Velez College

College of Nursing
F. Ramos St., Cebu City

A Case Study on Px J.S., 70 years old, Female, diagnosed with Celiac Disease

Submitted by:
Lapera, Ashley Twayne
Laurence, Krystal
Laurente, Joshua Ed
Liu, Allyzsa May Pearl

Submitted to:
Mrs. Rose Angelyn Meneses San Pedro - Calunsag RN, MSN(c)
 INTRODUCTION

Celiac disease is a genetic, immune, digestive disorder that causes problems in your small intestine caused by eating foods that have
gluten. Gluten is a protein found in the grains, wheat, rye, and barley. It may also be in other products like vitamins and supplements,
hair and skin products, toothpastes, and lip balm.

In people who have celiac disease, gluten causes the immune system to attack the small intestine which causes damage. When this
happens, your body doesn’t absorb or get the important nutrients it needs. These include vitamins, calcium, protein, carbohydrates, and
fats. Your body can’t work well without these nutrients.

There are two types of Celiac Disease:

A. Non-Responsive Celiac Disease

● This is a continuing symptom of persistent symptoms, elevated antibodies or small intestinal damage even after
following a strict gluten-free diet for six to 12 months. This is common in both children and adults.

● Some people with celiac disease don't respond to what they consider to be a gluten-free diet. Nonresponsive celiac
disease is often due to contamination of the diet with gluten. Working with a dietitian can help you learn how to avoid
all gluten.

● People with nonresponsive celiac disease might have:

○ Bacteria in the small intestine (bacterial overgrowth)
○ Microscopic colitis
○ Poor pancreas function (pancreatic insufficiency)
○ Irritable bowel syndrome
○ Difficulty digesting sugar found in dairy products (lactose), table sugar (sucrose), or a type of sugar found in
honey and fruits (fructose)
○ Refractory celiac disease

● In recent years, endoscopy and biopsy studies have shown that non-responsive celiac disease includes a larger group of
patients than previously thought. While current scientific literature indicates that about 30% of patients have non-
responsive celiac disease, there is evidence the number is closer to 50% when those who don’t have symptoms but
continue to have damage to the intestine, called mucosal atrophy, are included.
 B. Refractory Celiac Disease
● Refractory celiac disease is marked by a lack of response to a strict gluten-free diet after six to 12 months, with
symptoms, intestinal damage and an abnormal population of white blood cells in the GUT. This is believed to be
independent of gluten since the gluten-free diet is not effective in preventing the lymphocytes from increasing.
● These cells, called abnormal intraepithelial lymphocytes, are unique immune cells found in the lining of the small
intestine. Their presence is the distinguishing and disturbing characteristic of refractory celiac disease because they can
be the beginning of cancer.
● A patient is classified as having refractory celiac disease Type I or II based on the proportion and characteristics of the
intraepithelial lymphocytes. For diagnosis, the cells are counted by a flow cytometer, an instrument that analyzes the
chemical and physical properties of particles. Patients with less than 20 percent of the abnormal lymphocytes have Type
I refractory celiac disease, and those with more than 20 percent, Type II.
● Most cases of both types of refractory celiac disease occur in older patients who are not diagnosed until later in life.
Typically, they suffer symptoms for many years until severe pain develops and abnormalities such as severe anemia are
discovered. Finally, celiac disease is pinpointed as the cause. Refractory celiac disease only appears in patients who have
not been on a gluten-free diet or have not followed the diet correctly for decades.

Celiac disease, in general, affects each person differently. Symptoms may occur in the digestive system, or in other parts of the body.
One person might have diarrhea and abdominal pain, while another person may be irritable or depressed. Irritability is one of the most
common symptoms in children. Some people have no symptoms.

Some people with celiac disease don’t notice or have symptoms. But most people do have symptoms. Symptoms includes:

In infants and young children

● Digestive trouble, including abdominal pain, bloating, vomiting, diarrhea, and constipation.
● Feeling irritable, fretful, emotionally withdrawn, or excessively dependent.
● Failure to grow and gain weight.
● Damage to tooth enamel.
● Being overweight or obese.

In teenagers
● Digestive issues such as diarrhea and constipation.
● Delayed puberty.
● Slowed growth and short height.
● Hair loss.
In adults
● Digestive symptoms, such as diarrhea or constipation (less likely than children).
● General feeling of poor health, including fatigue and bone or joint pain.
● Irritability, anxiety, and depression.
● Missed menstrual periods in women.
● Osteoporosis(loss of calcium from the bones) and anemia.

Other common symptoms in people of any age with celiac disease include:
● Lactose intolerance: A problem digesting milk products.
● Dermatitis herpetiformis: An itchy, blistery skin problem.
● Canker sores in the mouth.

Doctors and researchers don’t know exactly what causes celiac disease. It’s more common in people who:
● If you have a family member with celiac disease. If 1 member of your family has it, about 1 out of 10 other family members likely
has it.
● Have an autoimmune disease. This could include type 1 diabetes, rheumatoid arthritis, autoimmune thyroid or liver disease,
Addison’s disease, or Sjogren’s syndrome.
● Have a genetic disorder such as Down syndrome or Turner syndrome.

Celiac disease can be hard to diagnose. Its symptoms are similar to other digestive disorders, such as irritable bowel syndrome. But
blood tests can help the doctor diagnose this disease. If your blood test indicates that you might have celiac disease, an intestinal biopsy
is often done. Using a thin tube, this takes a small piece of tissue from your small intestine. Positive biopsy results will confirm you have
celiac disease. Diagnosis of dermatitis herpetiformis with a positive blood test will also confirm it.

Complications for Celiac Disease includes:

● Malnutrition. This occurs if your small intestine can't absorb enough nutrients. Malnutrition can lead to anemia and weight loss.
In children, malnutrition can cause slow growth and short stature.
● Bone weakening. Malabsorption of calcium and vitamin D can lead to a softening of the bone (osteomalacia or rickets) in
children and a loss of bone density (osteopenia or osteoporosis) in adults.
● Infertility and miscarriage. Malabsorption of calcium and vitamin D can contribute to reproductive issues.
● Lactose intolerance. Damage to your small intestine might cause you abdominal pain and diarrhea after eating or drinking dairy
products that contain lactose. Once your intestine has healed, you might be able to tolerate dairy products again.
● Cancer. People with celiac disease who don't maintain a gluten-free diet have a greater risk of developing several forms of
cancer, including intestinal lymphoma and sma]ll bowel cancer.
 ● Nervous system problems. Some people with celiac disease can develop problems such as seizures or a disease of the nerves to
the hands and feet (peripheral neuropathy).

Sadly, this is a serious disease and there is no way to prevent this disease but there are ways to treat this. Fortunately, you can control
the disease by following a gluten-free diet. This means you remove gluten completely from your diet. By doing this, you can reverse the
damage caused by celiac disease. Symptoms come back once the person starts to intake gluten foods.

ANATOMY AND PHYSIOLOGY

The digestive system is uniquely designed to turn the food you eat into nutrients,
which the body uses for energy, growth and cell repair.

The mouth is the beginning of the digestive tract. In fact, digestion starts here as soon
as you take the first bite of a meal. Chewing breaks the food into pieces that are more
easily digested, while saliva mixes with food to begin the process of breaking it down
into a form your body can absorb and use.

The throat, also called the pharynx, the throat is the next destination for food you've
eaten. From here, food travels to the esophagus or swallowing tube.

The esophagus is a muscular tube extending from the pharynx to the stomach. By
means of a series of contractions, called peristalsis, the esophagus delivers food to the
stomach. Just before the connection to the stomach there is a "zone of high
pressure," called the lower esophageal sphincter; this is a "valve" meant to keep food from passing backwards into the esophagus.

The stomach is a sac-like organ with strong muscular walls. In addition to holding the food, it's also a mixer and grinder. The stomach
secretes acid and powerful enzymes that continue the process of breaking down the food. When it leaves the stomach, food is the
consistency of a liquid or paste. From there the food moves to the small intestine.

The small intestine is made up of three segments, the duodenum, jejunum, and ileum, the small intestine is a long tube loosely coiled in
the abdomen (spread out, it would be more than 20 feet long). The small intestine continues the process of breaking down food by using
enzymes released by the pancreas and bile from the liver. Bile is a compound that aids in the digestion of fat and eliminates waste
products from the blood. Peristalsis (contractions) is also at work in this organ, moving food through and mixing it up with digestive
secretions. The duodenum is largely responsible for continuing the process of breaking down food, with the jejunum and ileum being
mainly responsible for the absorption of nutrients into the bloodstream.

Three organs play a pivotal role in helping the stomach and small intestine digest food:

● Pancreas. Among other functions, the oblong pancreas secretes enzymes into the small intestine. These enzymes break down
protein, fat, and carbohydrates from the food we eat.
● Liver. It makes and secrete bile, and it cleanses and purifies the blood coming from the small intestine containing the nutrients
just absorbed.

● Gallbladder. This is a pear-shaped reservoir that sits just under the liver and stores bile. Bile is made in the liver then if it needs
to be stored travels to the gallbladder through a channel called the cystic duct. During a meal, the gallbladder contracts, sending
bile to the small intestine. Once the nutrients have been absorbed and the leftover liquid has passed through the small intestine,
what is left of the food you ate is handed over to the large intestine, or colon.

The colon is a 5- to 6-foot-long muscular tube that connects the cecum (the first part of the large intestine to the rectum (the last part of
the large intestine). It is made up of the cecum, the ascending (right) colon, the transverse (across) colon, the descending (left) colon,
and the sigmoid colon (so-called for its "S" shape; the Greek letter for S is called the sigma), which connects to the rectum.

Stool, or waste left over from the digestive process, is passed through the colon by means of peristalsis (contractions), first in a liquid
state and ultimately in solid form as the water is removed from the stool. A stool is stored in the sigmoid colon until a "mass movement"
empties it into the rectum once or twice a day. It normally takes about 36 hours for stool to get through the colon. The stool itself is
mostly food debris and bacteria. These bacteria perform several useful functions, such as synthesizing various vitamins, processing waste
products and food particles, and protecting against harmful bacteria. When the descending colon becomes full of stool, or feces, it
empties its contents into the rectum to begin the process of elimination.

The rectum (Latin for "straight") is an 8-inch chamber that connects the colon to the anus. It is the rectum's job to receive stool from the
colon, to let you know there is stool to be evacuated, and to hold the stool until evacuation happens. When anything (gas or stool)
comes into the rectum, sensors send a message to the brain. The brain then decides if the rectal contents can be released or not. If they
can, the sphincters (muscles) relax and the rectum contracts, expelling its contents. If the contents cannot be expelled, the sphincters
contract and the rectum accommodates, so that the sensation temporarily goes away.

The anus is the last part of the digestive tract. It consists of the pelvic floor muscles and the two anal sphincters (internal and external
muscles). The lining of the upper anus is specialized to detect rectal contents. It lets us know whether the contents are liquid, gas, or
solid. The pelvic floor muscle creates an angle between the rectum and the anus that stops stool from coming out when it is not
supposed to. The anal sphincters provide fine control of stool. The internal sphincter keeps us from going to the bathroom when we are
asleep, or otherwise unaware of the presence of stool. When we get an urge to go to the bathroom, we rely on our external sphincter to
keep the stool in until we can get to the toilet.

GORDON’S FUNCTIONAL HEALTH PATTERN AND PHYSICAL ASSESSMENT

CASE SCENARIO:

Ms. JS is 5 foot 2 inches tall and weighs 90 pounds. She arrives at the CVGH emergency department from a home for the aged where she
had been staying for five years. She has an elevated temperature and a decreased blood pressure and heart rate from her baseline. She
is a 70-year-old woman with a history of: Malabsorption syndrome (celiac disease); chronic wounds; pancreatitis with a pancreatic
resection; and depression. Her oxygen saturation is 87% on room air. A stage III pressure ulcer on her coccyx is also noted. She is allergic
to erythromycin, tetracycline, tape, pneumococcal polysaccharide (pneumonia) vaccine.

Laboratory tests in the emergency department reveal Ms. JS’s white blood cell (WBC) count is 13,000 cells/mm3, red blood cell (RBC)
count is 3.16 million/mm3, hemoglobin (Hgb) 8.9 g/dL, hematocrit (Hct) 25.7%, mean cell (or corpuscular) volume (MCV) 70.8 μm3,
mean cell (or corpuscular) hemoglobin (MCH) 20 pg, ferritin 7 mg/L, iron (Fe) 30 μg/L, total iron binding capacity (TIBC) 496 μg/ dL, and
transferrin 195 mg/dL. Her potassium (K+) is 1.7 mEq/L, sodium (Na2+) 128 mEq/L, chloride (Cl2) 79 mmol/L, calcium (Ca2+) 7.8 mg/dL,
and protein 4.0 g/dL.

Ms. JS is admitted to a private room at PPS 3rd Floor, room 303. She is started on 5 liters of oxygen by the nasal cannula. Her oxygen
saturation improves to 95%. A regular diet is prescribed, with strict intake and output documentation and calorie counts. Because she
will be primarily on bed rest, compression boots, graduated compression stockings (TEDs), and heel protectors are prescribed. Her
dressing change documentation for the wound on her coccyx indicates that during each shift, the wound is to be gently irrigated with
250 mL of normal saline (NS), Mesalt rope moistened with NSS is to be packed in the wound and in the areas of undermining, and then
the entire wound is to be covered with Mesalt gauze dressings.

GORDON’S FUNCTIONAL HEALTH PATTERN PHYSICAL ASSESSMENT

Client J.S., 70 years old, female, widowed, Roman Catholic, General Appearance
Filipino, born on January 9, 1951, and is currently residing in Casa Px seen on bed awake, alert, conscious, responsive, afebrile, with
sa Gugma home for the aged, Barrio Luz, Mabolo, Cebu City. She nasal cannula in place. Vital signs of:
was admitted at Cebu Velez General Hospital last February 25,
2021 via ambulance accompanied by a caretaker from the home Vital Signs
for the aged. She was admitted to the CVGH emergency with an BP = 110/70 mmHg
elevated temperature and a decreased blood pressure and heart HR = 66 bpm
rate, and her oxygen saturation is 87% on room air. Px is admitted RR = 14 cpm
to a private room at PPS 3rd Floor, room 303. T = 36.2 °C/axilla
O2 Sat. = 95%
History of Present Illness:
Client J.S. Past health history includes malabsorption syndrome Height: 5 foot 2 inches
(celiac disease), chronic wounds, pancreatitis with a pancreatic Weight: 90 lbs. or 40.8 kg
resection, and depression. She has been staying in the home for IBW: 116 lbs. or 52.7 kg
the aged for five years with stage III pressure ulcer on her coccyx. BMI Interpretation: Underweight (16.5 BMI)
She is allergic to erythromycin, tetracycline, tape, pneumococcal
polysaccharide (pneumonia) vaccine. Skin
Px has fair skin color with age spots noted. Skin is warm, slightly
Laboratory tests in the emergency department shows signs of rough to with few wrinkles , thin but callused, and cracks on the
infection with the different altered levels of the cbc results with: plantar area. Senile tugor noted. Stage lll pressure ulcer at coccyx
WBS count - 13,000 cells/mm3 area is noted.
RBC count - 3.16 million/mm3
Hgb - 8.9 g/dL Scalp and Hair
Hct - 25.7% Brown with gray/white roots with thinning patches at crown area.
Mean cell (or corpuscular) volume (MCV) 70.8 μm3 Scalp has no lesions, no lice infestation, no patches with minimal
Mean cell (or corpuscular) hemoglobin (MCH) 20 pg sparse dandruff.
Ferritin - 7 mg/L
Nails
Iron (Fe) - 30 μg/L
Nails are naturally pink in color, well-trimmed, clean and the hard
Total iron binding capacity (TIBC) 496 μg/ dL
palate is firmly attached to the nail bed. Nail beds return to pink
Transferrin - 195 mg/dL
in less than 2 seconds after the nail is blanched, no clubbing
Potassium (K+) - 1.7 mEq/L
noted.
Sodium (Na2+) - 128 mEq/L
Chloride (Cl2) - 79 mmol/L Head and Face
Calcium (Ca2+) - 7.8 mg/dL Head is normocephalic, erect at midline, hard and smooth. Face is
Protein - 4.0 g/dL symmetrical, no abnormal facial movements noted.

Past Health History: Eyes and Vision

6 months PTA, she underwent a pancreatic resection due to her Eyeball symmetrical; eyebrows and eyelashes are color black and
pancreatitis. She was also diagnosed with Malabsorption symmetrical. Eyeballs have minimal wrinkles with loose folds.
Syndrome (Celiac Disease). During her stay in the home for the White sclera with clear and moist bulbar conjunctiva. Iris is round
aged she has developed chronic wounds and pressure ulcer on and uniform in color. Clients’s eyesight is 20/40.
her coccyx. She has been diagnosed with depression by the
resident psychiatrists in the home for the aged due to her present Ears and Hearing
condition, death of her late husband and her bad relationship Ears are equal in size bilaterally (4- 10 cm). Client was able to
with her only daughter. repeatedly say 3/3, 2 syllable words (apple and pencil) through
the whisper test. Client was not able to hear the ticking of the
I. Health Perception - Health Management watch 3-4 inches from the ear.
J.S. defined health as taking care of one’s body by regaining
Nose and Sinuses
health back through constant check - ups, consultations and
Color is the same as the rest of the face. Nasal structure is smooth
surgery as necessary as possible, and cause of illness is when your
and symmetric. No tenderness. The client is able to sniff or exhale
body fails to function normally. Px rated her present health 6 out
while the nostril is occluded. Nasal mucosa is dark pink, moist,
of 10 where 1 is the lowest and 10 is the highest because of her
and free of exudate. Nasal septum is intact and free of ulcers or
condition. The px believes that a return to the hospital is
perforations. Turbinates are dark pink, moist, and free of lesions.
inevitable due to her condition for further observations, check -
No tenderness nor crepitus.
ups and follow - ups of treatment. She believed that the way to
manage her present health is to stick to her diet. Mouth and Pharynx
Pinkish lips with whitish to yellowish teeth. Patient wears
Px never smoked, drank alcohol and used recreational drugs. No dentures. Patient has mouth sores on her mouth.
use of safety devices noted. Px does not make use of herbal
medication. Neck
Neck is symmetric, with head centered and without bulging
Px reports that there is an annual health check-up in the home for masses. Neck movement is smooth and controlled. No
the aged she is staying and reports that her recent health checkup enlargement or tenderness.
was earlier this year.
Breast
The px is a retired and states that she was satisfied when she Round and pendulous. Right breast larger than the left. Nearly
chose to retire. equal bilaterally in size and in the same location on each breast.
Nipples are everted. Breast rises symmetrically with no sign of
For the past 5 years, the client has been living in Casa sa Gugma, a dimpling or retraction. No masses, dimpling, or retraction. No
home for the aged in Mabolo, Cebu City upon the death of her discharge. No palpable nodes.
husband. Strong construction materials were used. The home is Chest and Lungs
elderly friendly being only 1 storey high with ramps and stairs Client is sitting and relaxed, breathing with no usage of any
with side rails leading to the entrance. Door levers are used in accessory muscles and nasal flaring noted.
place of door knobs for all the doors and the home is properly lit.
Fixed bath/shower and toilet with appropriate handlebar Heart and Peripheral Vasculature
positions are found in the home. The toilet type is flush type and Radial pulse of 66 bpm and no abdominal pulsation noted.
the toilet system is closed/blind drainage.
Abdomen
Abdomen is flat. Abdomen is symmetric. No abdominal pain. 32
APPENDIX A: Family Genogram
clicks per minute.
II. Nutritional Metabolic Rectum
A. Food and Fluid Intake Hairless, moist, tightly closed. Skin around anus is coarser and
darkly pigmented. Surrounding areas free of abnormalities.
Meal of Day 24-hour Diet Recall Usual/Typical Diet Smooth, free of redness and hair. Sphincter relaxes and allows
the finger to enter anus. Client can close the sphincter on
Breakfast Time last taken: 7am Time last taken: 7am command. Anus is smooth, non-tender, free of nodules and
Meal taken at: Home forMeal taken at: Home for hardness. Mucosa is soft, smooth, nontender, and free of nodules
the aged the aged
Components of Meal: Components of Meal: Male Genitalia and Prostate
N/A
● ½ cup rice ● ½ - 1 cup of rice
● 1 pc. sunnyside -up ● Egg Female Genitalia
egg ● Steamed vegetable Pubic hair distributed in an inverted triangle with no signs of
● 1 serving of steamed ● 1 glass of water infestation. No enlargement or swelling of lymph nodes. Labia
vegetable majora are equal in size and free of lesions, swelling, and
● 1 glass of water excoriation. Perineum is smooth. Labia minora is symmetric, dark
● 1 pc. banana pink, and moist, Clitoris is a small mound of erectile tissue,
varying in size. Vaginal opening is positioned below the urethral
meatus. Urethra is small and slit -like. Bartholin’s glands are soft,
non -tender, and drainage free. Client was able to squeeze around
their fingers. Surface of the cervix is smooth, pink, and even.

Back and Extremities (Musculoskeletal)

Steady gait when walking with slightly kyphotic posture. Muscle
Lunch Time last taken: 12pm Time last taken: 12pm strength of 3/5 in both extremities. Decreased ROM.
Meal taken at: Home forMeal taken at: Home for Neurologic
the aged the aged Client is cooperative and able to express feelings appropriately for
Components of Meal: Components of Meal: the situation. Maintain good eye contact, use soft low tone when
● 1 cup of rice ● 1 serving of talking with clear and moderate pace.
● 1 bowl of tinolang tinolang isda
isda ● 1 serving of utan Mental Status/Cerebral Function:
● 1 glass of water bisaya Alert and oriented. GCS score of 15. Cooperative and purposeful
● 1 pc. banana ● 1 cup of rice in interactions, affect is appropriate for a situation.
● 1 glass of water
Dress, Hygiene, Grooming: Dress is appropriate for occasion and
weather. Client is clean and groomed appropriately for occasions.
Facial Expressions: maintains eye contact.
Dinner Time last taken: 8pm Time last taken: 8pm Speech & Vocabulary: clear, moderate tone and pace, culturally
Meal taken at: Home forMeal taken at: Home for appropriate.
the aged the aged Thought Processes: expresses full, free-flowing thoughts.
Components of Meal: Components of Meal: Attention: listens and follows directions without difficulty.
● ½ cup of rice ● 1 bowl of soup Remote Memory: difficulty recalling past events
● 1 serving of minced ● 1 serving of meat Recent Memory: recalls events without difficulty.
meat ● 1 cup of rice Fund of Information: can recall words after 5, 10, and 30 min.
Abstract Reasoning & Similarities: explains similarities and
differences correctly.
Judgement: sound and rational answers.
Visual Perceptual and Constructional Ability: Can copy simple
AM Snacks Time last taken: Time last taken: 10 am
figures.
Meal taken at: Home forMeal taken at: Home for
the aged the aged Motor/Cerebellar Function:
Components of Meal: Components of Meal: Finger-Thumb Test: Can touch rapidly on slow pace but cannot
● None ● Depending on follow the same pace for moderate and fast pace
what’s available at Heel-to-Shin Test: can run each heel smoothly down each shin,
the institution Button-Unbutton Shirt: can button and unbutton in short span of
time
Tandem Walk: >10sec.
PM Snacks Time last taken: 4 pm Time last taken: 4 pm Romberg Test: Stands erect with minimal swaying.
Meal taken at: Home forMeal taken at: Home for Involuntary Movements: none
the aged the aged Sensory Function:
Components of Meal: Components of Meal: Discrimination bet. Sharp and dull sensations: can slightly
● 1 serving of boiled ● Depending on differentiate between light, dull and sharp sensation.
corn with cheese what’s available at Temperature Sensation: can differentiate hot from cold.
the institution Vibratory Sensation: can correctly identify sensation.
Two-Point Discrimination: - fingertips: 2 -5mm - forearm: 40 mm -
dorsal hands: 20-30 mm - back: 40 mm - thighs: 70 mm.
Stereognosis: can identify simple objects.
B. General Diet Information Graphesthesia: can identify numbers.
Due to her condition, the px has been careful with the food that Kinesthesia: can identify direction of movements.
she consumes. Food preference is lean meat and gluten free
vegetables. She eats the prepared meals every day and she
usually eats with the other elders at the home for the aged. She Cranial Nerve Testing:
has taken some vitamins and dietary supplements prior to
CN I (olfactory):
condition.
Correctly identifies scent present in each nostril
C. Nutrition Knowledge CN II (optic):
She describes a healthy diet as a diet consisting of rice, 20/40
vegetables, and meat. She also believes that it is best to drink at
least 8 glasses of water a day. She used to read the food labels CN III (oculomotor), CN IV (trochlear), CN VI (abducens):
when her eyesight was not yet bad. Eyelid covers about 2 mm of iris. Eyes move in smooth,
coordinated motion in all directions. Bilateral illuminated pupils
D. Dental Regimen constrict simultaneously. Pupil opposite the one illuminated
She brushes her teeth 2 times a day and does not rinse with oral constricts simultaneously.
antiseptic. She was able to receive dental care yearly in the home
for the aged. She wears a dental appliance which is a denture. CN V (trigeminal):
Temporal and masseter muscles contract. Client correctly
E. Other identifies stimulus; Corneal reflex present; identifies light, sharp &
She is 5’2 inches tall. Her usual body weight is 80-90 lbs. She is dull tough to forehead, cheek & chin; clenches teeth
“ok” with her present weight because she believes that it comes CN VII (facial):
with her old age as she can not be physically active anymore. Her
present illness has affected her eating pattern since she has to Movements are symmetric; Able to smile, frown, wrinkle
maintain a healthy gluten free diet to regain a good immune forehead, show teeth, puff out cheeks, purse lips
system.
CN VIII (vestibulocochlear):
III. Elimination Client can hear whispered words. AC > BC.
A. Bowel Elimination
CN IX (glossopharyngeal), CN X (vagus): :
The px defecates once to twice a day. She described her normal
Uvula and soft palate rise bilaterally and symmetrically, gag reflex
stool as a sausage-like or snake-like that is smooth and soft. But
intact, client swallows without difficulty.
currently, px experiences loose watery stool accompanied by
abdominal cramping and increased urge to defecate. When CN XI (spinal accessory):
experiencing difficult elimination, she doesn’t treat herself with Strong contraction of trapezius and sternocleidomastoid muscles.;
any medication but instead she increases her water so that her Equal shoulder shrug against resistance; turns head in both
usual bowel movement goes back to normal. directions against resistance

B. Bladder Elimination CN XII (hypoglossal):

Px said that she normally urinates 3-5 times a day with varying Smooth and symmetric tongue movement and bilateral strength
amounts, clear, and odorless. Due to old age, she sometimes
experiences urinary incontinence. In addition, in the midst of her
sleep, she wakes up just to urinate (nocturia). Deep Tendon Reflexes
L R
IV. Activity - Exercise
Px explained that during the diagnosis of her condition, her Biceps +1 +2
activity and exercise pattern has changed she could not handle
the muscle pains and preferred to rest and lay in bed. She used to Patellar +2 +2
engage in physical activity and exercises such as Zumba and
walking around the institution but now finds it extremely difficult. Triceps +1 +1

Achilles +2 +2
V. Cognitive - Perception
A. Cognitive Pattern Brachioradialis +1 +2
Px is able to read, write, comprehend instructions, and could
recall some long-term memories especially those significant to Grading Deep Tendon Reflexes
her. +4 - Hyperactive, very brisk, rhythmic oscillations
(clonus); abnormal and inactive disorder
Px is multilingual. She speaks Filipino, English, and a little bit of
Spanish. She has been speaking bisaya since she grew up in Cebu. +3 - More brisk and active than normal, but not
indicative of disorder
Px is a cum laude graduate of BS Business and Management at +2 - Normal, usual response
UST and has been working in the HR Department in a private +1 - Decreased, less active than normal
company here in Cebu. 0 - No response

Px is aware of the different diseases she had such as having a

history of Pancreatitis that she needs to have pancreatic Superficial Reflexes
resectioning, she was diagnosed of depression due to her medical Abdominal: abdominal muscles contract, umbilicus deviates
condition, and has a stage 3 pressure ulcer that needs utmost toward the side being stimulated.
caring. Plantar: flexion of toes.
Due to her multiple conditions, she is always ready to learn to Pathologic Reflexes
help herself because one thing she learned while having these Brudzinki’s Sign: hips and knees remain relaxed and motionless.
diseases is that instead of feeling sorry for herself why not help Kernig’s Sign: no pain is felt.
herself out so that she could recover sooner.

She prefers demonstration while leaving a written copy for her

guide in case she might forget. Her potential barriers to learning
maybe her age since she’s 70 years old and she couldn’t
remember all the details taught to her so she needs someone
whom she could ask; and her physical limitation since she has
pressure ulcer stage 3 at her buttocks area. She is not that flexible
anymore, it would be difficult for her to reach out that area. Her
learning needs include medications since she tends to be forgetful
at times, her self-care needs/management since she is old, she
cannot do most things on her own, and her diet due to her
financial status she might not be able to afford the foods that are
supposed to be appropriate for her condition.

B. Vision
Px is dissatisfied with her vision because she already needs
reading glasses for her to be able to see and read the texts. But
once her glasses are on, she can clearly see them and it doesn’t
make it hard for her to read the texts. She just finds it slightly
annoying since she sometimes forget where she would place her
glasses thus she needs to make it a necklace. She doesn’t like
accessories much which is why she finds the glasses quite
irritable.

Since the client lives in the home for the aged, she doesn’t need
to wear sunglasses. But previously, during her teenage years, she
wears them out of fashion to match her outfit especially when
she goes to the beach.

The px’s last eye exam was January 5, 2020 because of the change
of her grade. She experienced lightheadedness and headache that
opted her to visit an ophthalmologist to see what’s going on. Her
eyesight is 20/40.

C. Hearing
Px is satisfied with her ability to hear. So far, she could still hear
sharply even if it is not as sharp as when she was still younger.
She is happy that she doesn’t need any hearing aid considering
her age.

Px uses cotton buds to clean the outside of her ears after she
takes shower. There were a lot of times wherein she tried ear
candles to remove the wax inside.

Px doesn’t wear any earplugs during swimming. She hasn’t

submitted herself to any hearing exam.

D. Other Pertinent Information

Px is dissatisfied with her ability to taste since she has been
having canker sores in the mouth which she reports to be painful
and affects her eating pattern. Although her ability to smell has
not changed drastically, she was concerned for her taste.

Px has not changed in her ability to feel pain & sensation,

temperature changes, feel other bodily sensations, and is not
hallucinating/delusional.

VI. Sleep - Rest

Px’s usual bedtime is 8 PM and usually wakes up around 5 to 6
AM. In between, she wakes up because of her urge to urinate
(nocturia) but could fall asleep minutes after. She has day time
naps that last for 1 to 2 hours. Her sleep pattern doesn’t differ
much from weekdays to weekends because most of the time she
is just at the home for the aged. There are times where she has
trouble sleeping because of thinking of so many things so she sits
on the rocking chair to help her sleep.

Upon waking up she feels tired and has no energy. This is because
she is no longer able exercise due to osteoporosis, one of the
symptoms of Celiac disease causing her to feel fatigue and bone
or joint pain.

Px’s sleeping environment has a noise level of 4 since the location

of the institution is just located near a high-way so passing cars
can be heard. Px has 1 pillow for her head, 1 booster for her legs
and arms to hug, and 1 blanket since the room is air conditioned
ranging from 23 to 19 degrees Celsius. There is a night lamp on
one end of the bed since px prefers to have a bit of light than
having a completely dark room.

Before sleeping, px prays the rosary or talks to her husband until

she dozed off. Everytime she cannot sleep, she doesn’t take any
medications but instead goes to their rocking chair. Px doesn’t
smoke, drink, nor drink coffee within 2 hours from bedtime. But
she reported drinking water before she sleeps because she feels
that her throat is dry which could have been the cause for her
nocturia.

VII. Self-perception - Self-concept

Px described herself as a goal-oriented and hardworking person.
She was a workaholic and spent many late nights in the office and
admittedly says that she lost time taking care of her daughter
during her growing years which resulted in a not so close
relationship with her.

For her, her greatest strength is that she is flexible that is why
despite the pressure in time to meet the deadlines, she is able to
do them on time. She is also good in personal relations which is
probably the reason why she chose to work in the HR
Department.

Her weakness could have been that she is not able to express her
negative feelings towards other people because she prefers
keeping it on her own.

Others described her as friendly and very approachable. She had

a lot of friends when she was young. When she was in college,
she was Miss Intramurals 2006 and was the Best Muse of the
same year.

Her greatest life accomplishment are being able to graduate with

high honor, was able to save 7 digit number in her savings
account, was able to build her own house, was able to purchase
her own car, was able to build a family of her own and was able to
send her child to school.

She is not easily angered but she is easily anxious over small
matters that have to be presented in large crowds. Her greatest
fear is height, which is why when she is using an elevator or
escalator, she doesn’t look down. This is also the reason why she
is not fond of going to amusement parks.

During the depression screening, px’s scored 4 out of 9. Within

the past 2 weeks, px admitted feeling sad, low, down, depressed,
or hopeless; lost interest or pleasure in the things she usually likes
to do; have lost appetite; and have been feeling tired or having
little energy. She was diagnosed with Depression previously when
her husband died and she started feeling sick.

Px does not have suicidal thoughts as she believes that life is a gift
and we have no right to take it away.

In general, her present condition greatly affected that way the px

feels about herself and her body especially her pressure ulcer at
her buttocks.

VIII. Role - Relationship

Client is strongly attached to God; moderately attached to her
child, relatives and siblings; and slightly attached to the
neighborhood and community.

Px lives in a nuclear family prior to being transferred to the Home

for the Aged. Currently, px is in the Home for the Aged since her
husband died.

Px is a widow and mother of 1. She has had misunderstandings

with her daughter in the past which resulted in their bad
relationship.

In the family, the decision lies between her and her husband. But
since her husband died and her daughter had grown, the decision
is addressed to themselves.
During family conflict, they usually prefer to not talk about and
leave it unresolvedSince they do not like confrontations and
prefer to keep negative feelings on their own. Her daughter has
not been visiting her in the home for the aged for the last 5 years
causing severe sadness. She wished to resolve the issues with her
daughter and be able to restore their relationship especially that
she is getting old.

Currently, px is not working anymore. She also doesn’t belong to

any groups or organizations in the church or community.

APPENDIX B: Ecomap

IX. Sexuality - Reproductive

Px started her menarche at the age of 12 years old. She can no
longer remember the date of her LMP but she could recall that
her menstruation stopped when she was around 45 years old. She
was irregular at first few months but eventually became regular.
She sometimes has delayed periods such as 2-4 days behind
considering that there were a lot of stressors during her teenage
years from school then work then family.

When she was still menstruating, it usually lasted for a week

having spotting prior to day 1 as she counts. Because of heavy
flow, she could consume about 5 day pads and 2 night pads in a
day. She changes them when they are fully soaked but most of
the time, every four hours.

Since she doesn’t track her period using any mobile application
because it was nonexistent during her time, she usually notice
that everytime her period is about to start she will have pimples
on her face, shoulders, and chest area; dysmenorrhea; picky-eater
but at the same time craves for certain foods; and is very
sensitive to things. When her period starts, she experiences
dysmenorrhea at times but usually just more sensitive than she
usually is.

Px has 1 child. She is living and delivered by her doctor at Chong

Hua Hospital. Her only child is 45 year old. During her pregnancy,
she visited her Ob-Gyn doctor for prenatal checkups. She
remembered that she had 3 appointments in total.

Other information has not been recalled by the patient.

Her obstetrical score is G1P1P0A0L1.

X. Coping/Stress Tolerance
Px defined stress as something disrupting in her life that affects
life’s different aspects. She is able to recognize stress which
affects her greatly. She becomes worried and anxious that
disrupts her sleep and loses appetite.

Her long-term and current stressor has always been her medical
conditions. Ever since she started to have these diseases, it has
not ended and her treatment keeps going and going. The
symptoms she feels have not been easy for her to handle and has
been giving her pain, headache and much stress ever since. It has
reached the point that she becomes powerless and all she can do
is go to church and pour her heart out. She prefers keeping her
problems on her own because she doesn’t want to add to the
problems and stress of others.. Although she understands that
this is not healthy for her, she is a woman of principle and she will
do what it takes to not disturb others.

XI. Value - Belief

The values the px learned when she was still a child and up to
right now she has been possessing is respect. She believes that
this value encompasses all ages, that is why regardless of age,
each person (and also other living creatures) deserves respect.
Aside from that, humility is also vital to attain peace in the world.
One can have pride but one should learn to be humble.

The life goal of the patient was to be successful in life. Px

describes herself as very resourceful and a hardworking person
thus she believes that if she continues to persevere, she will
achieve something greater in life. But as she gets older and is
about to reach her end, she just wants a peaceful life. Moneys
and golds will bring her luxury but peace in her life is something
that she needs before her end.

In life, her source of hope, strength, comfort, and peace is God.

Despite her condition, she believes that God will continue to help
overcome everything.

The px practices hilot because ever since she was young, she has
been introduced to that and as she grows older, it becomes
innate to her.

Px prays rosary every night, goes to church every Sunday, and was
a former choir member during her teenage years. Before she
could do fasting every April but she couldn’t practice that any
longer due to her health issues.

Overall, her relationship with God has always been strong. In fact,
her relationship grew a bit stronger when she had this disease
because it is only to Him that she could pour her heart out.
APPENDIX A: Family Genogram
APPENDIX B: Ecomap
LABORATORY AND DIAGNOSTIC TESTS
1. Celiac Disease Antibody Tests
a. Description: Celiac disease antibody tests help diagnose and monitor the disease and a few other gluten-sensitive
conditions. These tests detect autoantibodies in the blood that the body produces as part of the immune response.
b. Purpose: To help diagnose celiac disease and to evaluate the effectiveness of a gluten-free diet.
c. Normal Findings: Negative.
d. Significant Findings: Positive. Candidate for biopsy.
e. Nursing Care:
i. Before:
● Explain test procedure.
● Explain that slight discomfort may be felt when the skin is punctured.
● Encourage to avoid stress if possible because altered physiologic status influences and changes normal
hematologic values.
● Explain that fasting is not necessary.

ii. During:
● Use standard precaution /sterile technique as appropriate.
● Provide emotional and physical support to the patient.
● Monitor vital signs.
● Ensure correct labeling and transportation of specimen.

iii. After:
● Apply manual pressure and dressings over the puncture site on removal of dinner.
● Monitor the puncture site for oozing or hematoma formation.
● Instruct to resume normal activities and diet.

2. Genetic Testing
a. Description: Genetic testing is a type of medical test that identifies changes in chromosomes, genes, or proteins. The
results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person's chance of
developing or passing on a genetic disorder.
Genetic testing can be done by blood test, saliva test or cheek swab.
b. Purpose: Genetic testing for human leukocyte antigens (HLA-DQ2 and HLA-DQ8) can be used to rule out celiac disease.
c. Normal Findings: Negative
 d. Significant Findings: Positive
e. Nursing Care:

Blood test
i. Before:
● Explain test procedure
● Explain that slight discomfort may be felt when the skin is punctured.
● Encourage to avoid stress if possible because altered physiologic status influences and changes normal
hematologic values.
● Explain that fasting is not necessary.
ii. During:
● Use standard precaution /sterile technique as appropriate.
● Provide emotional and physical support to the patient.
● Monitor vital signs.
● Ensure correct labeling and transportation of specimens.
iii. After:
● Apply manual pressure and dressings over the puncture site on removal of dinner.
● Monitor the puncture site for oozing or hematoma formation.
● Instruct to resume normal activities and diet.

Saliva test, cheek swab

iv. Before:
● Before a person has a genetic test, it is important that he or she understands the testing procedure, the
benefits and limitations of the test, and the possible consequences of the test results.
● Wait at least one hour after eating a meal before collecting saliva.
● Rinse mouth thoroughly with water to remove any food particles or other contaminants, then wait a full
ten minutes before collecting the saliva sample. Collecting saliva too soon after rinsing may reduce the
amount of DNA that can be extracted, and it can also affect hormone/biomarker analyses.
v. During:
● Use standard precaution /sterile technique as appropriate.
● Provide emotional and physical support to the patient.
● Use a permanent marker to write a patient identifier, date of birth and date and time of the collection
on the label in the kit. Attach it to the outside tube of the collection device.
 ● Take the cap or stopper off the container to get to the swab; Never touch the swab with your hands.
Always leave the insert inside of the tube. The insert is needed to process the specimen at the lab
(laboratory).
● Tip the tube directly inside the mouth; The swab should fall on top of or under the tongue so that it can
move freely in the mouth. Do not let the swab go in between the cheek and gum.
● Watch closely to be sure that they do not choke on or swallow the swab.
● Ask the patient to roll the swab inside their mouth for 2 to 3 minutes. It is OK to gently chew it. The
swab must be completely wet to do the test right.
● Ensure correct labeling and transportation of specimens.
vi. After:
● All specimens need to be kept cold in the refrigerator until you take them to the nearest laboratory.
● Perform after care.
● Saliva must be clear. If you see blood, mucus or bits of food or debris, the patient will need to do the
test again.

3. Endoscopy or Capsule Endoscopy

a. Description: Endoscopy is a procedure that allows a doctor to view the inside of a person's body. Doctors use it to
diagnose diseases in the following parts of the body: Esophagus. Stomach.
b. Purpose:
● This enables the doctor to view your small intestine and take a small tissue sample (biopsy) to analyze for
damage to the villi.
● This test uses a tiny wireless camera to take pictures of your entire small intestine. The camera sits inside a
vitamin-sized capsule, which you swallow. As the capsule travels through your digestive tract, the camera takes
thousands of pictures that are transmitted to a recorder.
c. Normal Findings: Clean and clear small intestine
d. Significant Findings: Presence of damaged villi or small intestine; inflammation
e. Nursing Care:
i. Before:
● Schedule at least 2 days after barium swallow or upper gastrointestinal series.
● Ensure the informed consent is signed prior to premedication and procedure.
● Encourage questions, and provide answers and support.
● Withhold food and fluids for 6 to 8 hours before the procedure.
● Remove dentures and eyewear. Provide mouth care.
ii. During:
 ● Use standard precaution /sterile technique as appropriate.
● Provide emotional and physical support to the patient.
● Preparing the instruments, equipment, and supplies for the procedure.
● Cleaning and sterilizing equipment before use.
● Providing assistance to Doctors throughout the procedure.
● Monitor vital signs.
iii. After:
● Inform the patient that they will be allowed to eat and drink as soon as their gag reflex returns and you
are able to swallow.
● May experience mild bloating, belching, or flatulence following the procedure.
● Instruct the patient to come back on a scheduled follow-up check up.
● Advise the patient to immediately seek medical help if any unusualities occur.

MEDICAL MANAGEMENT

Gluten-free diet
● Celiac disease is a condition in which gluten triggers immune system activity that damages the lining of the small intestine. Over
time this damage prevents the absorption of nutrients from food. A gluten-free diet is essential for managing signs and
symptoms of celiac disease and other medical conditions associated with gluten. Following a gluten-free diet requires paying
careful attention to food selections, the ingredients found in foods, and their nutritional content.

Many naturally gluten-free foods can be a part of a healthy diet:

● Fruits and vegetables
● Beans, seeds, legumes and nuts in their natural, unprocessed forms
● Eggs
● Lean, non processed meats, fish and poultry
● Most low-fat dairy products

Grains, starches or flours that can be part of a gluten-free diet include:

● Arrowroot
● Buckwheat
● Corn — cornmeal, grits and polenta labeled gluten-free
● Flax
 ● Gluten-free flours — rice, soy, corn, potato and bean flours

Avoid all foods and drinks containing the following:

● Wheat
● Barley
● Rye
● Triticale — a cross between wheat and rye
● Oats, in some cases

Processed foods that often contain gluten:

● Cakes and pies
● Cereals
● Cookies and crackers
● French fries, Pasta
● Salad dressings
● Sauces, including soy sauce (wheat)
● Seasoned rice mixes
● Seasoned snack foods, such as potato and tortilla chips
● Self-basting poultry
● Soups, bouillon or soup mixes
● Vegetables in sauce

When you are buying processed foods, you need to read labels to determine if they contain gluten. Foods that contain wheat, barley, rye
or triticale — or an ingredient derived from them — must be labeled with the name of the grain in the label's content list. Keeping a
strict gluten-free diet is a lifelong necessity for people with celiac disease. Following the diet and avoiding cross-contamination results in
fewer symptoms and complications of the disease.

Benefits of a gluten-free diet:

● Weight loss
● Overall improved health
● Improved gastrointestinal health
● Improved athletic performance
● Improved lifestyle
 PHARMACOLOGIC TREATMENT:

● Azathioprine (Imuran)
○ Classification:
● Immunosuppressants

○ Action:
● Azathioprine (AZA) is an immunosuppressive agent that acts through its effects as an antagonist of purine
metabolism, resulting in the inhibition of DNA, RNA, and protein synthesis.

○ Indication:
● RA
● Kidney transplantation
● Ulcerative colitis
● Lupus
● Crohn disease

○ Contraindication:
● Hypersensitivity
● Pregnancy, lactation
● Rheumatoid arthritis
● Bad infection
● Significant anemia
● Decreased blood platelets; severe decrease in white blood cells
● Blood clot in a vein of the liver
● Acute inflammation of the pancreas

○ Adverse Reaction:
● Abdominal pain
● Alopecia
● Arthralgia
● Bacterial, fungal, protozoal, viral infections
● Bone marrow suppression
 ● Diarrhea
● Fever
● Hepatotoxicity
● Macrocytic anemia
● Myalgia
● Nausea or vomiting
● Rash
● Thrombocytopenia

○ Nursing Responsibilities:
● BLACK BOX WARNING: Monitor blood counts regularly; severe hematologic effects may require the
discontinuation of therapy; increases risk of neoplasia.
● Patient should be informed of the necessity of periodic blood counts while they are receiving the drug and
should be encouraged to report any unusual bleeding or bruising to their physician.
● Inform the patient of the danger of infection while receiving IMURAN and ask him/her to report signs and
symptoms of infection to their physician.
● Careful dosage instructions should be given to the patient, especially when IMURAN is being administered in the
presence of impaired renal function
● Provide safety measures (e.g. adequate lighting, raised side rails, etc.) to prevent injuries.
● Educate the patient on drug therapy to promote compliance.

● Prednisone
○ Classification:
● Corticosteroids

○ Action:
● Elicits mild mineralocorticoid activity and moderate anti-inflammatory effects; controls or prevents
inflammation by controlling rate of protein synthesis, suppressing migration of polymorphonuclear leukocytes
(PMNs) and fibroblasts, reversing capillary permeability, and stabilizing lysosomes at cellular level

○ Indication:
● Arthritis
● Blood disorders
● Breathing problems
 ● Severe allergies
● Skin diseases
● Cancer
● Eye problems
● Immune system disorders

○ Contraindication:
● Untreated serious infections
● Documented hypersensitivity
● Varicella
● Pregnancy, lactation

○ Adverse Reaction:
● Bradycardia, cardiac arrest, cardiac arrhythmias, congestive heart failure, fat embolism
● Acne, allergic dermatitis, facial erythema
● Fluid retention, potassium loss, hypertension, hypokalemic alkalosis
● Arthropathy, loss of muscle mass, muscle weakness, osteoporosis
● Nausea, vomiting, loss of appetite/increased appetite and weight gain
● trouble sleeping, increased sweating

○ Nursing Responsibilities:
● Inform patient to take with meal or snack
● High-dose glucocorticoids may cause insomnia
● Assess history of: Infections; renal or liver disease, hypothyroidism, inflammatory bowel disease, CHF,
hypertension, thromboembolic disorders, osteoporosis, seizure disorders, diabetes mellitus; hepatic disease;
lactation
● Increase dosage when the patient is subject to stress.
● WARNING: Taper doses when discontinuing high-dose or long-term therapy to avoid adrenal insufficiency.
● Do not give live virus vaccines with immunosuppressive doses of corticosteroids.

● Dapsone
○ Classification:
 ■ Antileprotics
○ Action:
■ inhibits the synthesis of dihydrofolic acid by competing with para-aminobenzoic acid for the active site
of dihydropteroate synthetase in susceptible organisms. Its mechanism of action in the treatment of
acne vulgaris is still unknown; however, it may be a result from both of its anti-inflammatory and
antimicrobial effects.
○ Indication:
● Dermatitis herpetiformis: (D.H.)
● Leprosy: All forms of leprosy except for cases of proven dapsone resistance.
○ Contraindication:
● Hypersensitivity to dapsone
● Severe anaemia
● Porphyria
● severe G6PD deficiency
● Congenital or idiopathic methaemoglobinaemia (topical)
○ Adverse Reaction:
● Dry, red skin
● Peeling skin
● Allergic reaction
● Joint swelling or pain
● Belly pain
● Lightheadedness
● Symptoms of hemolytic anemia (dapsone):
○ Weakness
○ Paleness
○ Shortness of breath
○ Dark urine
○ Yellowing of the skin and whites of the eyes

○ Nursing Responsibilities:
■ Monitor for therapeutic effectiveness that may not appear for leprosy until after 3–6 months of therapy. Skin
lesions respond well; recovery from nerve involvement is usually limited.
■ Lab tests: Perform baseline then weekly CBC during the first month of therapy, at monthly intervals for at least 6
months, and semi annually thereafter.
 ■ Determine periodic dapsone blood levels.
■ Perform liver function tests in patients who complain of malaise, fever, chills, anorexia, nausea, vomiting, and
have jaundice. Dapsone therapy is usually suspended until etiology is identified.
■ Monitor severity of anemia. Nearly all patients demonstrate hemolysis. Manufacturer states that Hgb level is
generally decreased by 1–2 g/dL; reticulocytes increase by 2–12%; RBC life span is shortened; and
methemoglobinemia occurs in most patients receiving dapsone.
■ Monitor temperature during the first few weeks of therapy. If fever is frequent or severe, leprosy reactional
state should be ruled out. Reduction of or interruption of therapy may be sufficient for improvement.
■ Report cyanotic appearance or mucous membranes with brownish hue to physician as possible
methemoglobinemia.

● Infliximab (Avsola, Inflectra, Remicade, Renflexis)

○ Classification: Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

○ Action: Binds with high affinity to the soluble and transmembrane form of tumor necrosis factor-α (TNF-α) thereby
inhibiting binding of TNF-α to its receptors

○ Indication:
● Rheumatoid arthritis
● Fistulising Crohn’s disease
● Ankylosing spondylitis
● Plaque psoriasis
● Psoriatic arthritis
● Ulcerative colitis
● Refractory celiac disease

○ Contraindication:
● Tuberculosis
● Sepsis
● Abscesses
● Moderate or severe heart failure (NYHA class III or IV)
● Special precaution in:
○ Mild heart failure (NYHA class I or II)
 ○ History of blood dyscrasias
○ Chronic or recurrent infection
○ Children
○ Pregnancy and lactation

○ Adverse Reaction:
● Chills
● Fever
● Dyspnea
● Chest pain
● Hypertension or hypotension
● Urticaria
● Pruritus
● Nausea and vomiting
● Diarrhea
● Abdominal pain
● Fatigue
● Dizziness
● Headache
● Signs of an allergic reaction:
○ Hives
○ Chest pain, difficult breathing
○ Fever, chills, severe dizziness
○ Swelling of your face, lips, tongue, or throat

○ Nursing Responsibilities:
● Monitor vital signs every 2-10mins if reaction is noted during infusion.
● Perform hepatitis B virus screening prior to and hepatitis B virus carriers during and after several months after
therapy.
● CBC with differential
● Liver function tests
● Assess px if s/he has:
○ an active infection (fever, cough, flu symptoms, open sores or skin wounds);
○ heart failure or other heart problems;
 ○ diabetes;
○ a weak immune system;
○ liver failure, hepatitis B, or other liver problems;
○ chronic obstructive pulmonary disease (COPD);
○ heart problems;
○ cancer;
○ seizures;
○ numbness or tingling anywhere in your body;
○ a nerve-muscle disorder, such as multiple sclerosis or Guillain-Barré syndrome;
○ phototherapy for psoriasis;
○ vaccination with BCG (Bacille Calmette-Guérin); or
○ if scheduled to receive any vaccines.

● WARNING: Using infliximab may increase your risk of developing certain types of cancer, including a rare fast-
growing type of lymphoma that can be fatal.

SURGICAL MANAGEMENT

There is no specific surgical treatment for patients with Celiac Disease. Surgery is not used to treat celiac disease per se but rather to
treat complications of the disease, including bowel obstruction, perforation, hemorrhage, and malignancy (cancer).

CONCEPT MAP
NURSING CARE PLAN
The nursing diagnosis is arranged according to Maslow’s Hierarchy of Needs, Prioritization of Risks, and the Airway-Breathing-Circulation
Pattern of the patient.
NURSING DIAGNOSIS
Diarrhea related to intestinal inflammation After 8 hours of nursing intervention, the
secondary to Celiac Disease as evidenced patient will be able to:
by loose watery stool, abdominal
cramping, increased urgency to defecate,
and increased bowel sounds.
Scientific Basis:
Diarrhea is the most common symptom in
untreated celiac disease and is present in
45-85% of all patients. Diarrhea caused by
celiac disease is due to the maldigestion
and malabsorption of nutrients.
Source:
Gaobel, S. (2019). Celiac Disease (Sprue)
Clinical Presentation: History, Physical
Examination. Retrieved 3 March 2021,
from
https://emedicine.medscape.com/article/1
71805-clinical#:~:text=Diarrhea%20is
%20the%20most%20common,gray%2C
%20and%20oily%20or%20frothy.
DESIRED OUTCOME
● Return to a more normal stool
consistency and frequency.
● Verbalize understanding
causative factors.
● Demonstrate appropriate behavior
to assist with resolution of
causative factors.
● Adhere to the proper food
regimen.
● Present understanding of the
certain foods to avoid.
INTERVENTIONS
Dependent:
1. Administer medications for Celiac
Disease as prescribed.
R: Steroids may be prescribed to treat
of intestinal inflammation. Antidiarrheals and
antispasmodics may also help.
Independent:
1. Commence a stool chart. Use a
standardized stool assessment tool
such as Bristol Stool Chart.
R: To monitor the px’s bowel pattern.
2. Encourage to increase oral fluid
intake as tolerated, ideally at least
2L per day. Avoid cold drinks.
Check if the px is in any fluid
restriction before doing so.
R: To help ensure that the px will not have
dehydration due to severe diarrhea. Cold
drinks can increase intestinal motility.
3. Help the px to select appropriate
dietary choices to avoid gluten-
containing foods. Encourage her to
reduce the intake of milk products.
R: To relieve abdominal pain and cramping,
alleviate diarrhea, and to promote healthy
food habits. To avoid flare ups of Celiac
disease. Many pxs with Celiac disease are

Imbalanced Nutrition: Less Than Body After 8 hours of nursing intervention, the
Requirement related to reduced patient will be able to:
absorption of nutrients secondary to Celiac ● Verbalize understanding of
Disease as evidenced by diarrhea, causative factor when known and
abdominal pain and cramping, weight loss, adhering to the necessary
nausea and vomiting, and loss of appetite interventions.
● Demonstrate progressive weight
Scientific Basis: gain towards goal.
The impact of nutrient malabsorption ● Display normal laboratory values
caused from untreated celiac disease is and be free of signs of
well documented. The diet and gluten-free malnutrition.
products are often low in B vitamins, ● Demonstrate behaviors, lifestyle
also lactose intolerant.
Collaborative:
1. Ensure the px has a gluten-free
diet.
R: A strict gluten-free diet is the number
one ttt for Celiac disease. This includes
avoiding wheat, barley, malt, rye, and
other gluten-containing foods.
2. For severe diarrhea, start the px on
NPO status, and gradually
progress to clear liquids, followed
by bland diet, and low residue diet.
The px can have a low fat/residue,
low fiber diet on a long-term basis,
as recommended by the dietitian.
R: NPO status can help rest the bowel by
decreasing peristalsis. Gradual progression
from NPO up to low fat and low fiber,
gluten-free diet can help manage the
symptoms of Celiac disease.
Dependent:
1. Administer supplements of
vitamins as prescribed.
R: Vitamin and mineral supplementation
may be required for nutritional
deficiencies. Some of the vitamins and
minerals recommended for Celiac disease
pxs include: Vit. B12, Vit. D, Vit. K, Zinc,
Copper, Folate, and Iron.
Independent:
1. Explore the px’s daily nutritional
calcium, vitamin D, iron, zinc, magnesium,
and fiber. Few gluten-free products are
enriched or fortified, adding to the risk of
nutrient deficiencies.
Source:
Kupper, C. (2005). Dietary guidelines and
implementation for celiac disease.
Gastroenterology, 128(4). doi: 10.1053
Fatigue related to the decrease in energy
levels secondary to celiac disease.
Scientific Basis:
changes to regain and or to intake and food habits (e.g.:
maintain appropriate weight. mealtimes, duration of each meal
session, snacking, etc.).
R: To create a baseline of the px’s
nutritional status and preferences.
2. Create a daily weight chart and a
food and fluid chart. Discuss with
the px the short-term and long-
term nutrition and weight goals
related to Celiac disease.
R: To effectively monitor the px’s daily
nutritional intake and progress of weight
goals.
3. Help the px to select appropriate
dietary choices to avoid gluten-
containing foods. Encourage her to
reduce the intake of milk products.
R: To relieve abdominal pain and cramping,
alleviate diarrhea, and to promote healthy
food habits. To avoid flare-ups of Celiac
disease. Many pxs with Celiac disease are
also lactose intolerant.
Collaborative:
1. Refer the px to the dietitian.
R: To provide a more specialized care for
the px in terms of nutrition and diet in
relation to newly diagnosed Celiac disease.
After 8 hours of nursing intervention, the Dependent:
patient will be able to: 1. Review medication regime or other
● Report improved sense of energy. drug use.
● Identify the basis of fatigue and R: many medications have potential side
One study found that 82% of those newly
diagnosed with celiac disease complained
of fatigue. Some researchers speculate
that fatigue may be caused by
malnutrition, at least in those with celiac
disease—celiac-induced intestinal damage
can mean your body doesn't absorb
nutrients well.
Source:
Anderson, J. (2020). Do You Get Gluten-
Induced Fatigue? Here's How to Cope.
Retrieved 3 March 2021, from
https://www.verywellhealth.com/fatigue-
caused-by-gluten-how-you-can-cope-
562318#:~:text=One%20study%20found
%20that%2082,doesn%27t%20absorb
%20nutrients%20well.
individual area of control. effect of causing or exacerbating fatigue
● Perform activities of daily living
and participate in desired activities Independent:
at level of ability. 1. Assess vital signs. Measure the
● Participate in a recommended physiological response to activity
treatment program. (e.g. changes in BP or HR and RR)
R: to evaluate fluid status and
cardiopulmonary response to activity
2. Assess psychological and
personality factors that may affect
reports of fatigue level
R: client can potentially have issues that
affect desire to be active, resulting and
over - or underactivity or concerns of
secondary gain from exaggerated fatigue
reports
3. Determine the presence or degree
of sleep disturbances
R: fatigue can be a consequence of ,
and/or exacerbated by, sleep deprivation
4. Obtain client or SO description of
fatigue
R: to assist in evaluating the impact on the
clients life
5. Identify the presence of physical
and/or psychological conditions.
R: important information can be obtained
from knowing 1.) if fatigue is a result of an
underlying condition or disease process;
2.)the current status of an exacerbating or
remitting condition; or 3.) whether fatigue
has been present over a long time without
any identifiable cause
 6. Ask the client to rate fatigue using
numerical scale and its effect on
the ability to participate in desired
activities
R: fatigue may vary in intensity and is often
accompanied by irritability, lack of
concentration, difficulty on decision-
making, problems with leisure, and
relationship difficulties that can add to
stress levels and aggravate sleep.
7. Accept the reality of client reports
of fatigue and do not
underestimate effect on clients
quality of life
R: fatigue is subjective and often
debilitating
8. Plan interventions to allow
individually adequate rest periods.
Schedule activities for periods
when the clients has the most
energy
R: to maximize participations and energy
9. Encourage the use of assistive
devices
R: to extend active timer conserve energy
for other task encourage nutritionally
dense, easy-to-prepare, easy-to-consume
foods, and avoidance of caffeine and high
sugar foods and beverages
10. Assist the client to identify
appropriate coping behaviors
R: this promotes a sense of control and
improves self esteem.

Ineffective Coping related to grief and the After 8 hours of nursing intervention, the
recent change in life situation as evidenced patient will be able to:
by the lack of appetite. ● Identify ineffective coping
behaviors and consequences.
Scientific Basis: ● Verbalize awareness of own coping
Although celiac disease can be managed by abilities.
strict adherence to a gluten-free diet, ● Verbalize feelings congruent with
dietary management can be challenging. behavior.
The Psychological General Well-Being ● Meet psychological needs as
Index and the Brief COPE were used to evidenced by appropriate
measure the major variables. Results expression of feelings,
Collaborative:
1. Evaluate the need for individual
assistance or assistive devices
2. Discuss alternative therapies
R: complementary therapies may be
helpful in reducing muscle tension and
pain to promote relaxation and rest
3. Treat underlying condition where
possible
R: to reduce fatigue caused by treatable
condition
4. Refer to comprehensive
rehabilitation program, physical
and occupational therapy for
programed daily exercises and
activities
R: to improve stamina, strength, and
muscle tone and to enhance sense of well
being
5. Refer to counselling or
psychotherapy
Independent
1. Assess the current situation
accurately.
R: Assessing the current functional
capacity and noting how it is affecting the
individual’s coping ability will help in
evaluating the needs of the patient.
2. Assess level of anxiety and coping
on an ongoing basis.
R: In order to establish a baseline data.
3. Determine alcohol intake, drug
indicated that problems outside the home identification of options, and use use, smoking habits, sleeping and
interfere with dietary adherence. of resources. eating patterns.
R: These mechanisms are often used when
Reference: an individual is not coping effectively with
Smith MM, Goodfellow L. The relationship stressors.
between quality of life and coping 4. Note speech and communication
strategies of adults with celiac disease patterns.
adhering to a gluten-free diet. R: To be aware of negative or
Gastroenterol Nurs. 2011 Nov- catastrophizing thinking.
Dec;34(6):460-8. doi: 5. Determine previous methods of
10.1097/SGA.0b013e318237d201. PMID: dealing with life problems.
22129799. R: To identify successful techniques that
can be used in current situations.
6. Devote time for listening.
R: May help the patient express emotions,
grasp situations and feel more in control.
7. Provide a quiet environment.
R: Anxiety is increased by noisy/unpeaceful
surroundings.
8. Introduce relaxation, breathing
techniques and coping statements.
R: To help manage stress and anxiety.

Dependent
1. Discuss use and appropriateness of
anxiolytic medications or herbal
supplements
R: to provide assistance in staying calm and
reduce anxiety

Collaborative
1. Collaborate with a dietitian or
nutritionist for a meal plan that

Pain related osteoporosis like pain as After 8 hours of nursing intervention, the
evidenced by decreased ROM and a muscle patient will be able to:
strength of 3/5. ● Demonstrate the use of
appropriate diversional activities
Scientific Basis: and relaxation skills.
When a person with celiac disease or a ● Describe satisfactory pain control
gluten sensitivity eats gluten (gliadin and at a level less than 3 to 4 on a
glutenin proteins) the immune system rating scale of 0 to 10.
jumps into action, causing inflammation. ● Display improved well-being such
This inflammation can affect the body’s as baseline levels for pulse, BP,
organs and soft tissue. A person may not respirations, and relaxed muscle
notice external signs of inflammation, such tone or body posture.
as redness and swelling, but may notice ● Use pharmacological and
other symptoms, such as joint pain. nonpharmacological pain-relief
strategies.
Reference: ● Display improvement in mood,
Christopher Pomeroy, M., 2021. How coping.
Gluten Can Cause Joint Pain. [online]
Arthritis-health. Available at:
<https://www.arthritis-health.com/types/g
eneral/how-gluten-can-cause-joint-pain>
[Accessed 15 March 2021].
will help in maintaining the
patient's nutritional status
R: To help regain strength caused by
various treatments.
Independent
1. Perform history assessment of pain
R: It is important to know the effectiveness
of previous pain treatment or
management, what medication were taken
and when
And allergies or know side effects to
medication
2. Determine the client’s perception
of pain.
R: provide an opportunity for the client to
express in their own words how they view
the pain and the situation to gain an
understanding of what the pain means to
the client.
3. Investigate signs and symptoms
related to pain.
R: Bringing attention to associated signs
and symptoms may help the nurse in
evaluating the pain. In some instances, the
existence of pain is disregarded by the
patient.
4. Provide nonpharmacologic pain
management
R: Nonpharmacologic methods in pain
management may include physical,
cognitive-behavioral strategies and lifestyle
pain management
5. Evaluate the patient’s response to

Risk for fluid volume deficit related to After 8 hours of nursing intervention, the
poor gastrointestinal absorption of patient will be able to:
nutrients related to diarrhea
Scientific Basis:
When you are experiencing Celiac Disease
accompanied by diarrhea, you lose
extracellular fluid rapidly. If you don’t stay
hydrated and can’t keep fluids down, you’ll
begin to experience the symptoms of a
fluid volume deficit.
Reference:
Sticks, P., Save, S., Bottle, W., Locator, S.,
works, H., Compares, H., Research, O. and
timeline, M., 2021. Fluid Volume Deficit:
Symptoms, Causes, and Treatment Plans.
[online] DripDropORS. Available at:
<https://dripdrop.com/blogs/news/fluid-
volume-deficit> [Accessed 15 March 2021].
● Be compliant with the dietary
regimen
● Verbalize the effects of consuming
gluten foods.
● Verbalize awareness of causative
factors and behaviors essential to
correct fluid deficit.
● Explains measures that can be
taken to treat or prevent fluid
volume loss.
pain and management strategies.
R: It is essential to assist patients to
express as factually as possible (i.e.,
without the effect of mood, emotion, or
anxiety) the effect of pain relief measures.
6. Evaluate the effectiveness of
analgesics as ordered and observe
for any signs and symptoms of side
effects.
R: The effectiveness of pain medications
must be evaluated individually by the
patient since they are absorbed and
metabolized differently.
Independent
1. Assess skin turgor and oral mucous
membranes for signs of
dehydration.
R: Signs of dehydration are also detected
through the skin. Skin of elderly patients
loses elasticity, hence skin turgor should be
assessed over the sternum or on the inner
thighs. Longitudinal furrows may be noted
along the tongue.
2. Note the presence of nausea,
vomiting and fever.
R: These factors influence intake, fluid
needs, and route of replacement.
3. Weigh daily with the same scale,
and preferably at the same time of
day.
R: Weight is the best assessment data for
possible fluid volume imbalance. An
increase of 2 lbs a week is considered
normal.
4. Monitor active fluid loss from
wound drainage, tubes, diarrhea,
bleeding, and vomiting; maintain
accurate input and output record.
R: Fluid loss from wound drainage,
diarrhea, bleeding, and vomiting cause
decreased fluid volume and can lead to
dehydration.
5. Aid the patient if he or she is
unable to eat without assistance,
and encourage the family or SO to
assist with feedings, as necessary.
R :Dehydrated patients may be weak and
unable to meet prescribed intake
independently
6. Urge the patient to drink
prescribed amount of fluid
R: Oral fluid replacement is indicated for
mild fluid deficit and is a cost-effective
method for replacement treatment

Collaborative:
1. Refer patient to home health nurse
or private nurse in order to assist
patient, as appropriate.
R: Continuity of care is facilitated through
the use of community resources.
 ETHICO-MORAL-LEGAL RESPONSIBILITIES

For the ethical principles, these are the following:

AUTONOMY
● The right/freedom to decide (the patient has the right to refuse despite the explanation of the nurse)
● Is upheld when the nurse accepts the client as a unique person who has the innate right to have their own opinions,
perspectives, values and beliefs. Nurses encourage patients to make their own decision without any judgments or coercion from
the nurse. The patient has the right to reject or accept all treatments.
● Ex. surgery, or any procedure

VERACITY
● Is being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to
patient distress.

BENEFICENCE
● Is doing good and the right thing for the patient
● For the goodness and welfare of the clients

NONMALEFICENCE
● Is doing no harm, as stated in the historical Hippocratic Oath, wherein harm can be intentional or unintentional
● The duty not to harm/cause harm or inflict harm to others maybe physical, financial or social

JUSTICE
● Fairness
● How do we differentiate fair from being equal? For example: A hospital has an available oxygen tank. If we talk about equality,
we go to all patients who are admitted with oxygen tanks. But when we speak of being fair, we give the oxygen tank to admitted
patients who need assistance in their breathing and not to all admitted patients.

FIDELITY
● Is keeping one's promises. The nurse must be faithful and true to their professional promises and responsibilities by providing
high quality, safe care in a competent manner.
ACCOUNTABILITY
● Is accepting responsibility for one's own actions. Nurses are accountable for their nursing care and other actions. They must
accept all of the professional and personal consequences that can occur as the result of their actions.

For the moral principles, we should always take note of:

● Golden Rule. Do not do to others what you don’t want others to do unto you. As nurses, we should always care for our patients
as if they are our family because in return, a good karma comes back.
● The principle of Totality. The whole is greater than its parts. No one is perfect but everyone has flaws that is why we shouldn’t
look at our patients by their flaws but as a whole human being. Having an amputated leg, deformed face, etc., doesn’t make one
less of a human being.
● Epikia. There is always an exemption to the rule. As nurses, we weigh-in our duty, responsibility, and upholded ethico-moral
principles.
● A little more or a little less does not change the substance of an act. The famous line, “We did everything we could, but we
couldn’t revive him” is one example. No matter how much professionals try, how much theories have been practiced, how deep
these principles have been uprooted; but in our line of profession, we should always put our best.

DISCHARGE PLAN

MEDICATION:
● Provided the patient, and S.O with an accurate list of medications.
● Educated the patient and S.O prior to discharge, including:
○ proper storage and use of medications
○ what to do if a dose is missed
○ potential side effects
○ when to call about any concerns
● Provided a written copy of all information that is given verbally.
● Ensured that the patient is able to follow medication instructions.
● The first-line drug of choice is a class of steroids known as a glucocorticoid. Prednisolone and budesonide are the two oral
glucocorticoids mostly commonly prescribed.
● Other pharmaceutical options include:
 ○ Asacol (mesalamine), an oral nonsteroidal anti-inflammatory drug (NSAID) sometimes used in people with Crohn's
disease
○ Cyclosporine, an oral disease-modifying antirheumatic drug (DMARD) used to treat a variety of autoimmune disorders
○ Imuran (azathioprine), an oral immunosuppressive drug traditionally used in organ transplant recipients
○ Remicade (infliximab), an injectable biologic drug that blocks the chemical processes that lead to inflammation

● Other promising drugs in the developmental pipeline including larazotide acetate (a potent digestive enzyme that breaks down
dietary gluten) and BL-7010 (a high-density polymer that binds to gluten so that it cannot be absorbed).
● In rare cases when T-cell lymphoma is diagnosed, combination chemotherapy would be used. The mainstay of treatment is
CHOP therapy (an anagram referring to the drugs cyclophosphamide, doxorubicin, vincristine, and prednisone).
● Explained the medication, its purpose, importance and expected side effects of medications like headache, N&V, drowsiness,
hypertension, behavioral changes, suicidal ideation
● Educated the patient on the importance of following prescribed medication regimen.
● Instructed the patient to read the medication name and check the correct dosage before taking.
● Instructed the patient to take medication at the right time and right frequency.
● Instructed the patient not to take medications not prescribed by the physician.

ENVIRONMENT:
● Instructed the patient and S.O. to maintain an environment conducive for rest and sleep.
● Instructed the patient and S.O. to have a well-ventilated environment.
● Instructed the patient and S.O. to clean the surroundings to avoid infection.
● Advised the patient to promote space for ambulation and light exercises.
● Encouraged the patient to allow S.O. or family members to do things for her and not to hesitate to ask for help.
● Instructed the S.O. to offer emotional support, understanding, patience, and encouragement.
● Encouraged the patient to try to spend time with other people and confide in a trusted friend or relative.

TREATMENT:
● Explained that there is no available surgical treatment for Celiac disease and that chemotherapy can be performed, if
appropriate.
● Practice a gluten-free diet
● Introduced CAM options
○ Peppermint oil has antispasmodic effects that may help ease intestinal cramping and spasms. Research from the
University of South Alabama reported that a sustained-release peppermint oil capsule was twice as effective in
alleviating irritable bowel syndrome (IBS) than a placebo.4 Whether the same would occur with celiac disease has yet to
 be confirmed. Peppermint oil taken directly by mouth may cause heartburn and stomach upset. Enteric-coated
peppermint capsules are less likely to cause harm. Excessive doses of peppermint oil can be toxic.
○ Slippery elm powder is derived from the bark of the slippery elm. Some people believe that it can protect the intestines
by creating a mucus-like coating as it is digested. A 2010 study in the Journal of Alternative and Complementary
Medicine reported that slippery elm powder was able to ease symptoms of constipation-dominant irritable bowel
syndrome (IBS-C). The same effect may be useful in treating constipation that commonly occurs with a gluten-free diet.
There is no evidence thus far that slippery elm powder can treat symptoms of celiac disease itself.

HEALTH TEACHINGS:
● Read food labels. Gluten sometimes appears in foods or places you wouldn’t expect:
○ It’s used as a thickening agent in many gravies and sauces.
○ It’s sometimes used in medicines. Talk to your doctor or pharmacist before taking a new medicine. This includes vitamins
and supplements.
○ It can be found in lip balm, lipstick, and other cosmetics.
● Understand where gluten is "hidden" in foods
● Find the appropriate foods to eat in restaurants
● Avoid accidental gluten cross-contamination at home or elsewhere by:
○ Keeping gluten-free and gluten-containing foods separate in sealed containers and in separate drawers or cabinets.
○ Cleaning cooking surfaces and food storage areas.
○ Washing dishes, utensils, and food preparation equipment thoroughly.
○ Avoiding wood utensils or cutting boards that can absorb food and potentiate cross-contamination.
○ Speaking to your child's teachers and lunch staff if he or she has celiac disease so that accidents can be avoided and
special accommodations can be made.
○ Checking restaurant menus online before eating out to be sure there are food items you can eat.
○ Calling the restaurant in advance to inform them about your health concerns and dietary needs.
○ Booking early or late when a restaurant is less busy and better able to accommodate your special requests.

OUTPATIENT AND OBVIOUS SIGNS & SYMPTOMS:

● Instructed px to contact the primary health care provider in the event that the symptoms do not get better, or if they get
worse, even after treatment.
● Instructed px when her next visit/follow-up check up with her healthcare provider.

DIET:
● Avoid eating gluten foods such as:
○ Wheat (including durum, einkorn, and emmer)
 ○ Wheat germ
○ Rye
○ Barley
○ Bulgur
○ Couscous
○ Farina
○ Graham flour
○ Kamut matzo
○ Semolina
○ Spelt
○ Triticale
● Avoid ingredients or packaged foods that contain or are derived from the above-listed grains. These may include:
○ Bacon
○ Baked goods
○ Beer
○ Bouillon cubes
○ Bread
○ Breakfast cereals
○ Candies
○ Canned baked beans
○ Cold cuts
○ Egg substitutes
○ French fries (which are often dusted in flour)
○ Gravy
○ Hot dogs
○ Ice cream
○ Instant hot drinks
○ Ketchup
○ Malt flavoring
○ Mayonnaise
○ Meatballs
○ Non-dairy creamer
○ Oats or oat bran (if not certified gluten-free)
○ Pasta
 ○ Processed cheese
○ Pudding and fruit filling
○ Roasted nuts
○ Salad dressings
○ Sausage
○ Seitan
○ Soups
○ Soy sauce
○ Tabbouleh
○ Veggie burgers
○ Vodka
○ Wheatgrass
○ Wine coolers
● The person must practice having a gluten-free diet. This may include:
○ Eggs
○ Dairy including yogurt, butter, and non-processed cheeses (but check the label of flavored dairy products)
○ Fruits and vegetables including most which are canned or dried
○ Grains including rice, quinoa, corn, millet, tapioca, buckwheat, amaranth, arrowroot, teff, and gluten-free oats
○ Legumes like beans, lentils, peas, peanuts
○ Meat, poultry, and fish (not breaded or battered)
○ Non-gluten starches including potato flour, corn flour, chickpea flour, soy flour, almond meal/flour, coconut flour, and
tapioca flour
○ Nuts and seeds
○ Soy foods like tofu, tempeh, and edamame
○ Tamari (a good substitute for soy sauce)
○ Vegetable oils (preferably monounsaturated or polyunsaturated)
○ Oats
Some oat products can be contaminated with wheat gluten. Because of this, some people choose to avoid oats.

SPIRITUALITY:
● Advised the patient to always be strong and optimistic in facing changes encountered in life.
● Encouraged the patient to continue their usual spiritual practices.
● Encouraged the patient to continue having faith as God will always be there for guidance.
● Advised the patient to pray to God for maintenance of good health and be open to Him concerns bothering the patient.
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