Cotabato Medical Foundation College, Inc

Quezon Ave. Población 8, Midsayap, Cotabato

Tel: 064-229-8207

CLINICAL
CASE ANALYSIS OF
ULCERATIVE COLITIS
WORKSHEET

Submitted by: Tricia Denise Estabillo

Date Presented:
Date Submitted:
Semester SY: 1st Semester 2023-2024

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 Cotabato Medical Foundation College, Inc
Quezon Ave. Población 8, Midsayap, Cotabato
Tel: 064-229-8207

TABLE OF CONTENTS

Page
Cover Page
Introduction (Includes the Background and Rationale of the analysis). . . . . . . . . . . . .. . 1
Scenario (if presented in a virtual progressive scenario, write the summary) . . . . . . . . . .2
Phenomenon (Series of incidents leading to the occurrence
of the main (health) problem) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .3
Concept Map (brief but concise graphical presentation of the phenomena) . . . . . . . . . .4
Learning Objectives (SMART; includes the main parts of the Clinical
Case Analysis Worksheet; Nursing Process – Approached) . . . . . . . . . . . . . . . . 5
Clinical Case Analysis Worksheet
Patient’s Personal Data
I. Family Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .6
II. Developmental Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .7
III. Chief Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .8
IV. Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . .. .9
V. Complete Diagnosis of the case chosen . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .10
a. Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . .11
b. Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 12
c. Symptomatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .14
d. Anatomy and Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 15
e. Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
VI. Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . ..17
a. Laboratory Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .17
b. Drug Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
VII. Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
a. Nursing Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .... 20
b. Nursing Care Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .21
VIII. Evaluation and Implication of the case to: . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .22
a. Nursing Practice (What might the case mean for other nurses?) . . . . . . . . . . . . .23
b. Nursing Education (What might the case contribute to education) .... . . . . . 24
c. Nursing Theory (applicable nursing theory in the care of the case) . . . . . . .25
d. Nursing Research (any related issues that may need investigation) . . . . . . 26
IX. Recommendations/Referrals/ Follow – ups . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .27
X. Journal Reading Related to the Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 28
XI. APPENDIX (Any relevant documentation as long as it will
not violate the Intellectual Property Rights) . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .29

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 Cotabato Medical Foundation College, Inc
Quezon Ave. Población 8, Midsayap, Cotabato
Tel: 064-229-8207

INTRODUCTION

Ulcerative colitis is a chronic inflammatory bowel disease (IBD) in which abnormal reactions of
the immune system cause inflammation and ulcers on the inner lining of your large intestine in 2023, the
prevalence of ulcerative colitis was estimated to be 5 million cases around the world, and the incidence
is increasing worldwide (Lancet,2023). In the Philippines, the prevalence of Ulcerative colitis is 1.22
per 100,000 persons (BID,2023).

This clinical study will provide descriptive information about the clinical case scenario of A 50-
year-old male presented to the hospital with complaints of fever and shortness of breath. He was
diagnosed with COVID-19, and a 7-day therapy with hydroxychloroquine and azithromycin was
initiated. After completing the treatment, the patient developed bloody diarrhea, which led to a diagnosis
of ulcerative colitis triggered by COVID-19. Treatment with 5 amino salicylic acid was effective in
resolving the symptoms. The patient also tested positive for anti-SARS CoV-2 antibodies and showed
regression in chest CT findings. Biopsies showed mucin loss and distortion in colonic glands, PMNL
and plasma cell infiltration, cryptitis, and a crypt abscess

This case study focuses on the Ulcerative Colitis triggered by Covid 19, for us novice, soon to be nurses;
this knowledge will help us to promote awareness to the families and guardians about this problem and
may improve outcomes and primary prevention about ulcerative colitis. Furthermore, the relevance of
discussing this case will promote the standards of care in handling patients diagnosed with this
condition. This might address the gaps identified in patients with ulcerative colitis and would benefits
for the health care workers and nursing students to gain more knowledge.

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Quezon Ave. Población 8, Midsayap, Cotabato
Tel: 064-229-8207

SCENARIO

A 50-year-old male patient presented to the internal disease’s outpatient clinic on April 16, 2020, with
complaints of fever and shortness of breath lasting for 3 days. In the physical examination, the fever was
37.8°C, respiratory rate was 24/min, and heart rate was 105/min. There was no organomegaly, and the
patient was a non-smoker. In the initial investigation, WBC was 6.4 × 10 /L, C-reactive protein (CRP)
was 4.6 mg/L (0-5 mg/L), ferritin was 162 ng/mL (22-274 ng/mL), D-dimer was 842 ng/mL (0-630
ng/mL), and the nasopharyngeal swab polymerase chain reaction (PCR) test was negative. However,
diffuse ground-glass opacities consistent with viral pneumonia were observed on the chest computed
tomography (CT), and PCR tests of the patient’s wife and 2 children were positive, so the patient was
diagnosed with COVID-19, and a 7- day therapy with hydroxychloroquine and azithromycin was
initiated.

The patient was clinically stabilized and taken to ambulatory follow-up. However, the patient revisited
the hospital due to bloody diarrhea, which began 2 weeks after the completion of COVID-19 treatment.
In the stool examination, 10-12 erythrocytes and 5-6 leukocytes were found. Tests for amoebas and
Clostridium difficile toxins A+B were negative, while complete blood count and CRP were within the
normal ranges. The patient was prescribed ciprofloxacin, metronidazole, and probiotics and was
followed up. However, despite a week of treatment, his complaints did not improve, and the stool
calprotectin level was reported as 1800 µg/g (normal range: 0-50 µg/g). In a colonoscopic examination,
the rectum and sigmoid colon had a diffuse, micro ulcerated, granulated appearance, and the submucosal
vascularization was distorted.

Biopsies were taken with presumed diagnoses of infectious colitis and ulcerative colitis. During the
pathological examination, mucin loss and distortion in the colonic glands were found, and
polymorphonuclear leukocytes (PMNL) and plasma cell infiltration were observed. Cryptitis and a crypt
abscess were observed between the glands, while no granulomatous or specific microorganisms were
detected. The patient was determined to have ulcerative colitis triggered by COVID-19, and
5-aminosalicylic acid (5-ASA) therapy was initiated orally and by enema. Bloody diarrhea stopped, and
his complaints disappeared 3 days after initiation of this new drug therapy. Anti-SARS-CoV-2
antibodies were found as IgG positive and IgM weak positive. On the repeat control chest CT, a
significant regression from the initial findings and a sequela lesion were observed. Written informed
consent was obtained from the patient for this case report. Histopathological images of the patient are
given in.

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Quezon Ave. Población 8, Midsayap, Cotabato
Tel: 064-229-8207

PHENOMENON

A-50-years-old Male revisited Hospital

Chief Complaint:
 Bloody Diarrhea

Past History (April 16,2020)

Physical Examination
o Body temp. 37.8°c
o Respiratory rate 24/min
o Heart rate was 105/min

Treatment:

o Hydroxychloroquine
o Azithromycin

Laboratory:

WBC was 6.4 × 10 /L ↑

D-dimer was 842 ng/mL ↑

2 WEEKS AFTER THE COMPLETION OF COVID-19 TREATMENT

Diagnostic:

- Colonoscopy
- Biopsy
- Pathological Examination
- Anti-SARS-COV-2
- Chest CT scan

Treatment:

- 5 – amino salicylic acid (5-ASA)

- ENEMA

AFTER 3 DAYS OF INITIATION OF NEW DRUG THERAPY BLOODY

DIARRHEA STOP AND HIS COMPLAINTS DISAPPEARED

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CONCEPT MAP

A-50-years-old Male revisited Hospital

Chief complaint:
 Bloody diarrhea

2 WEEKS AFTER THE

COMPLETION OF
PAST HISTORY COVID-19
TREATMENT
(APRIL 16,2020)
Physical examination
Diagnostic Procedure:
 Body temp. 37.8°c
 Respiratory rate 24/min  Colonoscopy
 Heart rate was 105/min  Biopsy
 Pathological Examination
Treatment  Anti-SARS-COV-2
 Hydroxychloroquine  Chest CT scan
 Azithromycin
Laboratory Treatment:

 Wbc was 6.4 × 10 /l ↑  5 – amino salicylic acid (5-

 D-dimer was 842 ng/ml ↑ ASA)
 ENEMA

AFTER 3 DAYS OF INITIATION

OF NEW DRUG THERAPY
BLOODY DIARRHEA STOP AND
HIS COMPLAINTS
DISAPPEARED

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Quezon Ave. Población 8, Midsayap, Cotabato
Tel: 064-229-8207

LEARNING OBJECTIVES

After the completion and presentation of the clinical case study, the learners will acquire

knowledge and skill in the nursing care management of a patient with Ulcerative Colitis

Specifically, the learners will:

1. discuss the phenomenon as well as the scenario’s concept map;

2. determine the patient’s family history;
3. discuss the developmental data of patient;
4. define terms that are relevant to the case.
5. discuss the etiology and symptomatology of Ulcerative Colitis;
6. review the anatomy and physiology of Colon-Rectum regarding the present complication of the
patient and the organs involve;
7. discuss the pathophysiology of Ulcerative Colitis;

8. explain the mechanism of colon;

9. explain to the client the procedure that will be done, as well as other basic laboratory tests;
10. discuss the medication given to the patient;
11. identify priority nursing diagnosis for the patient;
12. create a nursing care plan based on the patient’s needs;
13. discuss the impacts of this case for nursing, practice, education, research and theory application
in the field of nursing;
14. recognize the recommendations, follow-ups, and referrals and;
15. discuss an evidenced-based practice research journal that is relevant to our scenario.

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Quezon Ave. Población 8, Midsayap, Cotabato
Tel: 064-229-8207

CLINICAL CASE ANALYSIS WORKSHEET

OF ULCERATIVE COLITIS

PATIENT’S PERSONAL DATA:

Name (optional): N/A Age: 50 Years old Sex: Male
Civil Status: N/A Religion: N/A
1. FAMILY BACKGROUND:

Occupation: N/A
Number of Siblings/Children: N/A
Other Relevant Data: N/A

2. DEVELOPMENTAL DATA: Specify the Stage.

(Based on Havighurst’s and Erikson’s Life and Developmental Task/Psycho-Social).

Erikson developmental task: (Generativity vs Stagnation Middle age from 40 to 65)

This case relates to the developmental task of generativity vs stagnation during middle age (40-65
years old) according to Erik Erikson's stages of psychosocial development. Generativity is the desire
to contribute to society, leave a legacy, and pass down knowledge to future generations. Stagnation,
on the other hand, is a sense of feeling stuck, unproductive, and unfulfilled.

The 50-year-old male patient in this case presents with COVID-19 and later develops ulcerative
colitis triggered by the virus. These health issues may have halted the patient's ability to contribute
to society and may have left him feeling stuck and unfulfilled. However, his positive response to
treatment and recovery can be seen as a sign of generativity as he can continue to contribute to
society and leave a legacy for future generations. Overall, this case highlights the importance of
maintaining a sense of fulfillment and contribution during middle age, even in the face of health
challenges.

Reference:

By, Mcleod, S., on, U., & 16, O. (2023, October 16). Erik Erikson’s stages of Psychosocial
Development. Simply Psychology. https://www.simplypsychology.org/erik-erikson.html

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CHIEF COMPLAINTS: Fever and shortness of breath lasting for 3 days, followed by bloody
diarrhea 2 weeks after completion of COVID-19 treatment.

HEALTH HISTORY:

Past Illness/Surgery: Covid-19 Pneumonia

Inclusive Period of Hospitalization: N/A

Present Illness:

He developed bloody diarrhea. Despite initial negative tests for amoebas and Clostridium difficile
toxins, the patient was ultimately diagnosed with ulcerative colitis triggered by COVID-19 based on a
colonoscopy and biopsy. Treatment with 5 amino-salicylic acid resulted in symptom improvement. The
patient also had anti-SARS CoV-2 antibodies and a significant regression of chest CT findings.

COMPLETE DIAGNOSIS OF THE CASE CHOSEN

a. Definition (at least 2 Definition with Bibliography)

ULCERATIVE COLITIS
Ulcerative colitis is a chronic inflammatory bowel disease (IBD) in which abnormal
reactions of the immune system cause inflammation and ulcers on the inner lining of your
large intestine.

U.S. Department of Health and Human Services. (n.d.). Ulcerative colitis - niddk. National Institute of
Diabetes and Digestive and Kidney Diseases.
https://www.niddk.nih.gov/health-information/digestive-diseases/ulcerative-colitis

ULCERATIVE COLITIS

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Ulcerative colitis is an inflammatory bowel disorder characterized by inflammation and ulcers of

the colon and rectum. Various factors can contribute to the development of this disease, like
immune system dysfunction, changes in the gut bacteria, genetics and environmental factors..

S.carter, freya. (2020). Ulcerative colitis: Symptoms, diagnosis and treatment. HAYLE MEDICAL.

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b. Etiology

Actual Etiology
List all the Basic Etiology Rationale (Include the reference as endnote)
on the Patient

the immune system mistakes "friendly bacteria" in the colon, which aid digestion, as a harmful infection,
Autoimmune Condition 
leading to the colon and rectum becoming inflamed. (NHS,2019)

Infections caused by viruses and bacteria in your environment might raise your chances of getting UC.

Viruses and Antigens  (webMD,2022)

Genetics genetic variations may make some individuals more prone to an overactive immune response to the bacteria
and other microbes in the intestines, which may cause the chronic inflammation that occurs in people with
ulcerative colitis (Medline,2023)

high intake of sugars, salt, saturated fats and trans fatty acids typical of a UPF-rich diet that directly promotes
Diet
the development of chronic inflammation (NCBI,2023)

Lifestyle increased consumption of polyunsaturated fatty acids may contribute to issues with digestive health.
(NCBI,2023)

Excessive use of NSAIDs

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may adversely affect the colon, either by causing a non-specific colitis or by exacerbating a preexisting colonic
disease (NCBI,2017)

Ageing diarrhea and bleeding are more likely present in older adults (sethi,2022)

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c. Symptomatology

Actual
List all the Basic
Symptomatology on Rationale (Include the reference as endnote)
Symptomatology
the Patient
Bloody stool The condition causes small ulcerations in the lining of the large intestine, which then leads to blood appearing

in the stools. (MIL,2021)

Abdominal Pain
 The combination of inflammation and ulcers often causes abdominal discomfort (Strauchm,2022)

Rectal Pain The pain may be related to changed mechanical properties of the rectum or to the inflammation per se.
(Inflammatory Bowel Diseases, Volume12, Issue 4, Pages 294-303)

Constant Urgency to Attack increases white blood cells in colon and rectum. Repeated attacks lead to chronic inflammation
defecate (chavoustie,2023)

Chronic fatigue Physical (low energy or strength, a feeling of heaviness). Mental (low motivation, concentration, or
alertness). A feeling of 'brain fog'. (Crohn’s&colitisuk,2022)

Frequent fevers As UC is a type of IBD, this may be one of the symptoms a person experiences as part of the body's
inflammatory response (sethi,2022)

Canker sores related to deficiencies, such as low B12, iron, folate and zinc levels in the blood. Certain food products, like
spices, could also cause these ulcers. (Crohn’s&colitisCA,2022)

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Joint pain lie in genes that make people with IBD more susceptible to arthritis. (Aremu,2021)

Nausea A stricture can prevent food from traveling normally through the digestive tract, causing nausea and vomiting.
(NYU,2022)

Mucous or Pus in stool During a flare-up, the mucous membrane of the large intestine becomes inflamed and develops ulcers. These
ulcers can bleed and produce pus and mucus. Mucus in the stool is more likely during a flare-up (sethi,2021)

Weight loss During flares, there's more inflammation in your colon, leading to severe symptoms such as diarrhea and
decreased appetite, which may lead to weight loss. (Sethi,2021)

Nutritional Deficiencies Severe diarrhea can cause dehydration, which means body may be depleted of fluids, nutrients, and necessary
electrolytes such as sodium, potassium, magnesium, phosphorus, and zinc. ((Crohn’s&colitisCA,2022)

Dehydration fluid loss and electrolyte imbalances are often a result of severe diarrhea (Arbor,2022)

Anaemia blood loss or malabsorption may lead to an iron deficiency anemia with hypochromic appearance.
(NCBI,2018)

Liver Diseases extensive colitis, which affects the entire colon. Continuous inflammation begins at the rectum and extends
beyond the splenic flexure. Extensive colitis affects men more than women. (Orlando,2022)

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d. Anatomy and Physiology

Anatomy of the Large Intestine

Right colic or hepatic flexure separates the ascending and transverse colon
Left colic flexure or splenic flexure (as it is close to the spleen) is the sharp bend between
the transverse colon and the descending colon
Taenia coli function as suspension cables upon which the circular muscle arcs are suspended,
facilitating efficient contraction of the circular muscle
Ileum is the final portion of the small intestine and absorbs final nutrients.
Haustra work to increase surface area
Sigmoid flexure is straightened out when the penis is extended for mating
Rectum is to collect and hold poop until it's time to release it.
Anus facilitates bowel movements

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 Cotabato Medical Foundation College, Inc
Quezon Ave. Población 8, Midsayap, Cotabato
Tel: 064-229-8207

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Quezon Ave. Población 8, Midsayap, Cotabato
Tel: 064-229-8207

The mechanism of action of heart contraction is a complex process that involves electrical signals and the coordinated contraction of heart muscle cells.

1. Electrical Signal: The process begins with the generation of an electrical signal in the heart's natural pacemaker, the sinoatrial (SA) node, located in the
right atrium.

2. Signal Spread: The electrical signal travels through the atria, causing them to contract and push blood into the ventricles. This is depicted on the ECG as the
P-wave, indicating atrial depolarization.
3. Atrioventricular (AV) Node: The electrical signal reaches the atrioventricular (AV) node, which briefly delays the signal to allow the ventricles to fill with
blood.

4. Signal Conduction: After the delay at the AV node, the electrical signal travels down the bundle of His and its branches, eventually spreading throughout
the ventricles. This is depicted on the ECG as the QRS complex, indicating ventricular depolarization.

5. Ventricular Contraction: As the electrical signal spreads through the ventricles, it causes them to contract, pushing blood out of the heart. This is depicted
on the ECG as the ST segment and T-wave.

6. Repolarization: After contraction, the heart muscle cells repolarize, preparing for the next cycle. This is also reflected on the ECG.

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Laboratory Management
Basic Diagnostic Purpose Result Of the Patient Clinical Significance Nursing Management
Procedure required
with Normal Values

Stool Examination

Colonoscopy It helps to diagnose UC, Sigmoid colon had a Indicates that the sigmoid colon is Before:
check the severity, and diffuse, Micro ulcerated, affected by ulcerative colitis  Educate the patient about the procedure,
(no growths (polyps) or see how well treatment Granulated Appearance, its purpose, and the preparation required
cancer have been found is working Submucosal for it.
in bowel.) Vascularization was
 Ensure that the patient consumes the
distorted
bowel prep as instructed by the physician
to clear the colon before the procedure.
 Review the patient's medication list,
including over-the-counter drugs, herbs,
and supplements, and adjust them
accordingly.

During:
 Continuously monitor the patient's vital
signs and level of consciousness during
the procedure.
 Ensure that the patient receives
medication for sedation if prescribed by
the physician.
 Assist the physician in positioning the

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patient correctly and comfortably.

After:
 Monitor the patient for any complications
such as bleeding, pain, or perforation.
 Monitor the patient's vital signs and level
of consciousness as they recover from the
sedation.
 Educate the patient on post-procedure
care instructions, including diet, exercise,
and medication management.
Biopsy to confirm the diagnosis presumed diagnoses of Indicates presence of infectious Before:
(negative, meaning the and determine if infectious colitis and colitis may be a secondary  Educate the patient about the biopsy
condition has not been dysplasia or cancer is ulcerative colitis infection related to the underlying procedure, purpose, and potential risks.
detected) present. During a biopsy, ulcerative colitis  Review the patient's medication list to
a small sample of tissue ensure that the patient is not taking any
is removed from the blood-thinning medications that may
lining of the colon or increase the risk of bleeding during the
rectum and examined biopsy.
under a microscope for  Ensure that the patient understands the
abnormalities. Biopsies informed consent form and that the
can also help to monitor patient has provided written consent.
the disease activity and
guide treatment During:
decisions. It is a  Continuously monitor the patient's vital
relatively simple and

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safe procedure, typically signs and level of consciousness during

performed during a the biopsy procedure.
colonoscopy or flexible  Assist the physician in positioning the
sigmoidoscopy. patient comfortably and correctly.
 Ensure that the patient receives
medication for sedation if prescribed by
the physician.

After:
 Monitor the patient's vital signs and level
of consciousness as they recover from
sedation.
 Assess the patient's pain level and
provide pain relief medication as needed.
 Monitor the biopsy site for bleeding or
signs of infection, such as redness,
warmth, swelling, or drainage.
 Educate the patient on post-procedure
care instructions, including wound care,
medication management, and any
restrictions on activities, such as exercise
or diet.
Pathological to confirm the diagnosis mucin loss and distortion indicates inflammation and Before:
Examination and assess the severity in the colonic glands were damage to the colon's inner lining.
of the disease found, and  Educate the patient about the biopsy
polymorphonuclear procedure, including its purpose, risks,
leukocytes (PMNL) and and possible complications.
plasma cell infiltration
 Obtains the patient's informed consent
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were observed before the procedure.

 Reviews the patient's medication list and
ensures that the patient understands any
medication changes that need to be made
before the procedure. The patient may
need to stop certain medications or adjust
the dosage.

During:

 Assists the physician in positioning the

patient comfortably and appropriately for
the procedure.
 Continuously monitors the patient's vital
signs and level of consciousness.
 Provides emotional support to the patient
during the procedure, as some patients
may feel anxious or uncomfortable.

After:

 Monitors the patient for any

complications, such as bleeding, pain, or
infection and checks the patient's vital
signs, including blood pressure, heart
rate, and oxygen saturation.
 Provides pain relief for any discomfort
experienced by the patient after the

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procedure.
 Educates the patient on any limitations or
restrictions after the procedure, such as
avoiding vigorous physical activity for a
certain period. also provides instructions
on wound care, diet, and medication
management.
 Schedule a follow-up appointment with
the physician to discuss the biopsy results
and develop a treatment plan.
Anti- SARS-COV-2 Monitor or diagnose 1 gG positive and 1gM Indicates has been infected Before:
conditions that cause too weak positive with the virus and may
much bleeding or too have developed some  Assess the patient's medical history,
much clotting. including any bleeding disorders or
immunity to it
medications that might affect platelet
function.
 Explain the purpose of the platelet count
test to the patient.
 explain any potential risks or discomfort
associated with the procedure

During:

 Address any patient concerns and

questions about the test
 Encourage the patient to relax and stay still
during the procedure.
 Ensure that the patient experiences minimal

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discomfort

After:

 Document the patient's information.

Chest CT scan To determine if patient 832 IU/ml An elevated Anti-Streptolysin O
had recent infection (ASO) titer or count in a blood
caused by group A test indicates exposure to a recent
streptococcus bacteria or past streptococcal infection,
typically caused by group A
streptococcus (Streptococcus
pyogenes).
 Monitor the patient for any immediate
adverse reactions, such as fainting or
excessive bleeding.
 Review the platelet count results once
they are available.
 Communicate the results to the patient
and healthcare provider as necessary.
 Collaborate with the healthcare provider
to determine the clinical significance of
the results and any required follow-up
actions
before:
 Discuss the ASO test procedure with the patient
and obtain informed consent.
 Ensure the patient understands the potential risks
and benefits of the test
 Assess the patient for allergies, especially to latex
or antiseptics, and any contraindications to the
procedure.

during:

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 Ensure that the patient is comfortable

after:

 Monitor the patient for any immediate adverse

reactions.
 Accurately document the patient's information.
 Encourage the patient to follow up with their
healthcare provider for the interpretation of the
ASO test results.

Drug Study (All drugs Indicated for the Patient’s Illness

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Generic Name Classification Dosage and Pharmacologic Indication and Side Effects Nursing Responsibilities
(Brand Name)
Route of Effects / Mechanism Contraindication
Administration of Action

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Generic Classification Dosage and Pharmacologic Indication and Side Effects Nursing
Name
Route of Effects / Contraindication Responsibilities
(Brand
Administration Mechanism of
Name)
Action

Drug Study (All drugs Indicated for the Patient’s Illness

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Generic Name Classification Dosage and Pharmacologic Effects /
(Brand
Route of Mechanism of Action
Name)
Administration
NSAIDs Available forms: primarily acts by
Naprosyn
Oral: inhibiting the activity of
(Naproxen) 125mg/25mL two isoforms of the
Tablets: cyclooxygenase (COX)
250mg,375mg enzyme, specifically COX-1
and COX-2. These enzymes
are involved in the
conversion of arachidonic
acid into prostaglandins,
which are signaling
molecules that play a key
role in the inflammatory
response, pain perception,
and fever.
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Indication and
Contraindication
Indication:
 indicated for the relief
of signs & symptoms of
osteoarthritis,
rheumatoid arthritis
Contraindication:
 Contraindicated to patient
hypersensitive to drugs an
din those with syndrome f
aspirin-sensitive asthma,
rhinitis
 Drug can cause serious skin
reactions. Stop drug at first
sign of rash or
hypersensitivity.
Side Effects Nursing Responsibilities
CNS: dizziness,
headache  Review 14 rights of drug
CV: edema administration.
EENT: auditory and  Review and check
visual disturbances doctor’s order.
GI: abdominal pain,  Establish rapport to the
diarrhea, nausea, patients and significant
thirst others.
SKIN: diaphoresis,  Assess patient’s medical
pruritus history
 Monitor vital signs for
baseline data.
 Explain the purpose of
the drug
 Instruct the patient to
promptly report adverse
reactions.
 Encourage patient to
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increased fluid intake.

 Monitor patient’s pain
level and response to the
medication.

I. NURSING MANAGEMENT

a. Nursing Diagnosis (Write five according to priority needs.)

1.

2.

3.

4.

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5.

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Date/Cues Needs Nursing Objective of Nursing Actions with Rationale Evaluation

Diagnosis Care
Subjective: P . . Goal met:
H Within 6 hours of nursing
Y intervention the patients
S blood pressure is within
I normal limits of 120/80
O mmhg.
L
O Goal partially met:
G Within 6 hours of nursing
I the patients blood
C pressure is within 140/90
mmhg.
N
E Goal not met:
E After 6 hours of nursing
D intervention the patient
S blood pressure is within
180/110 mmhg.

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Date/Cues Needs Nursing Diagnosis Objective of Care Nursing Actions with Rationale Evaluation

Subjective: P Within 8 hours of INDEPENDENT Goal met:

H Excess fluid volume
Y related to cardiac
S dysfunction as
Objective: I evidenced by
 Bilateral pedal O bilateral pedal
edema L edema and 200/120
 200/120 mmhg O mmhg.
G Assess causative factors of edema.
I Rationale:
C Excess fluid build-
up in the body
N causes edema.
E Edema is
E characterized by
D excess fluid
S accumulating in the
Fluid skin and
surrounding tissues.
nursing intervention Established rapport. After 8 hours of
patient will R: to improve patient compliance with treatment, nursing
demonstrate a clinical outcomes and patient satisfaction. intervention the
reduction of Assess vital signs and record. patient is free of
edema through R: establish a baseline data for an individual's health signs of edema.
physical and detect any changes that may require further
examination. investigation or intervention. Goal partially
met:
R: Edema may be caused by several factors including an After 8 hours of
underlying medical condition, allergic reaction to a nursing
medication, or temporary water retention. intervention the
Monitor the patient’s intake and output. patient is still
R: Imbalanced fluid intake and urine output can have a slight
indicate acute kidney injury or chronic renal failure and edema in ankle
may cause complications like cardiac problems and and legs.
pulmonary edema.
Restrict fluids as ordered. Goal not met:
R: Fluid restriction can decrease cardiac workload in After 8 hours of
patients with edema and fluid overload. Patients with nursing

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congestive heart failure, for example, are often on fluid intervention the
restrictions. patient edema did
not decrease.

Date/Cues Needs Nursing Objective of Nursing Actions with Rationale Evaluation

Diagnosis Care

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Subjective: Within 8 hours of INDEPENDENT GOAL MET:

P Risk for infection nursing Established rapport. After 8 hours of nursing
H related to intervention the R: to improve patient compliance with treatment, clinical intervention the patient
Y surgical incision. patient will outcomes and patient satisfaction. identifies the proper
Objective: S identify Assess vital signs and record. intervention on how to
***///////* I Rationale: interventions R: establish a baseline data for an individual's health and clean the surgical sites
O occurs when the how to prevent detect any changes that may require further investigation or such as proper hand
L natural defense risk for infection intervention. washing and keep the
O mechanisms of such as wash Wash your hands and use aseptic technique for nursing surgical site clean and
G an individual are hands before tasks involving non-intact skin or invasive lines. dry.
I inadequate to cleaning the Hand washing and using aseptic technique reduces the
C protect them. surgical site and likelihood of transmitting pathogens to the patient that can GOAL PARTIALLY MET:
Microorganisms keep the surgical cause infection. After 8 hours of nursing
N such as bacteria, site clean and Assess the patient for risk factors or current injuries or intervention the patient
E viruses, fungi, dry. treatments that could put the patient at risk for infection. shows only the proper
E and other Wounds, abrasions, or surgical sites hand washing.
D parasites invade These represent a compromise of the body’s physical defenses
S susceptible hosts and a potential source of infection GOAL NOT MET:
SAFETY through Monitor for signs of infection. After 8 hours of nursing
inevitable Early identification of infection allows for prompt treatment. intervention the patient
injuries and Monitor color and consistency of respiratory secretions. did not show any of safety
exposures. Thick, yellow, green, or tan colored sputum might indicate measures on how to
infection. A sputum culture may be indicated. prevent infection.

Encourage nutritional intake rich in calories and protein,

vitamins, and carbohydrates.
An adequate amount of calories helps the body use nutrients

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to build a strong immune system. Protein helps with wound

healing.
Teach the patient, family, and caregiver to wash hands
before and after using the bathroom, before meals, and
before and after self-care and wound care.
Hand hygiene between these tasks reduces the risk of
transmitting pathogens from one area to another and possibly
introducing germs into the body.
DEPENDENT:
Administer anti-infective agents as ordered.
Antibiotic treatment might start with an empiric approach
until the culture results can further narrow down the
appropriate antimicrobial therapy. Management may include
antibacterial, antifungal, antiviral, or antiparasitic, and
antipyretic treatment.
COLLABORATION:

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VII. EVALUATION AND IMPLICATION OF THE CASE TO:

Nursing practice: Nurses must be aware of the potential for COVID-19 infection to trigger
inflammatory bowel disease such as ulcerative colitis. Nurses should be knowledgeable about the
symptoms and complications of ulcerative colitis to provide early detection and intervention.
They should also ensure adequate infection control, including screening, triage, isolation, and use
of personal protective equipment when caring for patients with suspected or confirmed COVID-
19 infection. Nurses can collaborate with other healthcare professionals to develop and
implement a comprehensive management plan to address the complex needs of patients with
ulcerative colitis.

Nursing education: Nursing education must include updates on the latest research findings,
treatment strategies, and the correlation between COVID-19 pneumonia and ulcerative colitis.
Nurses must also learn essential communication and collaboration skills to work effectively with
interdisciplinary teams in providing high-quality, patient-centered care. Nursing education
should also emphasize the importance of patient education and support, highlighting the role of
self-management in promoting positive outcomes.

Nursing theory: The findings of this article underscore the importance of adopting a holistic
view of patient care that goes beyond symptom management. Nursing theory should promote a
comprehensive approach to ulcerative colitis management, considering patients' physical,
emotional, social, and spiritual needs. Nurses should also embrace the principles of patient-
centered care, focusing on building a therapeutic relationship with the patient, understanding
their preferences, values, and goals, and involving them in decision-making processes. Nursing
theory should also emphasize the need for ongoing education and research to advance the
understanding and management of ulcerative colitis.

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VIII. RECOMMENDATION/REFERRALS/FOLLOW-UPS

To the client

1. Encourage adherence to prescribed medications and treatment plans

2. Provide a balanced and nutritious diet, avoiding trigger foods
3. Encourage regular physical activity and adequate rest
4. Educate patients on self-management strategies and stress reduction techniques
5. Advise regular monitoring of symptoms and follow-up visits with healthcare providers

To the family

1. Encourage support, understanding, and active participation in care

2. Provide information on the disease process, treatment options, and potential
complications
3. Offer emotional support and encourage communication with healthcare providers
4. Address concerns and questions promptly

To the community

1. Advocate for increased awareness and education on ulcerative colitis and its impact
2. Encourage regular health check-ups and screenings
3. Promote support groups, forums, and resources for patients with ulcerative colitis and
their families
4. Collaborate with stakeholders to develop policies and programs that promote early
detection, intervention, and management of ulcerative colitis

To the nurses

1. Ensure thorough assessment and monitoring of patients with ulcerative colitis

2. Encourage treatment adherence and self-management strategies

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3. Provide patient education and support

4. Collaborate with interdisciplinary teams to develop comprehensive management
plans
5. Promote communication, collaboration, and ongoing education among healthcare
providers.

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IX. JOURNAL READINGS RELATED TO THE CASE (Should be an Evidence-Based Practice

(EBP) Reading: Attach the photocopy of your journal reading

Title: Ulcerative Colitis: Current Treatment Strategies and Future Prospects

References:

Garud, S., & Peppercorn, M. A. (2019, March). Ulcerative colitis: Current treatment strategies
and future prospects. Therapeutic advances in gastroenterology.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002512/

Summary:

The journal article "Ulcerative Colitis: Current Treatment Strategies and Future Prospects"
provides a comprehensive overview of the current treatment options available for ulcerative
colitis and highlights various promising future prospects for the disease. The article reviews the
commonly used medications for ulcerative colitis, including amino salicylates, corticosteroids,
immunomodulators, and biologics. It discusses the benefits, risks, and limitations of each
medication, highlighting the importance of selecting the right medication for each individual
patient. The article also covers the emerging therapies and strategies for ulcerative colitis, such
as stem cell therapy, microbiota-based therapies, and dietary interventions. Finally, the article
highlights the importance of patient-centered care, involving effective communication, shared
decision-making, and a comprehensive approach to the management of ulcerative colitis

Conclusion:

In conclusion, the management of ulcerative colitis is complex and requires a multidisciplinary

approach. However, with advances in therapies and treatment strategies, there is hope for
improving the quality of life for patients with ulcerative colitis.

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