Level 4

1st

CASE PRESENTATION Semester SY 2011-12

I.

Statement of Objective A. General Objectives This case analysis aims to increase the understanding and knowledge of student nurses on how to care for patients with Upper Gastric Ulcer Disease (UGIB) secondary to Benign Peptic Ulcer Disease (BPUD) Specific Objectives

B.

Specifically, this case analysis aims to: 1. Define and its effects to the body as Gastric Ulcer Disease (UGIB) a whole; 2. Illustrate the pathophysiology of Gastric Ulcer Disease (UGIB) and in relation to the signs and symptoms specifically observed in the client; 3. Describe and identify the common signs and symptoms of Gastric Ulcer Disease (UGIB); 4. Discuss the medical and surgical interventions for the management of Gastric
Ulcer Disease (UGIB)

5. Formulate appropriate nursing care plans suited for the client based on the assessment findings; 6. Identify care measures to be given to the patient and family to promote continuity of care and independence after discharge II. Client s Profile Name Age Birth date Sex Ethnic Background Civil Status Address Religion Occupation Admitting Diagnosis Final/Principal Diagnosis Admitting Physician Date and Time Admitted

: : : : : : : : : : : : :

E. L. A. 68 years old January 01, 1943 Female Kankanaey Single Country Club, Baguio City, Benguet Roman Catholic None Hypovolemic Shock 2 to UGIB 2 to BPUD Hypovolemic Shock 2 to UGIB 2 to BPUD Anne Rhea Dacayan, M. D. June 23, 2011 at 1:30 pm

III. Chief Complaint Vomiting of coffee-like granules of blood and defecates black-tarry stool. IV. Present History of Illness The patient was apparently well until 3 days PTA, she started to feel abdominal pain which was characterized as burning sensation starting from the epigastric region that radiates towards the esophagus rated as 6/10; 10 as the highest, she vomited coffee-like granules of blood approximately 1 cup with the previously ingested food and started to defecate black-tarry stool associated with diaphoresis though she haven t experienced fever, loss of consciousness, headache, dizziness, anorexia and body weakness. No consultation was made though she went to the RHU and requested for medicine such as Maalox and Kremel-S for (Antacid) and Paracetamol or Alaxan (Anti-inflammatory/antipyretic/NSAID) to decrease abdominal pain, in which the pain rated as 9/10. The condition persisted until 1 day PTA; her neighbor noticed that she was not coming out of her house anymore. Her neighbors went to her apartment to check her out and found her vomiting fresh blood and later it shifted to coffee-like granules of blood approximately 1-2 cup per bout and that she was pale and looks weak. After which they informed her relatives about it, upon knowing her condition her relatives fetched her and brought her immediately to BGHMC for evaluation. On their way to the hospital, she was still vomiting persistently approximately 1 cup per bout. She has a positive aspirin (NSAID) intake last week of May for heart problem. V. Past History of Illness When the patient was young in her elementary years, she had episodes of fainting and was frequently just found lying unconscious on the ground. They didn t consult any physician instead her family recommended her to rest and stay at home. The patient was hospitalized at Notre Dame due to abdominal pain in which she felt a burning sensation at the epigastric region and was diagnosed with ulcer at her 40 s. She complied with the medical regimen and then stopped when she felt better. VI. Family Health History The patient verbalized that they do not have a history of renal disease and other hetero-familial diseases though she mentioned that they have familial disease such as hypertension and diabetes mellitus. She emphasized that her mother died of cardiovascular disease while her one of her brother died due to alcoholism. VII. Developmental History The patient is 68 years of age and is the last child among the 11 siblings. Among the 11 children, 4 was aborted, 5 died and only two of them are alive. She only finished grade one due to episodes of fainting. In Erik Erickson s theory she is in the

stage of Integrity vs. Despair wherein she is alone in life. As mentioned, she lives alone and the source of her daily finances is from her late mother s pension and some of it is from her nieces, which is thought to be contributory factor for her detachment, she doesn t want to be operated even with concise and consequent explanation of the problem and her response is that she doesn t want to have the operation due to her age. VIII. Social and Environmental History The patient smokes and drinks alcohol. Her apartment is located along the road, so the environment is noisy. Her water source is from the water district. As mentioned, she is unemployed and her current financial source is from her mother s pension, to keep up with other needs, she is a part time Kobrador of jueteng, though her nieces gives complements one way or another. Mingles with neighbor at times and smokes cigarette and drinks rice wine about 1 cup with them. She spends most of her time inside her house watching television. IX. Lifestyle and Health Practices The patient started to smoke cigarette in her 50 s that varies from time to time but approximately 5-9 stick per day but then she also stopped it in her 50 s. She drinks 3 cups of coffee per day and four 330 mL bottles of water per day. During leisure time, she drinks approximately 1 cup of soft drinks like coke. During meals, she eats late and includes chili to increase appetite during mastication.