CASE

ANALYSIS
No. 2

SUBMITTED BY: CAPACIO, LIANE FAE B.

PATIENT’S PROFILE

LAST NAME FIRST NAME MIDDLE NAME/INITIAL AGE/SEX

BALVERDE RAQUEL LATUZA 25/F

ADDRESS 55 DIAMANTE CALOOCAN BIRTHDAY RELIGION

CITY 05-22-1997 CATHOLIC
CONTACT NO. DATE/TIME OF T: 35.60C DIAGNOSIS:
09457981297 ADMISSION WT: 61.2kgs ACUTE GASTRITIS
11-15-2022 3:21 AM BP: 122/61

HISTORY OF PRESENT ILLNESS

Patient arrived on November 15, 2022, at 3:21 am and reported having 10/10 pain in the upper
region of her abdomen and vomiting. Prior to admission, the patient stated that she had upper
abdominal discomfort since last August, which was relieved by taking a painkiller. Thereafter, she
continued to take a painkiller anytime she experienced stomach pain. Patient typically eats late (lunch at
3 pm and dinner at 1 am), and because she always felt full and would like to vomit (nausea), she
occasionally just ate once a day. Patient always drinks Cola and occasionally consumes food that
contains chili. Patient goes to bed at 7 am and wakes up at 2 pm because she works from home. Family
hx: The patient said that three years ago, her elder sister experienced the same symptoms as she does
today but she just declined to go to the hospital.
PATHOPHYSIOLOGY

Predisposing factors Precipitating factors

-25 y/o –T:35.60C, W: 61.2 -Bile reflux -Spicy foods
-F -BP:122/61 -Dietary habit –Pain killer
Gastric mucous membrane
becomes edematous and
hyperemic

Gastric mucous membrane

undergoes superficial
obstruction

Scanty amount of gastric juices

is secreted with very little acid
but much mucus

Superficial Ulceration

Signs & Symptopms:

Nausea, Vomiting,
Epigastric pain
Medication:
Complications:
Omeprazole
Dehydration
Ketorolac
NURSING CARE PLAN FOR VOMITING
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Vomiting ST: Independent: -Understanding After nursing
After related to Within 6 -Assess patient the severity of intervention
consuming gastric hours of for the degree of symptoms can the patient
spicy meals, distention as nursing vomiting: mild (1- help determine vomit less
she began to evidenced by intervention 2x/day), the course of than 2 times in
experience epigastric the patient moderate treatment. 24 hours; the
epigastric pain pain with a will vomit (3-7x/day) or patient
that was rated pain scale of less than 2 severe (8 or maintain
10 on the pain 10 times in 24 more or vomits adequate
scale. hours; the everything hydration
and she took patient will consumed) -Monitor for
pain killer maintain fever or signs Goal met.
medication but adequate -Assess vital of dehydration
no effects, then hydration signs every 4 including
after that she hours tachycardia
started to LT: and tachypnea.
Vomit (4x, with
interval of 10- -Encourage the -Increase fluid
20 mins, patient to take intake
started before at least 1500ml replenish the
arrival; Nov. to 2000ml of fluid deficit in
15) fluid a day the body and
prevent
- Educate dehydration.
Objective: patient and
110/70 family on BRAT -This diet is
T: 36.5 diet (Bananas, easy on the
W: 61.2kgs
Rice, digestive
-Facial grimace Applesauce, system and
-Pallor and Toast) helps to
-Sweating decrease
diarrhea and
Dependent:
replace
-Administer
nutrients lost
medications as
prescribed by
- Anti-nausea
doctor:
Omeprazole medication
-40mg/ 4ml TIV may be given
Ketorolac depending on
-30 mg q6hr; not the severity of
to exceed 120 vomiting.
mg/day, TIV
DRUG STUDY
DRUG MECHANISM OF INDICATION CONTRAINDICATION ADVERSE/ NURSING
ACTION SIDE EFFECTS RESPONSIBILITIES
Ketorolac The exact Short-term Contraindicated -Headache -Monitor signs of
mechanism for (5 days or in patients with -Dizziness allergic reactions
Brand name: ketorolac less) relief of moderate or -Drowsiness and anaphylaxis,
TORADOL is not known. mild to severe renal -Diarrhea including
Ketorolac, like moderate impairment -Constipation pulmonary
Classification
NSAIDs blocks pain. (serum -Sweating symptoms
NSAID
cyclooxygenase Ophthalmic: creatinine >160 µ -Fever (laryngeal edema,
s (COX), which Relief of mol/l) or in -Back pain wheezing, cough,
are enzymes ocular patients at risk dyspnea) or skin
that convert itching due for renal failure reactions (rash,
arachidonic acid to seasonal due to volume pruritus, urticaria).
into allergic depletion or -Monitor injection
prostaglandin, conjunctivitis dehydration. site for pain,
prostacyclin, . Treatment Ketorolac is swelling, and
and postop for contraindicated irritation. Report
thromboxane. inflammation in pregnancy, prolonged or
The inhibition of following labour, delivery excessive
these cataract or lactation injection site
substances extraction, reactions to the
decreases pain. pain physician.
Fever, and following - Assess pain and
inflammation. incisional other variables
Ketorolac does refractive (range of motion,
so by inhibiting surgery. muscle strength)
both to document
cyclooxygenase whether this drug
-1 and is successful in
cyclooxygenase helping manage
- 2. It has higher the patient's pain
demonstrated and decreasing
potency than impairments.
other NSAIDs. - Assess blood
pressure (BP)
periodically and
compare to
normal values
(See Appendix F).
NSAIDs can
increase BP in
certain patients.