IA. Background of The Study

CASE STUDY: Peptic Ulcer Disease
February 10, 2010
I.INTRODUCTION
IA. Background of the Study
DEFINITION:
An excavation (hollowed-out area) that forms in the mucosal wall of the stomach, in the pylorus
(the opening the stomach and duodenum), in the duodenum (the first part of small intestine), or in the
esophagus. Erosion of a circumscribed area of mucous membrane is the cause. This Erosion may extend
as deeply as the muscle layers or through the muscle to the peritoneum
CLASSIFICATION:
 Stomach (called gastric ulcer)
 Duodenum (called duodenal ulcer)
 Esophagus (called esophageal ulcer)
 Meckel's Diverticulum (called Meckel's Diverticulum ulcer)
TYPES:
 Type I: Ulcer along the lesser curve of stomach
 Type II: Two ulcers present - one gastric, one duodenal
 Type III: Prepyloric ulcer
 Type IV: Proximal gastro esophageal ulcer
 Type V: Anywhere along gastric body, NSAID induced
CAUSES:
 Alcohol
o Alcohol can irritate and erode the mucous lining of your stomach and increases the
amount of stomach acid that's produced. It's uncertain, however, whether this alone can
progress into an ulcer or whether other contributing factors must be present, such as H.
pylori bacteria or ulcer-causing medications, such as NSAIDs.
 Nonsteroidal Anti-inflammatory Drug (NSAID)
o
 Tobacco Smoking
o Nicotine contained in cigarettes can increase parasympathetic nerve activity to the
gastrointestinal tract by acting on the nicotinic receptors at synapses - increased
stimulation to the enterochromaffin-like cells and G cells increases the amount of
histamine and gastrin secreted and therefore increases the acidity of the gastric juice.
o Similarly, glucocorticoids lead to atrophy of all epithelial tissues. However, these factors,
along with diet or spices, blood type, and other factors suspected to cause ulcers until late
in the 20th century, are actually of relatively minor importance in the development of
peptic ulcers.
 Stress
o Researchers also continue to look at stress as a possible cause, or at least complication, in
the development of ulcers. There is debate as to whether psychological stress can
influence the development of peptic ulcers. Burns and head trauma, however, can lead to
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February 10, 2010
physiologic stress ulcers, which are reported in many patients who are on mechanical
ventilation.
 Caffeine
o Caffeine seems to stimulate acid secretion in the stomach, which can aggravate the pain
of an existing ulcer. However, the stimulation of stomach acid cannot be attributed solely
to caffeine.
SIGNS AND SYMPTOMS

 EPIGASTRIC PAIN
o Duodenal Ulcer
 occurs 2-3 hrs after a meal; often awakened 1-2 AM(when gastric secretion tends
to be greatest): ingestion of food relieves pain
o Gastric Ulcer
 occurs ½ to 1 hr after a meal; rarely occurs at night; may be relieve by vomiting;
ingestion of food does not help, sometimes increases pain
 BLOATING or ABDOMINAL FULLNESS
o Due to excessive flatulence
 PYROSIS (HEARTBURN)
o A burning sensation usually in the midsternal area caused by reflux of gastric contents
into the esophagus
 NAUSEA AND VOMITING
o Nausea is the feeling of gastric uneasiness characterized by the urge to vomit. Vomiting
is the expulsion of gastric contents, most commonly an involuntary response
PREVELANCE RATE
 Mortality/Morbidity
o Complications of gastritis include PUD and, rarely, extensive bleeding.
o PUD remains a major cause of upper gastrointestinal bleeds in the United States.
o Ulcer perforation can lead to peritonitis and sepsis (rare).
o Other complications include gastric outlet obstruction and adenocarcinoma.
o The overall mortality rate is estimated at 1:100,000.
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February 10, 2010
II.OBJECTIVES
General Objectives:
Utilizing the nursing process, the group’s foremost objective is to gain knowledge about PEPTIC
ULCER DISEASE and to understand the care rendered.

Specific Objectives:
 To be able to do an ASSESSMENT of a patient with Peptic Ulcer Disease which include but are
not limited to:
o Performing physical assessment
o Interviewing the patient about her patterns of functioning
o Finding out about patient’s medical history

 To formulate appropriate NURSING DIAGNOSIS of the actual problems encountered by the
patient.

 To create NURSING CARE PLANS that would address the problems identified
 To understand medical treatment rendered to patient with Peptic Ulcer Disease

 To IMPLEMENT the nursing care plan prepared for the patient.
 To EVALUATE the effectiveness of the nursing interventions rendered
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February 10, 2010
III.THEORETICAL FRAMEWORK
Dorothea Orem’s Theory of Self-care
Orem’s theory focuses on each individual’s ability to perform self-care, defined as the “The
practice of the individuals initiate and perform on their own behalf in maintaining life, health, and well-
being.”
Each individual is viewed as a self-care agent who possesses capabilities termed self-care agency
that is essential o performing self-care action. Deliberate action is undertaken to meet the therapeutic self-
care demand but known needs for care. This varies throughout life. If the demand is not met, a self-care
deficit exists, which notes the need for nursing. This is a joint decision between the nurse and the patient.
The role of the nurse is to facilitate and increase the self-care abilities of the individual. Problems
identification consists of 1. Assessing the care demands of the individual patient and 2. The ability of the
patient to independently meet the self-care demand.
Orem has identified three classification of nursing system to meet the self-care requisites of the
patient. These systems are the wholly compensatory system, the partly compensatory system, and the
supportive educative system.
The wholly compensatory nursing system is represented by a situation in which the individual is
unable “to engage in those self-care actions requiring self-directed and controlled ambulation and
manipulative movement or the medical prescription to refrain from such activity. (Orem, 1991, p.289)
The partly compensatory nursing system is represented by a situation in which “both patient and
nurse perform care measure or other actions involving manipulative tasks or ambulation. The patient or
the nurse may have the major role in the performance of care measures.”
The third nursing system is the supportive educative system. In this system, the person “ is able to
perform or can and should lean to perform required measures of externally or internally oriented
therapeutic self-care but cannot do so without assistance”. This is also known as a supportive-
development system. In this system, the patient is doing all of the self-care. The patient’s requirements for
help are confined to decision making, behavior control, and acquiring knowledge and skills” the nurse’s
role then, is to promote the patient as a self-care agent
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February 10, 2010
Dorothea Orem’s Theory of Self-care
IV.PATIENT’S PROFILE
NAME Mr. M.F.J

ADDRESS 137 K-3rd St. Kamuning Quezon City
AGE 49
SEX Male
CIVIL STATUS Married
RELIGION Roman Catholic
BIRTHDAY July 16. 1960
BIRTHPLACE Quezon City
ATTENDING
Dr. Babaran
PHYSICIAN
MEDICAL Upper Gastrointestinal Bleeding
DIAGNOSIS secondary to Peptic Ulcer Disease
CHIEF
Black Tarry Stool x4 days
COMPLAINT
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February 10, 2010
V.MEDICAL HISTORY
A. History of Present Illness:
 3-4 days prior to admission, patient having experience of blackish stools, soft, no
abdominal pain, 80cc vomiting with rusty colored saliva. Persistence of illness lead to
consult. The patient is frequently taking NSAID’S at least once a week for headache and
misses meals. He is a smoker and a heavy drinker
B. Past Medical History
 The patient is known to be Hypertensive (Pretor Pulse) now on Combizar. The patient is
not known to have Diabetes Mellitus and Cancer
C. Family Medical History
 The patient’s family is known to have Diabetes Mellitus and Asthma on his mother side
and Hypertension, Diabetes Mellitus and Asthma on his father side His father died
because of heart attack.
D. Personal/Social History
 The patient is a smoker and consumes 2 packs per day and a heavy alcoholic drinker at
about 10 bottles a day.
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February 10, 2010
E. Environmental History
 The patient lives in a subdivision and verbalizes that their surroundings is somehow
polluted and thought to contribute to his present condition. The patient is frequently eats
in carinderias
VI.PATTERNS OF FUNCTIONING
Functional Health
Before Hospitalization During Hospitalization Analysis
Perception
Health Perception The patient drinks The patient takes his This shows that the
brandy before eating medications everyday patient’s ignorance
daily and sometimes, knowing that this would regarding what he felt
not eating at all. He also help in his recovery. He and the effects of
smokes 2 packs of stopped smoking drinking without eating
cigarettes a day. He cigarettes two months have contributed to his
started his vices when ago due to realizing that condition.
he’s in 2nd year high it would be dangerous to
school. One day, he felt his health.
a GI disturbance and
just ignored it. He kept
on doing his daily
routine until the day he
moved his bowel and
found out that blood is
present in his stool.
After that, he blacked
out and experienced
DOB.
Nutritional Metabolic The patient doesn’t eat The patient’s appetite The patient has
breakfast. He eats his increased due to his increased nutritional
lunch normally at home compliance with the diet intake because he now
consisting of 1 of cup of the doctor gave him. His eats three meals a day
rice and his wife’s drinking pattern of and doesn’t drink any
dishes like meat or fish alcohol is now alcoholic beverages, just
with vegetables. decreased because it is water.
Sometimes he eats at prohibited in the
eateries not ensuring the hospital, so now, his
cleanliness of the food, water consumption
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February 10, 2010
but he emphasized that increased.
as long as it’s cooked,
it’s clean enough for
him.
Elimination The patient defecates The patients still The patient’s
everyday and urinates defecates and urinates elimination pattern has
without having everyday without improved because there
problems, but having problems, but is no more presence of
sometimes, blood is still there is presence of blood in his stool.
present in his stool. He blood. Fortunately, due
emphasized that he feels to the medications he’s
uncomfortable if he taking, the presence of
wasn’t able to move a blood decreased until
day. it’s gone.
Functional Health
Perception
Activity Exercise The patient plays The patient does not The patient has limited
basketball before. have an activity in the activity due to his
hospital because he’s condition.
just staying on bed and
watching TV. But
sometimes he ambulates
around the room.
Sleep and Rest The patient verbalized The patient has The patient’s sleeping
that he sleeps at 9pm up interrupted sleeping and pattern has changed in
to 2am. He then sleeps rest patterns due to the hospital because he
again at 4am and wakes intrusions of medical usually lacks sleep.
up at 7am. This is his staffs.
regular pattern of
sleeping.
Role Relationship The patient doesn’t have The patient’s family The patient’s family
any problem with bond strengthened bond became stronger.
regards to his because his family gives
relationship with his him full support
family. everyday.
Coping Stress/ The patient usually The patient has now The patient has
Tolerance copes with stress by difficulty in coping with improved his coping
drinking alcoholic stress because of being mechanism because he
beverages and smoking admitted in the hospital realized that what he
cigarettes while but he realized that his was doing before was a
watching TV. He coping mechanism to factor that caused his
sometimes drinks stress before was wrong. condition and he is
alcoholic beverages to willing to change it.
facilitate sleeping.
Value Belief The patient has good The patient’s faith to The patient has a
faith to his creator. He God had grown more stronger faith to God.
prays always and asks due what happened.
for divine interventions.
The patient said that he
was baptized as a
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February 10, 2010
Roman Catholic and
proclaims that he is a
Christian.
Cognition and Patient is a college The patient’s cognition The patient’s perception
Perception graduate of Education. and senses remained and cognition remained
He is literate and speaks active and participates as before he was
well of his own ideas. in every care that was hospitalized.
given to him.
Functional Health
Perception
Self perception and The patient was not The patient was now The patient’s self
Self concept aware of his condition aware that his lifestyle realization made him
of having peptic ulcer before was a significant change for the better.
disease. He still factor in acquiring his
continues to drink and disease. He is now
smoke everyday even willing to change that
though he noticed for lifestyle and preserve
the first time that there anything that can lead to
is presence of blood in atrophy.
his stool. He did not
consult a physician
when this happened
because he did not
experience any pain in
defecation. He usually
self medicates when he
feels something wrong
and visits the doctor
only if that condition
worsens.
Sexual relationship The patient’s status is The patient’s sexuality No visible and
and Reproduction married. They have 4 and reproduction important changes were
children remained the same. noted in this pattern.
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February 10, 2010
VII.LABORATORY AND DIAGNOSTIC

EXAMINATION
COMPLETE BLOOD COUNT
 January 29, 2010

RESULTS REFERENCE ANALYSIS
BLOOD TYPE O+
HEMOGLOBIN L 85 Male: 135 - 160 Decrease due to
Female: 120 - 150 blood loss (melena)
severe hemorrhage
HEMATOCRIT L 0.24 Male: 0.40 - 0.48 Decrease due to
Female: 0.37 – 0.45 blood loss (melena)
severe hemorrhage
ERYTHROCYTE L 2.56 Male: 4.5 – 5.0 Decrease due to
Female: 4.0 – 5.0 blood loss (melena)
severe hemorrhage
MCV 94.90 80 - 96 Normal
MCH 33.20 27 - 33 Normal
MCHC 35.00 33 – 36 Normal
TOTAL WBC 93 5.0 – 10.0 Normal
NEUTROPHIL 0.60 0.55 – 0.65 Normal
LYMPOCYTES 0.38 0.25 – 0.40 Normal
MONOCYTES 0.01 0.02 – 0.06 Normal
EOSONOPHIL 0.01 0.01 – 0.050 Normal
BASOPHIL 0 0 – 0.005 Normal
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February 10, 2010
STAB 0 0.01 – 0.05 Normal
PLATELET Normal Normal
 January 31, 2010

Male: 135 - 160 Decrease due to
HEMOGLOBIN L 99 Female: 120 – 150 blood loss (melena)
severe hemorrhage
Decrease due to
Male: 0.40 - 0.48
HEMATOCRIT L 0.29 blood loss (melena)
Female: 0.37 – 0.45
severe hemorrhage
Decrease due to
Male: 4.5 – 5.0
ERYTHROCYTE L 2.45 blood loss (melena)
Female: 4.0 – 5.0
severe hemorrhage
PLATELET 245 150-440 Normal
 February 01, 2010

Decrease due to
Male: 135 - 160
HEMOGLOBIN L 99 blood loss (melena)
Female: 120 - 150
severe hemorrhage
Decrease due to
Male: 0.40 - 0.48
HEMATOCRIT L 0.30 blood loss (melena)
Female: 0.37 – 0.45
severe hemorrhage
BLOOD CHEMISTRY REPORT

 January 29, 2010
NORMAL
TEST NAME RESULT UNITS ANALYSIS
VALUE
GLUCOSE 6.7 mmol/L 3.90-6.10 Normal
CHOLESTEROL 4.7 mmol/L 0.00-6.20 Normal
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February 10, 2010
CHEMISTRY REPORT (LIVER FUNCTION)

 January 29, 2010
NORMAL
RESULT UNITS ANALYSIS
VALUE
Indicates
AST HI 101 u/L 15.00-37.00 pronounced
liver damage
Indicates
ALT HI 92 u/L 30.00-65.00 pronounced
liver damage
ALKALINE
67 u/L 43.00-122.00 Normal
PHOSPATE
TOTAL
7.38 umol/L 0.00-17.10 Normal
BILIRUBIN
DIRECT
4.86 umol/L 0.00-5.00 Normal
BILIRUBIN
TOTAL PROTEIN 63.4 g/L 55.00-72.00 Normal
ALBUMIN 34.5 g/L 40.00-55.00 Normal
GLOBULIN 28.90 g/L 15.00-35.00 Normal
A/G RATIO 1.19 1.10-2.40 Normal
 January 30, 2010

NORMAL
VALUE
Indicates
liver damage
Indicates
liver damage
ALKALINE
69 u/L 43.00-122.00 Normal
PHOSPATE
Indicates
TOTAL
HI 19.01 umol/L 0.00-17.10 pronounced
BILIRUBIN
liver damage
DIRECT HI 8.36 umol/L 0.00-5.00 Indicates
BILIRUBIN pronounced
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February 10, 2010
liver damage
ALBUMIN 37.6 g/L 40.00-55.00 Normal
 January 31, 2010

NORMAL
VALUE
Indicates
liver damage
Indicates
liver damage
ALKALINE
67 u/L 43.00-122.00 Normal
PHOSPATE
TOTAL
7.38 umol/L 0.00-17.10 Normal
BILIRUBIN
DIRECT
4.86 umol/L 0.00-5.00 Normal
BILIRUBIN
Suggest liver
ALBUMIN LO 34.5 g/L 40.00-55.00
disease
FECALYSIS
 February 01, 2010
RESULT ANALYSIS
CHARACTER FORMED Normal

COLOR BROWN Normal
BLOOD NEGATIVE Normal
MUCUS NEGATIVE Normal
PARASITES NO OVA OR PARASITES, NO Normal
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February 10, 2010
PROTOZOA
ROENTGENOLOGICAL REPORT (01/29/10)

 EXAMINATION (CHEST AP)
 Lungs are both cleared
 Heart, diaphragm, casopherenicsinuses and underlying osseous structure are intact
 Impression:
o Normal Chest Findings
ULTRASOUND OF THE WHOLE ABDOMEN (01/30/10)

 Impression:
o Hepatomegaly with fatty infiltration
o Partially contracted gallbladder with calculi
o Non-dilated biliary tree
o Normal ultrasound of the pancreas, kidneys spleen, abdomen aorta and prostate gland
ENDOSCOPY (01/30/10)
 Clinical Problem: Melena
 Indication: Melena
 Pre-endoscopic Impression: UGIB-PUB
 Findings:
FINDINGS RESULT ANALYSIS
ESOPHAGUS At the end of the distal Indicates esophageal ulceration
esophagus CE junction with ulcer
about 1.5cm boozing from
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February 10, 2010
margin noted
CE JUNCTION Normal
 Cardia  Normal Normal
 Fundus  Normal
BODY
 ANTERIOR WALL  Normal Normal
 POSTERIOR WALL  Normal
ANTUM Normal Normal
PYLORIC RING Normal Normal
DUODENAL BULB Normal Normal
POST BULBAR Normal Normal
 Endoscopic Impression:
o Esophageal Ulcer
 Duration: 8 minutes
VIII.PHYSICAL EXAMINATION
Part of the Body Normal Findings Actual Findings Interpretation

Skin Color varies from light to deep ● Pale skin color Dry skin due to fluid
brown; from ruddy Pink to light ● Uniform in skin volume loss and pale
pink; from yellow overtones to color skin due to bleeding
olive ● Dry skin
Generally uniform in skin color, ● No edema
except in areas exposed to sun; ● Dry skin
areas of lighter pigmentation ● Uniform
(palms, lips, nail beds) in dark temperature
skinned people ● When pinched,skin
No edema present springs back to
Moisture in skin folds and axillae previous state
(varies with environmental
temperature & humidity, body
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February 10, 2010
temperature & activity)

Uniform temperature; within
normal range
When pinched, skin springs back
to previous state
Evenly distributed hair over the ● Hair evenly

scalp distributed
There are no
Thick hair ● Thick silky and
abnormalities in the
Hair Silky, resilient hair resilient hair
patients hair
No infection or infestation ● No present
Variable body hair infection or
infestation
Convex curvature; angle of nail
plate about 160 degrees
● Concave curvature;
Smooth texture
160 degrees nail plate
Fingernails and toenails are
angle
highly vascular & pink in light-
● Fingernails and
skinned clients; dark skinned
toenails are pale in Finger nails and
clients may have brown or black
Nails color toenails are pale due
pigmentation in longitudinal
● Intact epidermis to bleeding
streaks
surrounding nails
Intact epidermis surrounding the
● Capillary refill less
nails.Prompt return of pink or
than 3 seconds
usual colour (generally less than 4
seconds)
Part of the Body Normal findings Actual findings Interpretation

Rounded in shape (normocephalic
and symmetrical, with frontal,
parietal & occipital prominences);
●Skull normal in
smooth skull contour
shape
Smooth, uniform in consistency;
●No nodules or Skull and face have
absence of nodules or masses
Skull & Face masses no abnormalities
Symmetric or slightly asymmetric
●Symmetrical facial
facial features; palpebral fissures
movements
equal in size; symmetric
nasolabial folds
Symmetric facial movements
Eyes Eyebrows hair are evenly ●Eyebrows hair are

distributed; skin intact distributed evenly
Eyebrows symmetrically aligned; and both eyebrow are
equal movement symmetrical in shape
Equally distributed eyelashes; ●Eyelashes equally
curled slightly outward distributed and is
Eyelids skin intact; no discharge; slightly curled
no discoloration outward
Lids close symmetrically ●Eyelids skin intact
Approximately 15-20 involuntary without discoloration
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February 10, 2010
blinks per minute; bilateral
blinking
or discharge and is
When eyelids open, no visible
closing
sclera above the corneas, and
symmetrically
upper and lower corneas are
●At least 15 to 20 Pale conjuctive due to
slightly covered
involuntary blinks blood loss.
Transparent bulbar conjunctiva;
per minute
capillaries sometimes evident;
●No visible sclera
sclera appears white (yellowish in
above the cornea
dark-skinned clients)
●Transparent bulbar
Shiny, smooth palpebral
pale conjunctiva
conjunctiva; pink or red in color
●Anicteric sclera
No edema or tenderness over the
●Shiny smooth
lacrimal sac
palpebral conjuctiva
No edema or tearing from the
●No edema over
lacrimal sac and nasolacrimal
lacrimal sac
duct
Transparent, skinny and smooth
cornea; details of the iris are
visible
In order people, a thin, grayish
white ring around the margin,
called arcus senilis, may be
evident
Parts of the body Normal findings Actual findings Interpretation

Eyes No edema or tearing from the ●Eyebrows hair are Pale conjuctive due to
lacrimal sac and nasolacrimal distributed evenly blood loss
duct and both eyebrow are
Transparent, skinny and smooth symmetrical in shape
cornea; details of the iris are ●Eyelashes equally
visible distributed and is
In order people, a thin, grayish slightly curled
white ring around the margin, outward
called arcus senilis, may be ●Eyelids skin intact
evident without discoloration
Client blinks when the cornea is or discharge and is
touched, indicating that the closing
trigeminal nerve is intact symmetrically
Transparent anterior chamber ●At least 15 to 20
No shadows of light on iris involuntary blinks
Depth of about 3 mm per minute
Pupils are black in color; equal in ●No visible sclera
size; normally 3- 7mm in above the cornea
diameter; round, smooth border, ●Transparent bulbar
iris flat and round conjunctiva
Illuminated pupil constricts ●Anicteric sclera
(direct response) ●Shiny smooth
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February 10, 2010
Non-illuminated pupil constricts
(consensual response)
palpebral conjuctiva
●No edema over
Pupils constrict when looking at
lacrimal sac
near objects; pupils dilate when
●Transparent,skinny
looking at far objects; pupils
and smooth cornea
converge when near object is
●Pupils black in
moved toward the nose
color equal in size,
(Visual fields) when looking
round, smooth border
straight ahead, client can see
●Pupils constrict and
objects in the periphery.
dilate in relation to
(Extraocular Muscle Tests)
the distance of the
Both eyes coordinated, move in
distance of objects
unison with parallel alignment
being looked at
(Visual Acuity) Able to read
●Client can see the
newsprint
periphery when
20/20 vision on Snellen Chart
looking straight
●Both eyes
coordinated, move in
unison with parallel
alignment
●Able to read
newsprint
20/20 vision on
Snellen Chart

Auricles are same with facial skin ●Auricle is
color symmetrical and its
Symmetrical color is same with
Auricle aligned with outer skin color
canthus of the eye, about 10 ●Auricle aligned
degrees form vertical with outer canthus of
Auricles are mobile, firm & not eye and recoils when
tender; pinna recoils after it is folded
folded ●Distal third of
Distal third contains hair follicles auricle has hair
No ear and hearing
& glands follicles and glands
Ears abnormalities
Dry cerumen, grayish-tan color; ●Can hear normal
sticky, wet cerumen in various voice
shades of brown ●Able to hear ticking
Pearly gray color, semitransparent in both ears/localized
tympanic membrane at the center of the
(Gross Hearing Acuity Tests) head
Normal voice tones are audible ●Air conducted
Able to hear ticking in both ears hearing is greater
Sound is heard in both ears or is than bone conducted
localized at the center of the head hearing
(Weber negative)
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February 10, 2010
Air conducting (AC) hearing is
greater than bone – conducted
(BC) hearing, (positive Rinne)
●Symmetrical and
Symmetrical & straight in shape straight
& size ●No discharge or
No discharge or flaring flaring
Uniform in color ●Uniform in color
Not tender; no lesions ●Not tender and
Air moves freely as the client without lesions No nasal
Nose & Sinuses breathes through the nares ●Air moves freely abnormalities
Mucosa pink when breathing
Clear watery discharge ●Clear watery
No lesions discharge
Nasal sputum intact & in midline ●Nasal septum at
No tenderness with the maxillary midline and intact
& frontal sinuses ●No tenderness on
maxillary and frontal
Uniform in color (darker in ●Dark colored lips
Mediterranean & dark skinned ●Dry and rough in Dryness is due to
clients) for the outer lips texture deficiency in fluid and
Soft, moist, smooth texture ●Symmetry of the yellow teeth color
Mouth
Symmetry of contour countour might be related to
Ability to purse lips ●Can purse lips smoking
Uniform pink color (freckled ●Pinkish color of the
brown pigmentation in dark- buccal mucosa
Parts of the body Normal Findings Actual Findings Interpretation
Mouth skinned clients) for inner lips & ●Moist, soft and Dryness is due to
buccal mucosa smooth oral mucosa deficiency in fluid and
Moist, smooth, soft, glistening & ●Complete adult the yellow teeth color
elastic texture (drier oral mucosa teeth; smooth and might be related to
in elderly due to decreased yellowish in color smoking
salivation) Pink gums with firm
32 adult teeth; smooth, white, texture
shiny tooth enamel ●Tounge in central
Pink gums (bluish or dark patches position and is pink
in dark skinned clients); Moist, in color
firm texture to gums ●Raised papillae
Smooth, intact dentures ●Moves freely
Tongue is in central position ●Tounge base
Pink color (some brown prominent with veins
pigmentation on tongue borders ●No nodules
in dark skinned clients); moist; Light pink palates
slightly rough; thin whitish
coating
Smooth lateral margins; no
lesions
Raised papillae
Moves freely; no tenderness
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February 10, 2010
Smooth tongue base with
prominent veins
Smooth with no palpable nodules
Salivary duct openings are same
color as the buccal mucosa &
floor of mouth
Light pink, smooth, soft palate
Lighter pink hard palate, more
irregular texture
Positioned in midline of soft
palate
Muscles equal in size; head
centered
Coordinated, smooth movements
with no discomforts:
Head flexes 45 degrees
Head hyperextends 60 degrees
Head laterally rotates 70 degrees
Muscle strength:
Neck
Equal strength of the
sternoclaidomastoid muscle
Equal strength of the trapezius
muscle
No palpable lymph nodes

Central placement of the trachea
is in midline of neck; spaces are
equal in both sides
Thyroid gland is not visible on
inspection
Gland ascends during swallowing
but not visible
Neck Thyroid gland robes may not be
palpated
If palpated, lobes are small,
smooth, centrally located,
painless, & rise freely with
swallowing
Absence of bruit
Thorax & Lungs Anteroposterior to transverse ●Intact chest wall No thorax and lungs
diameter in ratio 1:2 without masses abnormalities
Chest symmetric ●Symmetric chest
Spine vertically aligned ●Full and symmetric
Spinal column is straight, right & chest expansion
left shoulders and hips are at ●Bilateral symmetry
same height of vocal fremitus
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February 10, 2010
Skin intact; uniform temperature
Chest wall intact; no tenderness;
no masses
Full & symmetric chest expansion
(normally thumbs separate 3-5cm
= 1 ½ - 2 inches during deep
inspiration)
Bilateral symmetry of vocal
fremitus
Fremitus is heard most clearly at
the apex of the lungs ●Positive vesicular
Low pitched voice males are and bronchovesicular
Anteroposterior to transverse breath sound
diameter in ratio 1:2 ●Quiet, rhythmic and
Chest symmetric effortless breath
Spine vertically aligned sounds
Spinal column is straight, right &
left shoulders and hips are at
same height
Skin intact; uniform temperature
Chest wall intact; no tenderness;
no masses
Full & symmetric chest expansion
(normally thumbs separate 3-5cm
= 1 ½ - 2 inches during deep
inspiration)
Bilateral symmetry of vocal
Thorax & Lungs fremitus ●Intact chest wall No thorax and lungs
Fremitus is heard most clearly at without masses abnormalities
the apex of the lungs ●Symmetric chest
Low pitched voice males are ●Full and symmetric
more readily palpated than higher chest expansion
pitched voices of females ●Bilateral symmetry
Percussion notes resonate, except of vocal fremitus
over scapula ●Positive vesicular
Lowest point of resonance is at and bronchovesicular
the diaphragm breath sound
Note: percussion on a rib ●Quiet, rhythmic and
normally elicits dullness effortless breath
Excursion is 3–5cm bilaterally in sounds
women & 5-6cm in men
Diaphragm is usually slightly
higher on the right side
Vesicular & bronchovesicular
breath sounds
Quiet, rhythmic & effortless
respirations
Costal angle is less than 90
degrees & ribs insert into the
21
February 10, 2010
spine at approximately a 45
degree angle
Full symmetric excursion
Same as posterior vocal fremitus;
fremitus is normally decreased
over heart & breast tissues
Percussion notes resonate down
to the 6th rib at the level of the
diaphragm but are flat over areas
of heavy muscle and bone, dull
on areas over the heart and the
liver & tympanic over underlying
the stomach
Bronchial & tubular breath
sounds
Bronchovesicular & vesicular
breath sounds
No pulsations on the aortic &
pulmonic areas
No pulsations on the tricuspid ●No pulsation on
area aortic and pulmonic
Heart & Central No lift or heave areas No heart and central
Vessels Pulsations visible in 50% of ●Full pulsations vessel abnormalities
adults & palpable in most PMI ●Quality of pulse
(point of maximal impulse) in 5th remains the same
LCIS at or medial to MCL
Diameter at 1-2cm
Heart & Central Aortic pulsations ●No pulsation on No heart and central
Vessels S1: usually heard at all sites aortic and pulmonic vessel abnormalities
Usually louder at apical area areas
S2: usually heard at all sites ●Full pulsations
Usually louder at the base of the ●Quality of pulse
heart remains the same
Systole: silent interval; slightly
shorter duration than diastole at
normal heart rate (60–90 bpm)
Diastole: silent interval; slightly
longer duration than systole at
normal heart rates
S3: in children and young adults
S4: in many old adults
Symmetric pulse volumes of the
carotid artery
Full pulsations, thrusting
qualityremains the same when
client breathes, turns head &
changes from sitting to supine
position
Elastic arterial wall
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February 10, 2010
No sound heard on auscultation
from the carotid artery
Veins not visible (indicating right
side of the heart is functioning
normally)
Symmetrical pulse volumes
Full pulsations
Independent position, presence of
distension & nodular bulges at
calves
When limbs elevated, veins
collapse (veins may appear
torturous or distended in older
people) ●Symmetrical pulse
Limbs not tender volumes
No peripheral
Peripheral Symmetric in size ●Full pulsations
vascular system
Vascular System Skin of the extremities are pink in ●Limbs not tender
abnormalities
color No edema
Skin temperature not excessively
warm or cold
No edema
Skin texture resilient & moist
Buerger’s test: Original color
returns in 10 seconds; veins in
feet or hands fill about 15 seconds
Capillary refill test

Breasts & Axillae Females: Rounded shape; slightly ●Breast even with No breast and axillae
unequal in size; generally chest wall abnormalities
symmetric ●Round areola and
Males: Breasts even with chest bilaterally the same
wall; if obese, may be similar in ●No tenderness,
shape to female breasts masses or nodules
Breast skin uniform in color ●No discharge
(same in appearance as skin of
abdomen or back) Skin smooth &
intact
Diffuse symmetric horizontal or
vertical vesicular pattern in light
skinned people
Striae (stretch marks); moles or
nevi
Areola is round or oval &
bilaterally the same
Color varies widely, from light
pink to dark brown
Irregular placement of sebaceous
glands on the surface of the areola
(Montgomery’s tubercles)
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February 10, 2010
Nipples are round, everted, &
equal in size; similar in color; soft
& smooth; both nipples point in
same direction
No discharge, except from
pregnant or breast-feeding
females
Inversion of one or both nipples
that is present from puberty
No tenderness, masses or nodules
in the breasts areola & nipples nor
nipple discharge
Unblemished abdominal skin

Uniform in color
Silver-white striae (stretch marks)
or surgical scars
Flat, rounded (convex) abdominal
contour, or scaphoid (concave)
No evidence of enlargement of
Abdomen
liver or spleen
Symmetric contour
Symmetric movements caused by
respiration
Visible peristalsis in very lean
people

Aortic pulsations in thin persons
at epigastric area No visible
vascular pattern
Audible bowel sounds
Absence of arterial bruits
Absence of friction rub
Tympany over the stomach &
gas-filled bowels; dullness,
especially over the liver & spleen,
or a full bladder 6-12 cm in
Abdomen
midclavicular line
No tenderness; relaxed abdomen
with smooth, consistent tension
Tenderness may be present near
xiphoid process, over cecum &
over sigmoid colon
Liver may not be palpable
Border feels smooth
Bladder is not palpable (for
urinary retention)
Muscles Equal size on both sides of the ●Equal size on both No muscle
body body sides abnormalities
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February 10, 2010
No contractures on muscles & ●No contractures
tendons ●No tremors
No fasisculation or tremors Firm
Normally firm ●Smooth coordinated
Smooth coordinated movements movements
Equal strength on each body side ●Equal strength
●There are neither
No deformities on bone structure No bone
Bones deformities nor
No tenderness or sweeling abnormalities
swelling
No joint swelling
No tenderness, swelling,
crepitation, or nodules
●No tenderness and
Joints move slowly
Joints swelling No joint abnormalities
Varies to some degree in
accordance with person’s genetic
makeup and degree of physical
activity
Can read, write & respond to ●Can read and write No language
Language
signs without difficulty without difficulty abnormalities
Awareness of place, time and ●Aware of place, No orientation
Orientation
people time and people abnormalities
Ability to recall certain events ●an immediately
Memory (immediate recall, recent memory recall events No memory problem
& remote memory)
Ability to concentrate; completes No problem in
Attention Span & ●Able to concentrate
the serial sevens test in 90 attention span and
Calculation
seconds calculation
●Perfect Glasgow
Level of No problem on level
15 points on Glasgow coma scale coma scale
Consciousness of consciousness
Biceps reflex – normal slight
flexion of the elbow
Triceps reflex – normal slight
extension of the elbow
Bronchoradialis reflex – normal
flexion & supination of the arm,
●All reflexes are
fingers may also extend slightly No problem in
Reflexes present
Patellar reflex – normal extension reflexes
or kicking out of the leg
Achilles reflex – normal plantar
flexion or downward jerk of the
foot
Plantar or Babinski reflex – may
be absent in adults
Motor Function Has upright posture & steady gait ●Has upright posture Has no problem in
with opposing arm swing; walks & steady gait with motor function
unaided, maintaining balance opposing arm swing;
Negative Romberg: may sway walks unaided,
slightly but is able to maintain maintaining balance
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February 10, 2010
upright posture & foot stance
Maintain stance for at least 5
seconds ●Negative
Maintains heel-toe walking along Romberg’s test
straight line ●Maintain stance for
Able to walk several steps on toes at least 5 seconds
or heels ●Maintains heel-toe
Repeatedly & rhythmically walking along
touches the nose straight line
Can clearly supinate & pronate ●Able to walk
hands at a rapid pace several steps on toes
Performs with coordination & or heels
rapidity ●Can clearly move
Performs with accuracy & hands at a rapid pace
rapidity ●Performs with
Rapidity touches each finger to coordination, rapidity
thumb with each hand and accuracy
Demonstrates bilateral equal ●Demonstrated
coordination bilateral equal
Moves smoothly with coordination
coordination ●Able to determine
Light tickling or touch sensation hot from cold
Able to discriminate sharp & dull ●Able to determine
sensations sharp from dull
Able to discriminate between hot
& cold sensations

Motor Function Can readily determine the ●Has upright posture Has no problem in
position of the fingers and toes & steady gait with motor function
Perception varies widely in adults opposing arm swing;
over different parts of the body. walks unaided,
Normally, a person can maintaining balance
distinguish between one-and-two ●Negative
point stimulus within the Romberg’s test
following distances: ●Maintain stance for
Fingertips: 2.8 mm at least 5 seconds
Palms of hands: 8-12 mm ●Maintains heel-toe
Chest & forearm: 40 mm walking along
Back: 50-70 mm straight line
Upper arm, thigh: 75 mm ●Able to walk
Toes: 3-8 mm several steps on toes
Recognizes common objects or heels
Able to identify numbers or ●Can clearly move
letters written on palm hands at a rapid pace
Both points of stimulus are felt ●Performs with
coordination, rapidity
and accuracy
●Demonstrated
bilateral equal
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February 10, 2010
coordination
●Able to determine
hot from cold
●Able to determine
sharp from dull
IX.LIST OF NURSING DIGANOSIS
CUES NUSING DIAGNOSIS JUSTIFICATION
“noong nasa bahay pa ako, bago The patient had experience

Deficient fluid volume related to
maconfine nanghihina at excessive bleeding due to his
active fluid volume loss
dumidilim ang paningin ko ulceration in the upper
(hemorrhage) as manifested by
tuwing pagkatapos ko dumumi at gastrointestinal tract specifically
weakness
hanggang sa matumba na lang in the esophagus brought by
ako” as verbalized by the patient peptic ulcer disease.
27
February 10, 2010
“Umiinom kasi talaga ako ng Due to the ulceration in the

Acute pain related to presence of
alak, kahit hindi pa ko kumakain gastric area made by the
ulceration in the gastric mucosa
kaya sumasakit ang sikmura ko” excessive alcohol intake, the
secondary to alcohol intake
as verbalized by the patient patient experiences pain in the
Epigastric region
“Babawasan ko na ang yung Readiness for enhanced self-care The patient is ready for a change
paginom at pagyoyosi ko” as related to expression of desire to in lifestyle to prevent any
verbalized by the patient maintain life, health personal complications of his disease.
development and well being
X.ANATOMY AND PHYSIOLOGY
STOMACH
 is a muscular organ of the digestive tract

 is a muscular sac located on the left side of the upper abdomen which receives food from
esophagus
 produces protease enzymes and hydrochloric acid which kills bacteria and gives the right pH for
the protease enzyme to work
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February 10, 2010
ANATOMY OF THE STOMACH
The stomach lies between the esophagus and the duodenum (the first part of the small intestine). It is on
the left upper part of the abdominal cavity. The top of the stomach lies against the diaphragm. Lying
behind the stomach is the pancreas. The greater omentum hangs down from the greater curvature.
Two smooth muscle valves, or sphincters, keep the contents of the stomach contained. They are the
esophageal sphincter (found in the cardiac region) dividing the tract above, and the Pyloric sphincter
dividing the stomach from the small intestine.
The stomach is surrounded by parasympathetic (stimulant) and orthosympathetic (inhibitor) plexuses

(networks of blood vessels and nerves in the anterior gastric, posterior, superior and inferior, celiac and
myenteric), which regulate both the secretions activity and the motor (motion) activity of its muscles.
29
February 10, 2010
In humans, the stomach has a relaxed, near empty volume of about 45 ml. It is a distensible organ. It
normally expands to hold about 1 litre of food, but will hold as much as 2-3 litres.
FUNCTION OF DIGESTIVE SYSTEM
The function of the digestive system is digestion and absorption. Digestion is the breakdown of food into
small molecules, which are then absorbed into the body. The digestive system is divided into two major
parts:
The gastrointestinal (GI) tract (alimentary canal) is a continuous tube with two openings, the mouth and
the anus. It includes the mouth, pharynx, esophagus, stomach, small intestine, and large intestine. Food
passing through the internal cavity, or lumen, of the GI tract does not technically enter the body until it is
absorbed through the walls of the GI tract and passes into blood or lymphatic vessels.
 Accessory organs include the teeth and tongue, salivary glands, liver, gallbladder, and pancreas.
 The treatment of food in the digestive system involves the following seven processes:
 Ingestion is the process of eating.
 Propulsion is the movement of food along the digestive tract. The major means of propulsion is
peristalsis, a series of alternating contractions and relaxations of smooth muscle that lines the
walls of the digestive organs and that forces food to move forward.
 Secretion of digestive enzymes and other substances liquefies, adjusts the pH of, and chemically
breaks down the food.
 Mechanical digestion is the process of physically breaking down food into smaller pieces. This
process begins with the chewing of food and continues with the muscular churning of the
stomach. Additional churning occurs in the small intestine through muscular constriction of the
intestinal wall. This process, called segmentation, is similar to peristalsis, except that the
rhythmic timing of the muscle constrictions forces the food backward and forward rather than
forward only.
 Chemical digestion is the process of chemically breaking down food into simpler molecules. The
process is carried out by enzymes in the stomach and small intestines.
 Absorption is the movement of molecules (by passive diffusion or active transport) from the
digestive tract to adjacent blood and lymphatic vessels. Absorption is the entrance of the digested
food into the body.
 Defecation is the process of eliminating undigested material through the anus
Once food has been chewed and mixed with saliva in the mouth, it is swallowed and passes down the
esophagus. The esophagus has a stratified squamous epithelial lining (SE) which protects the esophagus
from trauma; the submucosa (SM) secretes mucus from mucous glands (MG) which aid the passage of
food down the esophagus. The lumen of the esophagus is surrounded by layers of muscle (M)- voluntary
in the top third, progressing to involuntary in the bottom third- and food is propelled into the stomach by
waves of peristalisis.
The stomach is a 'j'-shaped organ, with two openings- the esophageal and the duodenal- and four regions-
the cardia, fundus, body and pylorus. Each region performs different functions; the fundus collects
30
February 10, 2010
digestive gases, the body secretes pepsinogen and hydrochloric acid, and the pylorus is responsible for
mucus, gastrin and pepsinogen secretion.
The stomach has five major functions;
 Temporary food storage

 Control the rate at which food enters the duodenum
 Acid secretion and antibacterial action
 Fluidisation of stomach contents
 Preliminary digestion with pepsin, lipases etc
The small intestine is the site where most of the chemical and mechanical digestion is carried out, and
where virtually all of the absorption of useful materials is carried out. The whole of the small intestine is
lined with an absorptive mucosal type, with certain modifications for each section. The intestine also has
a smooth muscle wall with two layers of muscle; rhythmical contractions force products of digestion
through the intestine (peristalisis). There are three main sections to the small intestine;
The duodenum forms a 'C' shape around the head of the pancreas. Its main function is to neutralise the
acidic gastric contents (called 'chyme') and to initiate further digestion; Brunner's glands in the
submucosa secrete an alkaline mucus which neutralises the chyme and protects the surface of the
duodenum.
The ileum. The jejunum and the ileum are the greatly coiled parts of the small intestine, and together are
about 4-6 metres long; the junction between the two sections is not well-defined. The mucosa of these
sections is highly folded (the folds are called plicae), increasing the surface area available for absorption
dramatically
XI.PATHOPHYSIOLOGY
BOOK BASE PATHOPYSIOLOGY
Acid and pepsinogen Infection with

release with chronic Helicobacter Pylori
vagal response to
increased stress
31
February 10, 2010
Damage to mucosal
wall alcohol abuse,
smocking, use of
NSAID’s
Imbalance
Damage of
mucosal
aggressive
barrier and
defensivefactor
Low of mucosal cells;

low quality of
mucous; less of tight
junction between cells
Infection gives
increased gastrin and
decrease somatostatin
production
32
February 10, 2010
Erosive gastritis
inflammation >>
decrease acid and
intrinsic factor
Mucosal ulceration,
possible bleeding and
scaring
Damage mucosa
could not secrete
enough mucus to act
Severe Ulceration
Signs and Symptoms:
Epigastric pain
Hematemesis/Melena
Dyspepsia
Pyrosis
PATIENT BASE PATHOPHYSIOLOGY
MODIFIABLE:
Alcohol abuse, smocking, use of NSAID’s and

Chronic vagal response to increased stress
Acid and Pepsinogen

release
33
February 10, 2010
Damage mucosal wall
Imbalance of aggressive
and defensive factor
Low of mucosal cells; low

quality of mucous; less of
tight junction between cells
Infection gives increased

gastrin and decreased
somatostatin production
Erosive gastritis
inflammation >> decreased
acid and intrinsic factor
34
February 10, 2010
Mucosal ulceration,
possible bleeding and
scaring
A damage mucosa could

not secrete enough mucus
to act as a barrier against
gastric acid
SEVERE ULCERATION
Signs and Symptoms:
Epigastric pain
Melena
Dyspepsia
Pyrosis
XII.MEDICAL/SURGICAL INTERVENTION
 BLOOD TRANSFUSION (01/30/10), (01/31/10), (02/02/10)
 A blood transfusion is a safe, common procedure in which blood is given to you through an
intravenous (IV) line in one of your blood vessels.
 Blood transfusions are done to replace blood lost during surgery or due to a serious injury. A
transfusion also may be done if your body can't make blood properly because of an illness.
35
February 10, 2010
 During a blood transfusion, a small needle is used to insert an IV line into one of your blood
vessels. Through this line, you receive healthy blood. The procedure usually takes 1 to 4 hours,
depending on how much blood you need.
36
February 10, 2010
37
February 10, 2010
XIII.DRUG STUDY
GENERIC BRAND MECHANIS ADVERSE NURSING

DOSAGE INDICATION CONTRAINDICATION
NAME NAME M EFFECT RESPONSIBILITIES
Metoclopramide Plasil Adult: Dopamine Disturbances of GI hemorrhage, Drowsiness, Assess patient’s GI
1tab TID antagonist that GI motility. mechanical obstruction fatigue and complaints, nausea,
or 10 ml acts by nausea and or perforation, epileptics lassitude, vomiting, anorexia
TID increasing vomiting, anxiety,
receptor insomnia, Monitor BP
sensitivity & headache,
response of nausea, Monitor drug induced
upper GIT bowel adverse reactions.
tissues to disturbance
acetylcholine. s
This causes
contraction of
gastric smooth
muscles,
relaxation of
pyloric
sphincter &
duodenal bulb
& increased
peristalsis w/o
stimulating
gastric
secretions.
Produces
sedation &
induces release
prolactin
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February 10, 2010

Esomeprazole Nexium 40 mg po Proton Pump Erosive reflux Known hypersensitivity Headache, Assess hepatic
OD Inhibitor. esophagitis. to esomeprazole abdominal pain, function because
Blocking the Prevents diarrhea, drug is extensively
final step in relapse of flatulence, metabolized by the
acid healed nausea/vomiting, liver.
production, esophagitis, constipation,
thereby treatment of dermatitis, Assess patient’s
reducing GERD pruritus, condition before and
gastric acidity dizziness, dry during drug therapy.
mouth, blurred
vision Monitor for adverse
reactions of the drug.
Rebamipide Mucosta Adults: Anti- Gastritis, Patient with a history of Acute respiratory Ensure patient’s
1 tab inflammatory gastric ulcer; in hypersensitivity to any distress swallow ER tablet
orally 3X and anti-free combination ingredient of mucosta syndrome, whole.
a day radical with offensive anaphylactic
scavenging of factor inhitors shock, bllod Ensure patient is
cytokine (proton pump pressure systolic well-hydrated
induced inhibitors, decrease,
destructive anticholinergic duodenal ulcer Encourage complete
substances, , H2- hemorrhage, full course therapy
induction of antagonist) duodenal ulcer
synthesis of perforation,
formation of dyspnoea,
good and erythema,
mucosa hemoglobin
friendly decrease.
prostaglandin Ischaemic stroke,
inhibitaion of pruritus, shock,
the secretion skin reaction,
and release of upper
pro- gastrointestinal
39
February 10, 2010
inflammatory hemorrhage
cytokinase by
immne cells
and quite
possibly also,
its ability to
sequester or
modulate the
effects of
responding
neutrophils to
the site of the
mucosal
injury.
40
February 10, 2010
XIV.NURSING CARE PLAN
 DEFECIENT FLUID VOLUME
NURSING
ASSESSMENT INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Deficient fluid >the patient Short term 1. Assess v/s, -to evaluate degree There was no
“Noong nasa bahay volume related experiences goal: noting low BP, of fluid deficit. order to repeat
palang ako, bago ko ma- to active fluid gastrointestinal -After 8hours of rapid heart beat CBC, but goal
confine, nanghihina at volume loss bleeding by the nursing and thready was met based on
dumidilim na ang (hemorrhage) as presence of intervention, the peripheral pulses. the assessment
paningin ko hanggang sa manifested by melena patient will be that there was no
natumba nalang ako” as weakness. able to prevent 2. Administer IV -to evaluate degree melena and no
verbalized by the patient. >the patient’s further fluid fluids, as indicated. of fluid deficit. hematochezia and
Objective: CBC result has a volume loss. Replace blood v/s improved.
- weakness low hemoglobin, products/plasma
- thirst hematocrit and Long term expanders, as
- decrease skin erythrocyte goal: ordered.
turgor percentage this -After 3days of
- dry skin brought by the nursing 3. Establish 24hr
- decrease urine bleeding in this intervention, the fluid replacement -prevent
output=400ml ulcer patient’s fluid needs and routes to peaks/valleys in
w/in 8hrs volume will be used. fluid volume.
- increase urine return to normal
concentration functional level 4. Keep fluids
- (+) melena for as evidenced by within client’s -to replace losses
individually reach and to reverse
7days
adequate encourage frequent pathophysiological
- decrease
urinary output intake, as mechanism.
BP=90/50mmH
with normal appropriate.
g
specific gravity,
- increase
stable v/s, good
PR=120bpm
41
February 10, 2010
NURSING
DIAGNOSIS
skin turgor and 5. Recommend -to promote
prompt restriction of wellness
capillary refill. caffeine, alcohol as
indicated.
42
February 10, 2010
 ACUTE PAIN
NURSING
DIAGNOSIS
Subjective: Acute pain Chemical burn Short term goal: 1.Perform a -to assess Short term:
“Umiinom kasi talaga related to of gastric After 30minutes of comprehensive etiology/ After 30 minutes
ako ng alak, kahit hindi presence mucosa nursing intervention, the assessment of pain; precipitating of nursing
pa ko kumakain kaya ulceration in patient will: include location, factors intervention, the
sumasakit ang sikmura the gastric - Verbalize characteristics, patient was able
ko” as verbalized by mucosa Damage methods that onset/duration, to verbalized
the patient. secondary to gastrointestinal will provide the frequency, quality, methods that
alcohol lining relief of pain severity (0-10) & will provide the
Objective: intake. - Demonstrate use precipitating/ relief of pain and
- Pain scale of 8 of relaxation aggravating demonstrate use
out of 10 Acute Pain skills and factors. of relaxation
- Facial mask of diversion skills and
pain activities as 2.Administer diversion
- Change in indicated for analgesics as activities.
appetite individual indicated. -to maintain
- Less eating situation. tolerable level Long term:
- Skipping of 3.Provide quiet of pain. After 2 hours of
meals Long term goal: environment, calm nursing
- Positioning to After 2hours of nursing activities. -to assist patient intervention, the
avoid pain intervention, the patient to explore patient was able
- Guarding will report pain is methods for to report that the
relieved and controlled alleviation/ pain was
behavior
(pain scale of 2/10 4.Provide comfort control of pain. relieved and
- Endoscopic
measures (back controlled.
impression:
rubbing, changing -to provide non-
esophageal
of position, using pharmacological
ulcer
of warm/ cold pain
compress) management.
43
February 10, 2010
NURSING
DIAGNOSIS
5.Encourage -to assist patient
diversion activities to explore
(watching TV methods for
/listening to radio) alleviation/
and use of control of pain.
relaxation
exercises (focused
breathing)
6.Encourage
adequate rest -to prevent
periods. fatigue
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February 10, 2010
 READINESS FOR ENHANCED SELF-CARE
NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Readiness for Short term: 1.Determine -to determine current Short term:
“Babawasan ko na ang enhanced self care After 2 hours of individual strengths self care status and After 2 hours of
paginom ng alak at pag- related to expression nursing intervention, and skills of the motivation for nursing intervention
yoyosi” as verbalized of desire to maintain the patient will be client. growth. the patient was
by the patient. life/ health personal responsible for responsible enough
development/well planning and -that could impact for planning and
Objective: being. achieving self care 2.Determine age/ potential for growth/ achieving self care
- Positive goals/ general well developmental issues, interrupt client’s goals/ general well
outlook in life being. presence of medical ability to meet own being.
Cooperative in conditions. needs.
treatment Long term: Long term:
After 8 hours of -so that client can After 8 hours of
nursing intervention, 3.Provide accurate/ incorporate into self nursing intervention
the patient will relevant information care plans while the patient was able
demonstrate regarding current/ minimizing problems to demonstrate
proactive future needs. associated with proactive
management of change. management of
potential potential
complications or -to assist client’s complications or
changes in 4.Discuss client’s plan to meet changes in
capabilities. understanding on individual needs. capabilities.
situation.
.
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February 10, 2010
XV.DISCHARGE PLANNING
MEDICATION
 The patient was instructed to take the ff. medication (as ordered by his physician)
Esomeprazole 40 mg i tab Once Daily for 10 days

EXERCISE
 The patient was adviced to refrain from doing strenuous activities.
The patient was also advised to engage in simple exercises as tolerated to prevent muscle atrophy.

TREATMENT
 Information given by the physician regarding further treatment such as quitting smoking, limiting
consumption of caffeine and alcohol and reducing stress can speed healing and prevent ulcers
from recurring.

HEALTH TEACHING
 The patient was advised of the ff.
o Be diligent in taking his medication.
o Refrain from smoking and drinking alcoholic beverages
o Avoid the foods which includes salty,spicy and acidic food.
o Visit places out of town were there is fresh air and environment. This will help the patient
promote his well-being.

OUT-PATIENT
 The patient was instructed to return for follow up check up six days after discharge.

DIET
 Promote adequate soft diet intake,including low fiber and acid diet that is tolerable by the patient.
The patient instructed to decrease low salt diet and do not skip meals and eat on time.
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February 10, 2010

IA. Background of The Study

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IA. Background of The Study

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CASE STUDY: Peptic Ulcer Disease

February 10, 2010

IA. Background of the Study

SIGNS AND SYMPTOMS

o Performing physical assessment

o Interviewing the patient about her patterns of functioning

o Finding out about patient’s medical history

 To understand medical treatment rendered to patient with Peptic Ulcer Disease

 To EVALUATE the effectiveness of the nursing interventions rendered

Dorothea Orem’s Theory of Self-care

Dorothea Orem’s Theory of Self-care

NAME Mr. M.F.J

A. History of Present Illness:

B. Past Medical History

C. Family Medical History

VII.LABORATORY AND DIAGNOSTIC

COMPLETE BLOOD COUNT

 January 29, 2010

 January 31, 2010

 February 01, 2010

BLOOD CHEMISTRY REPORT

CHEMISTRY REPORT (LIVER FUNCTION)

 January 30, 2010

 January 31, 2010

CHARACTER FORMED Normal

ROENTGENOLOGICAL REPORT (01/29/10)

ULTRASOUND OF THE WHOLE ABDOMEN (01/30/10)

Part of the Body Normal Findings Actual Findings Interpretation

temperature & activity)

Evenly distributed hair over the ● Hair evenly

Part of the Body Normal findings Actual findings Interpretation

Eyes Eyebrows hair are evenly ●Eyebrows hair are

Parts of the body Normal findings Actual findings Interpretation

Parts of the body Normal findings Actual findings Interpretation

Parts of the body Normal findings Actual findings Interpretation

Parts of the body Normal findings Actual findings Interpretation

Unblemished abdominal skin

Parts of the body Normal findings Actual findings Interpretation

Parts of the body Normal findings Actual findings Interpretation

IX.LIST OF NURSING DIGANOSIS

CUES NUSING DIAGNOSIS JUSTIFICATION

“noong nasa bahay pa ako, bago The patient had experience

“Umiinom kasi talaga ako ng Due to the ulceration in the

X.ANATOMY AND PHYSIOLOGY

 is a muscular organ of the digestive tract

ANATOMY OF THE STOMACH

The stomach is surrounded by parasympathetic (stimulant) and orthosympathetic (inhibitor) plexuses

FUNCTION OF DIGESTIVE SYSTEM

The stomach has five major functions;

 Temporary food storage

BOOK BASE PATHOPYSIOLOGY

Acid and pepsinogen Infection with

Low of mucosal cells;

PATIENT BASE PATHOPHYSIOLOGY

Alcohol abuse, smocking, use of NSAID’s and

Acid and Pepsinogen

Damage mucosal wall

Low of mucosal cells; low

Infection gives increased

A damage mucosa could

 BLOOD TRANSFUSION (01/30/10), (01/31/10), (02/02/10)

GENERIC BRAND MECHANIS ADVERSE NURSING