A Case Study

On
Upper Gastrointestinal bleeding,
secondary to bleeding peptic ulcer
disease

In partial Fulfillment
Of the requirement in
Related Learning Experience 40 Group 06

Presented by:
JoralynPacres
BSN-3

Presented to:
Jonathan Gesta RN
February 2011

INTRODUCTION
Upper gastrointestinal (GI) bleeding occurs when the inner lining (mucosa) of the
esophagus, stomach, or proximal small intestine (duodenum) is injured, exposing the
underlying blood vessels, or when the blood vessels themselves rupture. Upper
gastrointestinal bleeding (UGIB) is defined as hemorrhage that emanates proximal to the
ligament of Treitz. It is a common and potentially life-threatening condition. More than
350,000 hospital admissions are attributable to UGIB, which has an overall mortality rate of
10%. Although more than 75% of cases of bleeding cease with supportive measures, a
significant percentage of patients require further intervention, which often involves the
combined efforts of gastroenterologists, surgeons, and interventional radiologists.
Clinically, UGIB often causes hematemesis (vomiting of blood) or melena (passage
of stools rendered black and tarry by the presence of altered blood). The color of the
vomitus depends on its contact time with the hydrochloric acid of the stomach. If vomiting
occurs early after the onset of bleeding, it appears red; with delayed vomiting, it is dark red,
brown, or black. Coffee-ground emesis results from precipitation of blood clots in the
vomitus. Hematochezia (red blood per rectum) usually indicates bleeding distal to the
ligament of Treitz. Occasionally, rapid bleeding from an upper GI source may result in
hematochezia.
Upper gastrointestinal bleeding (UGIB) is a significant and potentially life-threatening
worldwide problem. Despite advances in diagnosis and treatment, mortality and morbidity
have remained constant.1 Bleeding from the upper gastrointestinal tract (GIT) is about 4
times as common as bleeding from the lower GIT. Typically patients present with bleeding
from a peptic ulcer and about 80% of such ulcers stop bleeding. Increasing age and comorbidity increase mortality. It is important to identify patients with a low probability of rebleeding from patients with a high probability of re-bleeding. Upper GI bleeding can range
in severity from clinically inapparent (insignificant) to large-volume, life-threatening
bleeding. A variety of conditions can cause GI bleeding, and effective treatment depends on
identification of the source of the bleeding and expeditious administration of therapy.
Upper GI bleeding can be divided into two broad categories: variceal bleeding and
non-variceal bleeding. Varices are dilated blood vessels found most frequently in the
esophagus and stomach. Non-variceal upper gastrointestinal bleeding can be caused by a
variety of conditions. Peptic ulcer is the most common cause. An ulcer bleeds when the
blood vessels at the base of the ulcer are disrupted. Ulcers are most likely to occur in the
stomach and duodenum and less frequently in the esophagus. Ulcers are caused most
commonly by an infection with the bacterium Helicobacter pylori or use of nonsteroidal antiinflammatory drugs.

http://emedicine.medscape.com/article/417980-overview
Indeed, I choose this case because I want to learn why gastrointestinal bleeding
occurs. To enhance my knowledge about GI bleeding. And as a health care provider I need
to know more about the disease in order for me to establish rapport to my patient and how
to deal with it.

PATIENTS PROFILE

Patient X is a 53-year-old male, Filipino. He is married. Having three children. He is

a Roman Catholic. Patient X is currently residing in Salay, Mis Or. He is working as a
farmer there. Patient X was admitted in the hospital last February 12, 2011 at exactly 8:20
pm. His Attending Physician is Dr. Brobo, M.D. He stayed at Annex 3 Floor 2 Male Charity
Ward..
Principal Diagnosis: Upper Gastrointestinal Bleeding
CHIEF COMPLAINT
isa nani ka tuig ga sakit akong tiyan pero abi nku ug wala ra, nya tong ning aging
adlaw kai nana man syay dugo ug sakit na ikalibang as verbalized by the patient
HISTORY OF PRESENT ILLNESS
Patient X had never undergone any procedure before. He felt abdominal pain a
year ago but tolerated it. He has been having on and off epigastric pain, associated with
occasional melena, cup in amount. He never consults a doctor or having his check up
about it. He is self-medicated and only with herbal medicines. Patient X has a difficulty in
defecating.
1 day prior to admission, had only 1 episode of melena, 1 spoon in amount,
prompting consult, hence admitted. He is also positive for hematemesis
PAST HEALTH HISTORY
Patient X has no previous hospitalization. He never undergoes any procedure. He
has no allergies in foods and medication. He is not hypertensive and not diabetic. But he is
a smoker and can consume 2 packs of cigarette a day. He is also an alcoholic and drink
every time he wants especially after doing things on the farm.
Upon assessment, the following data was obtained from patient X. BP= 130/90
mmHg; Temp. = 37.7C; Pulse rate= 55 bpm; Respiratory rate= 23 cpm

HEALTH- PERCEPTION/ HEALTH MANAGEMENT PATTERN

The patient is almost generally the same as how every Filipino seeks health
assistance. Without any problem regarding his health, he would not approach health
workers not unless it is life threatening. Patient complaints pain a year ago but tolerated it.
He is pale to look at.

NUTRITIONAL/ METABOLIC PATTERN

The patient eats three times a day. He said that he eats a fatty and salty diet and
no limit when it comes to food. He said that pobre raman me alang mamili pami unsai kanon, kaon jud kung unsai naa. During his hospitalization, he is instructed with diet as
prescribed by the physician. The patient consumed whole share of food with fair appetite.
He usually drinks 5-6 glasses of water per day. And stop drinking coffee a year ago
because of abdominal pain he felt after drinking coffee. Patients weight was 60 kg.
ELIMINATION PATTERN
According to the patient, when he is at home, he had difficulty in defecating and
when he push to do so, he has a black-tary color of stool. He said that every time he
defecates, his stool has a blood. During his hospitalization he defecates three to four times
a day.
He urinates an average of 850 cc per shift (8 hours) with yellowish colored urine.

ACTIVITY/ EXERCISE PATTERN

He spent most of his time doing things on the farm, and sometimes talk with
friends and family. He said he drinks alcohol everytime he wants especially when some of
his friends invite him after farming. He sometimes spends his time doing his usual
household chores as his exercise. During his confinement his leisure time is talking to his
daughter.

SLEEP- REST PATTERN

The patient sleeps for an average of 8 hours per day before his confinement.
During his hospital stay, he usually sleeps for 5-6 hours and takes nap in the morning and
afternoon. He said he had difficulty in sleeping because of the pain he felt in his abdomen.

SELF-PERCEPTION/ SELF-CONCEPT PATTERN

pobre gihapon, pero malipayon. Problima sa ibayad as verbalized. The patient
verbalized that being hospitalized was not a change for him, but it affects to his family since
they had a big problem financially.

COGNITIVE/ PERCEPTUAL PATTERN

Patient X is conscious, well oriented to time, place and person and is in a calm
emotional state. He exhibited appropriate behavior and response when communicating and
has not experienced any dizziness or tingling sensation.
ROLE/RELATIONSHIP PATTERN
Patient X is married, a farmer and has 3 children. The eldest is married and the
two are helping him in farm.
The patient lives with his family in Salay, Misamis Oriental and as for his
hospitalization expenses, his family especially his son find ways just to pay the bill. His
family feels worried about the situation, his wife wants to stay with him as well as his
children but they cant because they need to work to earn money for his hospitalization.

COPING/ STRESS-TOLERANCE PATTERN

kapoy mag puyo ug hospital labi na ug wla kay kwarta ika bayad as
verbalized.
His vital support group is his family and significant others.

VALUE/ BELIEF PATTERN

Patient X is a Roman Catholic. He always goes to church every Sunday with
his family. He thinks that God is vital to everyone and he trusts in God on whichever turn
his condition will be. He says that hospitalization truly interferes, as he cant go to church
because of his illness.

PHYSICAL ASSESSMENT

ASSESSMENT DATA

ASSESSMENT FINDINGS

SKIN
Color

Moist and pallor

Temperature

37.7 C

Turgor

Supple

Texture

Rough

Lesion

(-) Rash

Integrity

Intact

NAILS
Color

Pale

Texture

Smooth

Shape

Concave

Capillary refill

4 seconds

HAIR
Color

Black

Texture

Coarsely dry

Distribution

Evenly distributed

Quantity

Thin

HEAD
Shape

Round

Size

Normocephalic

Configuration

Symmetrical

Headache

None

EARS

Normal shape

Hearing

Can hear whispered voice

Tinnitus

None

Vertigo

No vertigo

Ear aches

No ear aches

Infection

No infection

Discharges

No discharges

NN NECK

Symmetry

Symmetrical

Condition of trachea Thyroid

Midline

Lymph nodes

(-) nonpalpable

LUNG

Symmetry

Symmetrical

A: P diameter

1:2

Shape of chest

Barrel

Number of breaths

23 cpm

NOSE AND SINUSES

Frequent colds

None

Nasal stiffness

None

Nose bleed

None

Sinus trouble

Sinuses are non tender

MOUTH & THROAT

Condition of teeth

Missing teeth

Bleeding gums

No bleeding

Tongue

Midline

Throat

Non-tender

Hoarseness

(-) Hoarseness

Mucous membrane

Pallor

Gums

Pallor

AUSCULTATION:

Character of respiration

(+) Crackles

HEART AND NECK VESSELS:

Apical Pulse

55 bpm

Cardiac Sounds

(-) Murmurs

Apical/Radial pulse data

55 bpm

Blood pressure

130/90 mmHg

Pulse pressure

60 mmHg

Any special procedure done

None

ABDOMEN:
Configuration

Globular

Bowel Sounds

Hypoactive

Percussion :

Dullness (3 clicks)

Palpation :

Muscle guarding

Usual urinary pattern:

850 cc/shift

Excess perspiration/ nocturnal sweats

None

MUSCULOSKELETAL SYSTEM:
Posture

Abnormal postures arent present

ROM

Active-passive

Muscle Strength

4/5

HEAD AND NECK:

Facial muscle symmetry

Symmetrical

Swelling

None

Scars

None

Discoloration

None

Weakness

(-) Weakness

ROM

Can turn head from side to side

Posterior neck cervical spine

Non-tender

Muscle spasm

(-) Spasm

Crepitus

(-) Crepitus heard

ANATOMY AND PHYSIOLOGY

The digestive tract (also known as the alimentary canal) is the system of organs
within multicellular animals that takes in food, digests it to extract energy and nutrients, and
expels the remaining waste. The major functions of the GI tract are ingestion, digestion,
absorption, and defecation. The picture to the right doesn't show the Jejunum. The GI tract
differs substantially from animal to animal. Some animals have multi-chambered stomachs,
while some animals' stomachs contain a single chamber. In a normal human adult male,
the GI tract is approximately 6.5 meters (20 feet) long and consists of the upper and lower
GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the
embryological origin of each segment of the tract.The first step in the digestive system can
actually begin before the food is even in your mouth. When you smell or see something that
you just have to eat, you start to salivate in anticipation of eating, thus beginning the
digestive process. Food is the body's source of fuel. Nutrients in food give the body's cells
the energy they need to operate. Before food can be used it has to be broken down into

tiny little pieces so it can be absorbed and used by the body. In humans, proteins need to
be broken down into amino acids, starches into sugars, and fats into fatty acids and
glycerol.
During digestion two main processes occur at the same time:
* Mechanical Digestion: larger pieces of food get broken down into smaller pieces while
being prepared for chemical digestion. Mechanical digestion starts in the mouth and
continues in to the stomach.
* Chemical Digestion: several different enzymes break down macromolecules into smaller
molecules that can be more efficiently absorbed. Chemical digestion starts with saliva and
continues into the intestines.
Esophagus
The esophagus (also spelled oesophagus/esophagus) or gullet is the muscular tube
in vertebrates through which ingested food passes from the throat to the stomach. The
esophagus is continuous with the laryngeal part of the pharynx at the level of the C6
vertebra. It connects the pharynx, which is the body cavity that is common to both the
digestive and respiratory systems behind the mouth, with the stomach, where the second
stage of digestion is initiated (the first stage is in the mouth with teeth and tongue
masticating food and mixing it with saliva).
After passing through the throat, the food moves into the esophagus and is pushed down
into the stomach by the process of peristalsis (involuntary wavelike muscle contractions
along the G.I. tract). At the end of the esophagus there is a sphincter that allows food into
the stomach then closes back up so the food cannot travel back up into the esophagus.

The GI System
The gastro-intestinal system is essentially a long tube running right through the
body, with specialised sections that are capable of digesting material put in at the top end
and extracting any useful components from it, then expelling the waste products at the
bottom end. The whole system is under hormonal control, with the presence of food in the
mouth triggering off a cascade of hormonal actions; when there is food in the stomach,
different hormones activate acid secretion, increased gut motility, enzyme release etc. etc.
Nutrients from the GI tract are not processed on-site; they are taken to the liver to be
broken down further, stored, or distributed.

The Stomach
The stomach is a 'j'-shaped organ, with two openings- the oesophageal and the
duodenal- and four regions- the cardia, fundus, body and pylorus. Each region performs
different functions; the fundus collects digestive gases, the body secretes pepsinogen and
hydrochloric acid, and the pylorus is responsible for mucus, gastrin and pepsinogen
secretion.
The stomach has five major functions;

Temporary food storage

Control the rate at which food enters the duodenum

Acid secretion and antibacterial action

Fluidisation of stomach contents

Preliminary digestion with pepsin, lipases etc.

The Small Intestine

The small intestine is the site where most of the chemical and mechanical digestion is
carried out, and where virtually all of the absorption of useful materials is carried out.
The whole of the small intestine is lined with an absorptive mucosal type, with certain
modifications for each section. The intestine also has a smooth muscle wall with two
layers of muscle; rhythmical contractions force products of digestion through the
intestine (peristalisis). There are three main sections to the small intestine;

The duodenum forms a 'C' shape around the head of the pancreas. Its main
function is to neutralise the acidic gastric contents (called 'chyme') and to initiate
further digestion; Brunner's glands in the submucosa secrete an alkaline mucus
which neutralises the chyme and protects the surface of the duodenum.

The jejunum

The ileum. The jejunum and the ileum are the greatly coiled parts of the small
intestine, and together are about 4-6 metres long; the junction between the two
sections is not well-defined. The mucosa of these sections is highly folded (the folds
are called plicae), increasing the surface area available for absorption dramatically.

The Pancreas
The pancreas consists mainly of exocrine glands that secrete enzymes to aid in the
digestion of food in the small intestine. the main enzymes produced are lipases,
peptidases and amylases for fats, proteins and carbohydrates respectively. These are
released into the duodenum via the duodenal ampulla, the same place that bile from the
liver drains into.
Pancreatic exocrine secretion is hormonally regulated, and the same hormone that
encourages secretion (cholesystokinin) also encourages discharge of the gall bladder's
store of bile. As bile is essentially an emulsifying agent, it makes fats water soluble and
gives the pancreatic enzymes lots of surface area to work on.
structurally, the pancreas has four sections; head, neck, body and tail; the tail stretches
back to just in front of the spleen.
The Large Intestine
By the time digestive products reach the large intestine, almost all of the nutritionally
useful products have been removed. The large intestine removes water from the
remainder, passing semi-solid faeces into the rectum to be expelled from the body through
the anus. The mucosa (M) is arranged into tightly-packed straight tubular glands (G) which
consist of cells specialised for water absorption and mucus-secreting goblet cells to aid the
passage of faeces. The large intestine also contains areas of lymphoid tissue (L); these
can be found in the ileum too (called Peyer's patches), and they provide local
immunological protection of potential weak-spots in the body's defences. As the gut is
teeming with bacteria, reinforcement of the standard surfacedefences seems only
sensible.
Gallbladder
The gallbladder is a pear shaped organ that stores about 50 ml of bile (or "gall") until
the body needs it for digestion. The gallbladder is about 7-10cm long in humans and is dark
green in appearance due to its contents (bile), not its tissue. It is connected to the liver and
the duodenum by biliary tract.
The gallbladder is connected to the main bile duct through the gallbladder duct (cystic
duct). The main biliary tract runs from the liver to the duodenum, and the cystic duct is
effectively a "cul de sac", serving as entrance and exit to the gallbladder. The surface
marking of the gallbladder is the intersection of the midclavicular line (MCL) and the trans
pyloric plane, at the tip of the ninth rib. The blood supply is by the cystic artery and vein,
which runs parallel to the cystic duct. The cystic artery is highly variable, and this is of
clinical relevance since it must be clipped and cut during a cholecystectomy.
The gallbladder stores bile, which is released when food containing fat enters the digestive
tract, stimulating the secretion of cholecystokinin (CCK). The bile emulsifies fats and
neutralizes acids in partly digested food. After being stored in the gallbladder, the bile

becomes more concentrated than when it left the liver, increasing its potency and
intensifying its effect in fats.

PATHOPHYSIOLOGY
PREDISPOSIN
G FACTORS:

Disruption of
mucous barrier

PRECIPITATING
FACTORS:

Inflammatory
effect on gastric

Ulcers burrows

Weakening and
necrosis of arterial

peripheral

Pale nail beds.

>4 sec

Body
weakness

Development of
pseudo
anuerysms

Weakened wall
raptures

UGIB

BP= 130/90
RR= 22
PR=55

DIAGNOSTIC PROCEDURES
And
LABORATORY RESULTS
HEMATOLOGY REPORT
DATE: 2-16-11
TEST
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW-CV
PDW
MPV
DIFFERENTIAL COUNT
Lymphocyte %
Neutrophil %
Monocyte %
Eosinophils %
Basophils %
Bands/stabs %
PLATELET

RESULT
13.8
5.52
10.6
33.4
60.5
19.2
31.7
19.0
10.9
9.3

UNIT
10^3/uL
10^6/uL
g/dL
%
fL
Pg
g/dL
%
fL
fL

REFERENCES
5.0-10.0
4.2 -5.4
12.0 16.0
37.0 47.0
82.0 98.0
27.0 31.0
31.5 35.0
12.0 17.0
9.0 16.0
8.0 12.0

17.9
54.9
5.5
21.6
0.1

%
%
%
%
%
%
10^3/uL

17.4 48.2
43.4 76.2
4.5 -10.5
1.0 3.0
0.0 2.0
1.0 2.0
150 400

605

DATE: 2-18-11
RESULT
11.4
5.72
11.5
35.9
62.8
20.1
32.0
21.9
10.4
8.6
16.8
53.0
8.1
22.0
0.1
517

INTERPRETATION:
An elevated WBC count occurs in infection, allergy, systemic illness,
inflammation, tissue injury, and leukemia.
A Low hemoglobin and hematocrit level indicates anemia. A low MCV number in a
patient with a positive stool guaiac test (bloody stool) is highly suggestive of GI cancer.
A low MCH indicates that cells have too little hemoglobin. This is caused by deficient
hemoglobin production

ULTRASOUND REPORT
DATE: 2-16-11
FINDINGS:
The liver appears normal in size but with slightly increased parenchymal
echogenicity. No mass or calcification seen. Intrahepatic bile ducts and common bile
duct are non-dilated.
Gallbladder is normal in size. Its wall is not thickened. No intraluminal mass or
lithiasis seen.
Pancreas, spleen and abdominal aorta are unremarkable. Right and left kidneys
measure 8.6 cm x 3.9cm and 9.0cm x 4.7cm, both with parenchymal thickness of
1.5cm. Central echocomplexes are intact. At least 3 tiny calcifications with the largest
measuring 0.5cm is seen in the left renal cortex. No stones, mass nor calfectasia noted.
Urinary bladder is moderately filled. Its wall is thickened to 4.0mm. No
intraluminal mass or lithiasis seen.
Prostate measures 3.6cm x 2.6cm approximately 15 grams.
DIAGNOSIS:
1. Fatty liver, grade 1
2. Cortical calcifications, left
3. Non-remarkable ultrasounds findings in the gallbladder, pancreas, spleen,
abdominal aorta, right kidney, urinary bladder and prostate.

FECALYSI

DRUG ORDER
(Generic name, brand
name, classification,
dosage, route, frequency)

GENERIC NAME:
omeprazole
BRAND NAME:
Losec
CLASSIFICATION:
Antisecretory
drug
Proton pump
inhibitor
DOSE:
20 g

MECHANISM OF
ACTION

Gastric acid-pump
inhibitor.
Suppresses gastric
acid secretion by
specific inhibition of
the hydrogenpotassium ATPase
enzyme system at
the secretory
surface of the
gastric parietal cells;
blocks the final
stage of acid
production.

ROUTE:
PO

INDICATIONS

short-term
treatment of
active
duodenal
ulcer

CONTRAINDICATIONS

ADVERSE EFFEC
THE DRUG

Contraindicated
with hypersensitivity
to omeprazole or its
components.

CNS: heada
dizziness, asthen
vertigo, insomnia
apathy, anxiety

Treatment
of heartburn
or
symptoms
of GERD

GI: diarrhea,
abdominal pain,
nausea, vomiting
constipation, dry
mouth, tongue ath

Short-term
treatment of
active
benign
gastric ulcer

Respiratory:
symptoms, cough
epistaxis

FREQUENCY:
BID

DRUG ORDER
(Generic name, brand
name, classification,
dosage, route, frequency)

MECHANISM OF
ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFEC
THE DRUG

GENERIC NAME:
sucralfate
BRAND NAME:
Carafate
CLASSIFICATION:
Antiulcer drug
DOSE:
1 gram

Forms an adherent
complex at
duodenal ulcer sites
protecting the ulcer
against acid, pepsin
and bile salts,
thereby promoting
ulcer healing; also
inhibits pepsin
activity in gastric
ulcer.

ROUTE:
PO

short-term
treatment of
active
duodenal
ulcer up to 8
weeks
maintain
therapy for
duodenal
ulcer at
reduced
dosage
after
healing.

Contraindicated
with allergy to
sucralfate, chronic
renal failure or
dialysis ( buildup of
aluminum may occur
with aluminumcontaining product.

CNS: dizzine
sleeplessness, ve

GI: constipatio
diarrhea, nausea,
indigestion, gastr
discomfort, dry m

Dermatologic
rash, pruritus

Other: back p

FREQUENCY:
QID

DRUG ORDER
(Generic name, brand
name, classification,
dosage, route, frequency)

MECHANISM OF
ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFEC
THE DRUG

GENERIC NAME:
rebamipide
BRAND NAME:
Mucosta
CLASSIFICATION:
Antigastric ulcer
DOSE:
100 mg

A mucosal protective
agent and
postulated to
increase gastric
blood flow,
prostaglandin
biosynthesis and
decrease free
oxygen radicals.

Acute
gastric and
acute
exacerbatio
n of chronic
gastritis

Contraindicated
with allergy to
rebamipide

Constipatio
Bloating
Diarrhea
Nausea
Vomiting
Rash
pruritus

ROUTE:
PO
FREQUENCY:
TID

ASSESMENT
DATA
(Subjective &
Objective Cues)

NURSING
DIAGNOSIS
(Problem and
Etiology)

GOALS AND
OBJECTIVES

NURSING
INTERVENTIONS

RATIONA

Subjective Cue:

Acute pain related

to underlying
pag-malibang ko, condition
sakit kayo ilibang
as verbalized.

report pain is
relieved/
controlled
follow
prescribed
pharmacologic
al regimen
demonstrate
use of
relaxation
skills and
diversional
activities.
Decrease in
pain scale
from 7/10 to 56/10

Objective Cues:
pain scale=
7/10
sleep
disturbance
irritability
restless

ASSESMENT
DATA
(Subjective &
Objective Cues)

After 8 hours of
nursing intervention
the patient will be
able to ;

NURSING
DIAGNOSIS
(Problem and
Etiology)

GOALS AND
OBJECTIVES

INDEPENDENT:
Teach the use of
nonpharmacologic
techniques such
as relaxation.

Instruct client to
perform deep
breathing
exercises
Encourage
adequate rest
COLLABORATIVE:
Administer pain
reliever as
ordered.

NURSING
INTERVENTIONS

.use of non
invasive p
relief meas
can increa
release of
endorphin
enhance th
therapeuti
effects of p
relief medi
To reduce
and promo
relaxation

To prevent

To alleviat

RATIONA

Subjective Cue:

Hyperthermia
related to
init akong lawas inflammatory
as verbalized.
response
secondary to
disease process
Objective Cues:
Temp = 37.7
Flushed skin
Restless

After 30 minutes of
nursing intervention
the patient will be
able to ;
maintain
temperature
within normal
range (37.5)
After 8 hours of
nursing intervention
the patient will be
able to:
remain free of
complications
such as
irreversible
brain/neurolog
ical damage.
free of seizure
activity

ASSESMENT
DATA
(Subjective &
Objective Cues)

NURSING
DIAGNOSIS
(Problem and
Etiology)

GOALS AND
OBJECTIVES

INDEPENDENT:
provide tepid
sponge bath

Help decre
temperatu

promote
surface cooling
by means of
understanding

Heat loss
radiation a
conduction

Maintain bed
rest

To reduce
metabolic
demands

DEPENDENT:
Administer
antipyretic
medications as
ordered
COLLABORATIVE:
Administer
replacements of
fluid and
electrolytes.

NURSING
INTERVENTIONS

To support
circulating
& tissue pe

Use of
pharmaco
means wil
decrease c
temperatu

RATIONA

Subjective Cue:
ga-lisod
kog
kalibang
as
verbalized.

Objective Cues:
Hard, formed
stool
Hypoactive
bowel sounds
Abdominal
tenderness
Distended
abdomen

Constipation
related to irregular
defecation habit

After 8 hours of
nursing intervention
the patient will be
able to:
Establish/
regain normal
pattern of
bowel
functioning
Participate in
bowel
program a
indicated
Demonstrate
behavior or
lifestyle
changes to
prevent
recurrence of
problem

INDEPENDENT:
Determine fluid
intake
Instruct the
patient to viod if
theres a feeling
of urgency
Note general
oral/dental
health
DEPENDENT:
Apply lubricant
COLLABORATIVE:
Encourage
treatment of
underlying
causes.

To evaluat
clients hyd
status
Prevent fu

That can im
dietary inta

To soften

To improve
function

DISCHARGE

PLAN

MEDICATION

ECONOMIC STATUS

TREATMENT

Discuss/instruct to the
patient with their
significant other the
importance as
prescribe by the
physician.

Emphasize on
compliance to
therapeutic and
medication regimen
and the information
regarding side effect of
the medications.

Patient with their

significant other need
to understand the
occurrence of the drug
effects in order to
when, what and whom
to report on any
symptoms present.

Pinpoint the patient

their capability to
purchase the
medications.

This is to make sure

that the compliance of
the medication will be
achieved.

The patient
accessibility to the
agency and should be
considered with
regards to follow-up.

To have immediate
interventions when
signs and symptoms
occur.

It is important to know
patient ability to afford
the expected
expenses.

To ensures the patient

adherence instructions.

Encourage patient to
have a vitamins
supplements.

To have a fast recovery

and to prevent
complications.

Compliance to
medication regimen.

Instruct the significant

others to assess the
patients incision and
drainage system.

To monitor wound
healing

HEALTH TEACHINGS

OUT-PATIENT

DIET

SPIRITUALITY

Encourage the patient

to prevent the stressful
activity and have
adequate rest.
Instruct the client and
the significant others to
monitor presence of
infection and report
immediately if signs and
symptoms of infection
occurs such as redness,
foul-smelling drainage,
temperature greater than
38.4 C.

Emphasize the
patients to schedule for
regular follow-up
appointment, and
discuss the importance
of regular check up
care.

Instruct patient to eat

high in protein such as
meat

Instruct patient to eat

high in carbohydrate.

Instruct patient to take

vitamin K

Allow the patient to

pray if possible all the
time to God.

Have faith in God.

To promote early
recovery.

To monitor any signs of

infection.

To monitor any
alternations in the
patients status and
ensure compliance to
medication regimen.

For tissue repair and

faster wound healing.

For energy

To prevent blood clot.

To provide and
optimistic approach
towards her problem.

LEARNING EXPERIENCE
When i had my first exposure in the area, last January 28, 2011 I always
endeavor to do what is finest and cool for my studies. I accomplished my requirements
that were requested to make. It is conspicuous for me to build up what i had attained
and be able to interpret what that is for. I was dazed because I was got carried away of
my nervousness. Almost all of us were nervous to handle our patient and also with their
chart because we were aghast to make our mistake. There were times that I get crap
out when an accidental situation happened to one of our patient and I did not perceived
what to do, but I was still thankful and glad that in spite of all the obstacle I had been
through our Clinical Instructor who are always at our side to help, accompany and
always intimate us what we should do to our patient.
Preparing this case study was a dare for me since it was my first time to alight
upon this kind of disease. I gained more learnings in this case study but comprising
this, needs more patiences and time. As what I achieved in my studies, I also learned to
be sensitive to my patients feelings and my patients conditions in order for me to impart
a therapeutic service that will nurture health and wellness on their sufferings. I also
acquired bob up on patients needs effectively.
By doing this simple things makes me realize that each and every assessment of
my patient or helping them through me, that I already step the new stage of my life as
nursing student. As I take over my responsibility in our duty, but sometimes as I go
along I encounter some difficulty during our service that can be manageable by helping
each other with my group mate. And most of all I treat them as a family and I learn how
to respect and socialize in one another. I learn also to strengthen my patience when it
comes to tiring moments of our duty and above all this learning experience I had God is
our staircase in our stairway of success.

REFERENCES
Book sources:
1. Black,

J.

and

Hawks,

J.

Medical-Surgical

Nursing:

Clinical

Management for Positive Outcomes. Elsevier Health Sciences:

Singapore. 2008
2. Karch, Amy M. Lippincotts Nursing Drug Guide. Lippincott Williams
& Wilkins. Philadelphia. 2007.
3. Marilynn E. Doenges and Alice C. Murr: Nurses pocket guide,
diagnoses, prioritized interventions and rationales
Internet sources:

1. http://emedicine.medscape.com/article/417980-overview
2. http://scribd.com/GIbleeding.htm