A2A round3

A case of Multiple Gastrointestinal problems:

Gastric Ulcer, Gastritis Erosive GERD grade A and

Fecal Retention

Competency Enhancement Training Program for Nurses (CETN) batch 24

A brief introduction

April

2012

Submitted by:

Team leader:

Members:

Submitted to:

Professional Development and Training Department

MAKATI MEDICAL CENTERNURSING SERVICE DIVISION

April 2012

CASE STUDY:[Title of the case ]

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TABLE OF CONTENTS

INTRODUCTION Background of the Study 1 Statement of the Problem 1 Scope & Limitation 3

CLINICAL FRAME WORK Course in the ward outline 6 Pathophysiological framework 6

DISCUSSION AND ANALYSIS 15 Demographic Profile 16 Pertinent Histories 17 Hollistic Assessment 18 Diagnostic Study 19 Pharmacological Study 20 Nursing Care Plans 21

SUMMARY OF FINDINGS 22 CONCLUSIONS 22 RECOMMENDATIONS 22

BIBLIOGRAPHY 23APPENDICES: (if any) 23


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INTRODUCTIONThis study is a partial requirement in the Competency Enhancement Training Program (CETN) of

Nursing Services Division. The study was done during the clinical exposure as trainee nurses on the 7th Floor Circular area of Makati Medical Center.

Gastritis is a condition in which the stomach lining—known as the mucosa—is inflamed. The stomach lining contains special cells that produce acid and enzymes, which help break down food for digestion, and mucus, which protects the stomach lining from acid. When the stomach lining is inflamed, it produces less acid, enzymes, and mucus. Erosive gastritis is a type of gastritis that often does not cause significant inflammation but can wear away the stomach lining. Erosive gastritis can cause bleeding, erosions, or ulcers. Erosive gastritis may be acute or chronic.

Gastroesophageal reflux is a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal. Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis). GERD is a chronic disorder that is largely treated on the basis of symptoms, especially in primary-care practice, irrespective of possible underlying mucosal damage or complications. Grade A GERD is defined as one (or more) mucosal break no longer than 5 mm that does not extend between the tops of two mucosal folds.

Gastric Ulcer is a round or oval sore where the lining of the stomach has been eaten away by stomach acid and digestive juices. Ulcers penetrate into the lining of the stomach. Gastritis may develop into Gastric Ulcers. Gastric ulcers usually occur along the upper curve of the stomach.

Fecal Retention or Constipation refers to a decrease in the frequency of bowel movements or difficulty in passing stools. The stool of a constipated person is typically hard because it contains less water than normal. Constipation is a symptom, not a disease.

Pyloric stenosis is defined as an obstruction to gastric emptying due to any cause situated above the biliary ampulla. In 80% the ulcer was situated at or near the pylorus, but in 6% there was a remote gastric ulcer with surrounding inflammatory and fibrous tissue which shortened the lesser curve and extended to envelop the pylorus. Earlier surgical treatment has reduced the number of peptic ulcers that progress to pyloric stenosis. In approximately half the patients in whom pyloric stenosis is diagnosed there are no abnormal physical signs. A gastric succussion splash, only significant if at least three hours have elapsed since the last meal, is the commonest abnormal finding. Visible waves of gastric peristalsis coursing across the abdomen from left to right are of great diagnostic value, and occasionally it is possible to see the outline of a grossly distended stomach.

USER, 04/09/12,

Hi, i think ung introduction dpat brief lang.. then ung nkalagay dto sa introduction nten is dpat nkalagay sa background of the study.. ang alam ko kse ung background of the study.. this includes the related lit.. ask ko lang kung san nakuha ung nkalagay sa intro.. kse ang alam ko ilalagay dpat ung reference at the end of the paragraph.. for example (WHO, 2009)


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Background of the Study

This study was conducted at the 7th Floor Circular Area. Makati Medical Center. 7th Circular is a general Nursing unit with total bed capacity of 22 large private rooms. The room starts from room 742-763. Unit accepts adult patients of any category of the patient with medical cases according to the implemented zoning. But if there are no available rooms in the units, it can accept patient out of zoning but refuses pediatric and maternity cases patients.

Statement of the Problem

This paper seeks to present an analysis of the given case encountered on Fecal Retention, Gastric Ulcer

Modified, Gastritis Diffuse erosive GERD Grade A. Specifically, it attempts to answer the following

questions:

1. What is Demographic profile of the case?

2. What are the significant histories of patient that may have contributed to the patient current

condition?

3. What is the status of patient in terms of physical and psychological aspects?

4. What are the significant diagnostics required for the patient? What is the significance of

performing the test in relation to patient diagnosis?

5. What are the prescribed medication / treatment regimen applied to the patient? What are the

classification, action, indication, contraindication, rationale, and adverse reaction of this drugs/

agents?

6. What are the priority nursing problems identified?

7. How should the nurse intervene to answer the identified problems?

USER, 04/09/12,

Baliktad nlng cguro clan ng intro nten....????


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Scope and Limitation

This study explores the condition of an adult female client who has Fecal Retention, Gastric

Ulcer, Modified Gastritis, diffuse erosive GERD grade A. This study is a retrospective A since the patient

was handled by the researcher from March 14 – 16 2012. This includes the exploration of the disease,

medical management and comprehensive nursing management as well as various nursing diagnoses

identified and plan of action for each.

The case was conducted at Makati Medical Center specifically at the 7th floor Circular area of

the hospital. The researchers were able to handle the patient from March 14-16. During the 6 – 2 am

shift and 2 – 10 pm shift. The patient was handled for a total of twenty four hours divided in two shifts.

The aspects that were looked into were the demographic profile of the client, patient’s verbalizations,

researcher’s observation of the client, patient’s chart, and the interventions done for the patient. The

researcher was able to recall significant verbalizations that lead to the development of the nursing

problems.

Data collection was done through the patient’s chart, verbalizations of the client and the

researcher’s observation. Psychological assessment and history was done by the researcher. Pertinent

laboratory results were not obtained because the copies were not filed???? in the chart.

USER, 04/09/12,

Admission to discharge b nhandle to?


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CLINICAL FRAMEWORK

COURSE IN THE WARD OUTLINE

Day 1 – MARCH 13, 2012

(2258H)

ER admission (+) stabbing abdominal pain of 9/10 on the right upper quadrant (+)right upper quadrant direct tenderness (-) right lower quadrant pain (+) murphy’s sign (-) Rovsing’s sign (-) pregnancy test Rectal examination not done Nothing by mouth For Complete Blood Count Therapeutics:

Hyoscine-N-Butyl Bromide, 20mg via IV Tramadol 50mg via IV

Clinical Impression: acute cholecystitis, biliary colic

(2315H)

Transferred to room per stretcher; conscious, coherent with D5LR 1L via left periline using gauge 18; infusing well at 875ml level.


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Day 2 – MARCH 14, 2012

(0007H)

stabbing abdominal pain of 9/10 on the right upper quadrant (+)right upper quadrant direct tenderness (+) murphy’s sign (+) nausea (-) vomiting IVF D5LR 1L to run at 100ml/hour Serum lipase (dKO NA TINANGGAL KHT WLNG RESULT PRA MLMN NA MAY GNITO SYANG TEST. OKS LNG?)

Result: unavailable Ultrasound of whole abdomen Nalbuphine, 5mg via IV for pain Metoclopramide, 10mg via IV for nausea and vomiting every 8 hours

(0017H)

Discontinue Metoclopramide Hold Nalbuphine

(0025H)

Hold ultrasound of the abdomen Schedule for Esophago-Gastroduodenoscopy with cleansing enema For plain film of the abdomen

o Result: Fecal retention Pantoprazole, 40mg via IV once a day

(0300H)

PROBLEM LIST:

1. Pyloric stenosis; s/p Pylorotomy

2. t/c acute cholecystitis

Pain scale alleviated to 5/10 from 9/10. (+) right upper quadrant tenderness


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Complete Blood Count resultso Hematocrit: 44.90% (35.9-44.6)o White Blood Cells: 12.00 (4.4-11)o Segmenters: 73.00% (40-70)o Lymphocytes: 18.00% (22-43)o Mean corpuscular hemoglobin concentration (MCHC): 31.8% (33.4-35.5)

(No time)

PROBLEM LIST:

1. Gastric ulcer, modified

2. Gastritis, diffuse GERD, fecal retention

Pre-procedural diagnosis: Gastric ulcer Pre-procedure assessment

o Vital signs: Temperature: 36.2C Pulse rate: 82 Respiratory rate: 19 BP: 100/60 O2 saturation: 100%

Intra-procedure assessmento Sedation start: 0803Ho Procedure start: 0808Ho Positioning: left lateral positiono Sedation evaluation: conscious sedation

1005H

S/P EGD + cleansing enema Enema solution: tap water

o Start time: 0910Ho End time: 1005Ho Tolerance of the procedure: without complication


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Post-operative assessmento BP every 30 minutes: 87/53

Post-operative order: For cleansing enema now Sedation medicines:

o Diphenhydramine, 25mg via IVo Fentanyl, 25mg via IVo Midazolam, 5mg via IV

Low fat diet; no coffee, no milk, no softdrinks Repeat CBC Liver function test Give Pantoprazole, 40mg via IV every 12 hours Resume Metoclopromide Lactulose, 30ml at bedtime Cefuroxime, 750mg via IV every 8 hours

(1200H)

IVF D5LR 1L to run at 100ml/hour Hyoscine N-Butyl bromide as needed for pain


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Day 3 – MARCH 15, 2012

Day 4 – MARCH 16, 2012

(No time indicated)

Discontinue all IV fluids and IV medications then shift to heplock Start Lanzoprazole for 30mg/tablet, 1 tablet now then 2 times a day before meals Domperidone, 10mg/tablet, three times a day before meals Repeat CBC results

o Red Blood Cells: 4.17 (4.5-5.1)o Monocytes: 8% (0-7)o Mean corpuscular hemoglobin concentration (MCHC): 31.9% (33.4-35.5)

(2015H)

Continue Cefuroxime, 500mg/tablet, 1 tablet two times a day

May go home anytime


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PATHOPHYSIOLOGICAL FRAMEWORK


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DISCUSSION AND ANALYSIS

1. What is Demographic profile of the case?

2. What are the significant histories of patient that may have contributed to his current condition?

History of Present IllnessChief complaint Right upper quadrant painSummarized Current Illness Episodes

Hours prior to admission patient had a sudden onset of severe abdominal pain caused by spasm on the right upper quadrant of the abdomen minutes after intake of banana-cue; no medications were taken. Pain was said to be about 4/10 in severity.One hour prior to admission, right upper quadrant pain persisted, non-radiating with associated nausea, no vomiting. Pain was 9/10 in severity thus prompting emergency department consultation.

Initial Vital signs Temp: 36.2 C PR: 82 bpmRR: 19 cpmBP: 100/70 mmHgPain: 9/10

Current contraptions NoneOther Patient History

Risk factors noted Female Family history of constipation Poor eating habit (Skipping meals) Stress (admitted to be severely stressed out with a scale of

10/10) Excessive alcohol drinking (6-7 bottles a day 2 weeks prior to

admission Jan 5,2012) Coffee drinking (3-4 cups a day) Sedentary lifestyle

Concurrent Disorder Fecal Retention, Gastric Ulcer, Modified gastritis,diffuse + erosive GERD grade A

Past medical History Duodenitis, pyloric stenosis, gastric ulcer, Pylorotomy (January 2012)Diet and nutrition Prior to admission: consumes 3-4 cups of coffee a day; consumes 4-5

glasses of water a day; skipping meals due to academic schedule (with

Date of Admission: March 14 2012 at 0013HName of patient: V.K.R.V Gender: Female Civil Status : SingleAddress: Cavite Age: 22years old DOB: January 3 1990Nationality: FilipinoReligion: Roman CatholicEducational attainment: College undergraduateAdmitting Impression: Acute Cholecystitis Final Diagnosis: Fecal retention; Gastric Ulcer, Gastritis, Erosive GERD grade A


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maximum 2 meals per day during days with classes; occasional drinker (history revealed that the patient has been drinking 6-7 bottles of alcoholic beverage for 2 weeks straight prior to January 5, 2012 admission)

Height: 150cmWeight:41.20kgBMI is 18.30 which is interpreted as underweight

While admitted: low fat, no milk, no coffee, no softdrinksPsychosocial history With significant other

Occupation: Law studentSupport system: FamilyCopes up with stress by going out with friends

Family History Both parents: with hypertension and diabetesDistant relatives: asthmaGrandmother and mother: constipation

3. What is the status of patient in terms of physical and psychological aspects?

Norm Variance Rationale relating to patient case

Neurological AssessmentAlert and oriented to person place and time. GCS=15 Behavior appropriate to situation. Pupils equal and reactive to light. Active ROM of all extremities and symmetry of strength. Cranial Nerves are Intact Etc.

No deficit

Cardiovascular AssessmentRegular radial pulse. Capillary refill time < 4 sec. peripheral pulses palpable. No edema. No calf tenderness or clubbing positive Allen’s Test Etc.

No deficit

Respiratory AssessmentRegular, non labored breath sounds clear and equal on all lobes. Respirations 12-20 per minute Sputum clear, nail beds and mucus membrane are pink Etc.

No deficit


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Gastrointestinal AssessmentAbdomen is soft, non-distended, non tender. Bowel sounds present in 4 quadrants. Bowel movements within own normal patterns and consistency. Etc

Abdomen flat, normoactive bowel sounds, no mass

noted, Right upper quadrant pain 9/10 in

severity, positive Murphy’s sign

Pain is due to presence of ulceration in the gastrointestinal wall due to exposure to increased concentration of acid-pepsin secretions. This frequently occurs when the stomach is empty or between meals.

A positive Murphy’s sign was assessed during the patient stay in the Emergency Department, that led to an initial clinical impression of Acute Cholecystitis

Integumentary AssessmentSkin color uniform within patient’s norm. Smooth, soft, warm dry and intact. Turgor skin lifts easily and snaps back immediately when release. Mucus membrane moist, intact pink. Hygiene good Etc.

No deficit

Musculoskeletal AssessmentAbsence of joint swelling and tenderness. Normal ROM of all joints. No muscle weakness. Surrounding tissues show evidence of inflammation, nodules, nail changes, ulceration or rashes. No deformity Etc.

No deficit

Genitourinary AssessmentAble to empty bladder without dysuria bladder not distended after voiding. Urine clear and yellow to amber content of urine. No contraptions attached

.

No deficit

Genitourinary AssessmentIf female, no vaginal bleeding, discharges or lesions. Normal menstrual periods. If male, no prostrate problems, penile bleeding, lesions or discharges. No complaints of sexual dysfunction

LMP: March 9, 2012

Psycho/Social AssessmentBehavior appropriate to situation. No deficit

USER, 04/09/12,

no variance ata dapat dito


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Cooperative congruent affect. Responds appropriately to all questions

Activities of Daily Living AssessmentADL needs ( for the whole time duration of care rendered )

a. Hygiene and Grooming: done independently b. Activity: as toleratedc. Nutrition: low fat, no milk, no coffee, no soft drinks (March 15-16)d. Toileting: done independently, voiding freely, continente. Sleep: able to sleep and rest

Sensory Deficits ( state if any ) – not applicablea. Vision: ___________________________________________________________________b. Hearing: __________________________________________________________________c. Speech: __________________________________________________________________d. Others: ___________________________________________________________________

Assistive Device use: not applicable

Cultural Spiritual AssessmentA. Are there any spiritual, traditional, ethnic or cultural practices that need to be part of your

patient care? NONE


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B. Is there any way the nurse can assist you with your religious/ spiritual practices? NONEWould you like to be visited by the hospital chaplain? NO

4. What are the significant diagnostics required for the patient? What is the significance of performing the test in relation to patient diagnosis?

Hematology March 14, 2012 March 15, 2012

Results Normal Value ResultsHematocrit 44.9% (high) 35.9- 44.6 % NormalRed Blood Cells normal 4.5-5.1 4.17(low)White blood Cells 12.0% (high) 4.4- 11% NormalSegmenters 73% (high) 40- 70% NormalLymphocytes 18% (low) 22-43% NormalMonocytes Normal 0-7% 8% (high)MCHC (Mean corpuscular Hemoglobin Concentrate)

31.8% (low) 33.5- 35.5% 31.9% (low)

Laboratory test were done to differentiate the main cause of the upper quadrant abdominal pain felt by the patient. The CBC is a very common test, this will help to determine patient’s general health status. An elevated hematocrit is most often associated with dehydration, which is a decreased amount of water in the tissues. This may be due to prolonged symptoms of nausea that led to decrease in appetite. Critically high or low levels should be immediately called to the attention of the patient's nurse or doctor; transfusion decisions are based on the results of laboratory tests. Findings of increased white blood cells suggest presence of infection. Low Lymphocytes are caused by immunity problems (weak immune systems) or infections. (Dito nlng siguro isingit ung increased ung segmenters kasi due to infection din un dba?) Hypochromic anemia indicated by low MCHC, indicates a decrease in concentration of hemoglobin in a given volume of blood, which can be caused by bleeding. This was also suggested by a slightly low level of RBC.

Bout sa increased monocytes... may nasearch ako na associated sya with recovery from an acute infection... since sa march 15 tumaas ung monocytes eh dba after na ng procedure nya un.. possible natreat na tlga ung infection.. yan lang ung nkkta kong correlation nila.. hahaha

Diagnostic Procedures Date ResultsPregnancy Test March 14, 2012 Negative

USER, 04/09/12,

possible pa po ba iadd ditto ung increased segmeneters and monocytes? thanks


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Abdominal Xray March 14, 2012 Fecal RetentionEsophagogastroduodenoscopy March 14, 2012 Healing Modified Gastric ulcer,

Gastritis, Diffused Gastroesophageal reflux disease

Pregnancy test is done mandatory in all female patients in the reproductive stage for preventing any drug interactions and contraindicated procedures for pregnant patients.

Abdominal x-ray was done to somehow visualize the abdominal area in a non-invasive manner and provide a general baseline data regarding the patient’s condition.

Esophagogastroduodenoscopy was done to visualize the gastrointestinal tract to find presence of any ulcerated area. This was also done to obtain biopsy specimens to test for Helicobacter pylori and exclude malignant disease.

5. What are the prescribed medication / treatment regimen applied to the patient? What are the classification, action, indication, contraindication, rationale, and adverse reaction of this drugs/ agents?


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Generic Name Brand Name Major Drug categoryMetoclopramide Cloprimed Antiemetic

Drug Action Uses Occurred Side Effects/ Adverse Reactions

An antiemetic that acts as dopamine antagonist. It inhibits dopamine

receptors that are part of the pathway to the vomiting center

Nausea and vomiting None noted

Significant Drug Interaction Common Drug Dose ContraindicationAntagonistic with antimuscarinic

agents and opioid analgesics. May affect absorption of other drugs

given concomitantly

10mg/2ml 1 ampule every 8 hours for nausea and vomiting IV push

History of seizures Peptic ulcer disease P heochromocytoma

Nursing Medication management1) Assessment 2) Intervention

For prevention of nausea and vomiting. 1. Monitored for presence of nausea and vomiting.

3) Education 4) Evaluation Informed patient of the drug’s purpose is to

alleviate nausea and vomiting Informed patient of untoward side effects to

report once administered: extrapyramidal symptoms such as acute dystonic reactions.

No nausea and vomiting noted

Generic Name Brand Name Major Drug categoryDuphalac syrup Lactulose Laxative



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Lactulose is a colonic acidifier that works by increasing stool water

content and softening the stool. It is a man-made sugar solution.

This medication is a laxative used to treat constipation. It may help to

increase the number of bowel movements per day and the number of days you have a bowel movement.

• Soft bowel consistency

Significant Drug Interaction Common Drug Dose Contraindication antacids containing

aluminum and/or magnesium,

Other laxatives.

15-45 ml/day • Galactosemia• Bowel obstruction• Hypersensitivity.


March 14, 2012: Fecal retention was identified1. Assessed the patient’s bowel movement, consistency and frequency2. Monitored intake and output. 3. Auscultated bowel sounds. 4. Checked the latest electrolyte results for early indication of electrolyte imbalance.5. Instructed significant others to report if there is no bowel movement or if there’s diarrhea. 6. Administered medication once daily after feeding via NGT.

3) Education 4) Evaluation• Instruct that the patient will obtain soft feces (a laxative that could help)• Maybe taken after meals

March 14, 2012: bowel movement of 4 timesMarch 15, 2012: bowel movement of 3 times

Generic Name Brand Name Major Drug categoryDomperidone Motilium Anti-emetic; anti-vertigo

preparations.Drug Action Uses Occurred Side Effects/ Adverse

Reactions


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increase the duration of antral and duodenal contractions to increase

gastric emptying.

generally to suppress nausea and vomiting, or as a prokinetic agent or

gastric emptying.

None

Significant Drug Interaction Common Drug Dose Contraindication anti-cholinergic drugs Anti-muscarinic agents and

opioid analgesics dopaminergic agonists.

10 mg presence of gastro-intestinal haemorrhage, obstruction or perforation. hypersensitivity to domperidone. prolactin-releasing pituitary tumour (prolactinoma).


March 14, 2012: Fecal retention was identified1. Monitor intake and output.2. Provided and monitored NGT feeding as

prescribed.3. Provided calm and comfortable environment4. Kept hydrated with intravenous fluid.

3) Education 4) Evaluation• Explained that this medication is given for the patient to move bowel• Instructed patient and significant others to report drowsiness, disorientation and extrapyramidal reactions.

No episodes of nausea and vomitingMarch 14, 2012: bowel movement of 4 timesMarch 15, 2012: bowel movement of 3 times

Generic Name Brand Name Major Drug categoryLanzoprazole Prevacid proton pump inhibitors


blocks the production of acid by the used for treating ulcers of the stomach pain, irregularity,


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stomach stomach and duodenum, gastroesophageal reflux disease

(GERD) and Zollinger-Ellison Syndrome.

diarrhea, headache, nausea and dizziness. – none noted yata to kasi na relieve yung pain after magbigay(I think tama ung yellow highlight)

Significant Drug Interaction Common Drug Dose Contraindication Boodthinners Ampicillin Atazanavir Iron Theophyline Clopidogrel Digoxin Ketoconazole

15 mg known hypersensitivity to lansoprazole or other substituted benzimidazoles such as omeprazole or esomeprazole


Patient is diagnosed to have Gastritis, Gastric ulcer and GERD

1. monitored for adverse effects such as headache, rashes2. monitored for gastric discomforts. 3. Auscultated bowel sounds

3) Education 4) Evaluation-Instructed that medication will be given before meals for better absorption-Instructed to report if there is stomachache, flatulence, nausea and vomiting.

March 15, 2012 0800H, Pain scale of 7/10 but relieved after medication.

March 16, 2012 1200H: Pain scale of 0/10

Generic Name Brand Name Major Drug categoryMidazolam Dormicum Anti-anxiety agents,

sedative/hypnotics, benzodiazepines



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increase the activity of GABA, thereby producing a calming effect,

relaxing skeletal muscles, and inducing sleep. Benzodiazepines

bind to the benzodiazepine site on GABA-A receptors, which

potentiates the effects of GABA by increasing the frequency of chloride

channel opening.

used for treatment of acute seizures, moderate to severe

insomnia, and for inducing sedation and anesthesia before medical

procedures

None noted

(NONE NOTED)

Significant Drug Interaction Common Drug Dose Contraindication alcohol, opioids,

barbiturates, other sedatives and anaesthetics.

opiates, phenobarbital, other benzodiazepines. Plasma concentrations increased by CYP3A4 inhibitors antiretroviral agents. Midazolam concentration decreased by phenytoin, carbamazepine, phenobarbital, rifampicin. Halothane, thiopental requirements may be reduced during concurrent use.

5mg Acute narrow-angle glaucoma; coma or patients in shock; acute alcohol intoxication; intrathecal and epidural admin. Acute pulmonary insufficiency or marked neuromuscular respiratory weakness including unstable myasthenia gravis; severe respiratory depression.


Pre-procedure medcation for esophagogastroduodenoscopy

• Assess level of sedation and level of consciousness throughout and for 2-6 hr following administration.• Monitor BP, pulse and respiration continuously during IV administration. Oxygen and resuscitative equipment should be immediately available.

3) Education 4) Evaluation-instructed that the medication makes the patient feel drowsy-instructed significant others regarding patient safety like keeping the siderails raised and keeping sharp objects away from the patient

Esophagogastroduodenoscopy tolerated well

Generic Name Brand Name Major Drug categoryCefuroxime Zegen Cephalosporin



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Second-generation cephalosporin that inhibits cell-

wall synthesis, promoting osmotic instability; usually

bactericidal.

Used to treat certain infections caused by bacteria

diarrhea,nausea, vomiting,headache, or migraines,

dizziness and abdominal pain. None noted

Significant Drug Interaction Common Drug Dose Contraindication Probenecid (Benemid);A

blood thinner such as warfarin (Coumadin); Cimetidine (Tagamet), famotidine (Pepcid), omeprazole (Prilosec), ranitidine (Zantac).Diuretics such as bumetanide (Bumex), furosemide (Lasix), indapamide (Lozol), hydrochlorothiazide (HCTZ, HydroDiuril, Hyzaar, Lopressor, Vasoretic, Zestoretic), metolazone (Mykrox, Zarxolyn), spironolactone (Aldactazide, Aldactone), torsemide (Demadex), and others.

500mg Contraindicated in patients hypersensitive to drug.

Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics..


March 14, 2012: Patient had high WBC count 12% (Normal Value: 4.4-11%)

Assess if patient is allergic to penicillins or cephalosporins.

Assisted in administering with food to prevent any stomach upset.

3) Education 4) Evaluation• Informed patient of untoward side effects to report once administered: severe skin rash, itching, hives, difficulty breathing or swallowing, wheezing, painful sores in the mouth or throat

March 15, 2012: 8.76% (Normal Value: 4.4-11%)

Generic Name Brand Name Major Drug categoryTramadol Analgesics (Opioid)



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inhibits reuptake of norepinephrine, serotonin and enhances serotonin release. It alters perception and response to pain by binding to mu-opiate

receptors in the CNS.

Used to treat moderate to severe pain

Used to treat moderate to severe chronic pain when treatment is

needed around the clock.

Hives, DOB; swelling of your face, lips, tongue, or throat. agitation, hallucinations, fever, tachypnea,

nausea, vomiting, diarrhea, loss of coordination, fainting;seizure, peeling skin rash; or shallow

breathing, weak pulse. None noted Significant Drug Interaction Common Drug Dose Contraindication Warfarin. Increased risk of

seizures with SSRI, TCA. Increased risk of serotonin syndrome with mirtazapine, venlafaxine, SSRI and MAOI;

MAOIs Reduced analgesic efficacy

of tramadol with carbamazepine, 5-HT3-receptor antagonist. Increased respiratory and CNS depression with CNS depressants

50mg Suicidal patients, acute alcoholism; head injuries; raised intracranial pressure; severe renal impairment; lactation


March 13, 2012 at emergency room: Pain scale is 9/10

Monitored patient for seizures. May occur within recommended dose range.

Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration

3) Education 4) Evaluation Instructed patient that medication can

cause side effects that may impair thinking or reactions.

Instructed patient not to stop using tramadol suddenly to avoid unpleasant withdrawal symptoms such as anxiety, sweating, nausea, diarrhea, tremors, chills, hallucinations, trouble sleeping, or breathing problems.

Instructed patient that tramadol can cause respiratory depression and seizures.

March 15, 2012 0800H, Pain scale of 7/10 but relieved after medication.


Generic Name Brand Name Major Drug categoryFentanyl Duragesic Narcotic agonist analgesic



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Acts at specific opioid receptors, causing analgesia, respiratory

depression, physical depression, euphoria

Analgesic action of short duration during anesthesia and immediate

postop period

Sedation, clamminess, sweating, headache, vertigo, floating feeling, dizziness, lethargy, confusion, light-headedness, nervousness, unusual

dreams, agitation, euphoria, hallucinations, delirium, insomnia,

anxiety, fear, disorientation, impaired mental and physical

performance, coma, mood changes, weakness, headache, tremor,

convulsions

Palpitation, increase or decrease in BP, circulatory depression, cardiac

arrest, shock, tachycardia, bradycardia, arrhythmia,

palpitations-sedation, weakness, decrease in bp lang nakita ko, pakicheck na lang ulit

sa data kung meron pa(SAME decrease in BP lng, conscious

sedation)

Significant Drug Interaction Common Drug Dose Contraindication Potentiation of effects

when given with other CNS acting drugs or barbiturate anesthetics; decrease dose of fentanyl when coadministering

25mcg Contraindicated with hypersensitivity to narcotics, diarrhea caused by poisoning, acute bronchial asthma, upper airway obstruction, pregnancy.


Pre-procedure Medication for esophagogastroduodenoscopy

Assessed for level of consciousness Observed for signs of side effects or adverse

effects Monitored for adverse reactions and if pain

increases

3) Education 4) Evaluation• Educate the patient about the possible side effects of the drug and monitor closely.

Esophagogastroduodenoscopy procedure was tolerated well.


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Generic Name Brand Name Major Drug categoryHyoscine-n-butylbromide Buscopan Antispasmodics


Hyoscine-n-butylbromide acts by interfering with the transmission of nerve

impulses by acetylcholine in the parasympathetic nervous system (specifically the vomiting center)

Paroxysmal pain in diseases of the stomach or intestine, spastic pain & functional disorders in the biliary &

urinary tracts & female uterine organs

Buscopan can cause tachycardia, urinary retention and xerostomia.

When administered IV, Visual accommodation disturbances

and dizziness - none notedSignificant Drug Interaction Common Drug Dose Contraindication

Medications such as antidepressants (tricyclic type) MAO inhibitors (e.g., phenelzine, linezolid, tranylcypromine, isocarboxazid, selegiline, furazolidone), quinidine, amantadine, antihistamines (e.g.,diphenhydramine), anticholinergics, potassium chloride supplements, antacids, absorbent-type antidiarrhea medicines (e.g.,kaolin-pectin).

Contraindicated to patient with myasthenia gravis, glaucoma, hypertrophy of the prostatew/ urinary retention,mechanical stenosis of GIT and tachycardia.


March 13, 2012 at emergency room: Pain scale is 9/10• Monitor heart rate• Take note for any reactions of the patient to the drug or therapy.• Prevent any side effects that may arise.• Be aware of the drug contraindications and drug interactions that may affect the action of the drug.• Be alert for drug adverse reactions and interactions.

3) Education 4) Evaluation


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• Educate patient to possible side effects of the drug. March 15, 2012 0800H, Pain scale of 7/10 but relieved

after medication.


6. What are the priority nursing problems identified? What should the nurse plan to render a quality health care in terms of identified problems?


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Nursing Diagnosis #1: Acute pain related to irritation/disruption of gastric tissue as evidenced by pain scale of 7/10.

Goal: To alleviate pain.

Rationale: In patients with gastric ulcer, pain is primarily the cause of the patient’s discomfort. Therefore, this is the first problem which healthcare providers tend to. This is caused by the irritation and erosion of the gastric mucosa by the excessive secretion of HCl (Smeltzer, 2009). This in turn causes a gnawing or burning pain in the epigastric region of the abdomen (Marieb, 2006).

Expected Outcomes:

At the end of 8 hours of nursing intervention, the patient will:

Report that pain is relieved/controlled Follow prescribed pharmacological regimen Demonstrate use of relaxation skills and diversional activities as indicated.

Interventions Evaluation

Independent:

1. Assessed characteristics of pain: location, severity, type, frequency, precipitating and relieving factors.

2. Encouraged verbalization of feelings.3. Monitored for changes in vital signs.4. Observed for nonverbal cues of pain.5. Note response to medications and report to

physician if pain is not being relieved.6. Promoted bed rest, allowing her to assume

position of comfort.7. Provided with calm and safe environment and

provided with adequate periods conducive for rest.

At the end of the nurse-patient relationship, the patient denies recurrence of abdominal pain. She was able to rest well and verbalizes a pain scale of 0/10.

USER, 04/09/12,

past tense ata dapat sa eval, thanks


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8. Encouraged to do deep breathing exercises and suggested diversional activities such as watching TV.

9. Reinforced use of call light as needed.10. All needs were attended to.

Dependent:

1. Assisted in administration of pain medication (Tramadol and Buscopan). – kla pakicheck sa data natin kung nagbigay ba nito nung time of care natin, nde ko ma verify sa patients data eh

GOAL MET

Nursing Diagnosis #2: Ineffective gastrointestinal tissue perfusion related to decreased levels of RBC as evidenced by abdominal pain and tenderness


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Goal: To promote effective tissue perfusion

Rationale: Ineffective tissue perfusion is defined as the failure to nourish the tissues in the capillary level (Doenges, 2008). The lack of oxygen supplied to the tissues causes the production of lactic acid in the area thus causing pain. It is important to promote good perfusion to the affected areas to promote better circulation and to prevent the chances of development of further problems.

Expected Outcomes:


Demonstrate increased perfusion as individually appropriate (vital signs within normal limits, balanced intake/output, free of pain/discomfort)


Independent:

1. Assessed general health condition.2. Monitored for changes in vital signs and level of

consciousness.3. Evaluated for signs of infection.4. Noted for reports of nausea/vomiting.5. Assessed location, severity, and quality of

abdominal pain.6. Auscultated bowel sounds.7. Noted for changes in characteristics and

frequency of stool and abdominal distention.8. Reviewed laboratory studies (CBC).9. Encouraged small frequent feedings.

Dependent:

At the end of the nurse-patient relationship, the patient’s vital signs were within her normal limits and was afebrile. She verbalized that she does not feel pain. Bowel movements seem to be regular with 2-3 bowel movements per day. There were no reports of nausea and vomiting.


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2. Assisted in administration of pain medication (Tramadol and Buscopan). kla pakicheck sa data natin kung nagbigay ba nito nung time of care natin, nde ko ma verify sa patients data eh

1.

GOAL MET

Nursing Diagnosis # 3: Imbalanced nutrition: less than body requirements related to inability to digest food properly as evidenced by BMI of 18.3 (underweight)

Goal: To promote balanced nutrition


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Rationale: The risk of being underweight is that the body has fewer energy reserves, in cases of illness this can worsen the condition and delay the recovery time.

Expected Outcomes:


Experience no aspiration as evidence by: noiseless respirations, and clear breath sounds. Verbalize understanding of risk factors and appropriate interventions. Demonstrate behaviors/lifestyle changes to prevent developing potential problem.


Independent:

1. Weighed as indicated.2. Consulted with patient about likes/dislikes, foods

that cause distress, and preferred meal schedule.3. Provided a pleasant environment at mealtime,

remove noxious stimuli.4. Provided oral hygiene before meals.5. Assessed for abdominal distention, frequent

belching, guarding behavior, and reluctance to move.

6. Assisted in ambulation as the patient tolerates.

Interdependent:

1. Coordinated with the Dietary Department to plan the patient’s diet based on her dietary needs. –

At the end of the nurse-patient relationship, the patient’s current weight is at 41.20 kg and the same BMI (18.3 – underweight). The patient was able to verbalize that she dislikes fatty foods and eats a lot of fruits and vegetables. The patient also admits to drink only 4-5 glasses of water a day and she also drinks alcohol and a lot of coffee (about 3-4 times a day). She also admits to skipping meals or having them at a later time. There is no abdominal distention or other discomforts noted, and patient was able to tolerate food well.


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GOAL PARTIALLY MET

Nursing Diagnosis # 4: Mild anxiety related to upcoming diagnostic procedure.

Goal: To ease anxiety

USER, 04/09/12,

hm, ipapalabas ba natin na nahandle sya before procedure?


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Rationale: Anxiety can be defined as a vague uneasy feeling of discomfort or dread accompanied by an autonomic response and a feeling of apprehension caused by anticipation of danger (Doenges, 2008). More often, anxiety in hospitalized patients is caused by lack of information about diagnostic procedures and about their health plan. Anxiety can trigger the body’s parasympathetic response and produce symptoms such as abdominal pain (Doenges, 2008) which in turn can aggravate the patient’s condition who is already suffering from abdominal discomfort.

Expected Outcomes:


Appear relaxed and report that anxiety is reduced to a manageable level Verbalize awareness of feelings of anxiety Use resources/support systems effectively


Independent:

1. Assessed general health condition and level of anxiety.

2. Established a therapeutic relationship with the patient conveying empathy.

3. Monitored for changes in vital signs.4. Observed for behavior which can point to the

patient’s level of anxiety.5. Observed for defense mechanisms being used.6. Encouraged patient to verbalize feelings.7. Provided calm environment conducive for rest.8. Promptly addressed the patient’s concerns by

answering their questions honestly and referring them to the proper individuals if the need arises.

At the end of the nurse-patient relationship, the patient is free from anxiety and was able to verbalize her feelings.

Nursing Diagnosis #5: Risk for aspiration related to incompetent cardiac sphincter secondary to GERD


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Goal: To prevent aspiration

Rationale: It is important to watch out for signs of aspiration especially in persons with GERD. If the refluxed fluids enter the pharynx and the larynx, it can result in coughing and choking. It can also cause pneumonia when the fluid causes inflammation within the lungs.

Expected Outcomes:


Maintain usual pattern of bowel functioning. Verbalize understanding of risk factors and appropriate interventions Demonstrate behaviors/lifestyle changes to prevent developing potential problem.


Independent:

1. Assessed general health condition and noted risk factors for aspiration.

2. Noted level of consciousness.3. Elevated head of bed to highest possible position

during mealtimes and encouraged the patient to sit up in bed when eating or drinking.

4. Advised to sit up in bed for at least 2 hours after eating to prevent reflux.

5. Encouraged to eat small frequent feedings.

At the end of the nurse-patient relationship, there was no incidence of aspiration noted. There was also no episode of vomiting noted. The patient was also able to tolerate her food well.

GOAL MET

Nursing Diagnosis #6: Risk for constipation related to fecal impaction secondary to pyloric stenosis

USER, 04/09/12,

Pwede p kyang pyloric stenosis? Status post pylorotomy n ksi sya ee


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Goal: To promote functional bowel elimination.

Rationale: Having a risk for constipation means that the patient is at risk for a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool (Doenges, 2008). Constipation can also be brought about by not eating enough foods containing fibers and not drinking enough water. The longer the stool is contained in the colon, the greater are the chances of it causing infection.

Expected Outcomes:


Maintain usual pattern of bowel functioning. Verbalize understanding of risk factors and appropriate interventions Demonstrate behaviors/lifestyle changes to prevent developing potential problem.


Independent:

1. Assessed general health condition.2. Auscultated abdomen for presence, locations, and

characteristics of bowel sounds reflecting bowel activity.

3. Encouraged to increased oral fluid intake.4. Encouraged early ambulation as tolerated.5. Assessed frequency, color, consistency, and

amount of stools.

Dependent:

1. Assisted in administration of stool softeners (Lactulose)

At the end of the nurse-patient relationship, the patient shows a low risk for constipation, as evidenced by (+) bowel movement of 2-3 times a day. Stool is soft and brown.

GOAL MET


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Nursing Diagnosis #7: Readiness for enhanced comfort as evidenced by appearance of being relaxed and active cooperation in plan of care

Goal: To promote enhanced comfort

Rationale: Readiness for enhanced comfort is defined as a pattern of ease and relief in a person’s different biopsychosocial dimensions (Doenges, 2008). It is important to recognize this pattern in the patient so that health teachings can readily be taught with the cooperation of the patient herself.

Expected Outcomes:


Verbalize sense of comfort Demonstrate behaviors of optimal level of ease Participate in desirable and health-seeking behaviors.


Independent:

1. Verified on how the client is managing pain and pain components effectively.

2. Assisted patient in discovering nonphramacological methods for pain management like guided imagery, and breathing exercises.

3. Provided with comfort measures.

Interdependent:

1. Collaborated with other members of the health team in treating/managing medical conditions involving oxygenation, elimination, mobility, electrolyte balance, and hydration to promote stability.

At the end of the nurse-patient relationship, the patient was able to verbalize that she was feeling fine and denies any further discomforts. She was able to rest and sleep well.


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GOAL MET

Nursing Diagnosis #8: Readiness for enhanced therapeutic regimen management

Goal: To promote enhanced therapeutic regimen management


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Rationale: Readiness for enhanced therapeutic regimen management is defined in NANDA as a pattern of regulating an integrating into daily living a program for treatment of illness and it sequelae that is sufficient for meeting health-related goals and can be strengthened.

Expected Outcomes:

At the end of the nurse-patient relationship, the patient will:

Assume responsibility for managing treatment regimen Demonstrate proactive management by anticipating and planning for the likelihood of

potential complications Identify and use available resources Remain free of preventable complications/progression of disease.


Independent:

1. Verify client’s knowledge of the therapeutic regimen.

2. Involved patient and he significant others in the plan of care.

Dependent

1. Reviewed take-home medications with the patient, taking note of dosage and frequency of intake.

2. Instructed as to when the patient is to return for her check-up.

At the end of the nurse-patient relationship, the patient was able to verbalize that she understood the discharge instructions that were given to her.

GOAL MET

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

Summary of Findings:


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I. Factors that led to the development of the problem:

Predisposing factors: Female Family history of Constipation (grandmother and mother)

Precipitating factors: Sedentary lifestyle Caffeine and excessive alcohol intake Poor eating habits (skipping meals and binge eating)

Perpetuating Stress

II. Interrelationship of factors identified that led to the development of multiple gastrointestinal problems such as Fecal retention, Gastritis, Gastric Ulcer, GERD-A:

According to studies, women are more likely to have digestive diseases than men since women are more sensitive to irritants in the digestive system. Moreover, women are more reportedly to have higher stress level than men which can aggravate digestive diseases. In relation to the case, the patient is a female and a law student. The patient admitted that she was experiencing severe stress rating of 10/10 because of heavy load of school works. With this, the patient experienced poor eating habits (eating a large bulk of meal not on time and only twice a day). To cope up with stress, the patient drinks coffee about 3-4 cups per day and have tried drinking alcoholic beverage 6-7 bottles a day for 2 weeks straight. With the factors mentioned that led to inflammation of gastric lining because of increase in gastric acid production, patient was diagnosed with gastritis. Furthermore, excessive gastric acid production led to gastric lining ulcerations. From this, formed scars from healing ulcers can lead to the thickening of the mucosal lining and most probably the pylorus of the stomach, thus leading to pyloric stenosis. To relieve such condition the patient underwent pylorotomy last January 2012. In addition, scarring or swelling of tissues from stomach to small intestine delays gastric emptying which caused increased pressure in lower esophageal sphincter making it incompetent, thus, patient was diagnosed with GERD.

Conclusions


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Based on the analysis of the different factors identified, the researcher therefore concluded that

the factors that led to the development of multiple gastrointestinal problems such as Fecal retention,

Gastric Ulcer, Gastritis and Erosive GERD grade A are multi-factorial in nature.

Recommendations

Based on the summary of findings and conclusion, the following are being recommended:

1. To the patient, that strict obedience will be implemented to the prescribed therapeutic regimen

after discharge.

2. To the family, to be able to provide a positive environment and support to help the patient in

recovering from her condition. The researchers also recommend that they read materials

regarding the prevention and treatment to promote knowledge within the family regarding this

condition.

3. To the healthcare team, that they thoroughly assess future patients with the same

manifestations to easily diagnose patients and provide healthcare immediately and prevent

further complications. Also, we recommend that they would continue to update recent studies

regarding this kind of condition in order to provide optimum health care service to future

patients.

4. To the Training Department, that they provide trainings and seminars for the enhancement of

nurses’ knowledge, skills and attitude in handling patients with such conditions upon admission

to discharge.


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5. To the Nursing Services Division, that holistic care will be provided by nurses effectively and

efficiently to patients who have multiple gastrointestinal problems. Programs may also be given

to nurses to develop the competence in caring for patients with similar condition. Moreover,

follow-ups may be conducted to guarantee the compliance of the patient with the discharge

instructions given and the progress in the patient’s health condition.

REFERENCES


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BOOKS

Porth, C (2005) Pathophysiology: Concepts of Altered Health Status. Quezon City Phippines. Lipincott William&Wilkins and C&E Publishing Inc.

Spratto, G. and Woods, A. (2008). 2008 Edition PDR Nurses’ Drug Handbook. Thomson Delmar Learning

JOURNALS / ARTICLES

C. T. HOWE, B.M., B.CH. Pyloric Stenosis in Adults Retrieved April 5, 2012 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2482055/pdf/postmedj00481-0045.pdf

INTERNET SOURCES

Best, M. (n.d.) Hematocrit. Retrieved April 5, 2012 from http://www.surgeryencyclopedia.com/Fi-La/Hematocrit.html#b#ixzz1rAcsWLIW

Zieve, D et al (2010). CBC. ADAM Inc. Retrieved April 5, 2012 from http://www.nlm.nih.gov/ medlineplus/ency/article/003642.htm

Best, M. (n.d.) Hematocrit. Retrieved April 5, 2012 from http://www.surgeryencyclopedia.com/Fi-La/Hematocrit.html#b#ixzz1rAcsWLIW

Patti, M.G. (2012). Gastroesophageal reflux disease. Retrieved from http://emedicine.medscape.com/article/176595-overview#a0104

OTHERS

APPENDICES


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Documents

A2A round3