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ANGELES UNIVERSITY FOUNDATION

Angeles City
College of Nursing

MEDICAL-SURGICAL NURSING CASE STUDY:


ANEMIA SECONDARY TO UPPER
GASTROINTESTINAL BLEEDING SECONDARY TO
PEPTIC ULCER DISEASE (DUODENAL)

Submitted by:
Enriquez, Rachelle
Pangilinan, Raidis
Sunga, Chrisha
Tapnio, Eleazar
Tuvera, James
BSN III-B GROUP 6

Submitted to:
Jasleen S. Yumang, RN. MN.

Date
October 05, 2016

1
Introduction

Take care of your body. Its the only place you have to live in.

-Anonymous

Our body is the place we live in and if you try to destruct it, it is possible that you
dont

have anywhere to go. It is like a house, if not maintained properly, it will slowly wear

out. It is like our health if not maintained properly it will result to different kind of

Illnesses and diseases that will put our lives at risk. It is a game between living or
dying.

To prevent it from deteriorating it is better to preserve,cherish and protect it as

early as possible.

Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper


gastrointestinal tract, commonly defined as bleeding arising from the esophagus,
stomach, or duodenum. Bleeding occurs when the inner lining of the esophagus,stomach,
or proximal intestine is injured, exposing the underlying blood vessels, or when blood
vessels themselves rupture. Upper gastrointestinal bleeding (UGIB) is defined as
hemorrhage that emanates proximal to the ligament of Treitz.

Duodenal peptic ulcer disease is a ulcerative disorders that occur in areas of the
upper gastrointestinal tract that are exposed to acid-pepsin secretions. The most common
forms of peptic ulcer are duodenal and gastric ulcers. Peptic ulcer disease, with its
remissions and exacerbations, represents a chronic health problem. Duodenal ulcers
occur five times more commonly than gastric ulcers. Ulcers in the duodenum occur at any
age and frequently are seen in early group, with a peak incidence between 55 and 70
years of age. Both types of ulcers affect men three to four times more frequently than
women. (Carol Mattson Porth, 2011)

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Anemia is clinical condition that results from an insufficient supply of healthy red
blood cells (RBCs), the volume of packed RBCs, and/or the quantity of hemoglobin.
Hypoxia results because the bodys tissues are not adequately oxygenated. Not a disease
in itself, anemia reflects a number of underlying pathologic processes leading to an
abnormality in RBC number, structure, or function. When anemia is identified, further
testing must be done to determine its cause. (JOYCE M. BLACK, 2010)

Upper gastrointestinal bleeding (UGIB) causes over $1 billion in medical


expenses annually.The National Hospital Discharge Sample from 1979 to 2009. Patients
with primary ICD-9 code representing a diagnosis of UGIB were included. The study was
to examine changes of UGIB mortality risks and trends. The results was UGIB mortality
risk decreased by 35.4 % from 4.8 % in the first decade to 3.1 % in the third decade. Most
significant decreases were observed in patients over 65 years and during the first day of
admission. Gastric and esophageal bleedings showed significant decreasing mortality
risk trends. Duodenal bleeding mortality risk was stable in three decades.

It is concluded that Upper gastrointestinal bleeding mortality risks, especially


of the first hospital day and geriatric patients, significantly decreased over the last three
decades, presumably from recent advances in emergency medical care. Mortality risk of
gastric, but not duodenal, bleeding had the most significant reduction. Critical care
improvements in patients with various comorbidities may explain significant UGIB
mortality risk reductions.http://www.ncbi.nlm.nih.gov/pubmed/23828142

Gathering data for the statistics about Upper Gastrointestinal Bleeding in the
Philippines, the incidence of UGIB is approximately 100 cases per 100,000 population
per year. Bleeding from the upper GI tract is approximately 4 times more common than
bleeding from the lower GI tract and is a major cause of morbidity and mortality. Mortality
rates from UGIB are 6-10% overall.(www.doh.com)

3
Gathering data for the statistics about Upper gastrointestinal bleeding done in Wales,
United Kingdom the overall incidence of hospitalization for UGIB was 134 per 100,000
population; incidence was higher among men than women (153 vs. 117 per 100,000).
Incidence was two times higher in areas with the lowest and highest socioeconomic
status. Overall case fatality rates at 30 days after hospital admission was 10.0%; fatality
rates rose with age and were higher for men than women and for those with comorbid
illnesses. Adjusted fatality rates were 13% higher for patients admitted on weekends than
on weekdays and 41% higher for patients admitted on holidays than on weekdays.
Fatality rates decreased from 11.4% to 8.6% during the study period.The authors
concluded that UGIB incidence, but not mortality, was associated with socioeconomic
deprivation. They also concluded that patients who were admitted on weekends or
holidays suffered higher mortality than those admitted on weekdays. They speculate that
this difference in mortality could be attributed to reduced staffing and lack of availability
of endoscopy on weekends and holidays in some hospitals.

Indeed, We chose the case because we want to learn why gastrointestinal


bleeding occurs in patients with UGIB. We wanted to enhance our knowledge and learn
carefully the pathophysiology of this case, so, it will help broaden our knowledge
regarding how UGIB is developed and what complications it could give to the body. For
these reasons, we the student nurses will be able to understand and as well apply the
appropriate nursing intervention needed to the patient suffering to this condition. And
lastly, this study by the group would serve as a reference for future studies with the same
condition.

Objectives

4
A. Nurse-centered

Short Term:

After the completion of the clinical case study, the student nurses shall have:

Established a therapeutic relationship with the patient ;


Drawn out pertinent data such as family history, past and present illness,
socioeconomic and cultural factors ;
Identified modifiable and non-modifiable factors that led to Upper Gastrointestinal
Bleeding Secondary to Duodenal peptic ulcer disease secondary to anemia
Elicited a focused physical examination that would expound the diagnosis of the
patient, and to identify the possible causes of the patients symptoms;
Described the diagnostics and laboratory procedures done to the patient;
Stressed out the importance of health teachings given and compliance to
treatment regimen and;
Formulated specific goals and objectives to serve as a guide in completing such
case study.

Long term:

At the end of the clinical case study, the student nurses shall have:

Collated and analyzed gathered laboratory values and diagnostic work ups;
interpret the findings accurately to serve as a basis in identifying and formulating
appropriate health problems;
Identified diagnostics tests, laboratory results, pathophysiology, medical and
nursing management applicable to manage the condition of the patient;

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Identified and prioritized actual and potential nursing care plans and document
patients progress through SOAPIEs;
Reiterated the importance of health teachings given regarding compliance to
treatment regimen to the patient and significant others before discharge to
hospital.

B. Patient-Centered

Short Term:

After the completion of the clinical case study, the patient shall have:

Expressed understanding of the purpose of the study;


Will openly answered the questions of the student nurse and share important
information of the completion of this study;
Taked part in the nursing assessment done by the student nurse;
Classified ways on how to understand the presented medical diagnosis with its
cause, signs and symptoms, and treatment;
Accomplished appropriate actions toward health problem as reflected in the
nursing diagnosis;
Exhibited proper health maintenance and healthy lifestyle from the health
teachings given by the student nurses.

Long Term:

At the end of the clinical case study, the patient shall have:

Maintained therapeutic relationship with the student nurse


Developed the understanding of the condition process;
Gained knowledge regarding the to his case

6
Demonstrated compliance to medical and nursing management and treatment
and;
Demonstrated lifestyle changes for the promotion of health and prevention of
further complications.

II. NURSING PROCESS

A. Assessment

1. PERSONAL HISTORY

A. Demographic data

Mrs. Bleed a single mother who is 69 years old female, born on March 02,
1947 in Pampanga. She has 7 children, 2 males and 5 Females. She is a Filipino citizen
and is affiliated to the Roman Catholic Church. Mrs. Bleed and her family currently
resides in Minalin, Pampanga.

During the interview with Mrs. Bleed daughter, who is the primary source of
information, last September 16, 2016. She disclosed that her mother on September 13,
2016, from tuesday afternoon until early morning of Wednesday has been suffering from
fever,productive cough, no appetite and body malaise. The same day of September 14,
2016,Wednesday at 2 am, her mother started vomiting blood for 5 times (Approximately
2 cups of blood) and also blood was present in her mothers urine. And at 6 am she was
sent to tertiary hospital and was admitted to Jose B. Lingad Memorial Hospital in San
Fernando,Pampanga on September 14, 2016 at 6:50 AM with a chief complaint of

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Hematemesis and hematuria. Her final diagnosis in the tertiary hospital was Upper
Gastrointestinal Bleeding Secondary to Duodenal peptic ulcer disease.

B. Socioeconomic and cultural factors

The family is an Extended type composed of Mrs. Bleed together with her 3
childrens (including her second daughter 50 y/o, third daughter 49 y/o and her 4th son 48
y/o) and her grand childrens and the wife and husbands of her children. Mrs. bleed has 7
children (5 females and 2 males) 3 of them lives together with her. Mrs.Bleed a single
parent who is 10 years separated with his husband (from year 2006) who works as a
construction worker in Saudi Arabia. Mrs. Bleed is a senior citizen, who used to be a
factory worker for 10 years, from year 1986 to 1996, and a dressmaker for another 10
years, from year 1996 to 2006, she used to make kurtina and sofa clothing. Despite of
her old age she still try to sew or repair clothes to add with their daily expenses.

The one providing her needs is her 3 children who lives together with her. The 3
children of Mrs. bleed who provides her needs is her Second daughter who sells kakanin
every morning, who earns more or less than 200-400 pesos a day ,her third daughter who
takes care of them and her son who is 4th among the 7 children, who works as a
construction worker earning 300-400 pesos a day, it depends if their is an available work
to do .

According to National Economic and Development Authority (NEDA) 2012 the


equivalent average income is around P2 873.33 per month or P86,199.99 per year per
family members should be the amount allotted to be able to maintain a decent living.

8
Below that amount, the family is considered poor and since the monthly income of the
family is more or less 7k-10k a month which is used for their daily expenses.

Mrs. Bleed usually wakes up early, at about 6:00 in the morning. She usually just
walk around the house and does simple exercise like stretching, walking then she will
have her coffee and breakfast with her family. She usually pass the time socializing with
neighbors,playing tong-its,mahjong and also by watching TV and sometimes she sew or
repair clothes and curtains where she earns a little. Mrs.Bleed has a poor personal habits
she does smoke usually 10 to 15 sticks a day for 10 years already, and drinks alcohol.

She usually retires at about 12:00 pm and when having difficulty in sleeping she
usually drink beer to be able to sleep. Mrs. Bleed loves to eat filipino dishes. They eat or
have their meals 4 times a day. For breakfast they have usually have rice,tuyo,itlog na
maalat and coffee which she drinks it 3 times a day. For lunch, rice,sinigang, adobo and
other filipino dishes and also softdrinks everyday. Dinner rice and ulam and for the
midnight snack, bread and pancit canton. Mrs. Bleed daughter described their meals as
quite unhealthy because they usually have oily and salty food. And also Mrs. Bleed
smokes and is a heavy drinker ( 1-2 lapad of Emperador).

Mrs.Bleed is an Elementary graduate, she wasnt able to pursue her studies due
to financial problem. She used to work in a factory, a 555 sardines manufacturer for 10
years, from year 1986-1996. And, also in a dressmaker factory for another 10 years from
year 1996-2006. The family of Mrs. Bleed was from Minalin,Pampanga. Mrs.Bleed
daughter verbalized that they believe that when someone in the family is having health
problems, they immediately seek a doctor for medical attention. They also use over the
counter drugs for minor illnesses such as fever, coughs and colds, and headaches
(eg.Paracetamol,Alaxan)

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3. History of Past Illness

Mrs. Bleed had mumps and measles when she was 4 years old, she encountered
fever, diarrhea, coughs and cold. Wherein, she managed it by buying and using over the
counter drugs such as analgesic and antibiotic. She doesnt have any allergies to
medications, nor acquired any accident trauma. When dealing with fever, she relies with
over the counter drugs like Paracetamol tablets, performing tepid sponge bath and
increasing fluid intake. On the other hand, when she is experiencing diarrhea, she just
increases her fluid intake and does not take any medication to stop diarrhea. She also
had anemia when she was 20 years old due to early pregnancy at age of 16 and without
ideal birth spacing for her children. She treated it with iron supplements such as Ferrous
Sulfate and Folic Acid plus Vitamin B12. She was hospitalized last 2014 at Tertiary
Hospital for 7 days because of pneumonia, the said hospital managed her disease
condition by providing antibiotics and oxygen inhalation. She was also diagnosed
hypertensive patient then, with blood pressure of 150/100 and currently taking Metoprolol
and Amlodipine.

4. History of Present Illness

On September 13, 2016 (Tuesday) afternoon, Mrs. Bleed have fever, productive cough,
no appetite and with body malaise. At 2am of September 14 (Wednesday) she vomits
blood (hematemesis) for 5 times, estimated 2 cups. She also have blood in urine
(hematuria) for 3 times, as if urinating red blood according to her. The said manifestations
continuous until her daughter decided to take her to a Tertiary Hospital around 6am. She
was admitted at 6:50 am of September 14. The said hospital provided her: PNSS
regulated at 30 gtts/min; oxygen via nasal cannula at 4 L/min; Requested for CBC with
platelet, BUN, Creatinine, NA, K; Started omeprazole 80mg IV q8, metoclopramide 10mg
IV q8, tranexamic acid 500mg IV q8; Requested for ABO RH typing and crossmatched
because she was subjected to blood transfusion of 1 unit Packed RBC on September 15
at 9pm; she also had Pre-BT meds paracetamol 300mg IV and diphenhydramine 50mg
IV prior to blood transfusion; She was also referred to Gastro for upper gasto-intestinal
examination.

10
5. Physical Examination (Cephalocaudal Approach)

Upon admission (Lifted from the chart)

September 14, 2016

Admitted a 69 year old patient accompanied by her daughter with chief complaint of
(hematemesis) vomiting of blood and (hematuria) blood in urine.
With initial vital signs of:

TEMPERATURE: 38.8 C
PULSE RATE: 84 bpm

RESPIRATORY RATE: 22 cpm

BLOOD PRESSURE: 130/70 mmHg

SKIN: Skin warm to touch, flushed skin

HEAD-EENT: no nasal discharge, no ear pain

MUSCULOSKELETAL: (+) weakness

CARDIOVASCULAR: (-) palpitation

RESPIRATORY: (+) productive cough

ABDOMEN: Soft, Non tender

GASTROINTESTINAL: (-) diarrhea, (-) constipation

NEUROLOGIC: no neurologic deficits

PAST MEDICAL HISTORY: (-) DM, (-) Thyroid Disease, (-) CA, (+) HPN

FAMILY MEDICAL HISTORY: (-) DM, (-) Thyroid Disease, (-) CA, (-) HPN

ADMITTING IMPRESSION: UGIB, uninvestigated secondary to DPUD and ANEMIA

11
1st day of NPI (September 16, 2016 )

3rd day of Hospitalization

General Survey

Mrs. Bleed is sitting on a wheelchair, accompanied by her daughter; oriented to


time, place and person; wearing hospital gown; on nebulizer; with oxygen therapy via
nasal cannula regulated at 2-4 L/min after nebulizer; with ongoing IVF of PNSS 1L at 800
cc level, regulated at 30 gtts/min infusing well on her left hand; appears weak; with
productive cough; with complaints of DOB; with fever and flushed skin.

Vital signs

T: 38.5 C

PR: 110 bpm

RR: 24 cpm

BP: 110/70 mmHg

Integumentary System

Skin: Pale and dry poor skin turgor. Warm to touch, flushed skin, Delayed capillary refill
time of 5 seconds.

Nails: The fingernails are pale and dirty same as the toenails.

Head

Scalp: Hair is thick black and evenly distributed absence of lice and flakes. With intact
skin. No masses noted upon palpation

Skull: No masses, nodules or tenderness upon palpation.

Face: Facial expressions are symmetrical, with intact skin absence of lesions. No masses
noted upon palpation.

12
Eyes

Eyes: Normal position and alignment in relation to the tip of the pinna.

Visual field: She can see and identify the penlight on her periphery when looking
forward.

Eyebrows: With black, thick hair evenly distributed. Alignment is symmetrical with intact
skin and equal movement

Eyelids: Symmetrical with intact skin. Absence of lesions

Eyelashes: Equally distributed black hair, short and curled slightly outward.

Cornea: Transparent, smooth and shiny; blink reflex is observed upon introduction of
the cotton ball to the cornea.

Iris: Dark brown in color

Lacrimal apparatus: No tenderness and edema noted

Conjunctiva: Bulbar conjunctiva is transparent, smooth, pale palpebral conjunctiva

Sclera: Anicteric

Pupils: Pupils are equal in size with consensual and direct response upon introduction
of light. Pupils dilate when staring at distant objects and constricting when staring at
near objects.

Ears

Auricle: The color is uniform with the facial skin, absence of redness or swelling and
with intact skin. Aligned with the outer canthus of the eye. It recoils after folding with no
pain felt upon application of pressure behind the ear.

External ear canal: Absence of discharge, moisten with earwax.

Hearing acuity: Able to hear normal voice tone

13
Nose and Sinuses

Nose: The external part has intact skin, the nasal septum is intact and in midline
position. No masses noted upon palpation.

Sinuses: No pain noted upon palpation of facial sinuses. No redness and swelling
observed

Mouth and Throat

Lips: Dry, paleand symmetrical with intact skin.

Oral Mucosa: with intact skin, slightly dryand pale. No lesions or redness noted.

Gums: No tenderness

Teeth: Old dental repairs on the upper front teeth noted.

Palate and uvula: slightly dry, pale. The anterior palate is hard whereas the posterior
palate is soft. Uvula is positioned in midline of the soft palate.

Tongue: Is centrally positioned, moves freely with no tenderness or swelling or lesions


observed.

Floor of the mouth: No lesions observed.

Pharynx: Absence of redness and swelling and with non-inflamed, pink tonsils.

Neck

Neck: No masses observed upon inspection. Absence of palpable lymph nodes. The
neck muscles are equal in size and smooth movement without discomfort is observed.
The head is centrally positioned.

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Thyroid Gland: Absence of nodules or tenderness upon palpation.

Thorax and Lungs

Respirations:

Posterior chest: The spinal column is centrally aligned, without any deviations. Upon
palpation there were no tenderness observed. Presence of productive cough, presence
of wheezes upon expiration

Anterior chest: Symmetrical chest expansion and with intercostal retractions observed
during inspirationwith labored breathing noted, with intact skin. Upon palpation there is
no tenderness

Cardiovascular system

Jugular vein: Not distended.

Apical pulse: 110 bpm

Breast and axillae

Breast: The skin is intact with uniform color, no tenderness or masses observed.
Symmetrical, absence of dimpling or flattening..

Axilla: No rashes observed. No palpable lymph nodes.

Abdomen

Symmetrical movements during inspiration. No pulsations seen. No evidence of


enlargement of liver and spleens. Upon auscultation bowel sounds are audible but
minimal 4-5 bowel sounds per quadrant, with absence of arterial bruits. No masses or
tenderness noted upon palpation.

15
Peripheral Vascular system

Upper extremities: Symmetric, absence of swelling with strong palpable pulsation, pale
skin and nails. Hair is evenly distributed, muscles are equal in size, no bone deformities.

Lower extremities:Symmetric, Hair is evenly distributed on the calf muscle, pale skin
and nails, Weak palpable pulse.

Musculoskeletal System:

Muscle Strength: Patient able to move but with assistance

2nd day of NPI (September 22, 2016)

9th day of Hospitalization

General Survey

Mrs. Bleed is lying on bed, accompanied by her daughter; oriented to time, place
and person; wearing hospital gown; with oxygen therapy via nasal cannula regulated at
2-4 L/min; with ongoing IVF of PNSS 1L at 480 cc level, regulated at 30 gtts/min infusing
well on her left hand; appears weak; with productive cough;

Vital signs

T: 36.5 C

PR: 106 bpm

RR: 24 cpm

BP: 120/70 mmHg

Integumentary System

Skin: Pale and dry poor skin turgor.

Nails: The fingernails are pale and same as the toenails.

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Head

Scalp: Hair is thick black and evenly distributed absence of lice and flakes. With intact
skin. No masses noted upon palpation

Skull: No masses, nodules or tenderness upon palpation.

Face: Facial expressions are symmetrical, with intact skin absence of lesions. No masses
noted upon palpation.

Eyes

Eyes: Normal position and alignment in relation to the tip of the pinna.

Visual field: She can see and identify the penlight on her periphery when looking
forward.

Eyebrows: With black, thick hair evenly distributed. Alignment is symmetrical with intact
skin and equal movement

Eyelids: Symmetrical with intact skin. Absence of lesions

Eyelashes: Equally distributed black hair, short and curled slightly outward.

Cornea: Transparent, smooth and shiny; blink reflex is observed upon introduction of
the cotton ball to the cornea.

Iris: Dark brown in color

Lacrimal apparatus: No tenderness and edema noted

Conjunctiva: Bulbar conjunctiva is transparent, smooth, pale palpebral conjunctiva

Sclera: Anicteric

Pupils: Pupils are equal in size with consensual and direct response upon introduction
of light. Pupils dilate when staring at distant objects and constricting when staring at
near objects.

Ears

17
Auricle: The color is uniform with the facial skin, absence of redness or swelling and
with intact skin. Aligned with the outer canthus of the eye. It recoils after folding with no
pain felt upon application of pressure behind the ear.

External ear canal: Absence of discharge, moisten with earwax.

Hearing acuity: Able to hear normal voice tone

Nose and Sinuses

Nose: The external part has intact skin, the nasal septum is intact and in midline
position. No masses noted upon palpation.

Sinuses: No pain noted upon palpation of facial sinuses. No redness and swelling
observed

Mouth and Throat

Lips: Dry, paleand symmetrical with intact skin.

Oral Mucosa: with intact skin, slightly dryand pale. No lesions or redness noted.

Gums: No tenderness

Teeth: Old dental repairs on the upper front teeth noted.

Palate and uvula: slightly dry, pale. The anterior palate is hard whereas the posterior
palate is soft. Uvula is positioned in midline of the soft palate.

Tongue: Is centrally positioned, moves freely with no tenderness or swelling or lesions


observed.

Floor of the mouth: No lesions observed.

Pharynx: Absence of redness and swelling and with non-inflamed, pink tonsils.

Neck

18
Neck: No masses observed upon inspection. Absence of palpable lymph nodes. The
neck muscles are equal in size and smooth movement without discomfort is observed.
The head is centrally positioned.

Thyroid Gland: Absence of nodules or tenderness upon palpation.

Thorax and Lungs

Respirations:

Posterior chest: The spinal column is centrally aligned, without any deviations. Upon
palpation there were no tenderness observed. Presence of productive cough, presence
of wheezes upon expiration

Anterior chest: Symmetrical chest expansion and with no intercostal retractions


observed during inspiration with intact skin. Upon palpation there is no tenderness

Cardiovascular system

Jugular vein: Not distended.

Apical pulse: 106 bpm

Breast and axillae

Breast: The skin is intact with uniform color, no tenderness or masses observed.
Symmetrical, absence of dimpling or flattening..

Axilla: No rashes observed. No palpable lymph nodes.

Abdomen

Symmetrical movements during inspiration. No pulsations seen. No evidence of


enlargement of liver and spleens. Upon auscultation bowel sounds are audible but
minimal 4-5 bowel sounds per quadrant, with absence of arterial bruits. No masses or
tenderness noted upon palpation.

19
Peripheral Vascular system

Upper extremities: Symmetric, absence of swelling with strong palpable pulsation, pale
skin and nails. Hair is evenly distributed, muscles are equal in size, no bone deformities.

Lower extremities:Symmetric, Hair is evenly distributed on the calf muscle, pale skin
and nails, Weak palpable pulse.

Musculoskeletal System:

Muscle Strength: Patient able to move but with assistance

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6. Diagnosis and Laboratory Procedures
HEMATOLOGY

Hematology is the branch of medicine concerning the study of blood, the blood-forming organs, and blood diseases.
Hematology tests include laboratory assessments of blood formation and blood disorders.

A complete blood count (CBC) gives important information about the kinds and numbers of cells in the blood, especially red
blood cells, white blood cells, and platelets. A CBC aids the physician check any symptoms, such as weakness, fatigue, or
bruising, that the client has. A CBC also helps the doctor diagnose conditions, such as anemia, infection, and many other
disorders

Diagnostic/ Date Ordered Indication(s) or Result Normal Values Analysis and


Laboratory (units used in Interpretation of
Date result(s) Purpose(s)
Procedure the hospital) results (CLIENT-
Received CENTERED)

1. COMPLETE DATE CBC is done as a


ORDERED: part of routine
BLOOD COUNT
analysis of the
(CBC) 09/14/16
body to gather
baseline data

21
DATE
RESULT(S)
RECEIVED:

09/14/16

Hemoglobin The test may be 90 130-180 g/L The result shows


used to screen a below normal
for, diagnose, or hemoglobin
monitor a number count. This
of conditions and indicates that a
diseases that low hemoglobin
affect red blood count is severe
cells (RBCs) and causes
and/or the symptoms like
amount of weakness and
hemoglobin in easy fatigability,
blood. the low
Hemoglobin is the hemoglobin count
iron-containing may indicate that
protein found in the patient has
all red blood cells anemia.
that enables

22
RBCs to bind to
oxygen in the
lungs and carry it
to tissues and
organs
throughout the
body

Since there is
affectation in the
cardiovascular
system as well as
the respiratory
system of the
patient, it is
indicated to the
client to assess
adequacy of her
tissue
oxygenation
primarily in the

23
heart and other
parts of the body.

Hematocrit This test was 0.27 0.37 0.47 x It is below the


done to measure 10^9/L g/L normal range.
the percentage by This indicates that
blood volume of percentage of red
packed RBCs in blood cells is
a whole blood below the lower
sample of the limits of normal
patient. It aids in Another term for
the diagnosis of low hematocrit is
anemia, anemia.
polycythemia and
abnormal
hydration.

Platelet A platelet count is 105 150 450 x Mrs. Bleeds


a lab test to 10^9/L platelet count
measure how result was below
many platelets normal. This
you have in your indicates that she

24
blood. Platelets doesnt have
are parts of the adequate amount
blood that help of platelet to
the blood clot. provide
They are smaller coagulation, and
than red or white she is in risk for
blood cells. The bleeding
number of
platelets in your
blood can be
affected by many
diseases.
Platelets may be
counted to
monitor or
diagnose
diseases, or to
look for the cause
of too much
bleeding or
clotting.

25
White blood cell White blood cells 11.5 4-10 x 109/L Above normal.
exist in the blood, The WBC count
the lymphatic is elevated in
system, and response to
tissues and are infection, stress,
an important part and inflammatory
of the body's disorders
defense system. (referred to as
Some diseases reactive
trigger a leukocytosis)
response by the
immune system
and cause an
increase in the
number of WBCs.
It is substantial
determinant of
infection or
inflammation.

26
Neutrophils It is the most 69 0.55-0.65 Above normal.
common The neutrophils is
polymorphonucle elevated in
ar leukocytes response to acute
(PMN) which is a infection and
division of WBC acute stress
in granulocytes.

It is indicated to
the patient to
determine acute
bacterial
infection.

Lymphocytes 40 25-35% Above normal.


Lymphocytes are
It is indicated to
an important part
the client to
of the immune
determine the
system. They
ability of the body
help fight off
to fight bacterial
diseases, so it's
infection.
normal to see a

27
temporary rise in
the number of
lymphocytes after
an infection.

Monocytes It is a phagocytic 7.9 3-6% Above normal.


cell capable of Elevated results
fighting bacterial shows that the
infection. body response to
infection and
stress,
It is indicated to
the client to
determine if there
is any bacterial
microorganism
invading the
body.

28
Nursing Responsibilities

Prior:

Check the physicians order.


Identify the client.
Explain the procedure to the patient, its purpose and how it is done
Tell the patient that no fasting is required.
Assure patient that collecting blood sample take less than 3 minutes.
Inform the patient that he/she will be experiencing pain on the site where the
needle was pricked.
Refer to other member of the health care team.

After:

Record the date and time of blood collection. Attach a label to each blood tube.
Properly dispose of contaminated materials.
Fill-up the laboratory form properly and send to the laboratory technician.
Check the venipuncture site for bleeding.
Obtain results and secure it to the patients chart.
Refer the result to the physician.

29
BLOOD CHEMISTRY

Blood chemistry tests or panels are groups of tests that measure many chemical substances in the blood that are released
from body tissues or are produced during the breakdown (metabolism) of certain substances. These tests are performed
on ablood sample

Laboratory Date Indication(s) Results Normal Analysis and Interpretation of results


Procedure ordered; or Purpose(s) values
Date
results in

This is a test The result of Mrs. Bleeds creatinine level is within above
Creatinine DO and specific for the 190 44-80 normalrange. It indicates that her kidneys are not
DR: assessment of ummol/ functioning well.
Septembe renal function L
r14, 2016 of
Mrs. Bleed

DO and This is a test 6.53 2.78 - The result of Mrs. Bleeds creatinine level is within normal
BUN DR: specific for the 8.07 range. This cannot indicates that her kidneys are
Septembe assessment of mmol/L functioning well or not, since BUN can be altered through
r14, 2016 diet and hydration

30
renal function
of
Mrs. Bleed

Sodium DO and This test is 133 135-145 Below normal range. Sodium is particularly important for
DR: specific for the mmol/L nerve and muscle function. Hyponatremia can cause
Septembe assessment of damage to cells. It makes them swell up with too much
r 14, 2016 electrolytes water. This may be particularly dangerous in areas such as
imbalances the brain.

Potassium DO and This test is 6.90 3.5-5.1 Above normal. The most common cause of high potassium
DR: specific for the mmol/L is kidney failure. When your kidneys fail, they cant remove
Septembe assessment of extra potassium from the body. This can lead to potassium
r 14, 2016 electrolytes buildup.
imbalances

31
NURSING RESPONSIBILITIES:

Prior:

Check doctors order


Identify the patient
Explain procedure to the SO and the purpose and importance of the test.
Inform the SO that there is no fluid or food restriction needed.
Inform the SO that the test requires blood sample, tell who will do the test and
when.
Inform SO that there will be a discomfort from needed puncture and pressure
from the torniquet.
Check the patients medication history for drugs that may interfere with test
results.

After:

If the patient is too weak and has no SO, assist him/her during the extraction of
blood.

32
URINALYSIS
Urinalysis is a test that evaluates a sample of your urine. Urinalysis is used to detect and assess a wide range of disorders,
such as urinary tract infection, kidney disease and diabetes. Urinalysis involves examining the appearance, concentration
and content of urine.

Diagnostic/Labor Date Results Normal values Analysis and Interpretation


atory ordered; General Indication of results
Procedures Date results
in

This was done to Color: yellow Color: Mrs. Bleeds results are
Urinalysis DO: the patient as a amber/yellow within above normal range.
September screening for This means that her urine is
14, 2016 abnormalities within Transparenc Transparency: concentrated that there are
DR: the urinary system y: Clear more solutes and less water
September as well as for Slightly turbid pH: 4.8-8.0 in the urine. Solutes are
14, 2016 system problems pH: 7.5 Specific gravity: dissolved particles, such as
that may manifest Specific 1.010- sugars, salts, and proteins. A
gravity: 1.030 1.025 urine concentration test can

33
through the urinary also be used to evaluate
tract. dehydration, kidney failure,
heart failure, other hormone
problems, complications of a
urinary tract infection

34
NURSING RESPONSIBILITIES:

Prior:

Check doctors order


Identify the patient
Explain procedure to the SO and the purpose and importance of the test.
Inform the SO that there is no fluid or food restriction needed.
Inform the SO that the test requires urine sample, tell who will do the test and
when.
Check the patients medication history for drugs that may interfere with test
results.

After:

If the patient is too weak and has no SO, assist him/her.

35
ABO TYPING, RH TYPING

The ABO system consists of A, B, AB, and O blood types. People with type A have antibodies in the blood against type B.
People with type B have antibodies in the blood against type A. People with AB have no anti-A or anti-B antibodies.
People with type O have both anti-A and anti-B antibodies. People with type AB blood are called universal recipients,
because they can receive any of the ABO types. People with type O blood are called universal donors, because their
blood can be given to people with any of the ABO types. Mismatches with the ABO and Rh blood types are responsible
for the most serious, sometimes life-threatening, transfusion reactions. But these types of reactions are rare. Rh system

The Rh system classifies blood as Rh-positive or Rh-negative, based on the presence or absence of Rh antibodies in the
blood. People with Rh-positive blood can receive Rh-negative blood, but people with Rh-negative blood will have a
transfusion reaction if they receive Rh-positive blood. Transfusion reactions caused by mismatched Rh blood types can
be serious.

36
Diagnostic/ Date
Laboratory ordered; General Indication Results
Procedures Date results
in

Blood is typed, or classified, according to B


ABO TYPING DO: the presence or absence of certain markers POSITIVE
RH TYPING September (antigens) found on red blood cells and in
14, 2016 the plasma that allow your body to
DR: recognize blood as its own. If another blood
September type is introduced, your immune system
14, 2016 recognizes it as foreign and attacks it,
resulting in a transfusion reaction..

37
ANATOMY AND PHYSIOLOGY

Anatomy of the Upper Digestive Tract

The upper digestive tract consists of the

mouth,
pharynx (throat),
esophagus,
stomach, and
duodenum (first part of the small intestine).

Mouth

Your mouth is the first part of your digestive tract. It is where food is chewed and mixed
with saliva until it becomes a soft mass that can be swallowed. Saliva is released into the

38
mouth even before food enters itthe odor or thought of food can make you salivate. An
enzyme in saliva called amylase starts breaking down the carbohydrates from food in
your mouth. When you swallow, food moves into your pharynx, a passageway that is 5
inches long and carries both food and air.

Esophagus

From the throat, food enters the esophagusa hollow, muscular tube about 10 inches
long. At the upper end of the esophagus is a circular area of muscle tissue called the
upper esophageal sphincter. When you swallow, this sphincter relaxes to allow food to
enter the esophagus.

After you swallow, the sphincter contracts to prevent air in the throat from entering the
esophagus. A structure called the epiglottis closes over the trachea to prevent the food
from entering the airways or lungs. Peristalsis pushes food through your esophagus.

The esophagus descends into the stomach through an opening in the diaphragm (a thin
muscle that separates your chest cavity from your abdominal cavity). At the lower end of
the esophagus is a ring of muscle tissue called the lower esophageal sphincter. When
food approaches, the lower esophageal sphincter relaxes to allow food to pass through
to the stomach. It then contracts to prevent reflux (the backflow of stomach contents into
the esophagus).

The esophagus contains a protective inner lining called the mucosa. In a healthy
esophagus, the mucosa is smooth and pink. The place where the esophagus makes
contact with the stomach is called the gastroesophageal junction; it forms an irregular
white line called the Z-line that can be seen by your doctor with an endoscope.

Stomach and Duodenum

Your stomach is a large, stretchy bag located slightly to the left in the upper portion of
your abdomen. Its function is to hold ingested food and to continue the digestive process

39
that began in your mouth by secreting gastric acid and digestive enzymes. Your stomach
has four sections:

the cardia, a short part next to the gastroesophageal junction


the fundus, the top of the stomach located under the left dome of the diaphragm
the body, the largest portion of the stomach located between the fundus and the
antrum
the antrum, a short, channel-like portion near the outlet of the stomach

The pylorus is a circular muscle below the antrum that connects the outlet of the stomach
with the duodenum. The duodenum, the first portion of the small intestine, is a C-shaped
tube that curves around the head of the pancreas. The part of the duodenum closest to
the stomach is called the duodenal bulb.

Farther along in the duodenum is the major duodenal papilla, a protuberance where the
common bile duct and main pancreatic duct enter the duodenum. The common bile duct
carries bile secreted from the liver after it is stored in the gallbladder into the duodenum;
the main pancreatic duct carries enzymes formed in the pancreas. The bile and
pancreatic enzymes help digest food in the duodenum.

Upper gastrointestinal bleeding

Upper gastrointestinal bleeding (sometimes upper GI, UGI bleed, Upper gastrointestinal
hemorrhage, gastrorrhagia) is gastrointestinal bleeding in the upper gastrointestinal tract,
commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood
may be observed in vomit (hematemesis) or in altered form in the stool (melena).
Depending on the severity of the blood loss, there may be symptoms of insufficient
circulating blood volume and shock. As a result, upper gastrointestinal bleeding is
considered a medical emergency and typically requires hospital care for urgent diagnosis
and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric
erosions, esophageal varices, and some rarer causes such as gastric cancer.

40
The initial assessment includes measurement of the blood pressure and heart rate, as
well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid
replacement is often required, as well as blood transfusion, before the source of bleeding
can be determined by endoscopy of the upper digestive tract with an
esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be
applied to reduce rebleeding risk. Specific medical treatments (such as proton pump
inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage)
may be used. Recurrent or refractory bleeding may lead to need for surgery, although this
has become uncommon as a result of improved endoscopic and medical treatment.

A number of medications increase the risk of bleeding including NSAIDs and SSRIs.
SSRIs double the rate of upper gastrointestinal bleeding. There are many causes for
upper GI hemorrhage. Causes are usually anatomically divided into their location in the
upper gastrointestinal tract. People are usually stratified into having either variceal or non-
variceal sources of upper GI hemorrhage, as the two have different treatment algorithms
and prognosis.

41
The causes for upper GI hemorrhage include the following:

Esophageal causes (gastrorrhagia):


o Esophageal varices
o Esophagitis
o Esophageal cancer
o Esophageal ulcers
o Mallory-Weiss tear
Gastric causes:
o Gastric ulcer
o Gastric cancer
o Gastritis
o Gastric varices
o Gastric antral vascular ectasia
o Dieulafoy's lesions
Duodenal causes:
o Duodenal ulcer

42
o Vascular malformation, including aorto-enteric fistulae. Fistulae are usually
secondary to prior vascular surgery and usually occur at the proximal
anastomosis at the third or fourth portion of the duodenum where it is
retroperitoneal and near the aorta.[3][4][5]
o Hematobilia, or bleeding from the biliary tree
o Hemosuccus pancreaticus, or bleeding from the pancreatic duct
o Severe superior mesenteric artery syndrome

43
8. PATIENT AND HIS ILLNESS
PATHOPHYSIOLOGY

a. SCHEMATIC DIAGRAM (BOOK-CENTERED)

MODIFIABLE RISK FACTORS: NON-MODIFIABLE RISK FACTORS:


Peptic Ulcer Disease 5th or 6th decade of life
Boerhaave Syndrome Men > Women
Mallory-Weiss Tear
Acute/Chronic Gastritis
Dieulafoy Lesions
NSAIDS Usage

Upper Gastrointestinal Bleeding:


Hematemesis Accumulation of blood in GI tract:
BP Increased peristalsis, digestion of
HR blood proteins, increased blood
Weak peripheral pulses Blood volume depletion urea nitrogen (BUN)
Acute confusion
Vertigo
Dizziness Decreased cardiac output:
Syncope Systolic BP, Pulse rate
Hgb and Hct
Electrolyte imbalance
Hypovolemic shock Compensatory constriction of peripheral
arteries

44
Blood flow to skin: Pallor Blood flow to kidneys: Blood flow to GI Blood flow to brain:
Urine output structures hypoxia, anxiety,
confusion, stupor, coma
Tubular necrosis
Abdominal Pain

Renal Failure:
Oliguria or Anuria Bowel infarction and Liver
necrosis

Anaerobic
metabolism

Lactic acid accumulation

Metabolic acidosis

Vasoconstriction

Blood supply to the


myocardium: Angina
Myocardial Infarction:
Dysrhytmias
Heart failure

Compensatory failure:
45
DEATH
b. Synthesis of the Disease
b.1. Definition of the Disease (Book-Centered)
UPPER GI BLEEDING
Gastrointestinal (GI) bleeding is a potentially life-threatening abdominal emergency
that remains a common cause of hospitalization. Upper gastrointestinal bleeding (UGIB)
is defined as bleeding derived from a source proximal to the ligament of Treitz.
The incidence of UGIB is approximately 100 cases per 100,000 population per year.
Bleeding from the upper GI tract is approximately 4 times more common than bleeding
from the lower GI tract and is a major cause of morbidity and mortality. Mortality rates
from UGIB are 6-10% overall.
The diagnosis of and therapy for nonvariceal upper gastrointestinal bleeding (UGIB)
has evolved since the late 20th century from passive diagnostic
esophagogastroduodenoscopy with medical therapy until surgical intervention was
needed to active intervention with endoscopic techniques followed by angiographic and
surgical approaches if endoscopic therapy fails.
The underlying mechanisms of nonvariceal bleeding involve either arterial
hemorrhage, such as in ulcer disease and mucosal deep tears, or low-pressure venous
hemorrhage, as in telangiectasias and angioectasias. In variceal hemorrhage, the
underlying pathophysiology is due to elevated portal pressure transmitted to esophageal
and gastric varices and resulting in portal gastropathy.
In patients with UGIB, comorbid illness, rather than actual bleeding, is the major cause
of death. Comorbid illness has been noted in 50.9% of patients, with similar occurrences
in males (48.7%) and females (55.4%).
One or more comorbid illnesses have been noted in 98.3% of mortalities in UGIB; in
72.3% of patients, comorbid illnesses have been noted as the primary cause of death.
Significant comorbidities have become more prevalent as the patient population with
UGIB has become progressively older. Rebleeding or continued bleeding is associated
with increased mortality; therefore, differentiating the patient with a low probability of
rebleeding and little comorbidity from the patient at high risk for rebleeding with serious
comorbidities is imperative.

46
b.2. Predisposing/Precipitating Factor

MODIFIABLE RISK FACTORS

a. Peptic Ulcer Disease - Bleeding peptic ulcers account for the majority of patients
presenting with acute upper gastrointestinal bleeding (UGIB). Peptic ulcer disease is
strongly associated with H pylori infection. The organism causes disruption of the
mucous barrier and has a direct inflammatory effect on gastric and duodenal mucosa.
In cases of ulcer-associated UGIB, as the ulcer burrows deeper into the
gastroduodenal mucosa, the process causes weakening and necrosis of the arterial
wall, leading to the development of a pseudoaneurysm. The weakened wall ruptures,
producing hemorrhage.

b. BoerhaaveSyndrome- During vomiting, the lower esophagus and upper stomach are
forcibly inverted. Vomiting attributable to any cause can lead to a mucosal tear of the
lower esophagus or upper stomach. The depth of the tear determines the severity of
the bleeding. Rarely, vomiting can result in esophageal rupture (Boerhaave
syndrome), leading to bleeding, mediastinal air entry, left pleural effusion (salivary
amylase can be present) or left pulmonary infiltrate, and subcutaneous emphysema.

c. Mallory-Weiss Tear- The massive UGIB results from a tear in the mucosa of the
gastric cardia. This linear mucosal laceration is the result of forceful vomiting, retching,
coughing, or straining. These actions create a rapid increase in the gradient between
intragastric and intrathoracic pressures, leading to a gastric mucosal tear from the
forceful distention of the gastroesophageal junction.

d. Gastritis- Acute stress gastritis results from predisposing clinical conditions that have
the potential to alter the local mucosal protective barriers, such as mucus,
bicarbonate, blood flow, and prostaglandin synthesis. Any disease process that
disrupts the balance of these factors results in diffuse gastric mucosal erosions.

e. Dieulafoy Lesions - The Dieulafoy lesion, is a vascular malformation of the proximal


stomach, usually within 6 cm of the gastroesophageal junction along the lesser
curvature of the stomach. However, it can occur anywhere along the GI
tract. Endoscopically, the lesion appears as a large submucosal vessel that has
become ulcerated. Because of the large size of the vessel, bleeding can be massive
and brisk. The vessel rupture usually occurs in the setting of chronic gastritis, which

47
may induce necrosis of the vessel wall. Alcohol consumption is reportedly associated
with the Dieulafoy lesion.

f. NSAIDS - NSAIDs cause gastric and duodenal ulcers by inhibiting cyclooxygenase,


which causes decreased mucosal prostaglandin synthesis and results in impaired
mucosal defenses. Daily NSAID use causes an estimated 40-fold increase in gastric
ulcer creation and an 8-fold increase in duodenal ulcer creation. Long-term NSAID
use is associated with a 20% incidence in the development of mucosal
ulceration. Medical therapy includes avoiding the ulcerogenic drug and beginning a
histamine-2 (H2)receptor antagonist or a proton pump inhibitor that provides mucosal
protection.

NON-MODIFIABLE RISK FACTORS


a. AGE (50-60 y/o) Result of natural thinning of the gastric mucosa with aging therefore
increasing risk for damage of the gastric mucosa which could then result to bleeding.
b. MEN>WOMEN Men are at risk of developing UGIB basically because of lifestyle
such as alcohol intake, cigarette smoking, and other factors which could predispose
someone for the development of any condition that could result to upper GI bleeding.

b.3. Signs and Symptoms with Rationale


1. Hematemesis bright red or coffee ground vomitus which is a constant manifestation
of upper GI bleeding and an indication of trauma to the upper GI mucosa.
2. Decreased BP due to decreased circulating blood volume in the body.
3. Increased HR compensatory mechanism of the body to increase contraction of the
heart therefore increasing blood supply to the system.
4. Weak Peripheral Pulses due to constriction of peripheral arteries to conserve blood
to the major organ of the body.
5. Acute Confusion due to decreased blood supply to the brain therefore resulting to
impaired cerebral perfusion.
6. Vertigo, Dizziness, Syncope due to impaired cerebral perfusion.
7. Decreased Hgb and Hct decreased haemoglobin and RBC due to decreased
cardiac output.
8. Pallor due to decreased circulating blood in the body therefore decreased oxygen
perfusion.
9. Decreased Urine Output due to decreased blood supply to the kidney because of
the body trying to conserve blood.
10. Angina due to decreased blood supply to the myocardium.
48
11. Metabolic acidosis anaerobic metabolism happens when there is decreased
oxygen supply to certain part or organ of the body and there is lactic acid accumulation
as the by-product of anaerobic metabolism resulting to metabolic acidosis.
12. Hypovolemic Shock due to excessively decreased circulating blood in the system.
13. Electrolyte imbalance due to release of some electrolytes during periods of
vomiting.

49
PATOPHYSIOLOGY
a. Schematic Diagram (Patient-Centered)

MODIFIABLE RISK FACTORS: NON-MODIFIABLE RISK FACTORS:


Peptic Ulcer Disease Age - 5th or 6th decade of life

Upper Gastrointestinal Bleeding:


Hematemesis (5x) Blood flow to Kidneys
HR (110 bpm)
RR (24 cpm)
Tubular necrosis
Hgb and Hct Blood volume depletion
Creatinine
Sodium Hematuria (3x)
Potassium Decreased cardiac output:
Pallor Pulse rate
Anorexia
Body malaise
Anemia (Hgb 90 g/dL)

50
b. Synthesis of the Disease
b.1. Definition of the Disease (Patient-Centered)
UPPER GI BLEEDING
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper
gastrointestinal tract, commonly defined as bleeding arising from the esophagus,
stomach, or duodenum. Bleeding occurs when the inner lining of the esophagus,stomach,
or proximal intestine is injured, exposing the underlying blood vessels, or when blood
vessels themselves rupture. Upper gastrointestinal bleeding (UGIB) is defined as
hemorrhage that emanates proximal to the ligament of Treitz.

Duodenal peptic ulcer disease is a ulcerative disorders that occur in areas of the
upper gastrointestinal tract that are exposed to acid-pepsin secretions. The most common
forms of peptic ulcer are duodenal and gastric ulcers. Peptic ulcer disease, with its
remissions and exacerbations, represents a chronic health problem. Duodenal ulcers
occur five times more commonly than gastric ulcers. Ulcers in the duodenum occur at any
age and frequently are seen in early group, with a peak incidence between 55 and 70
years of age. Both types of ulcers affect men three to four times more frequently than
women.

b.2. Predisposing/Precipitating Factor

MODIFIABLE RISK FACTOR

c. Peptic Ulcer Disease - Bleeding peptic ulcers account for the majority of patients
presenting with acute upper gastrointestinal bleeding (UGIB). Peptic ulcer disease is
strongly associated with H pylori infection. The organism causes disruption of the
mucous barrier and has a direct inflammatory effect on gastric and duodenal mucosa.
In cases of ulcer-associated UGIB, as the ulcer burrows deeper into the
gastroduodenal mucosa, the process causes weakening and necrosis of the arterial
wall, leading to the development of a pseudoaneurysm. The weakened wall ruptures,
producing hemorrhage.

51
NON-MODIFIABLE RISK FACTORS
d. AGE (50-60 y/o) Result of natural thinning of the gastric mucosa with aging therefore
increasing risk for damage of the gastric mucosa which could then result to bleeding.

b.3. Signs and Symptoms with Rationale


1. Hematemesis bright red or coffee ground vomitus which is a constant manifestation
of upper GI bleeding and an indication of trauma to the upper GI mucosa.
2. Increased HR compensatory mechanism of the body to increase contraction of the
heart therefore increasing blood supply to the system.
3. Decreased Hgb and Hct decreased haemoglobin and RBC due to decreased
cardiac output.
4. Pallor, Body malaise and Anorexia due to decreased circulating blood in the body
therefore decreased oxygen perfusion.
5. Hematuria due to damaged tubules of the kidneys because of decreased blood
supply to the organ therefore causing necrosis and mixing of blood with the urine.
6. Hyponatremia because of severe vomiting, certain electrolyte such as sodium is
being wasted.
7. Hyperkalemia due to inability of the kidney to excrete excess potassium because it
is damaged due to necrosis.
8. Hyperventilation compensatory mechanism of the body to increase oxygenation.

52
B. PLANNING (NURSING CARE PLANS)

Ineffective tissue perfusion related to decreased oxygen carrying capacity of the blood

Assessment Nursing Scientific explanation Objectives Nursing Rationale Evaluation


diagnosis intervention
S= Ineffective Loss of blood from the Short term 1. Monitor 1.To established Short term
tissue gastrointestinal tract is most vital signs baseline data
perfusion often the result of erosion or
related to ulceration of the mucosa but After 4 hours After 4 hours of
decreased may be the result of arterio- of nursing nursing
oxygen venous formation.Alcohol interventions, interventions,
carrying abuse is a major etiological 2.Assess 2. To gain the the patient shall
capacity of the factor in GI bleeding. the patient will have
O = The Patient patients knowledge of the
blood Gastrointestinal bleeding, be able to demonstrated
manifested: demonstrate general
secondary to may result from the lack of patients general increases tissue
pale palpebral anemia. RBC in our body especially increase tissue perfusion as
condition condition
conjunctiva hematocrit and hemoglobin perfusion as individually
weakness in our body which is individually appropriate.
important in carrying oxygen appropriate.
in our body. Once a 3.Monitor 3. To obtain
>Hemoglobin level of hemoglobin molecule is
90 g/L (9-14-16) glycated, it remains that and record baseline data for
way. A buildup of glycated vital signs future reference
>Hematocrit level hemoglobin within the red Long term:
cell, therefore, reflects the Long term:
Of 0.27 g/L(9-14-16) average level of glucose to
which the cell has been After 1 day of
exposed during its lifecycle. After 1 day of nursing
Because of the higher nursing interventions

53
Vital signs were taken amounts of glycosylated interventions 4. Review 4. It determines the patient shall
hemoglobin, that indicates the patient will laboratory extent of anemia have verbalized
and as follows:
poorer control of blood verbalize result for and its effect on understanding
glucose levels. The oxygen understanding hemoglobin energy output of condition,
T=37 C
supply that should be of condition, and appropriate therapy
carried by the red blood cell therapy hematocrit. measures regimen, and
PR= 106 bpm
is replaced by the glucose, regimen, and side effect of
so there is a decreased side effect of medication.
RR= 24 cpm
oxygen supply going to medication.
systemic circulation.
BP= 120/70 mmHg

The patient may


manifest:
fatigue 5.To decrease
tachycardia energy
dyshythmias 5.Maintain consumption and
hypotension bed rest. demand.
lethargy
seizure
6.This is to help
the patient in
attaining the
6.Assist in optimum level of
performing functioning.
activities of
daily living as
to feeding,

54
toileting and
bathing.

7.This is to
provide rest and
7. Provide
enough sleep
health
which decreases
teaching on
the demand on
maintaining
the kidneys to
a schedule
function.
that contains
adequate
time rest and
sleep should
be
considered.

8.Administer
medication
as ordered 8.This is to
pharmacologically
treat the client.
9. Refer to
medical
social

55
services as 9.This is to
necessary. counsel in about
the impact of
having such
10.Collabora disease.
te in
treatment of
underlying 10. To maximize
condition,suc systemic
h as circulation and
hypertension organ perfusion
,diabetes,car
diopulmonar
y conditions
and blood
disorders

Problem #2: Impaired gas exchange related to altered oxygen-carrying capacity of the blood as evidenced by
decreased level of hemoglobin

Assessment Nursing Diagnosis Scientific Explanation Objectives Nursing Interventions Rationale

S= Impaired gas exchange Short Term: 1.Establish therapeutic 1.To gain patients
is a state in which an relationship trust and
Patient may verbalize: Impaired gas individual experiences After 4-5 hours of cooperation
exchange related an excess or deficit in nurse-patient
>Dyspnea to altered oxygen- oxygenation and/or interventions, the
carrying capacity of carbon dioxide patient will

56
upon the blood as elimination at the demonstrate non
>Headache 2.Monitor and record 2. to acquire
evidenced by alveolar capillary pharmacologic
awakening vital signs baseline data
decreased level of membrane. Transport management as
>Visual Disturbances hemoglobin of oxygen is impaired evidenced by 3. Provide comfort 3. to provide
in anemia. Hemoglobin patient doing deep measures such as comfort
is lacking or the breathing, stretching bed linens,
number of RBCs is too coughing and cleaning bedside and
low to carry adequate turning exercises providing am care.
oxygen to tissues and
hypoxia develops. The 4. Encourage frequent
body attempts to position changes and
O= Long Term:
compensate for tissues deep breathing or
hypoxia by coughing exercises
Patient manifested: After 1-2 days of
nurse-patient 4. to promote
increasing the rate of 5. Encourage adequate
interventions, the optimum expansion
RBC production, rest and limit activities
patient will of the lungs and
>Hemoglobin level of increasing cardiac within client tolerance
demonstrate drainage of
90 g/L (9-14-16) output by increasing
adequate secretion
stroke volume or heart 6. Maintain adequate
rate, redistributing intake and output 5. to help limit
oxygenation of
blood from tissues of oxygen needs or
>Hematocrit level tissue by
low oxygen needs to consumption
hemoglobin result
tissues with high
Of 0.27 g/L(9-14-16) within clients 7. Provide psychological
oxygen needs, and
normal limits and support, active-listen
shifting of oxygen-
>pale bulbar and absence of
hemoglobin
palpebral conjunctiva respiratory questions/concern
dissociation curve to
distress.
the right to facilitate
the removal of more

57
oxygen by the tissues
>diaphoresis 8. Administer 6. to mobilize
at the same partial medication as indicated secretions
>restlessness pressure of oxygen such as recombinant
making the ability of human erythropoietin-
>vital signs were blood to carry oxygen beta
taken and as follows: decreased. Even
though there will be
T=37 C enough oxygen coming 7. to reduce anxiety
from the lungs, there is 9.Reinforce need for
PR= 106 bpm
a lesser carrying adequate rest, while
RR= 24 cpm capacity of oxygen to encouraging activities
the blood hence there such as deep breathing
BP= 120/70 mmHg is inadequate exercises and coughing
distribution of oxygen exercises
in the different parts of 8.to treat
the body giving rise to underlying
the problem impaired condition; to
gas exchange. increase red blood
cells
Patient may manifest:

>Confusion

>Abnormal breathing
9. to decrease
>hypoxia/hypoxemia dyspnea and
improve quality of
>Tachycardia life

58
Problem #3: Activity Intolerance
r/t muscle weakness secondary to decreased hemoglobin level

Assessment Nursing Scientific Objectives Intervention Evaluation


Diagnosis Explanation
S> Short-term: Independent: Short-term:
Nanghihina ako di Activity Decreased After 6 hours of Monior and After 6 hours of
ko kayang tumayo Intolerance oxygen carrying nursing record vital nursing
as verbalized by the related to muscle capacity Hgh will interventions, the signs interventions, the
patient. weakness lead to patient will report To obtain patient shall have
secondary to decreased the ability to baseline data reported
O> decreased nutrition in cells perform required and assess the ability to
The patient may hemoglobin level and decreased activities of daily changes perform required
manifests: ATP production living such as Establish activities of daily
Abnormal since oxygen is bathing, eating, guidelines and living such as
heart rate or needed for and walking goals of activity bathing, eating,
blood oxidation of CHO along corridor.

59
pressure / glucose. This with the patient and walking
response to deficiency in and/or SO. along corridor..
activity energy will Motivation and
ECG affects muscle cooperation are
changes and may lead to enhanced if the
reflecting muscle patient
arrhythmias weakness or participates in
or ischemia activity goal setting.
Dyspnea intolerance Have the patient
Fatigue at perform the
rest activity more
slowly, in a
longer time with
more rest or
pauses, or with
assistance if
necessary.
Helps in
increasing the
tolerance for the
activity.

60
Gradually
increase activity
with active
range-of-motion
exercises in
bed, increasing
to sitting and
then standing.
Gradual
progression of
the activity
prevents
overexertion.
Dangle the legs
from the bed
side for 10 to 15
minutes.
Prevents
orthostatic
hypotension.
Refrain from
performing

61
nonessential
activities or
procedures.
Patient with
limited activity
tolerance need
to prioritize
important tasks
first.
Assist with
ADLs while
avoiding patient
dependency.
Assisting the
patient with
ADLs allows
conservation of
energy.
Carefully
balance
provision of
assistance; facili

62
tating
progressive
endurance will
ultimately
enhance the
patients activity
tolerance and
self-esteem.
Provide bedside
commode as
indicated.
Use of
commode
requires less
energy
expenditure
than using a
bedpan or
ambulating to
the bathroom.
Teach energy
conservation

63
techniques,
such as: Sitting
to do tasks;
Frequent
position
changes;
Pushing rather
than pulling;
Sliding rather
than lifting;
Resting for at
least 1 hour
after meals
before starting a
new activity.
These
techniques
reduce oxygen
consumption,
allowing a more
prolonged
activity.

64
Encourage
verbalization of
feelings
regarding
limitations.
This helps the
patient to cope.
Acknowledgmen
t that living with
activity
intolerance is
both physically
and emotionally
difficult.
Encourage
physical activity
consistent with
the patients
energy levels.
Helps promote a
sense of
autonomy while

65
being realistic
about
capabilities.
Dependent:
Administer
oxygen via
nasal cannula
as indicated
To deliver
supplemental
oxygen and
prevent
hypoxemia
Refer to
physical/
occupational
therapy for
programmed
daily exercise
and activities
To increase
strength muscle

66
tone and
enhance sense
of well-being

Problem #4: Risk for deficient fluid volume

ASSESSMEN NURSING SCIENTIFIC PLANNING NURSING RATIONALE ASSESSMEN


T DIAGNOSIS KNOWLEDGE RESPONSIBILTI T
ES
S> Risk for The nursing Short term: Independent S>
deficient fluid diagnosis if Within 2 hours Provide To replace the
O> volume fluid volume of appropriate fresh fluid losses of O>
The client related to deficit related nursing water and the patients The client
manifested: excessive to loose stools interventions, oral fluids body manifested:
losses of and vomiting the patient will preferred
weak fluids through is a priority be able to by the weak
looking normal routes problem maintain client looking
dryness because the normal fluid unless To maintain dryness
of lips patient is at volume as contraindic normal of lips
observe risk for evidenced by ated intracellular observed
d hypovolemic maintenance and with cold
with cold shock, of urine output Maintain extracellular clammy
clammy experiencing of 4-5 times a patent IV fluid volume

67
extremiti vascular, day, normal access, extremiti
es cellular, or blood set an es
capillary intracellular pressure, appropriat capillary
refill dehydration pulse and e IV refill
within 4 due to current body infusion within 4
seconds condition, thus temperature flow rate seconds
tissue the need for and To detect and tissue
perfusio hydration is a administer prevent perfusion
n within priority at a occurrence of within 4
4 Long term: constant hypovolemia seconds
seconds After 3 days of flow rate frequent
frequent nursing as passing
passing interventions, ordered. of black
of black the patient will colored
be able to Body weight stool
colored maintain fluid Watch for changes (approxi
stool volume at a early signs reflect mately 3
(approxi functional level of changes in times)
mately 3 as evidenced hypovolem body fluid with
times) by individually ia, volume vomitus
with adequate including of
vomitus urinary output restlessne approxim
of with normal ss, ately 2
approxi specific weakness, cups
mately 2 gravity, stable muscle To determine if characte
cups turgor and cramps there is an rized as
characte prompt and existing bloody
rized as capillary refill postural deficiency in
bloody fluid volume

68
hypotensio The client may
The client may n. manifest:
manifest:
Monitor neck
neck daily veins flat
veins flat weight for when
when sudden client is
client is decreases, supine
supine especially change
change in the in mental
in mental presence status
status of To inform elevated
elevated decreasing physician of BUN and
BUN and urine the present Hct
Hct output or condition of decrease
decreas active fluid the patient and in urine
e in loss be able to output
urine carry out any with
output Monitor immediate increase
with total fluid orders to d
increase intake and prevent any specific
d output complications gravity
specific every 8
gravity hours.

Render
health
teachings:

69
o Avoid
humid
places to
reduce
insensible
fluid
losses
o Replenish
lost fluids
after daily
activities
through
intake of
water and
other liquid
products.

Collaborative
Refer the
patients
frequent
passing of
stool and
vomiting to
the
attending
physician.

70
Problem #5: Ineffective Protection
Assessment Nursing Scientific Objectives Intervention Evaluation
Diagnosis Explanation
S> Risk for infection Bleeding is the Short-term: Independent: Short-term:
name commonly After 6 hrs. Of Monior and After 6 hrs. Of
used to describe nursing record vital signs nursing
O> blood loss. It can interventions, the To obtain interventions, the
The patient may refer to blood patient will baseline data and patient shall have
manifests: loss inside the demonstrate assess changes demonstrated
Presence of body (internal techniques, techniques,
Establish
infections bleeding) or lifestyle changes lifestyle changes
guidelines and
Presence of blood loss to promote safe to promote safe
goals of activity
damaged outside of the environment. environment.

71
tissues upon body (external with the patient
diagnostic bleeding). and/or SO.
procedures Infection is the Motivation and
Increased WBC invasion of an cooperation are
count organism's body enhanced if the
tissues by
patient
disease-causing
participates in
agents, their
goal setting.
multiplication,
Emphasize
and the reaction
constant and
of host tissues to
proper hand
these organisms
and the toxins hygiene

they produce. To prevent


exposure to
different
microorganisms
Perform snd
instruct daily
mouth care
To prevent mouth
infections

72
Cover perineal
and pelvic region
dressing when
using bedpan
To prevent
contamination
maintain
adequate
hydration
To prevent
urinary infections

73
MEDICAL MANAGEMENT
INTRAVENOUS FLUID THERAPY
Medical Date General Indication Clients reaction
Management description
PNSS 1L x Date A isotonic solutions This solution is Patient responded
120cc/hr Ordered: having the same meant to replace well to the treatment
09/14/16 concentration of fluid loss caused and received the
solutes maintain by upper bleeding. nutrients needed by
Date Started: cell size and Since the patients the body such as
09/14/16 hydration. It blood was water, sodium and
contains 154 mEq hypertonic due to chloride. He did not
of Na and 154 mEq increase blood experience any
of chloride glucose level, an potential IVF therapy
isotonic solution related complications
counter the such as febrile
problem by diluting response, infection at
the excess solute, the site of injection,
which will cause a venous thrombosis or
decline in the phlebitis extending
tonicity of patients from the site of
blood. This causes injection,
an increase of extravasations and
fluids in the hypovolemia
intravascular
space to increase
the blood pressure
of the patient.

NURSING RESPONSIBILITIES:

Before the Procedure:

1. Check for the doctors order

2. In administering and starting the IV line of the patient, always start with
identifying the patient and explaining the procedure to the SO to gain their trust

3. Always observe and check for the correct type of IVF as well as the clarity of fluid

4. Observe universal precautions for the prevention of transmission of blood borne


pathogens

During the Procedure:

74
1. Select vein and apply tourniquet

2. Clean the site using cotton with alcohol in a circular motion going outwards

3. Puncture the vein, advance catheter then remove the needle and release the
tourniquet

4. Connect the tubing and secure the site

5. Ensure appropriate infusion flow

6. Adhere to standard precaution, then regulate flow rate as per doctors order

After the Procedure:

1. Check and observe the puncture site for bleeding, edema or thrombophlebitis

2. Documents the patients response

Medical Date General Indication Clients


Management description reaction

75
D5 W 90cc + Date Dextrose 5% in Source of The patient
80mg Ordered: Water (D5W) with water, didnt
omeprazole 09/14/16 omeprazole raises electrolytes experience
sidedrip total fluid volume it and calories or any adverse
regulated @ Date is also helpful in as an reaction upon
80 cc / hr Started: rehydrating, alkalinizing administration
09/14/16 excretory agent. of the drug
purposes and such as
reduce gastric acid headache,
and protects the fever, pain
GI lining and mild
diarrhea

NURSING RESPONSIBILTIES

Before:

1. Check for the doctors order


2. In administering and starting the IV line of the patient, always start with
identifying the patient and explaining the procedure to the SO to gain their
trust
3. Always observe and check for the correct type of IVF as well as the clarity of
fluid
4. Observe universal precautions for the prevention of transmission of blood
borne pathogens

5. Suspend container from eyelet support.

6. Remove plastic protector from outlet port at bottom of container.

7. Attach administration set. Refer to complete directions accompanying set

During:

1. Select vein and apply tourniquet


2. Clean the site using cotton with alcohol in a circular motion going outwards
3. Puncture the vein, advance catheter then remove the needle and release
the tourniquet
4. Connect the tubing and secure the site

76
5. Ensure appropriate infusion flow
6. Adhere to standard precaution, then regulate flow rate as per doctors order

After:

1. Check and observe the puncture site for bleeding, edema or


thrombophlebitis
2. Documents the patients response
3. If an adverse reaction does occur, discontinue the infusion, evaluate the
patient, institute appropriate therapeutic countermeasu

Blood Transfusion
Medical Date General Indication Clients
Management description reaction
Blood Date The transfer of Transfusions The patient
Transfusion Ordered: blood or blood are given to had
1 unit Packed 09/14/16 components from restore lost developed
RBC Type B+, Date one person (the blood, to reactions
Properly started: donor) into the improve such as
cross-matched 09/15/16 bloodstream of clotting time, having
another person and to improve erythematous
(the recipient). the ability of skin
the blood to inflammation
deliver oxygen on the face
to the body's and difficulty
tissues. of breathing

NURSING RESPONSIBILITIES:

BEFORE:

77
Check physicians order, including blood type, product and number of units and
period of time blood must be transfused.

Obtain consent from patients family.

Prepare the needed materials.

Transfusion must be started 30 minutes after blood is taken from the refrigerated
storage.

Check the patients vital signs.

Warm blood by wrapping it in a towel and store at room

DURING:

Stay with the patient with at least 15 mins. or the first 50ml of transfusion in order
to observe reactions and complications.

Blood should not be allowed to hang at 4-6 hours at room temperature because
of the danger of proliferation and RBC hemolysis.

Monitor vital signs.

Monitor patient for side effects and adverse reactions.

AFTER:

After completion of transfusion, flush remaining blood on tubing with PNSS.

Check the vital signs.

Document the procedure, time, vital signs, and reactions.

Medical Date General Indication Clients


Management description reaction

78
Oxygen Date Oxygen therapy is To deliver Patient
Inhalation via Ordered: the administration relatively low tolerated the
nasal cannula 09/14/16 of oxygen as a concentration management
4 LPM medical of oxygen and
intervention, which when minimal improved
can be a variety of oxygen support condition as
purposes in both is required. evidenced
chronic and acute by absence
patient care. of pallor and
Oxygen is dyspnea. No
essential for cell presence of
metabolism and in wheezes
turn tissue upon
oxygenation is exhalation
essential for all
normal
physiological
functions

NURSING RESPONSIBILITIES:

Before:

Be sure to check the doctors order


Check the humidifier
Check the flow rate of oxygen to the patient
Avoid cotton objects or anything that can initiate fire since oxygen is combustible
Place a no smoking sign near the oxygen or the room

During:

Regulate for the proper flow rate and monitor patients respiratory rate
The nurse should place the patient in a comfortable position, preferably semi-
fowler or full fowlers position to assist breathing.
Note the patients level of consciousness

After:

79
The nurse should stay with the patient for a while to reassure the patient and
observe his or her reaction to the therapy
The patients vital signs should be monitored, along with the level of
consciousness, comfort with the oxygen apparatus and oximetry levels
Oxygen connections and settings should be checked

DRUGS
Name of Date Route/ General Indication/ Clients
drug ordered/ Dosage/ action/mecha Purpose response
Date Frequency of nism of action to medicine
started/ administration with actual
Date s/e
change
d
Generic Date Route of It works by For gastric Had given
name: Ordered Administration: enhancing mucosal and reaction
09/14/16 Oral mucosal lesions in occurred.
Rebamipide defense, acute
scavenging gastritis and
Brand name: Dosage and free radicals, acute
Frequency: and temporarily exacerbation
Mucosta 50 mg/cap, 1 activating of chronic
cap TID genes gastritis.
encoding
cyclooxygenas
e-2.

NURSING RESPONSIBILITIES:

BEFORE:

Check the doctors order

Check and determine the prescribed drug

Explain the procedure, purpose, indication and side effects of the drug

Assess clients condition before starting the therapy.

80
Be alert for adverse reactions and interactions

Orient client on some possible side effects of drug.

DURING:

Special care is required in elderly patients to minimize the risk of gastrointestinal


disorders because these patients may be physiologically more sensitive to
mucosta than younger patients.
Monitor for any adverse reactions
Inform patient that drug may be taken with or without food
Mucosta should be administered to pregnant or possibly pregnant women only if
the anticipated therapeutic benefit is thought to outweigh any potential risk.
If abnormal findings are observed, Mucosta should be discontinued and
appropriate measures taken.

AFTER

Chart the procedure including the time, name and dosage of the drug and the
clients response to the administration.

Assess patients infection

Name of drug Date ordered/ Route/ General Indication/ Clients


Date started/ Dosage/ action/mechani Purpose response to
Date changed Frequency sm of action medicine
of with actual
administrati s/e
on

81
Generic name: Date Route of Forms a This is This is due to
Ordered: Administrati reversible indicated for upper
Tranexamic acid 09/14/16 on: complex that patients gastroesopha
IVP displaces with geal bleeding,
Brand name: plasminogen bleeding the desired
Dosage and from fibrin disorder effect of the
Cyklokapron Frequency: resulting in such as drug was
500 mg now inhibition of treatment of achieved as
Classification: then q 8 fibrinolysis; it severe evidenced by
hours x 3 also inhibits the localized an absence
Antifibrinolytic doses proteolytic bleeding by of bleeding
activity of helping the and
plasmin blood to clot hematemesis
normally as
in the case

NURSING RESPONSIBILITIES:

Before:

Check the doctors order

Check and determine the prescribed drug

Explain the procedure, purpose, indication and side effects of the drug

Dosage modification, required in patients with renal impairment

Perform ANST prior to admission, should not be given if positive skin test

Inform the patient about the possible side effects of the drug

Prepare the drug the materials

During:

Check for vital sings to obtain baseline data


Observe for initial assessment
Slow IV push
Do not give the drug with penicillin
Observe for any initial response to the treatment
Obtain prothrombin time of the patient

82
After:

Document that the medicine has been administer


Observe for clients reaction
Advise patient to report any discomfort on the IV insertion site
Instruct patient to consult physician if experience the following adverse effect

Name of Date Route/ General Indication/ Clients


drug ordered/ Dosage/ action/mechani Purpose response to
Date started/ Frequency of sm of action medicine
Date administration with actual
changed s/e
Generic Date Route of Chemical Given to Had given
name: Ordered: Administration: Effect: reduce and reaction
09/14/16 Via IV inhibits acid gastric acid. occurred.
Omeprazole pump and binds
Dosage and to hydrogen-
Brand name: Frequency: potassium
D5 W 90 cc + adenosine
Losec Omeprazole 80 triphosphate on
mg regulated at secretory
80cc/hr. surface of
gastric parietal
cells to block
formation of
gastric acid.
Therapeutic
Effect:
Relieves
symptoms
caused by

83
excessive
gastric acid.

NURSING RESPONSIBILITIES:

BEFORE:

Check the doctors order


Explain the procedure and the action of the drug
Make sure that it is the right drug, right dosage. Check for the expiration of
the drug
Explain the importance and action of the drugs.
Tell the possible reaction or side effects of the drugs.
Monitor patient for any adverse reaction.
Asses other medications patient may be taking for effectiveness and
interactions (especially those dependent on cytochrome P450 metabolism or
those dependent on an acid environment for absorption).
Monitor therapeutic effectiveness and adverse reactions at beginning of
therapy and periodically throughout therapy
Assess GI system: bowel sounds 8 hourly, abdomen for pain and swelling,
appetite loss
Monitor hepatic enzymes: increased alkaline phosphatase during treatment

DURING:

Instruct patient to take as directed, before eating


Do not crush or chew capsules
Delayed release capsule may be opened and contents added to apple sauce

AFTER:

Caution patient to avoid alcohol, salicylates, ibuprofen: may cause GI irritation

84
Patient may experience anorexia; small frequent meals may help to maintain
adequate nutrition
Report severe headache, unresolved severe diarrhea, or changes in respiratory
status.
Stay with the client for at least 15-30 minutes after giving the drug

Be alert for adverse reaction and drug interaction.

Monitor patients hydration

Name of drug Date Route/ General Indication/ Clients


ordered/ Dosage/ action/mech Purpose response to
Date Frequency of anism of medicine
started/ administration action with actual
Date s/e
changed
Generic name: Date Route of Competitively This was The desired
Ordered: Administration: blocks the used as effect of this
Diphenhydramine 09/14/16 IVP effects of premedicati drug was
histamine at on prior to achieved as
Brand name: Dosage and H1-receptor first blood evidence by
Frequency: sites, has transfusion an absence
Allerdryl 50 mg atropine-like, to prevent of allergic
anti-pruritic allergic reactions
Classification: and sedative reactions. such as
effect The drug fever,
Antihistamine, was also elevated
sleep aid, used to vital signs
antitussive prevent during blood
allergic transfusion
reactions
during blood
transfusion

NURSING RESPONSIBILITIES:
BEFORE:
Check the doctors order
Explain the procedure and the action of the drug

85
Make sure that it is the right drug, right dosage. Check for the expiration of the
drug
Assess allergy to any anti-histamines
Do not combine drug with amobarbital, amphotencin, B hydrocortisone
Do not mix with foscarnet

DURING:
Give without regards to meals
Ensure that the syringe containing the medication has no bubbles in it
Give the medication via slow push

AFTER:
Monitor patients response
Monitor blood pressure
Tell the patient that she may experience side effects such as dizziness, sedation
and drowsiness
Explain to the client that arising quickly form a lying or sitting position may cause
orthostatic hypotension
Document what have done and all the necessary outcomes

Name of drug Date Route/ General Indication/ Clients


ordered/ Dosage/ action/mechanism Purpose response to
Date Frequency of of action medicine
started/ administration with actual
Date s/e
changed
Generic name: Date 20 mg IV q 12 This drug is a loop To prevent The
Ordered diuretic that inhibits fluid expected
Furosemide 09/14/16 reabsorption of accumulation effect was
sodium and chloride due to achieved by
Brand name: from proximal and decrease the patient
Lasix sital tubules and albumin as
ascending limb to production evidenced
loop of Henle, and to by absence
leading to sodium- manage of edema
rich diuresis. The hypertension and

86
decreased fluid will decreased
result to decreased blood
blood volume leading pressure
to decreased blood upon the
pressure course of
treatment of
furosemide

NURSING RESPONSIBILITES:

Before:

Check the doctors order


Check and determine the prescribed drug
Explain the procedure, purpose, side effects, indications of the drug
Check for blood pressure if it is increased
Assess for presence of edema on extremities or edema-prone areas

During:

check for vital signs to obtain baseline data


observe for any initial response to the treatment
do not exceed the recommended dosage
reduce dosage with hepatic impairment or hepatic coma
administer with milk to prevent GI upset
give early in the morning to facilitate urination at less sleeping hours
monitor intake and output on daily basis
monitor electrolytes levels for depletion possibilities
arrange for liver and renal function test during the course of drug treatment

After:

document that the medicine has been administered


instruct patient to report to the physician the undesired effects such as weight
gain, dizziness and cramps
monitor the blood pressure for sudden drop

87
Name of drug Date Route/ General Indication/ Clients
ordered/ Dosage/ action/mechanism Purpose response to
Date Frequency of of action medicine
started/ administration with actual
Date s/e
changed
Generic name: Date Route of Stimulates motility of This can be The desired
Ordered Administration: upper GI tract used to treat effect of the
Metoclopromide 09/14/16 IVP without stimulating nausea and drug was
gastric, biliary, vomiting, it achieved by
Brand name: Dosage and or pancreatic can also decreasing
Frequency: secretions; appears raise lower the
Plasil 50 mg to sensitivity tissues esophageal intravariceal
to action of sphincter blood flow
acetylcholine; pressure. as
relaxes pyloric evidenced
sphincter, which, by an
when combined with absence of
effects on motility, vomiting
accelerates gastric episodes
emptying and and
intestinal transit little hematemesi
effect on gallbladder s
or colon motility,
increases lower
esophageal
sphincter pressure;
has
sedative properties;
induces release of
prolactin

NURSING RESPONSIBILIITIES

Before

1. Observe 15 rights in drug administration.


2. Assess for allergy to metoclopramide.
3. Assess for other contraindications.
4. Keep diphenhydramine injection readily available in case extrapyramidal
reactions occur (50 mg IM).

88
5. Have phentolamine readily available in case of hypertensive crisis.

During

1. Monitor BP carefully during IV administration.


2. Monitor for extrapyramidal reactions, and consult physician if they occur.
3. Monitor diabetic patients.
4. Give direct IV doses slowly over 1-2minutes.
5. For IV infusion, give over at least 15minutes.

After

1. Dispose of used materials properly.


2. Educate patient about side effects.
3. Instruct to report involuntary movement of the face, eyes, or limbs, severe
depression, and severe diarrhea.
4. Instruct patient to take drug exactly as prescribed.
5. Instruct not to use alcohol, sleep remedies or sedatives; serious sedation could
occur. Do proper documentation

Name of Date Route/ General Indicatio Clients


drug ordered/ Dosage/ action/ n/ respons
Date Frequency mechanism of Purpose e to
started/ of action medicin
Date administrati e with
changed on actual
s/e
Generic name: Date Route of Antipyretic: Temporary The desired
Ordered Administration: Reduces fever by reduction of effct of the
Paracetamol 09/14/16 IV acting directly on fever, drug was
the hypothalamic temporary achieved by
Brand name: Dosage and heat-regulating relief of an absence
Frequency: center to cause minor aches of
Tylenol 300 mg vasodilation and and pains transfusion
sweating, which caused by reaction

89
helps dissipate common during the
heat. colds and procedure
headache. like fever,
rashes or
difficulty of
breathing.
This means
that the
blood
product is
compatible
with the
patient.

NURSING RESPONSIBILTIES

Before:

Check for doctors order


Check and determine the prescribed drug
Explain the procedure, purpose and indication of the drug

During:

Check vital sign to obtain baseline data


Observe for any initial assessment
Do not exceed the recommend dosage
Reduce dosage with hepatic impairment
Avoid using multiple preparations containing acetaminophen. Carefully check all
OTC products
Give drug with food to prevent GI upset

After:

Document that the medicine has been administer

90
Instruct the patient to consult physician if experienced adverse effects like
unusual bleeding, bruising and changes in the voiding pattern

Name of drug Date Route/ General action/ Indication/ Clients


ordered/ Dosage/ mechanism of Purpose response to
Date started/ Frequency of action medicine
Date administration with actual
changed s/e
Generic name: Date 50 cc/hr OD Sodium Treating Patients
Kayaxelate Ordered polystyrene high potassium
09/14/16 sulfonate is potassium level
Brand name: a cation-exchange levels in the decreased
Kalexate, resin taken orally blood. after drug
Kayexalate, that is used to Kayexalate administratio
Kionex reduce high levels powder is a n
of potassium in the potassium-
blood removing
(hyperkalemia). resin. It
Sodium works by
polystyrene drawing
sulfonate removes potassium
potassium by into the
exchanging large
sodium ions for intestine
potassium ions in and then
the intestine. removing it
from the
body.

.
NURSING RESPONSIBILITIES:

Before:

91
Check for doctors order
Explain the procedure, purpose and indication of the drug
Monitor response of symptoms of hyperkalemia (fatigue, muscle weakness,
paresthesia, confusion, dyspnea, peaked T waves, depressed ST segments,
prolonged QT segments, widened QRS complexes, loss of P waves, and
cardiac arrhythmias).
Assess for development of hypokalemia (weakness, fatigue, arrhythmias, flat
or inverted T waves, prominent U waves).
Monitor intake and output ratios and daily weight.
Assess for symptoms of fluid overload (dyspnea, rales/crackles, jugular
venous distention, peripheral edema). Concurrent low-sodium diet may be
ordered for patients with HF.
In patients receiving concurrent digoxin, assess for symptoms of digoxin
toxicity (anorexia, nausea, vomiting, visual disturbances, arrhythmias).
Assess abdomen and note character and frequency of stools.
Discontinue sodium polystyrene sulfonate if patient becomes constipated.
Concurrent sorbitol or laxatives may be ordered to prevent constipation or
impaction. Some products contain sorbitol to prevent constipation. Patient
should ideally have 1 2 watery stools each day d

During:

Give as a suspension in a small quantity of water or in syrup. Usual amount of


fluid ranges from 20100 mL or approximately 34 mL/g of drug.
Use warm fluid (as prescribed) to prepare the emulsion for enema.
Administer at body temperature and introduce by gravity, keeping suspension
particles in solution by stirring. Flush suspension with 50100 mL of fluid;
then clamp tube and leave it in place.
Urge patient to retain enema at least 3060 min but as long as several hours
if possible.

92
Irrigate colon (after enema solution has been expelled) with 1 or 2 quarts
flushing solution (non-sodium containing). Drain returns constantly through a
Y-tube connection.
Store remainder of prepared solution for 24 h; then discard.

After:

Observe patient closely for early clinical signs of severe hypokalemia (see
Appendix F). ECGs are also recommended.

Consult physician about restricting sodium content from dietary and other
sources since drug contains approximately 100 mg

Document the outcome of the treatment

Table 13.Type of Diet


Type of diet Date General Indications Specific Clients
Prescribe description foods taken response
d
NPO 09/14/16 NO solid For patients none The patient was
foods or prior to complaint and
either liquids operation. did not manifest
to be any complication
ingested as evidence by
she did not
manifest
episodes of
vomiting or
aspiration during
the procedure.
She tolerated
the NPO status
as evidence by
absence of
abdominal
discomfort.

Clear liquid 09/16/16 The clear used to juice, gelatin The patient was
liquid diet maintain and complaint and

93
has traditiona hydration while vegetable tolerated the diet
lly been minimizing broth as evidenced by
composed of colonic residue absence of
foods that abdominal pain
are and
transparent hematemesis
and liquid at and melena
body
temperature.
Soft diet 09/20/16 Foods that For patient -oatmeal Able to comply
are mashed who has -porridge
or pureed, difficulty -mashed
placed in swallowing, potatoes
soups, stews, surgery
chili, curries, involving the
or made into mouth or
sauces. gastrointestinal
tract, and pain
from newly
adjusted
braces.

NURSING RESPONSIBILITIES:
BEFORE:
Relieve illness symptoms that depress appetite prior to meal time (e.g. give an
analgesic for pain)
Provide familiar food that the person likes.
Avoid unpleasant or uncomfortable treatments immediately before meals.
Provide a tidy, clean environment that is free of unpleasant sights and odors.
Wash hands and other appropriate infection control.

94
DURING:
Warn the patient if the food is hot or cold.
Allow ample time for the client to chew and swallow the food before offering
more.
Provide fluid as requested and needed.
Use a straw or special drinking cup to avoid spills.
AFTER:
Assist the client to clean the mouth and hands.
Have the client rest for 30 minutes to one hour to prevent aspiration.
Reposition the client.

Table 14.Exercise
Type of Date General Indication/ purpose Clients
exercise started description response to
activity/
exercise
Active September Isotonic exercise To maintain or The patient
ROM 23, 2008 in which the increase muscle was able to
patient strength and move freely.
independently endurance and
movers each joint health to retain
in the body cardiorespiratory
through its Function.
complete range of To prevent
movement, deterioration of
maximally joint capsules.
stretching all ankylosis, and
muscle groups contractures.
within each plane
over the joint.
(Active ROM of
upper extremities

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may include
combing of hair,
bathing and
dressing)

NURSING RESPONSIBILITIES:
BEFORE:
Assess patients ability to move
Raise side rails
Cloth patient with loose gown
Teach/demonstrate the exercise
DURING:
Perform each ROM to point of slight resistance, but not beyond never to point
discomfort
Assist the patient during exercise
AFTER:
Let the patient take enough rest after the exercise
RECORDNURSING MANAGEMENT (Actual SOAPIERs)
S=

O= Received patient on bed in supine position, awake and coherent with an ongoing IVF
of 0.9Nacl IL x 30 gtts/min at 800 cc level infusing well on her left hand.

Hematocrit level of 0.27 g/L, Hemoglobin level of 90 g/L

With Vital Sign taken as followed:

T=37 C, PR= 106 bpm, RR= 24 cpm, BP= 120/70 mmHg

A= Impaired gas exchange related to altered oxygen-carrying capacity of the blood as


evidenced by decreased level of hemoglobin

P= After 4-5 hours of nurse-patient interventions, the patient will demonstrate non
pharmacologic management as evidenced by patient doing deep breathing, coughing and
turning exercises

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I=

>Monitored and recorded vital signs

>Provided comfort measures such as stretching bed linens, cleaning bedside and
providing am care.

>Encouraged frequent position changes and deep breathing or coughing exercises

>Encouraged adequate rest and limit activities within client tolerance

>Noted clients nutritional and fluid status

>Maintained adequate intake and output

>Provided psychological support, active-listen questions/concerns

>Administered medication as indicated such as recombinant human erythropoietin-beta

>Assisted with procedures as individually indicated

>Reinforced need for adequate rest, while encouraging activities such as deep breathing
exercises and coughing exercises

E= Goal met as evidenced by patient demonstrating nonpharmacologic management

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D. EVALUATION
1. Clients Daily Progress Chart (From admission to last nurse-patient interaction)
DAYS September 14, 2016 September 16, 2016 September 22, 2016
Admission 3rd day 9th day
Nursing Problems
1.Ineffective tissue
perfusion
2.Impaired gas exchange
3.Activity intolerance
4.Risk for fluid volume
deficit
5.Risk for infection
Vital Signs
Temperature T: 36C T: 36.8C T: 38.5C
Pulse Rate PR: 65 bpm PR: 83 bpm PR: 110 bpm
Respiratory rate RR: 20 cpm RR: 25 cpm RR: 24 cpm
Blood Pressure BP: 100/70 mmHg BP: 100/70 mmHg BP: 110/70 mmHg

Dx/Lab Procedures
CBC
ECG test
Blood Typing
Cross Matching
Blood Chemistry
Drugs/Medications Metoclopramide 10mg IV q8 Metoclopramide 10mg IV q8 Metoclopramide 10mg IV q8
Paracetamol 350mg IV Paracetamol 350mg IV Paracetamol 350mg IV
Omeprazole 80mg IV OD Omeprazole 80mg IV OD Omeprazole 80mg IV OD
Furosemide 4mg IV q6 Furosemide 4mg IV q6 Furosemide 4mg IV q6
Tranexamic 500 mg q8 Tranexamic 500 mg q8 Salbutamol neb. q6
Kayaxelate sachet + 50cc OD

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Kayaxelate sachet + 50cc Kayaxelate sachet + 50cc Diphenhydramine 50mg IV
OD OD
Diphenhydramine 50mg IV Diphenhydramine 50mg IV
Diet NPO Clear liquid diet Soft diet
Activity/Exercise Active ROM Active ROM Active ROM

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2. Discharge Planning
a. General Condition of Client upon Discharge
The client can now be discharge because he can walk on his own, he showed no
complications and the laboratory results are within normal ranges. The client verbalizes
understanding about the disease condition and demonstrated ways how to prevent the
recurrent of the disease. METHOD should be emphasized to the client upon
discharged.

b. METHOD
Medication - Continue medications as prescribed.
- Explained important reminders and
their side effects.
Exercise - Encouraged to exercisefor at least
30mins./day for 3-4 times a week.
Treatment - Stress importance in complying to
medications.
- Follow up check-ups as scheduled.
Health Teachings - Taught client to avoid gastric irritants
- Avoid stressful activities
- Avoid vices such as smoking and
alcohol.
Observation - Encouraged client to observe
appearance of urine, stool and other
secretions.
Diet - Instructed client to eat iron-rich foods
to rebuild the iron stores that were
lost during bleeding episodes.
- Instructed client to eat high-fiber diet
to soften stools to prevent straining
due to constipation.
- Instruct to eat high protein diet to
promote faster healing of damaged
tissues.
- Avoid intake of alcohol, caffeine,
spicy foods, because these are
potential gastric irritants. Re-introduce
these foods into diet slowly, until GI
tract can handle them.

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III. SUMMARY OF FINDINGS

The following are the findings of the study:

1. The nurse researchers gathered all the needed information concerning to the
patient condition especially those risk factors that may contribute to the patients
condition. The patient cooperated and provided an accurate information needed
by the researchers and complied well during the nurse cooperated and-patient
interaction.
2. The nurse researchers intensively analyzed and interpreted the gathered
abnormal data.
3. The nurse researchers gain more knowledge and understanding of the existing
condition and provided interventions for the wellness of the patient.
4. The nurse researchers provided health teachings such as in taking medications,
the effects of the drug, their importance and their mechanism of action.
5. The nurse research team handled the patient for 1 day and performed physical
assessment 5 problems were identified and prioritized according to severity.
Nursing care plans were implemented to deal with the problems of the patient.
6. The nurse research team provided health teaching/interventions concerning to a
specific problem and were explained why there were explained why these were
necessary. Hygiene, food preparation, stable environment and health teachings
were emphasized during the nurse-patient interactions.
7. The evaluation was made to know if the interventions done were effective.
8. The patient verbalized understanding of the condition and health teachings and
cooperated through the course of the case study.
9. The patient receives the possible nursing care for the client as evident in the
client improvement during the study.
10. The patient put into action the health teachings given by the nurse researchers
for the clients health improvement.

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IV. CONCLUSION

The nurse research team gain more knowledge and understanding of the condition; the
pathophysiology, the etiology, and the risk factors involve in its development and
progression. The team explains to the client the different procedures and interventions
and their importance in treating his condition. The researchers handled the patient for 1
day and formulated nursing care plans and implemented them. The researchers also
provided health teachings regarding the condition and explained the necessary
interventions to promote cooperation with the patient. Hygiene, food preparation, stable
environment were emphasized during the course of the nurse-patient interaction. Other
problems of the patient were referred to the attending physician. The patient verbalized
understanding of the health teachings and for his condition.The research team provided
comfort and relaxation to the patient to prevent stress and to minimize complications.

V. RECOMMENDATION

At the course of the study, the research team had found out that in-depth knowledge
about the condition process will benefit not only the patient and its family but also the
nurse and the medical staff as well. The following is a list of recommendations made by
the research team:

For the Student Nurses it is recommended knowing the proper interventions and
management to provide an efficient nursing care to their client that has the same
condition. To have a sufficient knowledge is a must to improve the health teachings to
attain their optimum level of functioning.

For the Nurse Educators the study can become a basis for nursing educator
because it provides depth information about the condition and its complications. The
researchers recommend the nurse educator to provide health teachings regarding the
risk factors that could lead to the condition.

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For the Health Care Provider learning never stops in comes to the medical practitioner
and nurses because new innovation are made to improve patient quality of life everyday
in health care. Health care delivery system plays an important role in helping patient with
this condition and thats why nurses and medical practitioners update themselves in the
different new discoveries with this condition.

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VI. LEARNING DERIVED

Each patient carries his/her own doctor inside.


-Albert Schweitzer

What the quote would like to point out is that a person should know how to prevent
different diseases and what to do when he/she is sick. We student nurses were able to
hear from the different patients in the ward that they admitted that they are the cause why
theyre hospitalized. They told us that theyre not taking good care of their health. One of
our responsibility as a nurses is to educate the people for them to become an independent
individuals and to prevent different diseases and to prevent different complications that
may arise if the disease is not treated immediately. We were able to emphasized to our
patients the health teachings and they were able to verbalized and understand it.

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BIBLIOGRAPHY

BOOKS

Weber Kelly Health Assessment in Nursing

Brunner and Suddarths Handbook of laboratory and diagnostic tests

Edition 12 Doenges Moorhouse Murr Nurses Pocket Guide

Seeleys Essentials of Anatomy and Physiology

Spratto Woods Delmar Nurses Drug handbook

Medical-Surgical Nursing Clinical Management for positive outcomes Joyce M Black and
Jane Hokanson Hawk 8th edition

Pathopysiology: The Biologic Basis for Diseases in Adults and Children Kathryn L.
McCance, Sue E. Huether 2nd Edition

WEBSITES

https://www.nice.org.uk/guidance/cg141?unlid=805622976201622522739

http://emedicine.medscape.com/article/187857-treatment

http://patient.info/doctor/upper-gastrointestinal-bleeding-includes-rockall-score

http://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-
adults

http://www.aafp.org/afp/2012/0301/p469.html

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