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TABLE OF CONTENTS

I. Introduction
a. Overview of the case
b. Objective of the study
c. Scope and Limitation of the study
II. Health History
III. Developmental Data
IV. Medical Management
a. Medical orders with rationale
b. Drug Study
c. Laboratory results
V. Anatomy and Physiology with Pathophysiology
VI. Nursing Assessment
VII. Nursing Management
a. Ideal Nursing Management
b. Actual Nursing Management (SOAPIE)
VIII. Referrals and Follow-up
IX. Evaluation and Implications
X. Bibliography





I. INTRODUCTION
a. Overview of the Case
Gastritis is inflammation of the lining of the stomach and has many possible
causes. Common causes of gastritis are excessive alcohol consumption or
prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs)
such as aspirin or ibuprofen. Gastritis may also develop after major surgery,
traumatic injury, burns, or severe infections. Gastritis may also occur in those who
have had weight loss surgery resulting in the banding or reconstruction of the
digestive tract. Chronic causes are infection with bacteria, primarily Helicobacter
pylori, chronicbile reflux, and stress; certain autoimmune disorders can cause
gastritis as well. The most common symptom is abdominal upset or pain. Other
symptoms are indigestion, abdominal bloating, nausea, and vomiting
and pernicious anemia. Some may have a feeling of fullness or burning in the
upper abdomen. An esophagogastroduodenoscopy, blood test, complete blood
count test, or a stool test may be used to diagnose gastritis. Treatment includes
taking antacids or other medicines, such as proton pump inhibitors or antibiotics,
and avoiding hot or spicy foods. For those with pernicious anemia, B
12
injections
are given, but more often oral B12 supplements are recommended.
Many people with gastritis experience no symptoms at all. However, upper
central abdominal pain is the most common symptom; the pain may be dull, vague,
burning, aching, gnawing, sore, or sharp. Pain is usually located in the upper
central portion of the abdomen, but it may occur anywhere from the upper left
portion of the abdomen around to the back.
Other signs and symptoms may include:Nausea,Vomiting (if present, may be clear,
green or yellow, blood-streaked, or completely bloody, depending on the severity
of the stomach inflammation),belching (if present, usually does not relieve the pain
much)Bloating.Early signs are loss appetite,unexplained weight loss.
Acute gastritis is a gastric mucosal erosion caused by damage to mucosal
defenses. Alcohol consumption does not cause chronic gastritis. It does, however,
erode the mucosal lining of the stomach; low doses of alcohol


stimulate hydrochloric acid secretion. High doses of alcohol do not stimulate
secretion of acid. NSAIDs inhibit cyclooxygenase-1, or COX-1, an enzyme
responsible for the biosynthesis of eicosanoids in the stomach, which increases
the possibility of peptic ulcers forming. Also, NSAIDs, such as aspirin, reduce a
substance that protects the stomach called prostaglandin. These drugs used in a
short period are not typically dangerous. However, regular use can lead to gastritis.


b.General Objective
The objective of making this case study is to identify the problem of our patient
and to determine the factors that contribute to this kind of disease so that specific
actions should be done and rendered to our patient. I have selected this patient having
this kind of disease because the primary concept that should fit our study is all about
abnormalities pertaining a child with physiologic disorders. Having this kind of case
study is a privilege for me because it would be a good learning process by adding new
knowledge and concept about different kinds of diseases that may be present in some
patients. By making this case study I can identify the disease step by step, its nature on
how this disease occur, and nursing actions that would be appropriate for the patient.
This study aims to convey familiarity and to provide an effective nursing care to a
patient diagnosed with Acute Gastritis through understanding the patient history,
disease process and management.
c.Specific Objectives
At the end of this study, we will be able to:
1. Define Acute Gastritis
2. Identify the development theory of the patient
3. Discuss the health history of the patient
4. Identify the history of the patient
5. Discuss the medical management of the disease
6. Show the physical assessment of the patient


7. Discuss the pathophysiology of the disease
8. Enumerate and discuss the nursing management
9. Identify the drugs administered to the patient
10. Discuss the health teachings which includes the referral and follow-up

d. Scope and Limitations
The scope of this study covers from the patients health history, developmental
data, and as well as with her medical and nursing management. Based upon the
assessment done, appropriate interventions were implemented to have a proper care
for the clients health.

The study is limited from the information being collected from the patient. The
data gathering through objective and subjective assessment was limited based upon my
interview to Ms.RFE and nursing assessment. The patient was being assessed for 1
day from the time we had our ward duty exposure.












II. HEALTH HISTORY
a. Profile of Patient
Patients Name : Ms. RFE
Address : Yacapin Burgos CDOC
Age : 28 y.o
Sex : Male
Birth Date : 10-11-86
Religion : Roman Catholic
Nationality : Filipino
Civil Status : Single
Family Income : 10,000/month
Occupation : Nurse
Date of Admission : 2-714 3:25 PM
Admitting Diagnosis : T/C Acute Gastrtis
Attending Physician : Dr. Tan


b. Personal Health History
According to Ms. RFE, they dont had history of acute gastrtis in her
mother side and DM in her father side. She also admits drinking of alcoholic
beverage for socialization purposes. She even claims to have known the
negative effect of these products but would always associate it with enjoying
life and some sort of relaxation. Patient has no allergy to foods. She loves to
eat fatty and acidic foods and on her teenage days she mentioned that she
had stop drinking.

c. History of Present Illness
One day prior to admission patient had onset of abdominal pain radiating to
right epigastric region. Four days prior to admission pain at the epigastric
region is frequently occuring.


d. Chief Complaint
10/10 pain scale of abdomen.

III. DEVELOPMENTAL DATA
As part of understanding our clients totality, we as nurses should understand
their developmental aspects and compare them with that of the well-known
theories formulated by Erikson, Freud, and Havighurst.
A. Erikson's Stages of Psychosocial Development
Psychosocial development as articulated by Erikson describes eight
developmental stages through which a healthy developing human should pass from
infancy to late adulthood. In each stage the person confronts, and hopefully masters
new challenges. Each stage builds on the successful completion of earlier stages. The
challenges of stages not successfully completed may be expected to reappear as
problems in the future.
Young Adulthood (19-40 yrs)
Intimacy vs. Isolation:
According to Erikson, this stage is characterized by increasing importance of
human closeness and sexual fulfillment: gradually, the acquisition of love.
Implication:
Based on our assessment the patient was able to participate easily and able to
build trust with others and accepts the chosen lifestyle and might do changes relating to
health.




B.Sigmund Freud's Psychosexual Development
The concept of psychosexual development as envisioned by Freud at the end of
the nineteenth and the beginning of the twentieth century is a central element in the
theory of psychology. It consists of five separate phases' oral, anal, phallic, latency, and
genital. In the development of his theories, Freud's main concern was with sexual
desire, defined in terms of formative drives, instinct and appetites that result in the
formation of an adult personality.
Genital (Puberty and after)
Energy is directed toward full sexual maturity and function and development of
skills, needed to cope with the environment.
Implication:
Based on our assessment, patient was able to have her own income as
evidenced of being independent for her self from her parents and do his own decision
making.
C.JEAN PIAGETS COGNITIVE THEORY
Piaget refers to the adulthood stage as the formal operational stage.The formal
operational stage is the fourth and final of the stages of cognitive development of
Piaget's theory. This stage, which follows the Concrete Operational stage, commences
at around 11 years of age (puberty) and continues into adulthood. It is characterized by
acquisition of the ability to think abstractly and draw conclusions from the information
available. During this stage the young adult functions in a cognitively normal manner
and therefore is able to understand such things as love, "shades of gray", and values.
Lucidly, biological factors may be traced to this stage as it occurs during puberty and
marking the entry to adulthood in Physiology, cognition, moral judgments (Kohlberg),
Psychosexual development (Freud), and social development (Erikson). Some two-thirds
of people do not successfully complete this stage, and "fixate" at the concrete
operational stage.


In case of Ms. RFE, she is on this stage since she has social groups and he has
sound judgments on problems that she may encounter.
PHASE AND STAGE AGE SIGNIFICANT
BEHAVIOR

Formal Operational
Phase

11-adulthood

Uses rational thinking
Reasoning is deductive
and futuristic


D.ROBERT HAVIGHURSTS DEVELOPMENTAL TASK THEORY
Robert Havighurst believes that learning is basic to life and that people continue
to learn throughout life. He describe growth and development as occurring during six
stages each associated with from six to ten tasks to be learned.
In the middle years, from about thirty to about fifty-five, men and women reach
the peak of their influence upon society, and at the same time the society makes its
maximum demands upon them for social and civic responsibility. It is the period of life to
which they have looked forward during their adolescence and early adulthood. And the
time passes so quickly during these full and active middle years that most people arrive
at the end of middle age and the beginning of later maturity with surprise and a sense of
having finished the journey while they were still preparing to commence it.
The biological changes of ageing, which commence unseen and unfelt during the
twenties, make themselves known during the middle years. Especially for the woman,
the latter years of middle age are full of profound physiologically-based psychological
change.



The developmental tasks of the middle years arise from changes within the
organism, from environmental pressure, and above all from demands or obligations laid
upon the individual by his own values and aspirations.
Since most middle-aged people are members of families, with teen-age children,
it is useful to look at the tasks of husband, wife, and children as these people live and
grow in relation to one another. Each family member has several functions or roles.


The Man of the Family The Woman of the Family The Teenager
a man a woman a person
a husband a wife a family member
a father a mother
a provider a homemaker &
a homemaker family manager

Unless the man performs well as a provider, it will be difficult for the woman to
perform well as a homemaker. Unless the woman performs well as a mother, it will be
difficult for the teen-age child to meet the tasks of adolescence. The developmental
tasks of family members then, are reciprocal; they react upon one another.







IV. MEDICAL MANAGEMENT
A. Doctors Order
Date Order Rationale
2/7//2014
4:35PM

























Pls. Admit to ROC under Dr.
Tan

Secure consent to care and
mgt.


DAT diet



IVF: PNSS iiL @ 25gtts




Monitor V/S q4, O2 sat q4



Labs: CBC, U/A,











Meds:
Omeprazol 40mg IV now
then OD Iin AM


-For constant monitoring by
hospital staff and for prompt
rendering of nursing care

-For legal purposes which
provides and protects
patients with his due right

-To maintain nutritional
supplementation


-To provide a quick route to
supply body with fluids and
electrolytes.


-For constant monitoring of
cardinal measurements,
especially patients RR

-CBC is ordered to
determine blood
component levels
including platelet, the
clotting factor of the
blood. U/A is ordered To
evaluate renal function


-Symptomatic
gastroesophageal reflux
disease (GERD) without
esophageal lesions























I and O q shift

Pls. Inform AP

Refer accordingly




-Measure fluid intake and
loss

-For medical mgt.

-For referral concerning
unusualities.

2/8/14
10AM

Give Tramadol 50mg IV now


For UTZ of upper abdomen



For CXL



Tramadol 50mg q8h (6am-
2pm-10pm)


D/C Omeprazol

IVF TF: D5NM IL @20gtts/min
x 3 bottles


- To relieve acute/
severe pain

-to evaluate the condition of
the digestive system



- To evaluate lung
condition
- To relieve acute/
severe pain



- To provide fluids
glucose and
electrolytes



Cefuroxime ( Kefox ) 75mg
IVTT ANST then q8h


D/C Tramadol


Ketorolac 15mg IVTT ANST
then q8h



IVF TF: D5NM IL @
20gtts/min












- Skin and skin structure
infections, infections of the
urinary and lower
respiratory tract



- Short term management
of moderately severe acute
pain for single dose
treatment


- - To provide fluids glucose
and electrolytes











B
.
D
r
u
g

S
t
u
d
y





B. N
a
m
e

u
g
Classification Dose/
frequen
cy
Mechanism
of Actions
Specific
Indication
Contraindica
tion
Side
effects
Nsg
Precautions
Omep
razole
GIT drugs
(Anti-ulcer
drugs) &
(Proton Pump
Inhibitors)
40mg IV
now
then OD
Iin AM
Inhibits
activity of
acid (proton)
pump and
binds to
hydrogen-
potassium
adenosine
triuphosphat
e at
secretory
surface of
gastric
parietal cells
to block
formation of
gastric acid
Symptom
atic
gastroeso
phageal
reflux
disease
(GERD)
without
esophage
al lesions
Contraindicat
ed in patients
with known
hypersensitivi
ty to drug or
its
components

Use
cautiously in
pregnant or
lactating
women
CNS:
headache,
dizziness,
asthenia

GI:
diarrhea,
abdominal
pain,
nausea,
vomiting,
constipati
on,
flatulence

Musculosk
eletal:
back pain
1. Administer
drug before
meals.

2. Provide
appropriate
safety and
comfort
measures if CNS
effects occur to
prevent injury.

3. Make sure
patient swallow
the tablets or
capsules whole
and not to open,
chew or crush.


A. N
g
Classification Dose/
frequen
cy
Mechanism
of Actions
Specific
Indication
Contraindica
tion
Side
effects
Nsg Precautions
Tram
adol
GIT drugs
(Anti-ulcer
drugs) &
(Proton Pump
Inhibitors)
50mg
q8h
(6am-
2pm-
10pm)

Centrally
acting
analgesic not
chemically
related to
opioids but
binds to mu-
opioid
receptors
and inhibits
reuptake
of norepinep
hrine and
serotonin
Used for
moderate
to severe
pain

Hypersensitiv
ity, acute
intoxication with
alcohol,
hypnotics
,centrally
acting
analgesics

Vasodila
tion,
dizzines
s/vertigo,
headache
,
stimulatio
n,
anxiety
,confusio
n and
sleep
disorder
Assess patientpain( location
andtypes)
- Assess for hypersensitivity
reaction: rash and pruritus
-Monitor for possible drug
induced adverse reaction
CNS; stimulation dizziness,
vertigo, headache,
CV: vasodilation
GI: nausea







A. N
a
m

D
r
u
g
Classification Dose/
frequen
cy
Mechanism
of Actions
Specific
Indication
Contraindica
tion
Side effects Nsg Precautions
Ketor
olac
Analgesic 15mg
IVTT
ANST
then q8h

Unknown.
May inhibit
prostaglandi
n synthesis,
to produce
anti
inflammatory
, analgesic,
and
antipyretic
effects

Short term
managem
ent of
moderatel
y severe
acute pain
for single
dose
treatment

Short term
management
of moderately
severe acute
pain for
single dose
treatment

CNS: drowsiness
CV: edema,
Hypertension
GI: nausea,
dyspepsia
Hematologic:
decreased platelet
absorption
Skin: pruritus
Other: pain at the
injection site

Correct hypovolemia
before giving
ketorolac

Carefully observe
patients with
coagulopathies and
those taking
coagulants drug
inhibit platelet
aggregation and
can prolong
bleeding time









A. N
a
m
e
D
r
u
g
Classification Dose/
frequen
cy
Mechanism
of Actions
Specific
Indication
Contrain
dication
Side
effects
Nsg
Precautions
Cefur
oxime
Cephalosporin
s
75mg
IVTT
now
then q8h
Second
generation
cephalospori
ns that
inhibits cell
wall
synthesis,
osmotic
instability,
usually
bactericidal
Skin and
skin
structure
infections,
infections
of the
urinary
and lower
respiratory
tract
Contraindi
cated in
patients
hypersens
itive to
drug or
other
cephalosp
orin
CNS: Fever,
headache
CV:
Diarrhea
GI: genital
pruritus
Hematologi
c:
thrombocyto
penia
Skin: pain in
Duration
Other:
hypersensiti
vity reaction
Before
administration,
ask the patient
if he is allergic
to penicillins or
cephalosporins

Monitor PT and
INR in patient
with impaired
vitamin K
synthesis or
low vitamin k
store. Vitamin
K may be
needed



B. Laboratory Results
X-RAY REPORT

Name:Ms. RFE Date: Febuary 8, 2014
Age/Sex: 28/F Examination: CXR PA
Requested by: Dr. Tan




Chest X-ray PA:

The lungs are clear
Heart is not enlarged
Aorta is not dilated
Diaphragm and both cotosphrenic sulci are intact
The rest of the visualized chest structures are unremarkable



Impression: No significant chest findings







HEMATOLOGY
Test Result References
Ranges
Implications
Total WBC 10.0 x 10 ^9/L 5.0 10.0 Normal
Total RBC 3.3 x 10 ^12/L 3.69 5.90
Hemoglobin 9.0 g/dL 13.70 16.70 *Low Hgb suggests
anemia
Hematocrit 29.9 % 40.00 49.70 *
MCV 89.5 fL 70.00 97.00 Normal
MCH 29.3 pg 26.10 33.30 Normal
MCHC 32.0 g/dL 32.0 35.0 Normal
Platelet Count 400 x 10^9/L 150.0 390.0 Normal
Differential Count


Neutrophils 77.50 % 54.0 - 62.0 * Increased due to
infection and stress
response PTB
and emotional
stress
Lymphocytes 19.20 % 20.0 - 40.0 * Decreased due to
advanced
tuberculosis cp
Monocytes 7.10 % 4.0 10.0 Normal
Eosinophils 2.10 % 1.0 6.0 Normal
Basophils 0.10 % 0.00 1.00 Normal
RDW - CV 11.6 % 11.5 14.5 Normal






Name: Ms. RFE Date done: 2/8/14
Age: 28/F Clinician: Dr. Tan


URINALYSIS
Test Result
Macroscopic
Color Yellow
Appearance Clear
Glucose Negative
Protein Negative
Reaction 6.0 pH
Specific Gravity 1.020
Microscopic
WBC 0-1
RBC 0-2
Epithelial Cells Few
Mucous Threads Rare
Urates None Seen
Bacteria Few






Name: Ms. RFE Date done: 2/8/14
Age: 28/F Clinician: Dr. Tan

Ultrasound report
Ultrasound of the Upper Abdomen
MEASUREMENTS
R Liver Lobe =14.73cm R Kidney =10.51 x 4.12 x 4.19 cm C-T = 0.97cm
L Liver Lobe= 12.82cm L Kidney=11.7 x 5.13 x 5.44 cm C-T =1.39cm
Gallbladder= 6.25 x 2.26 x 1.69cm Spleen = 9.40cm

The liver is normal in size and parenchymal echogenecity. No focal mass lesion seen.
The intrahepatic ducts and extrahepatic ducts are not dilated.
The gallbladder is normal in size and configuration with smooth and not thickened wall.
No intraluminal intense echo seen.
Pancreas and spleen are unremarkable.
Both kidneys are normal in size and echopattern. No pelvocallectasia nor lithiasis seen.
Impression: NEGATIVE ULTRASOUND OF THE LIVER , INTRAHEPATIC DUCTS,
EXTRAHEPATIC DUCTS, GALLBLADDER, PANCREAS, SPLEEN AND BOTH
KIDNEYS.






V. ANATOMY & PHYSIOLOGY with PATHOPHYSIOLOGY


The stomach is an expanded section of the digestive tube between the esophagus and
small intestine. Its characteristic shape is
shown, along with terms used to describe the
major regions of the stomach. The right side of the
stomach is called the greater curvature and the left
the lesser curvature. The most distal and
narrow section of the stomach is termed the
pylorus - as food is liquefied in the stomach it
passes through the pyloric canal into the small
intestine.
The wall of the stomach is structurally similar to other parts of the digestive tube, with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer, which aids in performance of complex grinding motions.
In the empty state, the stomach is contracted and its mucosa and submucosa are
thrown up into distinct folds called rugae; when distended with food, the rugae are
"ironed out" and flat. The image below shows rugae on the surface of a dog's stomach.


Within the stomach there is an abrupt
transition from stratified squamous
epithelium extending from the esophagus
to a columnar epithelium dedicated to


secretion. In most species, this transition is very close to the esophageal orifice, but in
some, particular horses and rodents, stratified squamous cells line much of the fundus
and part of the body.
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom). The creatures attached to the
surface are bots, larval forms of Gasterophilus.

If the lining of the stomach is examined with a hand lens, one can see that it is covered
with numerous small holes. These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules, forming gastric glands.
Types of Secretory Epithelial Cells
Four major types of secretory epithelial cells cover the surface of
the stomach and extend down into gastric pits and glands:
Mucous cells: secrete an alkaline mucus that protects the
epithelium against shear stress and acid
Parietal cells: secrete hydrochloric acid!
Chief cells: secrete pepsin, a proteolytic enzyme



G cells: secrete the hormone gastrin
There are differences in the distribution of these cell types among regions of the
stomach - for example, parietal cells are abundant in the glands of the body, but virtually
absent in pyloric glands. The micrograph to the right shows a gastric pit invaginating
into the mucosa (fundic region of a raccoon stomach). Notice that all the surface cells
and the cells in the neck of the pit are foamy in appearance - these are the mucous
cells. The other cell types are farther down in the pit and, in this image, difficult to
distinguish.
Mouth
Is the first portion of the alimentary canal that receives food and begins digestion by
mechanically breaking up the solid food particles into smaller pieces and mixing them
with saliva. The oral mucosa is the mucous membrane epithelium lining the inside of the
mouth.
Pharynx
The section of the alimentary canal that extends from the mouth and nasal cavities to
the larynx, where it becomes continuous with the esophagus.
Esophagus
The esophagus is a tube that carries swallowed foods to the stomach.
Stomach
Is a muscular organ of the digestive tract. It is located between the esophagus and the
small intestine. The stomach is hollow and sac-shaped. It is involved in the second
phase of digestion, following mastication (chewing).The stomach produces protease
enzymes and hydrochloric acid which kills bacteria and gives the right pH for the
protease enzyme to work.



Small Intestine
The part of the gastrointestinal tract (GI tract) that extends from the pyloric sphincter to
the ileocecal valve, where it empties into the large intestine. The small intestine finishes
the process of digestion, absorbs the nutrients, and passes the residue on to the large
intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive
system that are closely associated with the small intestine.

Large Intestine
The part of the gastrointestinal tract (GI tract) that extends from the pyloric sphincter to
the ileocecal valve, where it empties into the large intestine. The small intestine finishes
the process of digestion, absorbs the nutrients, and passes the residue on to the large
intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive
system that are closely associated with the small intestine






VI. NURSING ASSESSMENT TOOL
Name of Patient: Ms. RFE
VII. NURSING SYSTEM REVIEW CHART
Temp:
36C
PR:
90bpm
RR: 22cpm BP:
110/70mmHg
Height:
52
Weight:
60kg
Date:
2/9/14
EENT
[]impaired
vision
[]blind []pain
[]reddened []drainage []gums sunken eyeballs
[]hard
hearing
[]deaf []burning Cough
Vomiting
[]edema []lesion []teeth
Assess eyes, ears, nose, throat for any
abnormalities [x]no problem
Moderate diarrhea
Cough
RESPIRATORY Vomiting
[]asymmetric []tachypnea []apnea
[]rales [x]cough []barrel chest Abdominal Pain
5/10
[]bradypnea []shallow []rhonchi Abdominal Pain
3/10
[]sputum []diminished []dyspnea
[]orthopnea []labored []wheezing
[]pain []cyanotic
Assess respiration, rate, rhythm, depth,
pattern, breath sounds, comfort [x]no
problem


CARDIOVASCULAR
[]arrhythmia []tachycardia []numbness
[]diminished
pulses
[]edema []fatigue
[]irregular []bradycardia []murmur
[]tingling []absent
pulses
[]pain
Assess heart sound, rate, rhythm, pulse,
blood pressure, circulation, fluid retention,
comfort
[x]no problem



GASTROINTESTINAL TRACT
[]obese []distention []mass
[]dysphagia []rigidity [x]pain
Assess abdomen, bowel habits,
swallowing, bowel sound, comfort []no
problem




GENITO-URINARY & GYNE
[]pain []urine color []vaginal
bleeding

[]hematuria []discharges []nocturia
Assess urine frequency, control, color,
odor, comfort, gyne bleeding, discharges
[x]no problem


NEURO
[]paralysis []stuporous []unsteady
[]seizures []lethargic []comatose
[]vertigo []tremors []confused
[]vision []grip
Assess motor function, sensation, Loc,
strength, grip, gait, coordination,
orientation, speech [x]no problem


MUSCULOSKELETAL & SKIN
[]appliance []stiffness []itching
[]petechiae []hot []drainage
[]prosthesis []swelling []lesion
[]poor turgor []cool []deformity
[]wound []rash []skin color
[]flushed []atrophy []pain (back)
[]ecchymosis []diaphoretic []moist
Assess mobility, motion, gait, alignment,
joint, function, skin color, texture, turgor,
integrity [x]no problem




NURSING ASSESSMENT II
SUBJECTIVE DATA OBJECTIVE DATA
COMMUNICATIO
N
Comments: Maayo
man ako panan.aw
og pandungog as
verbalized.
[]Glasses []Languages
[]Hearing Loss []Contact Lens []Hearing Aide
[]Visual Changes Pupil
size
L3mm R3m
m
[]Speech difficulties
[x]Denied Reaction PERRLA
OXYGENATION Comments: giubo
ko pero wla man
noon plema as
verbalized.
Respiration []Regular [x]Irregular
[]Dyspnea Describe: Respiration is regular in rate
[]Smoking History

[x]Cough
[]Sputum R full chest expansion, symmetric to Left lung
[]Denied L full chest expansion, symmetric to right lung
CIRCULATION Comments: dili
man sakit ako
dughan og wala
man sad naminhod
ako kalawasan as
verbalized.
Heart Rhythm [x]Regular []Irregular
[]Chest Pain Ankle Edema: No ankle edema noted.
Pulse Car Rad AP Fem*
[]Numbness of
extremities
R + 90bpm + Refuse
d
L + 90bpm + Refuse
d
[x]Denied Comments
NUTRITION Comments: Maayo
man ako ako
pagkaon .
[]Dentures [x]None
Diet: DAT diet
Complete

Incomplete
[]Recent change
in weight and
appetite
Upper [] []
Lower [] []
[]Swallowing
Difficulty

[x]Denied
ELIMINATION Urinary frequency Comments: Bowel
sounds are hard as
gargles, prominent on
RLQ of abdomen.
Bowel Sounds
NORMOACTIVE Usual bowel
pattern
4-6 times a day
Once daily []Urgency Abdominal Distention
Constipation
Remedy
[]Dysuria []Yes [x]No
Eats Papaya []Hematuria Urine color,
consistency, odor
Pale yellow,
moderate, aromatic
Date of last BM []Incontinence
2/9/14 []Polyuria
Diarrhea
Character
[]Foley in place
[]Denied




MANAGEMENT OF HEALTH AND
ILLNESS
Briefly describe patients ability to follow
treatments (diets, medications, etc.)
Patient is able to comply with prescribed diet,
medications and treatment.
[x]Alcohol []Denied
gainom ko usahay pag nay mga
okasyon
[]SBE Last Pap Smear
LMP 2/1/14
SUBJECTIVE DATA OBJECTIVE DATA
SKIN INTEGRITY Comments: ok
raman ako pamanit
wala man sad
katol2x og dili pud
dry as verbalized..

[]Dry []Cold Pale
[]Dry []Flushed []Warm
[]Itching []Moist []Cyanotic
[x]Denied Rashes, ulcers, decubitus (describe size,
location, drainage, color, odor No rashes
noted

ACTIVITY & SLEEP Comments:
makalakaw man
noon ko og makaligo
na ako ra as
verbalized.
LOC & Orientation Patient is conscious and
is oriented to time, place, and date
[]Convulsion
[]Dizziness Gait: []Walker []Cane
[]Limited Motion of
Joints
[x]Steady []Unsteady
[]Sensory & motor losses in face and
extremities No sensory and motor losses in
face and extremities
Limitation in ability
to
[]Ambulate
[]Bathe self ROM Limitations: No ROM limitations
[x]Denied
COMFORT/SLEEP/AWAKE []Facial Grimace
[x]Pain(location,
frequency &
remedy
abdomen,pain
reliever
Comments: Magsakit
lang ako ako tiyan
usahay mao dili kayu
ko makatulog as
verbalized.
[]Guarding
[]Other signs of pain: no other signs of pain
noted


[]Nocturia
[]Sleep Difficulty
[x]Denied
























COPING Observed non-verbal behaviour: Patient is
typically quiet but very responsive when
asked
Occupation: Nurse
Members of household: 5 members Person and phone number that can be
reached at any time: 09067302815
Most supportive person: mother


VIII. NURSING MANAGEMENT
A. IDEAL NURSING MANAGEMENT
NURSING DIAGNOSIS: Airway Clearance, ineffective
May be related to
Thick, viscous, or bloody secretions
Fatigue, poor cough effort
Tracheal/pharyngeal edema
Possibly evidenced by
Abnormal respiratory rate, rhythm, depth
Abnormal breath sounds (rhonchi, wheezes), stridor
Dyspnea
Desired Outcomes
Maintain patent airway.
Expectorate secretions without assistance.
Demonstrate behaviors to improve/maintain airway clearance.
Participate in treatment regimen, within the level of ability/situation.
Identify potential complications and initiate appropriate actions.

Nursing Interventions Rationale
Assess respiratory function, e.g.,
breath sounds, rate, rhythm, and
depth, and use of accessory muscles.
Diminished breath sounds may reflect
atelectasis. Rhonchi, wheezes indicate
accumulation of secretions/inability to
clear airways that may lead to use of
accessory muscles and increased work of
breathing
Note ability to expectorate
mucus/cough effectively; document
character, amount of sputum,
presence of hemoptysis.
Expectoration may be difficult when
secretions are very thick as a result of
infection and/or inadequate hydration.
Blood-tinged or frankly bloody sputum
results from tissue breakdown (cavitation)
in the lungs or from bronchial ulceration
and may require further evaluation/
intervention.
Place patient in semi- or high-Fowlers
position. Assist patient with coughing
and deep-breathing exercises.
Positioning helps maximize lung
expansion and decreases respiratory
effort. Maximal ventilation may open
atelectatic areas and promote movement


of secretions into larger airways for
expectoration.
Clear secretions from mouth and
trachea; suction as necessary.
Prevents obstruction/aspiration.
Suctioning may be necessary if patient is
unable to expectorate secretions.
Maintain fluid intake of at least 2500
mL/day unless contraindicated.
High fluid intake helps thin secretions,
making them easier to expectorate.
Humidify inspired air/oxygen.
Prevents drying of mucous membranes;
helps thin secretions.
Administer medications as
indicated:Mucolytic agents, e.g.,
acetylcysteine
(Mucomyst);Bronchodilators, e.g.,
oxtriphylline (Choledyl), theophylline
(Theo-Dur);


Corticosteroids (prednisone).
Reduces the thickness and stickiness of
pulmonary secretions to facilitate
clearance.Increases lumen size of the
tracheobronchial tree, thus decreasing
resistance to airflow and improving
oxygen delivery.May be useful in
presence of extensive involvement with
profound hypoxemia and when
inflammatory response is life-threatening.
Be prepared for/assist with
emergency intubation.
Intubation may be necessary in rare
cases of bronchogenic TB accompanied
by laryngeal edema or acute pulmonary
bleeding.

NURSING DIAGNOSIS: Altered Sleep Pattern
Risk factors may include
Ambient temperature, humidity, lighting , noise
Caregiving responsibilities
Lack of sleep privacy
Interruptions
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]





Desired Outcomes
Report improve sleep
Report increased sense of well-being and feeling rested
Identify individually appopriate interventions to promote sleep
Nursing Interventions Rationale
Identify presence of factors known to
interefere with sleep, including current illness,
hospitalization
Sleep problems can arise form internal and
external factors, and may require
assessment over time to differentiate
specific causes
Ascertain presence of short term alteration in
sleep patterns, suach as can occur with travel,
sharing bed with new sleep partner, crisis at
work
Hepls identify circumstances thatare
known to interrupt sleep acutely, but not
necessary long term
Note environmental factors, such as
unfamiliar or uncomfortable room; excessive
noise and light; frequent medical and
monitoring interventions
These factors can reduce clients ability to
rest and sleep at a time when more rest is
needed
Listen to report of sleep quality
Helps clarify clients perception of sleep
quantity and quality response to inadequate
sleep
Turn on soft music, calm TV program, or quite
environment
To enhance relaxation
Minimize sleep-disrupting factors
To promote readiness of sleep, improve
sleep duration and quality






Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output,
note number, character and
amount of stools.
Assess vital signs changes.
Observe for excessively dry
skin and mucous
membrane, dry skin turgor.
Weigh daily.
Administer parenteral as
indicated.
Provide information about
over all fluid balance, renal
function and bowel diseases
control as well as guidelines
for fluid replacement.
Hypotension, tachycardia and
fever can indicate response of
fluid loss.
Indicates dehydration.
Indicator of overall fluid and
nutritional status.
Maintenance of bowel rest
that will require alternate fluid
replacement to correct losses.











Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea, skin/tissue
irritation, peri rectal fissures, fistulas

Note non-verbal cues.
Permit patient to assume
position of comfort.
Cleans rectal area with mild
soap and water wipes after
defecating.
Record abdominal distention
increase temperature and
decrease blood pressure.
Implement prescribe dietary
modifications, administer
medication as indicated.
Non-verbal cues may be used
in conjunction with verbal cues
to identify extent of the
problem.
Reduce abdominal tension
and sense of control.
Protect skin from undigested
bowel contents preventing
excoriation.
May indicate developing
intestinal obstruction from
inflammation.
Complete bowel rest can
reduce pain and cramping.


b. Actual Nursing Management (SOAPIE)

S

giubo ko pero wala man noon plema as verbalized by the patient.

O
Non-productive cough
Use of accessory muscles for breathing
RR: 22 cpm

A

Ineffective Airway Clearance related to excessive mucous production

P
Short Term: At the end of 1hr, I will be able to maintain patent airway

I

Independent
Placed patient in a semi-fowlers position to facilitate full lung
expansion.
Assisted patient with coughing and deep-breathing exercises.
Maintained fluid intake of at least 2500 mL/day unless
contraindicated.
Encoraged patient to eat foods rich in vit.c like orange, lemon


E
Objectives met. At the end of nursing exposure, patient was able to maintain
patent airway and cough out secretions w/out assistance.




S

sakit ako tiyan as verbalized.

O
Abdominal pain (5/10)
Facial grimace
PR= 90bpm

A
Acute pain r/t inflammation of gastric mucosa


P
At the end of 30mins patient will be able to reduce pain in a tolerable
level

I

Independent
Placed client in a comfortable position.
Encouraged patient in a diversional activities lik watching TV, reading
magazines
Encouraged deep breathing exercise and relaxation technique
Provide quite environment free from distractions
Collaborative
Administer pain reliever as ordered by the physician
E Objectives met. At the end of 30mins patient was be able to reduced pain in
a tolerable level







S

basa akong tae usahay as verbalized.

O
sleepy
moderate diarrhea
:sunken eyeballs

A

Risk for fluid volume deficient r/t excessive loss though vomiting and
diarrhea

P
At the end of 15-30 min of nursing interventions, patients will be able to
verbalize a normal pattern of bowel functioning.


I

>Monitor intake and output and compare to the normal variation, to
assess the level of dehydration
>Increase fluid intake to regain the fluid lose in the body.
>Monitor the vital signs every hour, to detect any alteration or to
identify any variation from normal values
>Monitor laboratory values, reflects hydration and identifies NA return
and protein deficient
Provide IVF Fluids and electrolytes for maintain hydration and
electrolytes balance.
E At the end of the 30 minutes the patient verbalized effectiveness of the
intervention given and would able to maintain normal bowel pattern.













S

baspermi ko ga-mata kay gasakit ako tiyan as verbalized.

O
>Irritable
>Restless
>Weak
>Crying

A

Sleep pattern disturbance related to abdominal discomfort

P
At the end of 8 hour the patient will able to have an adequate sleep.

I
>Organized nursing care. (to promote minimal interruption in sleep.)
>Instructed the mother of the patient to limit the fluid of the patient
before bedtime. ( to reduce voiding during sleeping hours.)
>Back rub, comfortable position done to the patient. ( to promote rest)
>Maintained environment conducive to sleep. ( to promote sleep)
E At the end of 8 hours patient achieved optimal amount of sleep as evidence
by rested appearance


Health Teachings
MEDICATION
Before the patient is discharge, She was instructed to comply all of her
medication regimen as prescribe by the attending physician,(Dr.Tan)..
EXERCISE
Encouraged to engage in light exercises or exercises he can tolerate
like brisk walking, jogging, or slow running. However, patient is
instructed to observe rest periods and consume oral fluids to replace
water lost through perspiration.
TREATMENT
Patient is also instructed to maintain adequate rest period. Instructed to
increase fluid intake to 3 liters per day. Taught preventive measures
including: role of nutrition and fluids; avoiding respiratory iiritants, vand
balance between activity and rest.
OUTPATIENT
(FOLLOW-UP)
Instructed patient to return one week after discharge at CPGH for
evaluation of overall physical condition.

DIET
Instructed to eat small frequent feedings DAT diet. Patient is also
encouraged to maintain adequate fluid intake and to consume fruits and
vegetable to supply necessary vitamins and minerals.





VIII. REFERRALS AND FOLLOW-UP

To allow continuous monitoring of the patients condition, she should visit the
doctor a week after discharge for follow-up checkup for OPD as scheduled. This will
ensure through follow up of his condition and prevention of potential complications.
Always apply the universal precaution which is the hand washing and improve
environmental sanitation. She was also advised to have proper personal hygiene. With
regard to his medications, she is advised to maintain a compliant behaviour as well as
to stick to his diet modification and lifestyle changes. And for any unusualities that the
patient may encounter always consult to the doctor for further assessment, test and etc.

IX. EVALUATION and IMPLICATION
My assessment for two successive days showed that the patients status has
slightly been stable and had improved the patients view towards promoting health. I
had established rapport and harmonious communication during the whole course of the
study, reviewed patients chart and had carried out doctors orders.
Moreover, I had understood the Anatomy, Physiology and Pathophysiology of the
disease condition of the patient which is Acute Gatritis. I had identified Patients Clinical
Manifestations as basis for the Actual and Ideal Nursing Care Plans and had intervened
identified problems through patient-based nursing care.
As a nursing student, the knowledge that I had gained during the 2 days
assessing and caring of the patient had enhanced my understanding about the patients
condition.
This exposure had helped me improved and developed my interpersonal
relationship to people whom I worked with.





X. BIBLIOGRAPHY
A. Books
Deglin, Judith Hopfer and Vallerand, April Hazard. Daviss Drug Guide for Nurses. 10
th

Edition. F. A. Davis Company. Philadelphia, Pennsylvania. 2009
Doenges, Marilyn. et.al., Nursing Care Plans-Guidelines for Individualizing Client Care
across the Life Span. F.A. Davis Company. Philadelphia, Pennsylvania. 2006.
Kozier, Barbara. et.al., Fundamentals of Nursing. 8
th
Edition. Pearson Prentice Hall.
Upper Saddle River, New Jersey. 2008.
Smeltzer, Suzanne. et.al., Textbook of Medical-Surgical Nursing. 11
th
Edition. Volume 2.
Lippincott Williams & Wilkins. Philadelphia. 2008
Source: Snell, Richard S. Clinical Anatomy by Regions. 8
th
Edition.Lipincott Williams &
Wilkins. 530 Walnut Street, PA. 2008.
Saxton Nugent, Pelikan. Comphrehensive Review of Nursing for NCLEX RN. 16
th

edition. Mosbys A Harcourt health sciences company, 1999.

B. Electronic Links
Medline Plus. Hypertension. Retrieved from http://www.nlm.nih.gov/medlineplus
/ency/article/000468.htm. Last accessed on February 25, 2013.

NursesLabs. Allopurinol Drug Study. Retrieved from http://nurseslabs.com/allopurinol-
aloprim-drug-study/#_. Last accessed on February 27, 2013.

Ivabradine (Coralan) Drug Information - Indications, Dosage, Side Effects and
PrecautionsMedindia http://www.medindia.net/doctors/drug_information/ivabradine.htm
#ixzz2sStsc4n