NCM 112a

CASE STUDY- GPH

BY:

Bonifacio, Honey Babes R.

BSN 3B
I. NURSING HISTORY

A. BIOGRAPHICAL DATA

Name: N.B Gender: Female

Address: Sitio Bitbit, Jania Jordan Phone Number: 0909367****

Date & Place of Birth: October 4, 1964, Janiuay Nationality: Filipino

Marital Status: Married Religion: Roman Catholic

Educational Level: Highschool Level Occupation Working Status: Housewife

Significant Others Living with the client: Husband

Caregivers and Support People for the Client: Children & Husband

Primary and Secondary Languages: Hiligaynon

B. REASONS FOR SEEKING HEALTH CARE

Ms. N.B. has been admitted to the hospital due to three days of muscle pain and
vomiting she's been enduring.

C. HISTORY OF PRESENT ILLNESS

After experiencing muscle pain and vomiting, Ms. N.B. skipped consulting a doctor and
went straight to the hospital after multiple vomiting episodes. She was hospitalized on
December 3rd, and her lab results indicate a low hemoglobin level.

D. PAST HEALTH HISTORY

Ms. N.B. reported no issues during birth or childhood illnesses. She has no history of
chronic diseases, accidents, injuries, or known allergies.

E. FAMILY HEALTH HISTORY

There are no familial diseases observed in hereditary history.
F. LIFESTYLE AND HEALTH PRACTICES PROFILE

Description of Typical Day

Ms. N.B. typically begins her day by waking around 7 a.m. Following that, she heads to
the kitchen for coffee before preparing breakfast. Once breakfast is ready, she settles in
to listen to the radio. By 9 or 10 a.m., she typically starts house cleaning. Lunch
preparation usually occurs around 11 a.m., followed by a short nap after eating. Dinner
is prepared around 6 p.m., after which she watches TV until around 10 p.m., her usual
bedtime.

Nutrition and Weight Management

Ms. N.B. mentioned that her usual diet consists of homemade soups with fish and
vegetables, and she tends to favor softer food options.

Activity Level and Exercise

Ms. N.B age has limited her from performing other rigorous activities thus she only does
her short morning walks.

Sleep and Rest

Ms. N.B.'s sleep schedule involves being awake during the daytime for 17 hours and
sleeping for 7 hours at night. Typically, she gets 6-7 hours of sleep each night and feels
refreshed upon waking.

Social Activities
Ms. N.B predominantly spends time with her close ones at home and enjoys watching
TV in her leisure hours.

Relationships
Ms. N.B currently lives with her husband.

Self-Concept and Self-Care Responsibilities

While at home, Ms. N.B remains active, handling tasks like laundry and cooking her
meals. She mentioned that she only goes to the clinic or hospital when she experiences
symptoms of illness.
 II. DRUG STUDY

Generic Route, Mechanism of Indication Contraindicat Special Side Nursing

name & dosage & action ion precaution effects responsibiliti
brand availability es
name
Omeprazol 80mg IVTT IM Omeprazole Omeprazole is used Omeprazole is This medicine is Headache, Nurses should
e (Prisolec, belongs to a class of to treat certain contraindicated in sometimes given Nausea, educate patients
Losec) medications called conditions where patients with a together with Diarrhea, about the
proton pump there is too much history of other medicines Abdominal importance of
inhibitors (PPIs). It acid in the hypersensitivity to to treat ulcers. pain, and adherence to the
works by reducing stomach. It is used the drug or any Be sure you flatulence. medication
the production of to treat gastric and excipients from the understand regimen and
stomach acid by duodenal ulcers, dosage form. about the risks potential side
inhibiting the erosive esophagitis, Hypersensitivity and proper use effects.
proton pumps in and reactions like of any other Nurses should
the stomach's gastroesophageal anaphylactic shock, medicine your advise patients to
lining. This reflux disease angioedema, doctor gives you report any
reduction in acid (GERD). GERD is a interstitial or your child unusual
secretion helps in condition where nephritis, together with symptoms or
healing acid-related the acid in the anaphylaxis, omeprazole. concerns while
damage to the stomach washes urticaria, and taking
esophagus, back up into the bronchospasm may omeprazole.
stomach, or esophagus. occur.
intestines.

Bacillus 5mL/amp PO Erceflora contribut It is commonly It is Specific Abdominal Educate the

Claussi es to the used to prevent or contraindicated in precautions can pain, patient and family
(Erceflora) recovery of the i treat various patients with vary. It's constipation about the possible
ntestinal microbial gastrointestinal hypersensitivity to essential to , gut side effects of the
flora altered during disorders such as Bacillus clausii or inform the discomfort, medication.
the course of mi diarrhea caused by its ingredients. healthcare and Encourage family
crobial disorders of antibiotics, viral provider about bellyaches. to report unusual
diverse origin. It infections, or other any ongoing effects and
produces various causes. It's also medical changes of the
vitamins, used to restore conditions, patient’s
particularly group B intestinal flora pregnancy, or condition upon
vitamins after disturbances lactation before administration
thus contributing due to various using Bacillus
to factors. clausii. Also,
correction of vita caution might be
min required in
disorders caused immunocompro
by antibiotics & mised
chemotherapeutic individuals.
agents. It
also promotes
normalization of
intestinal flora.
III. NURSING CARE PLAN

Nursing Planning Intervention Rationale Evaluation

Diagnosis
Imbalanced After 2 days of Independent: Goal not met.
Nutrition: less than nursing After 2 days of
body requirements intervention, the 1. Discourage the 1. Acidic foods such as nursing
related to patient will be able patient from citrus items may intervention the
insufficient to absorb an consuming spic worsen the patient’s patient was not
absorption of adequate amount foods, caffeine, and condition and able to absorb an
nutrients as of nutrients. alcohol. interfere with the adequate amount
evidenced by: treatment and healing of nutrients.
process.
Subjective:
“Daw wala ko gana
magkaon pila na ka 2. Encourage small, 2. This might help the
adlaw tungud frequent meals patient to tolerate
gasakit sulok sulok rather than three frequent small
ko” as verbalized by full meals. portions.
the patient.

Objective: 3. Obtain 3. Some food items

-Pale information about can exacerbate the
-Patient appears to the patient’s eating symptoms of gastritis.
be weak and drowsy habits. Acidic or citrus food
items may worsen
symptoms.

Dependent:
1. Medications or
1. Administer supplements can help
medications as reduce gastric acid
prescribed by the secretion such as
physician. omeprazole.

Interdependent: 1. The patient might

need an addition of
1. Collaborate with a supplements to
dietician compensate or
insufficient nutrient
intake.
IV. FDAR

Date Focus Data-Action-Response

12/6/23 Pain D: Reports severe headache

A: Provide comfort and adequate rest
Encourage deep breathing exercises
Place in a comfortable position
R: Reports less pain