations to be done.
Creatinine 0.80mg/dL 0.74-1.35mg/dL NORMAL 4. Advice the client to avoid food and liquids for about 8 hours until the test
will be done.
5. Monitor vital signs to establish baseline data.
6. Advice not to do unnecessary movements as blood is being drawn.
Posttest:
1. Monitor puncture site.
2. Apply pressure after procedure is done.
Assessment:
1. Monitor intake and output.
2. Assess skin turgor to detect hydration.
Patient Education:
1. Explain the results to the client.
2. Advice to continue fluid intake up to 2L, as tolerated.
3. Advice to control intake of sodium-rich foods, such as salted nuts, canned
goods, frozen breaded meats, and other fish and poultry products to control
blood pressure. Sodium affects the blood pressure via renin-angiotensin
mechanism.
4. Advice to consume more low-sodium foods such as berries, apples,
bananas, pears, grains, and beans.
5. Advice to consume calcium-rich foods in a limit, such as dairy, but instead,
patient can consume skim milk and yogurt to avoid high amounts of fat that
may affect blood pressure.
6. Advice to eat meat with low-protein to complement Creatinine levels and

blood pressure, such as fruits, green leafy vegetables, grains, and healthy
fats (avocado, olive oil, and coconut oil.)
COMPLETE BLOOD COUNT

TEST RESULTS NORMAL RANGE INTERPRETATION NURSING RESPONSIBILITIES
WBC 7,500 cells/mm3 4,500-10,500 cells/mm3 NORMAL Pre-test:
Neutrophils 4% 3-5% NORMAL 1. Explain the procedure to be done, how long it will take, and what to expect
Lymphocytes 26% 25-33% NORMAL during the procedure.
Monocytes 5% 3-7% NORMAL 2. Encourage to avoid stress if possible as altered physiologic status influences
Eosinophils 2% 1-3% NORMAL and changes normal hematologic values.
Basophils 0.5% 0-0.75% NORMAL 3. Explain that fasting is not necessary.
Neutrophils 41% Posttest:
40-45% NORMAL
1. Apply manual pressure over puncture site.
Hct 37% 42-52% BELOW NORMAL
2. Monitor puncture site for signs of infection.
(MAY INDICATE
3. Instruct to resume normal activities and diet as tolerated.
EXISTENCE OF
Assessment:
GASTRIC ULCER) 1. Monitor vital signs to establish baseline data.
Hgb 10g/dL 14-17g/dL BELOW NORMAL 2. Monitor exacerbation of lowered WBC count.
(MAY INDICATE 3. Assess capillary refill.
BLEEDING IN UPPER 4. Advice to inform about any exacerbation of abdominal pain.
GI TRACT) 5. Monitor intake and output.
6. Assess for sores in mouth, throat, and near anal region.
7. Assess breath sounds.
Patient Education:
1. Place client on reverse isolation.
2. Inform the clients to wear personal protective equipment, such as face
mask.
3. Advice visitors to avoid exposure to patient especially if they show signs of
respiratory tract infection.
4. Inform SO to wear face mask upon visitation.
5. Educate about proper handwashing technique to maintain sterility.
6. Advice to increase intake of iron-rich foods, such as beans, fortified grains,

eggs.
7. Advice to increase intake of foods rich in folic acid, such as green leafy
vegetables. Also, increase intake of vitamin C for increased immunity, such
as citrus fruits.
LIVER FUNCTION TEST

TEST RESULTS NORMAL VALUES INTERPRETATION NURSING RESPONSIBILITIES
ALT (SGPT) 45U/L 10-60U/L NORMAL Pre-test:
AST (SGOT) 16U/L 8-20U/L NORMAL 1. Explain the procedure to be done, how long it will take, and what to expect.
Bilirubin (Total) 0.8mg/dL 0.2-1.3mg/dL NORMAL 2. Advice the patient to relax as the procedure is done and avoid any
unnecessary movements.
3. Advice to avoid any liquids and solids for 8-12 hours. Liquids may be given
as long as it is provided in sips and are clear.
Posttest:
1. Apply pressure over puncture site.
2. Monitor for any signs of infection, such as redness, abscess, swelling, and
severe pain.
Assessment:
1. Assess the medications taken by patient.
2. Assess skin color and note for changes in complexion, such as developing
jaundice.
3. Palpate abdominal area as tolerated by patient. Noting the swelling of liver.
Patient Education:
1. Advice to maintain healthy diet.
2. Encourage to stop smoking as much as possible to avoid any complications.
3. Advice to take medications as prescribed to avoid damaging liver.
4. Advice to increase fiber intake.
5. Advice to continue hydration with 2L of fluids, as tolerated.
PANCREATIC FUNCTION TESTS

TEST RESULTS NORMAL VALUES INTERPREATION NURSING RESPONSIBILITIES

Amylase 90U/L 25-130U/L NORMAL Pre-test:
1. Explain the procedure to be done, how long it will take, and what to expect.
2. Advice the patient to relax as the procedure is done and avoid any
unnecessary movements.
3. Advice to avoid eating or drinking anything except water for at least 2 hours
before the test.
Posttest:
1. Apply pressure over puncture site.
2. Monitor for any signs of infection, such as redness, abscess, swelling, and
severe pain.
Assessment:
1. Assess the medications taken by patient.
2. Inspect abdominal area for changes.
3. Assess exacerbation of abdominal pain.
4. Palpate for Blumberg’s sign to differentiate peptic ulcer disease from
pancreatitis. Noting the swelling of the pancreas.
6. Monitor for signs and symptoms of nausea and vomiting.
Patient Education:
1. Encourage to continue avoiding alcoholic beverages.
2. Explain the results to the patient.
3. Encourage to continue healthy diet.
4. Encourage to conduct exercises as tolerated.
STOOL GUAIAC TEST

TEST RESULTS INDICATION NURSING RESPONSIBILITIES
Stool Heme (+) Positive ABNORMALITY (MAY INDICATE Pre-test:
BLOOD FROM DIGESTIVE 1. Explain to the client the procedure to be
TRACT) done, how long it takes, and what to
expect during the procedure.
2. Assess level of comfort.
3. Encourage to void prior procedure.

4. Advice to avoid any intake of laxatives.
Take note of Maalox as it has a
magnesium hydroxide component,
which is partly a laxative.
5. Educate to increase intake of red-meat
free diet.
Posttest:
1. Instruct patient to perform
handwashing technique.
2. Instruct that patient can perform regular
activities.
Assessment:
1. Monitor vital signs.
2. Assess rectal area for any signs of
bleeding.
3. Document characteristics of stool
sample, such as its appearance and
color.
Intervention:
1. Refer the results to the physician and
wait for additional orders, such as
Endoscopy, CT Scan or MRI.
Patient Education:
1. Explain the results to the patient to
alleviate anxiety.
2. Explain that patient may undergo
endoscopy to detect which area in the
GI tract the bleeding occurs.
3. Encourage patient to avoid dark-
colored foods that may cause confusion
to stool color.
4. Advice patient to avoid too much

straining upon defecation as bleeding
may occur anywhere in the GI tract.
5. Advice to avoid spicy foods as this
could irritate the mucosal barrier of the
GI tract.
URINALYSIS
TEST RESULTS NORMAL VALUES INTERPRETATION NURSING RESPONSIBILITIES
Color Pale Yellow Pale yellow to amber straw NORMAL Pre-test:
Specific Gravity 1.011 1.010-1.020 NORMAL 1. Explain the procedure to the client.
Osmolality 340mOsm/kg 300-900mOsm/kg NORMAL 2. Provide education that the specimen must be
pH 4.7 4.6-8.0 NORMAL collected midstream.
3. Avoid touching the insides of the cup to avoid
contamination.
4. Explain to place specimen cup on nurse’s station
afterwards.
Posttest:
1. Encourage client to wash hands after collection of
specimen.
Assessment:
1. Note color, frequency, and odor of urine sample.
Patient Education:
1. Educate patient to drink fluids as much as 2L, as
tolerated.
2. Educate to avoid holding urination.
3. Encourage to perform proper hygiene after
urination, especially on genital area.
ELECTROCARDIOGRAPHY
TEST RESULTS INTERPRETATION NURSING RESPONSIBILITIES
ECG Normal sinus rhythm w/o evidence of NORMAL Pretest:

ischemic changes 1. Explain to the patient the need to lie still, relax, and breathe normally
during the procedure.
2. Note current cardiac drug therapy on the test request form as well as
any other pertinent clinical information, such as chest pain or
pacemaker.
3. Explain that the test is painless and takes 5 to 10 minutes.
During the Procedure:
1. Place the patient in a supine or semi-Fowler’s position.
2. Expose the chest, ankles, and wrists.
3. Place electrodes on the inner aspect of the wrists, on the medical aspect
of the lower legs, and on the chest.
4. After all electrodes are in place, connect the lead wires.
5. Make sure that all leads are represented in the tracing. If not, determine
which electrode has come loose, reattach it, and restart the tracing.
6. All recording and other nearby electrical equipment should be properly
grounded.
7. Make sure that the electrodes are firmly attached.
Interventions:
1. Disconnect the equipment, remove the electrodes, and remove the gel
with a moist cloth towel.
2. If the patient is having recurrent chest pain or if serial ECG’s are
ordered, leave the electrode patches in place.
Patient Education:
1. Explain the results to the patient.
2. Encourage to perform cardio exercises to maintain normal sinus
rhythm.
3. Encourage client to report signs of tachycardia or bradycardia.
BLOOD CULTURE TESTING

Helicobacter pylori (+) Positive CONFIRMATORY DIAGNOSIS FOR Pretest:

PEPTIC ULCER DISEASE 1. Explain to the client the procedure
to be done and how it could help to
confirm the diagnosis.
2. Advice the patient to relax.
Posttest:
1. Apply pressure on puncture site.
Assessment:
1. Monitor vital signs and note for
signs of infection.
Intervention:
1. Refer results to physician.
2. Wait for additional orders.
Patient Education:
1. Advice patient to take medications
for reducing gastric acidity, such as
antacids.
2. Advice patient to take medications
for H. pylori, such as antibiotics as
ordered.
3. Education to take medication as
prescribed.
ENDOSCOPY
Endoscopy  Normal appearing esophagus LEVEL OF OBTAINED BACTERIA IS Pretest:
 1-cm gastric ulcer w/ evidence of recent LOW; PROGNOSIS OF PEPTIC 1. Secure an informed consent.
bleeding but no signs of acute ULCER DISEASE IS EARLY; 2. Explain the procedure to be done to
hemorrhage in the ulcer crater SUPPORTS DIAGNOSIS OF GI TRACT alleviate anxiety.
 Rapid urease test negative BLEEDING 3. Ensure if patient has complied with
bowel preparation
4. Establish IV line, as ordered.
5. Instruct to remove all metallic

objects on body.
During the procedure:
1. Assist in positioning.
2. Administer medications as ordered,
such as sedatives.
3. Instruct patient to bear down.
4. Change position of patient.
5. Encourage to take slow, deep
breaths.
Posttest:
1. Observe for signs of bowel perforation.
3. Observe for exacerbated bleeding.
4. Monitor vital signs.
5. Instruct to resume normal diet,
fluids, and activity as advised by
health care provider.
6. Provide privacy upon resting.
7. Encourage increased fluid intake.
NURSING CARE PLAN
ACUTE PAIN
NURSING ASSESSMENT NURSING DIAGNOSIS NURSING PLAN NURSING RATIONALE EVALUATION
INTERVENTIONS
Subjective: Acute pain r/t gastric acid After 8 hours of nursing 1. Assess client’s To determine how to help After 8 hours of nursing
- “Ang sakit ng sikmura reflux secondary to peptic intervention, the client will perception of pain. and approach the client in intervention, the client is
ko, parang nasusunog ulcer disease as evidenced be able to report lessened pain seen doing the relaxation
ang pakiramdam.” As by rubbing of chest and severity of pain as seen with techniques such as the deep
verbalized stomach pain scale of 4/10. 2. Assess and palpate To determine the breathing techniques and
- “hindi na nga naiibsan abdomen. Noting association of abdominal rated pain scale as 4/10.
sa Mylanta at gatas location, intensity, and pain with situation
yung sakit,” as characteristic of pain.
verbalized
- Rated pain scale as 7/10 3. Monitor exacerbation of To provide appropriate
abdominal pain. interventions
Objective:
- Seen rubbing chest and 4. Assess for referred pain, To determine other
upper abdomen as possible. possibility of underlying
- Seen in distress and condition or organ
facial grimace dysfunction that requires
- Vital signs treatment.
BP – 156/98 mmHg
5. Monitor pain scale. To determine progress of
pain and therapeutic
regimen.
6. Monitor vital signs, To determine how pain

especially Temperature affects client and how it
and BP. shows progress of pain
To provide baseline for

7. Assess client’s interventions
knowledge about pain
management.
Resting is a form of
8. Advice client to have
relaxation technique that
adequate amounts of
helps alleviate pain
rest.
To help lessen pain
9. Advice to perform
relaxation techniques,
such as meditation and
deep breathing
exercises.
10. Assist and educate

about proper body Body mechanics is a factor
positioning, such as as to why pain is being felt
sleeping on left lateral

side.
11. Encourage to express To understand the pain

feelings of pain. being felt by the client
12. Collaborate with To provide appropriate

physician. treatment efficiently as
possible
13. Administer medications To help lower down gastric

as ordered, such as acidity, because as long as
antacids. acid reflux occurs, the pain
will not subside.
DEFICIENT KNOWLEDGE
NURSING ASSESSMENT NURSING DIAGNOSIS NURSING PLAN NURSING RATIONALE EVALUATION
INTERVENTIONS
Subjective: Deficient knowledge r/t After 4 hours of nursing 1. Assess level of To determine patient’s After 4 hours of nursing
- “hindi na nga naiibsan misinformation from intervention, the client will knowledge about pain level of understanding intervention, the client
sa Mylanta at gatas others as evidenced by be able to verbalize management and about disease process. verbalized, “Ah, ganoon
yung sakit,” as verbalization of patient interferences to learning and disease process. pala iyon ano. Sige, nurse.
verbalized seeking consultation prior to Next time hindi ko na iyon
- “Umiinom din ako ng medication. 2. Assess the level of To identify if client has any gagawin.”
ibuprofen para sa sakit client’s capabilities and S/O or caregivers that can
ng tuhod ko at aspirin possibilities of the help him assist through
para sa puso ko.” As situation. treatment
verbalized
- “nalaman ko lang iyon 3. Educate the client about To ensure that all
sa mga kumpare ko.” As proper consultation and important details are
verbalized discussed briefly
pain management one at

Objective: a time and avoid jargon.
- Vital signs For the client to know
BP – 156/98 mmHg 4. Educate the client about when to and when to not
the advantages and use medication
disadvantages,
indications and
contraindications of the
drugs used. A question and answer
portion assures the client’s
5. Encourage the client to cooperation throughout the
raise concerns and ask health education.
questions.
To determine if further
health education is needed
6. Encourage to client to for client
repeat the details that
have been discussed. Photographic memory can
help the patient understand
7. Provide the learning
the learnings more.
materials, such as
pamphlets.
To provide more
information
8. Encourage to express
confusion.
If concern needs
collaborative approach,
9. Collaborate with inform the physician to
physician. provide
RISK FOR DEFICIENT FLUID VOLUME

NURSING ASSESSMENT NURSING DIAGNOSIS NURSING PLAN NURSING RATIONALE NURSING
INTERVENTIONS EVALUATION
Subjective: Risk for deficient fluid After 8 hours of nursing 1. Monitor vital signs, To monitor presence of After 8 hours of nursing
- “ Ang sakit ng sikmura volume r/t gastrointestinal interventions, the client will especially blood orthostasis that is checked intervention, the client did
ko, parang nasusunog bleeding as be able to prevent any signs pressure and pulse rate. by sitting, standing, and not show signs of GI
ang pakiramdam.” As of gastrointestinal bleeding, laying bleeding and results of Hct
verbalized as seen without shows 42% and Hgb shows
- “hindi na nga naiibsan hematemesis or melena and 2. Monitor physical To determine signs of shock 14g/dL.
sa Mylanta at gatas an increased hematocrit and changes, such as poor
yung sakit,” as hemoglobin levels. skin turgor, dry skin and
verbalized mucous membranes.
- Rated pain scale as 7/10
3. Monitor urine intake To assess changes in
Objective: and output circulatory blood volume
- Has Stool heme-positive that leads to decreased renal
- Has 1 cm perfusion
 Vital Signs
BP – 156/98mmHg 4. Monitor for any signs of The following signs show
 Laboratory Values nausea, vomiting, sign of GI bleeding
- Hct – 37% dizziness, and shortness
- Hgb – 10mg/dL of breath.
5. Encourage client to This is an urgent concern

report any signs of GI and needs to be reported to
bleeding as stated above. the physician.
6. Monitor laboratory
values, especially
hemoglobin and These two values, when

hematocrit levels. decreased, are associated
with GI bleeding.
7. Collaborate with
physician.
To determine if there are
developing signs of bleeding
and may be treated right
8. Administer medications away
as ordered, such as
antacids. To lower gastric acidity and
promote perfusion in
9. Administer fluids, such stomach
as D5LR as ordered.
IV fluids help expand
intravascular volume
SAMPLE CHARTING
NAME AGE ATTENDING PHYSICIAN WARD CASE NUMBER:

M.S. 56 years old Dr. O Medicine 123
FOCUS DATA/ACTION/RESPONSE
2/28/2022  ACUTE PAIN 6-2
6:30 AM >received on wheelchair with IVF of D5LR x 8 @800cc level regulated at 32 gtts/min inserted at ® metacarpal
vein infusing well, no redness nor swelling at insertion site, seen with distress ---------------------------------------------------
D>”sobrang sakit ng tiyan ko, apat na linggo nang ganito. Parang nasusunog pati hanggang baga ko, wala nang
ibang nakakaalis ng sakit,” as verbalized, rated pain as 7/10, seen rubbing chest and upper abdominal area, seen
with facial grimace and malaise --------------------------------------------------------------------------------------------------------------------
7:00 AM A>assessed general condition, NPI established w/ good rapport, medical history taken, initial VS taken, recorded
as follows: T -37.1C, PR 90bpm, RR – 18breaths/min, BP - 156/98mmHg left arm sitting, checked regulation of
IVF, asked about medical management for hypertension, referred to ROD, instructed SO and assisted into Semi-
9:00 AM fowler’s position, teach and demonstrated meditation and deep breathing exercises, health education done as
follows: a. proper usage of OTC drugs such as ibuprofen and aspirin, b. importance of consultation prior to medical
treatments, c. advantages and disadvantages of self-medicating, d. lifestyle, e. evaluation of laboratory results,
highlighting low WBC count, secured consent for confirmatory diagnostic tests, assisted client into laboratory,
10:00AM rechecked VS, encouraged to practice relaxation techniques, demonstrated deep breathing exercises, checked
12:00 PM capability to swallow, lunch taken lightly and as tolerated, explained importance of DASH diet and avoidance of
contraindicated foods, such as dark-colored and high-protein --------------------------------------------------------------------------
2:00 PM R>”medyo naiibsan naman yung sakit, may kaunting sunog sa pakiramdam, pero ayos naman” as verbalized,
seen without facial grimace, seen slightly rubbing upper abdominal area, VS taken – T-37.3C, PR – 84 bpm, RR
– 16breaths/min, BP – 130/90mmHg-------------------------------------------------------------------------------------------------------------
>Properly endorsed---------------------------------------------------------------------------------------------------------------------------------------
>Latest T – 37.5C
BP – 130/90mmHg------------------------------------------------------------------------------------------------------------- M.A. Mendoza
BSNIII-SLSU

Case Analysis Medicine Nursing

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Case Analysis Medicine Nursing

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SOUTHERN LUZON STATE UNIVERSITY

COLLEGE OF ALLIED MEDICINE

MENDOZA, MARIA ALESSANDRA A. 02-26-2022

Patient’s Chief Complaints

History of Present Illness

PE and Lab Tests

Laboratory Test Results

PLANNED ACTIVITIES (MORNING SHIFT)

TIME ACTIVITIES OBJECTIVES

1:50 pm Endorse properly To endorse to next nurse on duty

4. Inspect abdomen. Auscultate bowel

but appears to have prophylaxis leucopenia, pancytopenia 2. Administer adjunctive antacid

angioneurotic oedema). 3. Adhere to scheduled periodic

 Reproductive system and

1. Report any changes to urinary

6. Advice to eat meat with low-protein to complement Creatinine levels and

COMPLETE BLOOD COUNT

6. Advice to increase intake of iron-rich foods, such as beans, fortified grains,

LIVER FUNCTION TEST

PANCREATIC FUNCTION TESTS

TEST RESULTS NORMAL VALUES INTERPREATION NURSING RESPONSIBILITIES

STOOL GUAIAC TEST

3. Encourage to void prior procedure.

4. Advice patient to avoid too much

ECG Normal sinus rhythm w/o evidence of NORMAL Pretest:

BLOOD CULTURE TESTING

Helicobacter pylori (+) Positive CONFIRMATORY DIAGNOSIS FOR Pretest:

5. Instruct to remove all metallic

NURSING CARE PLAN

6. Monitor vital signs, To determine how pain

To provide baseline for

10. Assist and educate

sleeping on left lateral

11. Encourage to express To understand the pain

12. Collaborate with To provide appropriate

13. Administer medications To help lower down gastric

pain management one at

RISK FOR DEFICIENT FLUID VOLUME

5. Encourage client to This is an urgent concern

hemoglobin and These two values, when

NAME AGE ATTENDING PHYSICIAN WARD CASE NUMBER:

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