1

CHAPTER 1
Introduction

BACKGROUND AND RATIONALE

Peptic ulcers are dangerous. As one expert said, Your own blood will kill you. A
bleeding ulcer can kill you if left unattended for a long time. The pain of an ulcer is felt
anywhere in the area between the navel and the upper breast bone. But with the onset
of the bleeding, the ulcer will become painless as the blood neutralizes the acid that is
eroding on your raw flesh. Because it is mostly painless, it is difficult for most people to
realize that something is wrong. Some will actually think their ulcer just got better. One
out of every ten people with a bleeding ulcer has reported it to have been painless; this
can get very deadly very fast (Cooper, 2010).
Peptic ulcer disease is associated with major morbidity. Each year peptic ulcer
disease affects 4 million people around the world. Complications are encountered in
10%-20% of these patients and 2%-14% of the ulcers will perforate. Perforated peptic
ulcer is quite rare, but life threatening disease and the mortality varies from 10%-40%.
Females account for more than half the cases; they are older and have more
comorbidity than their male counterparts. According to the latest WHO data published in
April 2011 Peptic Ulcer Disease deaths in the Philippines reached 7,423 or 1.76% of
total deaths. The age adjusted death rate is 14.83 per 100,000 of population ranks
Philippines #2 in the world (Chua, 2012).

Peptic ulcer disease is one of the most common diseases affecting the GI tract.
An ulcer is an area of the stomach lining that is literally being eaten away by your
stomach acid. When a peptic ulcer affects the stomach it is called a gastric ulcer, one in
the duodenum is called a duodenal ulcer, while an esophageal ulcer is an ulcer in the
esophagus (Marks, 2012).
The most important symptoms that these ulcers cause are related to bleeding.
Bleeding from an ulcer can be slow and go unnoticed or can cause life threatening
hemorrhage. Ulcers that bleed slowly might not produce the symptoms until the person
becomes anemic. Symptoms of anemia include fatigue, shortness of breath with
exercise and pale skin color. Bleeding that occurs more rapidly might show up as
melena or even large amount of dark red or maroon blood in the stool. People with
bleeding ulcers may also vomit. This vomit may be red blood or may look like coffee
grounds. Other symptoms might include passing out or feeling lightheaded.
Symptoms of rapid bleeding represent a medical emergency (Marks, 2012).
Therefore, a timely diagnosis plays a crucial role in the treatment of stomach
ulcers. The sooner the stomach ulcer symptoms are recognized, the better it is. If the
symptoms are diagnosed early, this condition can be cured within a short span of time.
On the contrary, turning a blind eye to the early symptoms can worsen the situation, and
cause a lot of pain and discomfort to the individual (Cooper, 2010).
For that, the theory of Unpleasant Symptoms is an effective guide that can be
used to understand the different symptoms that the individual is experiencing. An
understanding of a nursing theory can help the healthcare providers to conceptualize

nursing care in the context of a comprehensive framework. Symptoms not only create
distress but also disrupt social functioning. A symptom is a subjective experience
reflecting changes in the bio psychosocial functioning, sensations or cognition of an
individual. Patients with peptic ulcer disease may experience a range of symptoms from
mild abdominal pain and burning to bleeding, vomiting or catastrophic perforation of the
organ lining, a life threatening condition requiring emergency surgery (Lenz, 2013).
Because the symptom experience, by definition, occurs at the level of individual
perception, the theory is applicable at the level of the individual. However, the TOUS
does not consider the individual in isolation. Rather, it positions the individual within the
context of his or her family, social and organizational networks and community by taking
into account situational factors in the environment that may influence the symptom
experience. It embodies an inclusive perspective that is not limited to the physical
domain of human experience of symptoms, but also acknowledges the important
influence of psychological factors and situational or environmental factors, as well as
their interplay on the experience of symptoms. It also defines the outcome of the
symptom experience in terms of performance, a notion that considers its impact on the
individuals interactions with others and his or her short and long term physical,
cognitive, and social functioning (Lenz, 2013).
Being able to personally experience having poor health, feeling incapable of
major activity, restricted on bed and unable to work because of abdominal pain are
some of the reasons why the researcher chose this study. The researcher also selected
this because of the flourishing number of people being affected with peptic ulcer
disease and how this case made a young patient in her teens struggle with various

symptoms and threatens her life. The researcher chose this theory because of its
emphasis on symptom management. The theory helps improve understanding of
symptom experience in various contexts and to provide information useful for designing
effective interventions to prevent, ameliorate or manage unpleasant symptoms and their
negative effects. Hopefully, the study will help in advancing patients knowledge by
being able to describe characteristics of their symptom experience and its
consequences in their daily life.

THEORETICAL BACKGROUND
The Theory of Unpleasant Symptoms (TOUS) was originally developed by Lenz,
Pugh, Milligan, Gift, and Suppe in 1995. In order to make the model of unpleasant
symptoms less linear and reflect the dynamics of clinical situations, the authors revised
the TOUS in 1999. The theory focuses on the symptom experience, with multiple
symptoms occurring together, rather than one symptom in isolation. TOUS is based on
the assumption that sufficient commonalities exist among symptoms. The theory
uniquely implies that the management of one symptom will contribute to the
management of other symptoms. TOUS therefore addresses the synchronic occurrence
of more than one symptom that may exert a multiplicative effect on symptom
experience, distress, and performance (Lenz, 2013).
The relationships among the components of the TOUS are interconnected with
one another. The symptoms that the individual is experiencing; the influencing factors
that give rise to or affect the nature of the symptom experience; and the consequences

of the symptom experiences. Physiological, psychological, and situational factors are

antecedent factors which influence the symptom experience. The consequence of
symptoms is performance which includes functional and cognitive activities (Lenz,
2013).
Symptoms are the central focus of the TOUS. Symptoms are defined as
perceived indicators of change in normal functioning as experienced by patients.
Symptoms can be considered alone or combination. They are seen as multiplicative,
rather than additive. In the original model of the TOUS, one symptom is depicted and it
is a purely linear model. The updated model of the TOUS proposes that symptoms can
occur alone or in isolation from one another but that, more often, multiple symptoms are
experienced simultaneously. The revised model also reflects more interaction among
key components (Lenz, 2013).
Multiple symptoms can occur together as a result of a single event. Each
symptom is conceptualized to be a multidimensional experience, which can be
conceptualized and measured separately or in combination with other symptoms.
Symptoms have the dimensions of intensity (severity), timing (frequency, duration, and
relationship to events), distress (the persons reaction to the sensation), and quality
(descriptors used to characterize the symptom, location of the symptom, or response to
intervention). Intensity refers to the severity, strength, or amount of the symptom being
experienced (Smith, 2013).
It is proposed that three categories of influential factors, physiological,
psychological,

and

environmental/situational

affect

ones

predisposition

to

or

manifestation of a given unpleasant symptom experience. The influencing factors are

also the antecedents of the symptom experience in the TOUS. Physiological factors are
often reflected in unpleasant symptoms associated with alterations in the normal
functioning of bodily systems or the existence of any pathology. Physiological
antecedents commonly characterize the severity of the disease, such as comorbidities,
abnormal laboratory findings or other pathological findings (Smith, 2013).
The psychological factors that are antecedents include the individuals mental
state or mood (depression), affective reaction to illness (mood status), psychological
response to stress (the degree of perceived stress or the level of anxiety) and degree of
uncertainty and knowledge about the symptoms and their possible meaning (perception
of illness experience or symptom experience). Situational/environmental antecedents
include aspects of the social and physical environment that may affect the individuals
experience and reporting of symptoms (Smith, 2013).
In the original model of the TOUS, influential factors are depicted exerting a
unidirectional influence on the symptom experience, and not related to one another. In
the updated model of the TOUS, some improvements have been made to more
accurately depict these relationships. First, the three types of influential factors are
related to one another over and above their individual relationships to symptoms.
Second, the model asserts that physiological, psychological, and situational factors can
interact with one another in their relation to symptoms (Brant, 2010)
Outcome or consequence of the symptom experience is the final component of
the theory of unpleasant symptoms. Performance is conceptualized to include functional

status or performance, cognitive functioning, and physical performance. Functional

performance is conceptualized broadly to include physical activity, activities of daily
living (ADLs), social activities and interaction, and role performance including work and
other role-related tasks. Cognitive performance includes concentrating, thinking, and
problem-solving. Performance is affected by the level and nature of the symptom
experience (Brant, 2010).
Compared to the original TOUS model, the revised TOUS model more accurately
depicts the relationships among symptom experiences, influential factors and outcomes.
First, the revised TOUS model depicts reciprocal relationships among central concepts
(influential/antecedent factors, symptom experience, and outcomes/ consequences).
Second, the experience of unpleasant symptoms can change ones physiological,
psychological, and situational status. Third, the revised TOUS model proposes that
outcomes (performance) have a reciprocal relation with the symptom experience. The
revised model also posits that decreased levels of performance can have a negative
feedback loop to the influential factors (physiological, psychological, and situational
factors). Additionally, antecedents/ influential factors can have an interaction effect in
their relation to the symptom experience. Furthermore, the symptom experience can
have a moderating or mediating influence on the relationship between influential factors
and outcomes (Smith, 2013).

THEORETICAL FRAMEWORK

Researcher Made Assessment Tool

CONCEPTUAL FRAMEWORK
U

KEY:

Interacts with
Feedback

(Shortness of Breath; Nausea and Vom

Using Lenzs Theory of Unpleasant Symptoms, a conceptual model of symptom

and symptom management was developed. The conceptual framework for this study
comprised of three key components: influential factors, symptom experience and
outcomes. Symptoms as conceptualized in the theory manifest multiple variables and
dimensions; these are being assessed in terms of their intensity, distress, time and
quality as per the study using the Memorial Symptom Assessment Scale. There were 14
unpleasant symptoms identified in the study. Unpleasant experiences or symptoms are

10

directly affected by influential factors such as physiological, psychological and

situational factors which were also assessed in the study using the Researcher- Made
Assessment Tool. Symptoms also have a mediating effect between influential factors
and symptom management. So, as the data were gathered, a nursing care plan was
formulated which guided the researcher in the implementation of the nursing
interventions all throughout the 50 hours intensive practicum. The interventions made
were specifically designed to prevent, ameliorate or manage the unpleasant symptoms
identified. The effectiveness of the symptom management rendered was then evaluated
by means of the performance outcomes which comprises of the physical, cognitive and
social functionality of the patient. Symptom management is the outcome of unpleasant
experiences; therefore unpleasant symptoms directly influence symptom management.

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STATEMENT OF THE PROBLEM

This study aimed to utilize the Theory of Unpleasant Symptoms in the care of a patient
with bleeding peptic ulcer disease.
It answers the following sub problems:
1. What are the different influencing factors of the patient causing unpleasant
symptoms in terms of the following factors:
1. a. physiological;
1. b. psychological;
1. c. situational?
2. What is the psychopathophysiological process of Bleeding Peptic Ulcer Disease?
3. What are the unpleasant symptoms identified by the researcher in terms of:
3. a. intensity;
3. b. distress;
3. c. time;
3. d. quality?
4. What nursing interventions are implemented to manage these unpleasant
symptoms?
5. What were the performance outcomes of the patient in terms of:
5. a. physical functioning;
5. b. cognitive functioning;
5. c. social functioning?

SIGNIFICANCE OF THE STUDY

The result of this study can serve as a guide in managing multiple symptoms
experienced by the patients. They are the recipients of nursing care and considered as
the beneficiaries of all nursing interventions to be implemented by the health care
providers in which appropriate therapy is given to promote faster recovery.

12

The patients significant others can also benefit from this study because it
teaches them about symptom identification and strategies that would manage
unpleasant symptoms on which they can apply in home care settings.
Moreover, this will also be helpful for the individual nurses as for them to be
aware on symptom identification and symptom management. This utilizes a
symptomatic approach in the care of a patient which is commonly seen in the hospital
setting. This equips them knowledge in providing care to patients in a symptomatic
approach.
Additionally the nurse practitioners can take middle range theories and develop
practice guidelines based on them. This helps them yield valuable information about
patients' symptom experiences. Theory guided practice elevates the work of nurses
leading to fulfillment and satisfaction and providing a satisfying professional model of
practice.
As for the nursing academe, the blossoming of middle range theories signifies a
growth of knowledge development in nursing because the growth of the nursing
discipline is dependent on the systematic and continuing application of nursing
knowledge in practice and development of new knowledge.
This study will also assist the student nurses to understand and be more aware
on the symptom characteristics. This helps the students realize that symptoms may be
interrelated with one another which can cause a greater stress to their patients. With the
help of symptom identification and the characteristics of each symptom in terms of

13

intensity, distress, time and quality, the student nurses can come up with care plans that
alleviate not only the symptom itself but also the etiology.
Furthermore, this study will also improve the nurse researchers understanding of
the theory as it was applied in an actual setting and care of a patient. This makes the
researcher understand how the influencing factors can affect the symptoms and in turn
affect the performance outcome of the patient.

METHODOLOGY
Research Design
The study made use of a qualitative case study research design that provides an
empirical inquiry that investigates a phenomenon within its real-life context by one or

14

more methods. Case studies focus intently on the collection and presentation of detailed
information on individuals or small groups to draw conclusions about the individuals or
groups in a specific context. The goal of case studies is not to find a definitive causeeffect relationship, but rather to describe and explore the behavior to reach a better
understanding of the research question (Thomas, 2010).
Research Locale
The study was conducted in Vicente Sotto Memorial Medical Center (VSMMC)
which is located at B. Rodriguez avenue Cebu City. In general, VSMMC is a tertiary
medical center as well as a teaching/ training medical facility owned by the Philippine
Government. It aims to provide health care services that are available, affordable,
accessible and acceptable to all regardless of social status. The hospital has 800 bed
capacities and accommodates various cases such as Internal Medicine, Pediatrics,
Surgery, Orthopedics, Obstetrics, Gynecology, Ophthalmology, ENT (Ears, Nose and
Throat), Psychiatry and Communicable Diseases. The hospital also offers Emergency
Room Services, Out-Patient Services, Clinical Specialty Services, Operating Room
Services, Organ Transplant Unit, Critical Care Unit Services, Cardiac Catheterization
Services, Hemodialysis Unit, Peritoneal Dialysis Unit, Laboratory and Diagnostic
Services. The Medical Ward (Ward IX) where the study was conducted had a 77 bed
capacity.
Research Instrument
The study made use of a researcher made assessment tool coupled by the
Memorial Symptom Assessment Scale (MSAS) developed by Russell Portenoy to aid in

15

gathering data. It is a patient rated instrument that was developed to provide

multidimensional information about a diverse group of common symptoms. The MSAS
is a reliable and valid instrument for the assessment of symptom prevalence,
characteristics and distress. It provides a method for a comprehensive symptom
assessment that may be useful when information about symptoms is desirable.
Data Gathering Procedure
The researcher made a letter of request which was approved by the dean of the
college of nursing, the VPAA and the school president. The letter was then submitted to
the chief nurse of VSMMC where the study was conducted. Subsequently, the
researcher engaged in a 50 hours intensive practicum at VSMMC. Patient selection
highly depended on the type and severity of the case presentation. Prior to any data
gathering procedure, the researcher introduced herself to the client and explained the
purpose of her visits to establish rapport and gain cooperation. Once a nurse- client
relationship was established assessment followed. Throughout the course of patient
care, demographic variables (gender, age, education, employment and marital status)
were taken. Clinical characteristics such as etiology of the illness, diagnosis, comorbidities, medical management done and prescribed medications given were
collected from the medical record. Assessment and gathering of data such as patient
history and evaluation of symptoms was aided by the researcher made tool and the
Memorial Symptom Assessment Scale.

16

CHAPTER 2
Results and Discussion

I. PATIENT PROFILE

17

A.R. is an 18 year old, female, single, Filipino, Roman Catholic, a second year
college student from Dalaguete Cebu. She was admitted for the second time at Vicente
Sotto Memorial Medical Center under the services of Dr. M. Suarez for complaints of
hematemesis and epigastric pain noted an hour PTA.
II. INFLUENCING FACTORS
A. Physiological Factor
Two days prior to admission, the patient had been experiencing intermittent
cramping pain at the epigastric area aggravated by eating. It was described to be nonradiating and was associated with shortness of breath, feeling of weakness, tarry stool
and hematemesis. Self-medicated with Aluminum Hydroxide +Magnesium Hydroxide+
Simethicone tablet, 1tab 3x a day which provided no relief. This condition hindered her
from doing her daily activities. Due to financial difficulty, patient endured the illness that
she was experiencing until the time that she could no longer bear the pain. Because
pain was becoming more intense, patient was brought to VSMMC by her sister to seek
for medical advice. Upon arrival at the emergency room patient vomited blood, now
approximating to be about 500 to 1000 ml of coffee ground vomitus. It was decided
upon based on the consideration of the symptoms that the patient manifested and on
the physical examination that the patient was to be admitted and to be closely
monitored.
For the patients past medical history, patient claimed that she experienced
common childhood diseases and minor illnesses, such as common cold, chicken pox,
mumps and measles. However, patient also mentioned that in year 2006 she was

18

admitted at VSMMC for the same complaint of epigastric pain and hematemesis, she
was discharged improved after 4 days with a diagnosis of peptic ulcer disease. Patient
is non- asthmatic, non-diabetic, non-hypertensive, non-smoker and a non-alcoholic
beverage drinker. She does not recall of having any history of allergies. Every time the
patient has a health problem, she would usually self-medicate with over the counter
drugs such as Paracetamol 500mg/tab taken every 4 hours for fever and Aluminum
Hydroxide +Magnesium Hydroxide+ Simethicone tablet taken three times a day for her
abdominal pain. And if the symptoms persist then she seeks medical assistance at the
barangay health center in their municipality.
Before hospitalization, the patient normally ate her meal before hospitalization at
6am-12pm-7pm. Patient claimed that due to school work and activities, she would
rather skip meals and finish her work. She didnt take any vitamin supplements. The
patient took 6 to 8 glasses of water daily. She usually consumes a cup of rice and a half
serving of viand every meal usually having vegetables or fish.
During hospitalization, the patient was placed on an NPO status and was advised
by the doctor to have a clear liquid diet after 4 days NPO and a soft diet meal after 2
days of clear liquid diet. The patient regularly ate her meal at 7am-11am-6pm. She was
served with a cup of rice porridge. She was given ferrous sulfate and multivitamins to
supplement her dietary intake. The patient took 6 to 8 glasses of water daily.
The patient had normal bladder elimination before hospitalization. She voided
three to four times a day. The amount of her daily voiding was approximately three to
four glasses of urine with yellow clear color. According to the patient, she experienced

19

no pain every time she urinated. During hospitalization, there was no change with
regards to her bladder elimination pattern.
Before hospitalization, the patient had regular bowel elimination twice daily. The
color of her stool was tarry black with a normal consistency as a manifestation of GI
bleeding. During hospitalization, she had one episode of bowel elimination after her
fourth day stay in the hospital after she was given a rectal suppository. The color of her
stool was still tarry black with normal consistency.
As for the patients sleeping pattern, she usually sleeps only six hours every night
before hospitalization and didnt take nap during the day. During hospitalization, her
sleeping pattern increased from six hours to eight hours but sometimes be awaken due
to heat and discomforts in the environment. She was still experiencing pain at
sometimes but it was relieved due to the medication given to her.
B. Psychological Factor
The patient could understand and express her feelings well. She is a second
year college student and a school scholar. The patient could interpret her physical
condition with regards to her illness and doesnt have difficulty expressing herself to her
family and others. Patient could recall important events of her life. The patient informed
that in making major decisions, the whole family discussed and together decides.
Patient did not have difficulty in decision making regarding her confinement.
The patient describes herself as a happy person. Her family gives her strength.
Her family feels saddened with her illness but they learned to accept it. She is satisfied
with her physical appearance and feels saddened with other people who had disabilities

20

and illness. She considers her present condition as the most stressful situation in her
life because it affects them financially and emotionally. Her family supports her to cope
up with her present condition. The patient is not so religious, but she often prays to God
for guidance and blessings. Her family serves as her motivation in life. The most
important for her is to have a good life together with her family and be able to provide
for their needs.
C. Situational Factor
Both of her parents are farmers in their hometown. The patient is the fourth
among the six siblings of which four are females and two are males. Currently, the
patient lives with her aunt in the city along with her two sisters. Except for herself, she
claimed that her family members are healthy. As stated by the patient, she perceived
herself a not so healthy individual for she was admitted twice and currently suffering
from PUD. Right now her normal activities are affected due to her present illness.
Before hospitalization, the patient usually starts her day at 5am to prepare for
school. She attends class at 7am and finishes at 6pm. She also helps her aunt in doing
household chores when she gets home and after which she studies her lessons and do
her home works. But due to increasing pain which happens intermittently during the day,
the patient was restricted of doing her normal daily activities. During hospitalization,
patient was confined in the hospital for recovery thus her daily activities were altered.
As a college scholar, she claimed that her major responsibility is to do well in
school and to have good grades. She is eager to finish school so that she could provide
financial support to her family. She considers her family as the most important aspect of

21

her life. She claimed that their neighborhood is peaceful and a good community and
they lived there a long time already.

III. PSYCHOPATHOPHYSIOLOGY of PEPTIC ULCER DISEASE

The stomach is located in the upper part of the abdomen just beneath the
diaphragm. The stomach is distensible and on a free mesentery, therefore, the size,
shape, and position may vary with posture and content. An empty stomach is roughly
the size of an open hand and when distended with food, can fill much of the upper
abdomen and may descend into the lower abdomen or pelvis on standing. The stomach

22

may be divided into seven major sections: the cardia that is distal to the
esophagogastric junction; the fundus that refers to the superior portion of the stomach;
the antrum which is the smaller distal one-fourth of the stomach; the narrow pylorus that
connects the stomach and duodenum; the lesser curve refers to the medial shorter
border of the stomach, whereas the opposite surface is the greater curve; the angularis
which is along the lesser curve of the stomach where the body and antrum meet, and is
accentuated during peristalsis (Hopkins, 2010).
The duodenum extends from the pylorus to the ligament of Treitz in a sharp
curve that almost completes a circle. It is so named because it is about equal in length
to the breadth of 12 fingers, or about 25 cm. It is largely retroperitoneal and its position
is relatively fixed. It is divided into four portions: the superior portion which begins at the
pylorus, and passes beneath the liver to the neck of the gallbladder; the descending
part takes a sharp curve and goes down along the right margin of the head of the
pancreas; the duodenum turns medially, becoming the horizontal portion, and passes
across the spinal column; the ascending portion begins at the left of the spinal column,
where the intestine angles forward and downward to become the jejunum. The stomach
and duodenum are closely related in function, and in the pathogenesis and
manifestation of disease (Hopkins, 2010).
Peptic ulcers are defects in the gastric or duodenal mucosa that extend through
the muscularis mucosa. The epithelial cells of the stomach and duodenum secrete
mucus in response to irritation of the epithelial lining and as a result of cholinergic
stimulation. The superficial portion of the gastric and duodenal mucosa exists in the
form of a gel layer, which is impermeable to acid and pepsin. Other gastric and

23

duodenal cells secrete bicarbonate, which aids in buffering acid that lies near the
mucosa. Prostaglandins of the E type (PGE) have an important protective role, because
PGE increases the production of both bicarbonate and the mucous layer (Anand, 2012).
In the event of acid and pepsin entering the epithelial cells, additional
mechanisms are in place to reduce injury. Within the epithelial cells, ion pumps in the
basolateral cell membrane help to regulate intracellular pH by removing excess
hydrogen ions. Through the process of restitution, healthy cells migrate to the site of
injury. Mucosal blood flow removes acid that diffuses through the injured mucosa and
provides bicarbonate to the surface epithelial cells (Longstreth, 2011).
Under normal conditions, a physiologic balance exists between gastric acid
secretion and gastroduodenal mucosal defense. Mucosal injury and, thus, peptic ulcer
occur when the balance between the aggressive factors and the defensive mechanisms
is disrupted. Aggressive factors, such as NSAIDs, H. pylori infection, alcohol, bile salts,
acid, and pepsin, can alter the mucosal defense by allowing back diffusion of hydrogen
ions and subsequent epithelial cell injury. The defensive mechanisms include tight
intercellular junctions, mucus, mucosal blood flow, cellular restitution, and epithelial
renewal (Taylor, 2013).
The gram-negative spirochete H. pylori is a major part of the triad, which includes
acid and pepsin, that contributes to primary peptic ulcer disease. The unique
microbiologic characteristic of this organism, such as urease production, allows it to
alkalinize its microenvironment and survive for years in the hostile acidic environment of
the stomach, where it causes mucosal inflammation (Anand, 2012).

24

Once the ulcer has developed, this causes inflammatory response in order to aid
in tissue repair. Inflammatory mediators cause pain in the area. Consistent irritation by
medications or irritating foods can aggravate the condition and lead to perforation or
hemorrhage. The presence of perforation may lead to peritonitis and may become lifethreatening because of sepsis and profuse bleeding (Taylor, 2013).

IV. UNPLEASANT SYMPTOMS IDENTIFIED

In the Memorial Symptom Assessment Scale (MSAS), there are 32 common
symptoms being identified. The scale measures the intensity, distress and frequency
level of each symptom. The symptoms identified in the MSAS are either physical
symptoms and or psychological symptoms. Among the 32 listed symptoms, only 14
symptoms were experienced by the patient.

25

Symptom 1. Shortness of Breath

Patient rated this symptom as very severe and claimed to be very much
distressed with the experience of this symptom. It was almost constantly present during
the entire course of her hospitalization.
Symptom 2. Nausea and Vomiting
Patient rated this symptom as very severe and claimed to be very much
distressed with the experience of this symptom. It was almost constantly present during
the entire course of her hospitalization.
Symptom 3. Dry Mouth
Patient rated this symptom as very severe and claimed to be very much
distressed with the experience of this symptom. It was almost constantly present during
the entire course of her hospitalization.

Symptom 4. Cough
Patient rated this symptom as severe and claimed to be very much distressed
with the experience of this symptom. It was almost constantly present during the entire
course of her hospitalization.
Symptom 5. Worrying

26

Patient rated this symptom as very severe and claimed to be very much
distressed with the experience of this symptom. It was frequently present during the
entire course of her hospitalization.
Symptom 6. Feeling Drowsy
Patient rated this symptom as very severe and claimed to be very much
distressed with the experience of this symptom. It was occasionally present during the
entire course of her hospitalization.
Symptom 7. Dizziness
Patient rated this symptom as moderately severe and claimed to be somewhat
distressed with the experience of this symptom. It was almost constantly present during
the entire course of her hospitalization.
Symptom 8. Lack of Energy
Patient rated this symptom as moderately severe and claimed to be quite a bit
distressed. This symptom was frequently present during the entire course of her
hospitalization.
Symptom 9. Difficulty Swallowing
Patient rated this symptom as moderately severe and claimed to be quite a bit
distressed with the experience of this symptom. It was frequently present during the
course of her hospitalization.
Symptom 10. Swelling of Legs

27

Patient rated this symptom as severe and claimed to be somewhat distressed

with the experience of this symptom. It was occasionally present during the course of
her hospitalization.
Symptom 11. Lack of Appetite
Patient rated this symptom as moderately severe and claimed to be somewhat
distressed with the experience of this symptom. It was frequently present during the
course of her hospitalization.
Symptom 12. Pain
Patient rated this symptom as moderately severe and claimed to be somewhat
distressed with the experience of this symptom. It was occasionally present during the
course of her hospitalization.
Symptom 13. Constipation
Patient rated this symptom as moderately severe and claimed to be a little bit
distressed with the experience of this symptom. It was frequently present during the
entire course of her hospitalization.
Symptom 14. Itching
Patient rated this symptom as moderately severe and claimed to be quite a bit
distressed with the experience of this symptom. It was rarely present during the course
of her hospitalization.

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