Presented by:

BSN II Group A
 Peptic Ulcer is circumscribed erosion in or
loss of, the mucous membrane lining in the
gastrointestinal tract. It may occur in the
esophagus (esophageal ulcer), stomach
(gastric ulcer), duodenum (duodenal ulcer) or
jejunum (jejunal ulcer). The stomach and
duodenum is the most common sites.
Peptic Ulcer may result from excess acid
production or from a breakdown in the
normal mechanisms protecting the mucous
membranes. It is also associated with stress
and intake of certain drug (eg.
Corticosteroids and certain NSAIDs).
Helicobacter pylori, a spiral shaped bacterium
found in the stomach is generally
acknowledged as the main cause for most
peptic ulcers and many cases of chronic
gastritis.
Duodenal Ulcer Gastric Ulcer
Age: 25-50 Usually 50 and over
Male:Female= 2-3:1 Male:Female = 1:1
88% of peptic ulcer are duodenal 15% of peptic ulcer are gastric
Signs and Symptoms, Clinical Findings
-Hypersecretion of stomach acid -Normal-hyposecretion of
(HCL) stomach acid (HCL)
-May have wt gain -wt loss may occur
-Pain occurs 2-3 hrs after a meal; -pain occur ½ to 1 hr after a meal;
often awakened 1-2am; ingestion rarely occurs at night; may be
of food relieves pain relieved by vomiting; ingestion of
-vomiting uncommon food does not help, sometimes
-hemorrhage less likely than with increases pain
gastric ulcer, but if present, -vomiting common
melena more than hematemesis -Hemorrhage more likely to occur
-more likely to perforate than than with duodenal ulcer;
gastric ulcers hematemesis more common than
-Common on type O melena.
Duodenal Ulcer Gastric Ulcer
•H. Pylori •H. Pylori
•Alcohol •Gastritis
•Smoking •Alcohol
•Cirrhosis •Smoking
•Stress •Use of NSAID’s
•Stress
 Over the past few decades,the incidence of
peptic ulcer disease and ulcer complication
has decreased.
 There has however,been an increase in ulcer

bleeding,especially in elderly patients.

 At present,there are several management

issue that need to be solved.

 For more than a century,peptic ulcer disease

was most often managed surgically,with

resulting high morbidity and mortality rates.
 Effective pharmacologic suppression of
gastric acid secretion began with the
introduction of histamine H2-receotor
antagonists(H2RAs) in the 1970s,which
greatly improved clinical outcome .
 During the 1980s elective peptic ulcer

surgery declined by 85%,which can be mainly

attributed to the use of the H2RAs cimetidine
and ranitidine.
 To improve the quality of life and promote
health for those who have peptic ulcer
disease.
 Recognize the potential causes of peptic ulcer

disease.
 Gain the necessary information about the

prevalence of peptic ulcer disease.

 To be able to demonstrate acceptance of the
disease that will motivate compliance with the
treatment.
 To prevent a plan of care for the prevention

and management for peptic ulcer disease and

its complications.
Name: AA
Address: Sta. Maria, Bulacan
Age: 49
Status: Married
Gender: Female
Religion: Catholic
Date of Admission: March 12, 2010
Time of Admission: 5 am
Attending Physician: Dra. Viray
Diagnosis: Severe Anemia secondary to UGIB
secondary to BPUD
 Biographical Data

Pt AA, 49 years old female, married with7

children, an active roman catholic, a former
business woman, currently residing at
Sta.Maria, Bulacan was admitted for the
second time at Cong. Rogaciano M. Mercado
Memorial Hospital last March 12, 2010 at
around 9:49 am.
 Chief Complaint

Pt was complaining of severe abdominal

pain, difficulty of breathing and stool with
dark red blood color (1 cup).
 History of Present Illness

One week prior to admission, Pt seek for

medical check up at RMMMH OPD due to
recurrence of blood in her stool and abdominal
pain. But because of frustration from waiting for
her turn to be examine, Pt left and went to a
small clinic (TAXI clinic). Pt was refused by the
doctor of the said clinic and was requested to be
admitted to any hospital that can provide her the
proper management for her condition. Pt did
took mefenamic acid to relieve her pain. One day
prior to her admission, Pt experienced severe
abdominal pain and weakness and so her
husband took her at the emergency room at
Rogaciano Hospital.
 History of Past Illness

Pt AA had her first confinement 7 years

ago at the same hospital due to difficulty of
breathing and abdominal pain. Pt does not
recover any medicines that was given to her
during her confinement.
 Socio Economics

Pt AA and her husband has a small feather

business. They travel most of the time
delivering chicken feathers to different
places. Pt has 7 children and due to this, the
couple work extra in order to provide the
needs of their children.
 Lifestyle

Pt AA has a very hectic schedule. She

sleeps at midnight and wakes up at 3am,
drinks coffee then start doing her house
chores before leaving the house. Pt AA has no
hobbies or any extra activity. She’s always
under stress and has no time to rest. Since Pt
AA always travel, she continuously skip meals
or eat late.
 Heredo Familial

Pt’s father side has history of HPN and her

mother side has history of anemia.
 March 12 (7-3 Shift)
Pt is admitted at ICU because of DOB, pallor, and
(+) melena. Consent is secured, seen and examined
by Dra. Viray and TPR q4h is taken. Initial BP is
100/60 and temp of 36.8ºC. Pt was requested to
have CBC, blood typing, urinalysis, creatinine, SGOT
and ECG done. Pt IVF is PNSS 1L to run for 12 hrs
and was hooked at left metacarpal vein, NPO was
ordered, Omeprazole 40mg IV q12 was given at
10:30am and tranexamic acid 1amp q8 IV at
10:35am. Pt was ordered to have BT of 3units of
PRBC type O +.
 (3-11pm)
1st unit of packed RBC type O+ with serial
# PNRC 402356 was hooked as side drip at
6:15pm. Pt has no negative reactions toward
BT and BT precaution was observed.
 (11-7am)
Pt on bed, awake with IVF of PNSS 1L @
400 cc level with 20 gtts/min. Pt is
experiencing mild DOB. BP is 110/70 and
temp of 36.5. 2nd unit PRBC was transfuse at
4:15am with serial # 402363 and was hooked
as side drip.
 March 13 (7-3pm)
Pt has an ongoing blood transfusion (2nd
unit type O+ serial # 402363) as side drip.
No negative reaction and v/s is recorded. 3rd
unit of PRBC type O+ with serial 402399 was
transfuse.
 (3-11pm)
Pt had Hgb and Hct done after 3rd unit was
consumed. From NPO pt was shifted to clear
liquid diet. Medication was given and v/s are
taken. Furosemide 20mg IV was given at
3:30pm.
 (11-7am)

Pt has (-) melena, afebrile and kept for

observation.
 March 14 (7-3pm)
Pt is awake, seen by Dra. Viray and diet
shift to soft diet.
 (3-11pm)

Tranexamic acid was discontinued. Lysmix

1 amp TIV q12 was given. IVF was change to
D5NM 1L KVO.
 March 15
Received Pt with BP of 100/70 and temp
of 37.1. The Doctor prescribed Amoxicillin
500mg 1 tab TID PO and Clarithromycin
500mg 1 tab BID PO. Pt was order to transfer
to female ward after getting Hgb level. Pt is
pallor as manifested by pale conjunctiva.
 March 16
Received Pt on bed without IVF. Pt is
transferred at Female Medical Ward around
10am. Due meds were given. Soft diet
maintained.
 March 17

May go home is ordered by the doctor.

 Patient AA is conscious and coherent, lying
on bed. She is overweight with BMI of 32.06
derived from her height of 5 feet 1 inch and
weight of 76 kg. She has foul smelling odor from
her body and from her mouth, her fingernails and
toenails were long and dirty. Her clothes were
soiled and the bed linen was soiled, too. She had
ongoing intravenous fluid line of D5NM at 900cc
level regulated at KVO (10-15 gtts/min), infusing
well at left metacarpal vein with no signs of
infiltration and phlebitis.
BODY PARTS ACTUAL FINDINGS INTERPRETATION
I. Integumentary
1. skin warm to touch, no edema, deviation from normal,
dry possible dehydration due to
blood loss, no moisturizer
II. Head
1. hair evenly distributed curly hair normal

2. scalp with flakes, no nits deviation from normal, dry

infestation scalp
3. cranium normocephalic, absence of normal
nodules and masses
4. face symmetrical and freely normal
movable
5. eyes
a. outer eye eyelids close symmetrically, normal
eyelashes evenly distributed,
no discharges

b. globe pupil 3mm PERRLA, white deviation from normal, due to

sclera, pale conjunctiva decreased blood volume and
oxygenation
6. ears
a. external ear color same as facial skin, normal
symmetrical, firm not tender
and recoils
b. external auditory with light cerumen, normal
tymphanic membrane pearly
gray color, semi transparent
c. hearing acuity normal voice tone audible, normal
Weber test: negative, Rinne
test: AC>BC
7. nose symmetric and straight, no Normal
discharge, not tender, no
lesions, air is present in
both nares, no flaring, inner
part with hair and pink
mucosa, sinuses not tender
8. mouth and oropharynx
a. lips, buccal mucosa and smooth, pale and moist deviation from normal due
gums to decreased blood volume
and oxygenation
b. roof of mouth hard, pale and moist normal
c. tongue central position, smooth normal
lateral margins, no lesion,
moves freely
d. throat pink, moist, uvula midline, normal
symmetrical
e. teeth 26 teeth available, deviation from normal due
yellowish-white, front to poor oral hygiene
incisor teeth were in
slanting position
III. Neck
1. carotid artery mild pulsations normal
2. jugular vein not distended normal
3. trachea midline, distinct rings normal
4. thyroid not visible, smooth normal
5. cervical lymph nodes not palpable normal
IV. Upper Extremities with ongoing IVF line on left
metacarpal vein
1. nails intact epidermis around the deviation from normal, needs to
nail, convex shape smooth be trim
texture, long and dirty,
a. blanch test slow capillary refill, 5 seconds deviation from normal, may
indicate circulatory impairment
2. muscle strength and tone symmetrical, equal strength, deviation from normal, may
poor muscle turgor, sagging indicate poor nutrition intake
skin
3. joint range and motion movable, can be bend, flex, normal
coordinated movement
4. brachial and radial pulses present, 78 bpm normal
5. sensation able to differentiate sensation normal
V. Chest and Back
1. thorax chest symmetric normal

2. posterior thorax and lungs quiet, rhythmic and symmetric normal

3. heart PMI can be palpated normal
4. Breast no discharge, no masses or normal
nodules, big fatty breast
5. axillae with hair, no tenderness or deviation from normal, odor
masses, slight unpleasant may due to poor hygiene
odor, dark in color
VI. Abdomen soft and sagging normal
1. skin blemished skin, uniform deviation from normal due
color, with stretch marks to G7007

2. sound audible 12 bowel normal

sounds/min
VII. Genitals left and right labia majora normal
are intact, no lesions,
pubic hair distribution in
inverted triangle, opening
appears stellate/slit like
and is midline

VIII. Anus and Rectum Looks moist and hairless, normal

no lesions and dark pink
to brown and closed,
smooth not tender
IX. Lower Extremities

1. toenails intact epidermis around deviation from normal,

the nail, convex shape needs to be trim
smooth texture, long and
dirty
2. gait and balance can walk alone but needs deviation from normal,
to be guided may be due to prolonged
bed rest in hospital
3. joint range and motion movable, no stiffness normal

4. popliteal and pedal present normal

pulses
5. tendon and plantar (-) babinski normal
reflexes (+) deep tendon reflexes
I. olfactory able to identify normal
different smells
II. optic visual field intact normal
III. oculomotor PERRLA, convergence normal

IV. trochlear inward and downward normal

eye movement

V. trigeminal clenching of teeth, normal

symmetric jaw
movement, face,
scalp, nasal mucous
membranes and
cornea
VI. abducens lateral eye movement normal
VII. facial able to make facial normal
expressions, able to
close eyes
VIII. acoustic nerve hearing acuity within normal
normal range
IX. glossopharyngeal able to swallow normal
X. vagus able to swallow and normal
has talking muscles of
the palate, pharynx
and larynx
XI. spinal accessory able to move trapezius normal
and
sternocleidomastoid
muscles
XII. hypoglossal able to move tongue normal
 The gastrointestinal tract is a 23-25 foot long
pathway that extend from the mouth to the
esophagus, stomach, small intestine, large
intestine and rectum to the terminal structure
the anus.
 Mouth
 Esophagus
Stomach
Four anatomic region:
-Cardia (entrance)
-Fundus
-body
-pylorus (outlet)
 Small Intestine
3 sections :
duodenum-proximal
jejunum-middle
ileum-distal
 Large Intestine
Completing terminal portion:
Sigmoid colon
Rectum
Anus
 GI tract receives blood from the arteries that
originate along entire length of the thoracic
and abdominal aorta and veins that return
blood from the digestive organs and the
spleen.
 Portal venous system is composed of 5 large

veins: superior mesenteric, inferior

mesenteric gastric, splenic and cystic veins
which eventually form the vena portae that
enters the liver.
 Once in the liver, the blood is distributed
throughout and collected into hepatic veins
that then terminate in the inferior vena cava.
 Oxygen and nutrients are supplied to the

stomach by the gastric artery and to the

intestine by the mesenteric arteries.
 Blood flow to the GI tract is 20% of the total

cardiac output and increases significantly

after eating.
 Both sympathetic and parasympathetic
portions of the Autonomic nervous system
innervate the GI tract.
Primary Functions are:
 Breakdown of food particles into the

molecular form for digestion.

 Absorption into the bloodstream of small

nutrient molecules produced by digestion.

 Elimination of undigested unabsorbed food

stuffs and other waste products.

 The stomach, which stores and mixes food with
secretions, secretes highly acidic fluid in
response to the presence or anticipated ingestion
of food.
 Hydrochloric Acid
 Pepsin
 Intrinsic Factor
 Peristalsis in the stomach and contractions of the

pyloric sphincter allow the partially digested food

to enter small intestine at a rate that permits
efficient absorption of nutrients.
 The digestive process continues in the
duodenum. Duodenal secretions come from
the accessory organs (pancreas, liver and
gallbladder) and the glands in the wall of the
intestine itself.
These secretions contains digestive enzymes:
 Amylase
 Lipase

 Bile

Intestinal secretions total approximately:

 1L/day of pancreatic juice
 0.5L/day of bile
 3L/day of secretions from the glands of small

intestine
Two types of contraction occur regularly in
small intestine
 Segmentation contraction
 Intestinal peristalsis
 Absorption is the primary function of the
small intestine. Process of absorption begins
in the jejunum and is accomplished by both
active transport and diffusion across the
intestinal wall into the circulation.
 Nutrients are absorbed at specific locations
throughout the small intestine and
duodenum, whereas fats, proteins,
carbohydrates, sodium, chloride are absorbed
in the jejunum. Vitamin B12 and bile salts are
absorbed in the ileum. Magnesium,
phosphate and potassium are absorbed
throughout the small intestine.
 Contributory Factors
Precipitating Factors
-skipping meals
-Lifestyle
-Diet: Coffee
-Work
-Stress and over work
-Diet
-use of NSAID’s
(mefenamic acid)

Increase HCl Predisposing Factors

production -Age: 49 y/o
Gender: Female

Abdominal pain
Irritation of the lining
(mucosa) of the stomach, Mesenteric
duodenum, proximal of insufficiency
small intestine.
 Mucosal Erosion

Ulceration of the lining

Bleeding/ Hemorrhage (+) Melena

↓ Blood vol ↓ Hgb (.42)and Hct (.12)

↓ O2 carrying
capacity

Anemia

Pallor Lightheadedness Weak

 ↓ Blood volume

↓ Cardiac Output
Bp: 100/60
PR: 78
Compensatory
↓ bld flow to GI
mechanism

Decrease
Shifting of bld to peristalsis
vital organs (ex.
Heart)
Bowel
obstruction

constipation
Name of Drug: Furosemide 20mg
IV after each unit
 Time Given:
March 13, March 14
Classification: Loop Diuretic
Adverse Effect: 
CNS: dizziness, vertigo, paresthisias, xanthopsia, weakness, headache,
drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss
CV: orthostatic hypotension, volume depletion, cardiac arrhythmias
Dermatologic: rash, photosensitivity, pruritus, urticaria, pupura, exofoliative
dermatitis, erythema multiforme
GI: nausea, vomiting, anorexia, oral and gastric irritation, constipation,
diarrhea, acute pancreatitis, jaundice
GU: polyuria, nocturia, glycosuria, urinary bladder spasm
Hematologic: leukopenia, anemia, thrombocytopenia, fluid and electrolyte
imbalance, hyperglycemia, hyperuricemia
Other: muscle cramps and muscle spasm
Indication: 
-treatment of edema associated with CHF, hepatic cirrhosis, renal disease
and hypertension
Contraindication: 
-contraindicated with allergy to furosemide, sulfonamides
-allergy to tartrazine
-anuria, severe renal failure, hepatic coma
-pregnancy and lactation
-use cautiously with SLE, gout and DM
Nursing Consideration:
 -profound diuresis with water and electrolyte depletion can occur; careful
medical supervision is required
-administer with food or milk to prevent GI upset
-reduce dosage if given with other antihypertensive; readjust dosage gradually
as BP respond
-give early in the day so that increased urination will not disturb sleep
-avoid IV use if oral is at all possible
-discard diluted solution after 24 hours
-refrigerate oral solution
-measure and record weight to monitor fluid changes
-arrange to monitor serum electrolytes, hydration, liver, and renal function
-arrange for potassium-rich diet or supplemental potassium is needed
Name of Drug: Omeprazole 40mg IV q12
Time Given:
March 12 (6am and 6pm)
 Omeprazole 40mg
IV OD
Time Given:
March 13 (6am)
March 14 (6am)
March 15 (6am)
 Omoprazole 200mg 1tab BID
Time Given:
March 16 (6am)
Classification: 
Antisecretory Drug, Proton Pump Inhibitor, Pregnancy Category C
Adverse Effect:
CNS: headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety,
paresthesias, dream abnormalities
Dermatologic: rash, inflamation, urticaria, pruritus, alopecis, dry skin
GI: diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue
atrophy
Respiratory: URI symptoms, cough, epistaxis
Other: cancer in preclinical studies, back pain, fever
Indication: 
-short term treatment of active duodenal ulcer
-first-line therapy in treatment of heartburn or symptoms of GERD
-short –term treatment of active benign gastric ulcer
-to maintain healing of erosive esophagitis
-in combination to clarithromycin to eradicate H. pylori; use
clarithromycin and amoxicillinin combination with omeprazole in
patients with a 1 year history of duodenal ulcers or active duodenal
ulcers to eradicate H. pylori
-Zegerid oral suspension: reduction of risk of upper GI bleeding in
critically ill patients
-Prilosec OTC: treatment of frequent heartburn
Contraindication:
-contraindicated with hypersensitivity to omeprazole and its
components
-use cautiously with pregnancy and lactation
-combination therapy with clarithromycin should not be use in pt with
hepatic impairment

 
Nursing Consideration:
-take drugs before meals. Swallow the capsules whole; do not chew, open
or crush them. If using oral suspension, empty packet into a small cup
containing 2 tbsp of water. Stir and drink immediately; fill cup with water
and drink the water. Do not use any other liquid or food to dissolve
packet. This drug will need to be taken for up to 8wks (short term
therapy ) or for a long period (more than 5 yrs)
-if you take Prilosec capsules and cannot swallow them whole, capsules
contents will be added to or sprinkle with 1 tbsp of apple sauce. Mix with
apple sauce, swallow immediately with chewing pellets, and follow it with
a glass of water. Zegerid capsules should not be opened or added to
food
-have regular medical follow up visits.
-you may experience this side effects: dizziness, headache, nausea,
vomiting, diarrhea; symptoms are URI, cough
-report severe headache, worsening of symptoms, fever and chills
Name of Drug: Clarithromycin 500mg 1tab BID
Classification: Macrolide Antibiotic
Adverse Effect: 
CNS: dizziness, headache, vertigo, somnolence, fatigue
GI: diarrhea, abdominal pain, nausea, dyspepsia, flatulence, vomiting,
melena, pseudomembranous colitis, abnormal taste
Other: superinfections, increased PT, decreased WBC
Indication: 
-treatment of URIs caused by Streptococcus pyogenes, Streptococcus
pneumoniae
-treatment of lower respiratory infections caused by Mycoplasma pneumonia,
Haemophilus influenzae, Moraxella Catarrhalis
-treatment of skin and skin-structure infections caused by Staphylococcus
aureus and S. pyogenes
-treatment of active duodenal ulcer associated with H. pylori in combination
with proton pump inhibitor
Contraindication: 
-contraindicated with hypersensitivity to clarithromycin, erythromycin, o any
macrolide antibiotic
-use cautiously with colitis, hepatic or renal impairment, pregnancy, lactation
Nursing Consideration:
-do not crush or cut, and ensure that pt does not chew ER tablets
-monitor pt for anticipated response
-take drug with food if G effects occur. Take the full course of
therapy
-do not drink grape fruit juice while taking this drug
-shake suspension before use; do not refrigerate; do not cut,
crush or chew extended release tablets; swallow them all
-you may experience these side effects: stomach cramping,
discomfort, diarrhea, fatigue, headache, additional infections in
the mouth or vagina
-report severe or watery diarrhea, severe nausea, vomiting, rash
or itching, mouth sores, vaginal sores
Name of Drug: Tranexamic Acid 1g IV q8
Time given:
March 12 (6am, 2pm, 6pm)
March 13 (6am, 2pm, 6pm)
March 14 (6am; stopped)
Adverse Effect: 
-gastrointestinal disturbances
-hypotension, particularly after rapid IV administration. Thrombotic
complications have been reported. Instances of transient disturbance of
color vision associated with its use.
Indication: 
-treatment and prophylaxis of hemorrhage associated with excessive
fibrinolysis
-prophylaxis of hereditary angioedema
Contraindication:
 -hypersensitivity
-patients with active intravascular clotting because of the risk of thrombosis
-severe renal insufficiency
-patients with microscopic hematuria
Nursing Consideration: 
Assessment:
-assess patients history, if with active intravascular clotting,
predisposed to thrombosis; hemorrhage due to disseminated
intravascular coagulation.
-monitor anti-coagulant cover
-perform eye examination
-perform liver function tests
-perform blood test
-obtain prothrombin time of the pt
 
-reduce dose for pt with renal impairment and children
 
IV injection or infusion: give 3x a day and maybe mixed with most
solutions but not with penicillins
 
-Should not be used in pt with active intravascular clotting
-possibility with skin reaction such as wide spread, patchy rash with
associated blisters
-advice pt to report visual abnormalities to the physician
Name of Drug: Amoxicillin 500mg
1tab TID
Classification: Antibiotic
(Penicillin- Ampicillin type)
Adverse Effect: 
CNS: lethargy, hallucination, seizure
GI: glossitis, stomatitis, gastritis, sore mouth, furry tongue, nausea,
vomiting, diarrhea, abdominal pain, bloody diarrhea, enteroclolitis,
pseudomembranous colitis, non-specific hepatitis
GU: nephritis
Hematologic: anemia, thrombocytopenia, leucopenia, neutropenia,
prolonged bleeding time
Hypersensitivity: rash, fever, wheezing, anaphylaxis
Other: super infections- oral and rectal moniliasis, vaginitis
Indication: 
-infections due to susceptible strains of Haemophilus influenza, E. coli,
Neisseria Gonorrhea, Streptococcus pneumoniae, Enterococcus fecalis,
Streptococci, non-penicillinase producing staphylococci
-H. pylori infection in combination with other agents
-post exposure prophylaxis against Bacillus Anthacis
Contraindication: 
-contraindicated with allergies to penicillins, cephalosporins
and other allergens.
-use cautiously with renal disorders, lactation
Nursing Consideration: 
-give in oral preparations only; amoxicillin is not affected by
food
-continue therapy for at least 2days after signs of infection
have disappeared; continuation for 10 full days is
recommended
-use corticosteroids or anti histamines for skin reactions
-take antibiotic around-the-clock
-this antibiotic is specific for this problem and should not be
used to self-treat other infections
-you may experience these side effects: nausea, vomiting, GI
upset, diarrhea, sore mouth
-report unusual bleeding or bruising, sore throat, fever, rash,
hives, severe diarrhea, DOB
 Blood Chemistry (March 12, 2010)
SI Unit Traditional SI Unit Traditional Interpretation

Glucose (FBS) 4.18-6.05 mmol/L 65-110 mg/dl

Blood Urea Nitrogen 2.5-6.43 mmol/L 7-18 mg/dl

Uric Acid (male) 0.15-0.4 mmol/L 2.6-7.2 mg/dl

(female) 0.09-0.35 mmol/L 1.5-6.0 mg/dl

Creatinine 1.1 mg/dl 35.4-124 mmol/L 0.4-1.4 mg/dl NORMAL

Cholesterol 3.64-3.24 mmol/L 140-240 mg/dl

Triglyceride 0.40-1.88 mmol/L 35-166 mg/dl

HDL- Cholesterol 0.72-1.95 mmol/L 30-75 mg/dl

LDL-Cholesterol 1.56-4.6 mmol/L 27-77 IU

Sodium 3.5-5.3 mmol/L 135-155 mg/L

Potassium 0.190 unit 3.6-5.5
Chloride 2.1-2.55 mmol/L 110-114 mEq/L

SGPT 4-39 IU/L

SGOT
Infant Up to 67
Children Up to 40
Adult 8.8 iu/L 5-43iu/L Up to 40 Normal
 Hematology
 March 12, 2010

Normal Value Found Value Interpretation

Hemoglobin M: 155- 175g/L 42.0 May indicated anemia
F: 115- 135g/L from blood loss, dietary
defeciency
Hematocrit 40-52 0.12 May indicated anemia
from blood loss, dietary
defeciency
WBC count 4.0 – 11.0 x 10/L 8.9x10 g/L NORMAL

Platelet Count 150-400 x 10/L

Bleeding Time
Clotting Time

Differential Count

Segmenters 0.59 NORMAL

Lymphocytes 0.35 NORMAL
Monocytes 0.06 NORMAL
Blood type O+
HbsAg
Others
 March 13, 2010 (9pm)
Normal Value Found Value Interpretation
Hemoglobin M: 155- 175g/L 95.2 g/L May indicated
F: 115- 135g/L anemia from blood
loss, dietary
defeciency
Hematocrit 40-52 0.28 May indicated
anemia from blood
loss, dietary
defeciency
WBC count 4.0 – 11.0 x 10/L

Platelet Count 150-400 x 10/L

Bleeding Time
Clotting Time

Differential Count

Segmenters
Lymphocytes
Monocytes
Blood type
HbsAg
Others
 Urinalysis
 March 13, 2010

Interpretation
Color Yellow Normal
Characteristic Clear Normal
Reaction NO STRIP
SP. Gravity NO STRIP
Albumin NO STRIP
Sugar NO STRIP
Pregnancy Test NO STRIP
WBC 1-3 HPF (range: 0-5)
RBC 0-2 HPF (range: 0-3) Normal
Epith. Cell Few Normal
Cast
Bacteria Few May indicate infection
Crystals
Miscellaneous
Health perception/Health Management

Nutritional /Metabolic

Elimination
Activity/Exercise

Sleep/Rest

Cognitive Perceptual
Roles/Relationship

Self-Perception/Self-Concept

Coping/Stress Tolerance
Value/Belief

Sexuality/Reproductive
Assessment Diagnosis Planning Intervention Evaluation

Subjective Self care deficit STG -Establish rapport STG

“Hindi ako related to -After 4 hrs of to patient -After 4 hrs of
nakaligo simula weakness as rendering nursing -Assist in sponge RNI and health
nung naospital manifested by intervention and bathing teaching, the pt is
ako”, as soiled clothing, health teaching, -Assist in clean and free of
verbalized by the foul smelling the pt will be changing clothes foul smelling
pt. body odor, clean and free of -Encourage the pt body odor.
halitosis, foul smelling to brush her teeth
Objective yellowish white body odor. -Encourage the pt LTG
-soiled clothing teeth with tartar, to take a bath and -After a week of
-foul smelling long and dirt LTG explain the RNI and health
body odor fingernails and -After a week of importance of teaching, the pt
-(+) halitosis toenails and RNI and health everyday bathing can perform self
-yellowish white uncombed hair. teaching, the pt to health care activities
teeth with tartar will perform self -Comb her hair within level of
-long and dirty care activities -Trim nails in own ability.
fingernails and within level of fingernails
toenails own ability. -Health teach
-uncombed hair patient about:
with flakes *proper diet for
her illness (iron
rich foods, soft
foods)
*enough rest and
sleep everyday
*how to manage
stress
Assessment Diagnosis Planning Intervention Evaluation

Subjective Risk for infection STG -Establish rapport STG

“Bakit ka naka- related to increased -After 4 hrs of to patient -After 4 hrs of
mask, hindi naman environmental rendering nursing -Health Teach and rendering nursing
nakakahawa ang exposure to intervention and encourage hand intervention and
sakit ko”, as pathogens as health teaching, the washing before and health teaching, the
verbalized by the manifested by pt will identify after eating pt can identify
pt. exposed to ICU interventions to -alcoholized hands interventions to
room filled with pt prevent or reduce whenever needed prevent or reduce
Objective with different kinds the risk of -encourage soiled the risk of
-exposed to a ICU of illness, infection. bed linen should be infection.
room filled with pt weakness, decrease changed
with different kinds Hgb, Hct and WBC. LTG -encourage soiled LTG
of illness/infection -After a week of clothing should be -After a week of
-weakness RNI and health put in a plastic bag RNI and health
-Hgb teaching, the pt will and bring it home teaching, the pt can
-Hct be able to by the SO. be able to
-WBC demonstrate -encourage pt to demonstrate
techniques to wear a mask techniques to
promote safe -used eating promote safe
environment. utensils should be environment.
wash immediately .
after using to
prevent flies and
cockroaches in
contaminating
them
-proper hygiene
should be observe
Assessment Diagnosis Planning Intervention Evaluation

Subjective Impaired dentition STG -Establish rapport STG

“Nahihirapan ako sa related to -After 4 hrs of to patient -After 4 hrs of
ngipin ko ineffective oral rendering nursing -inspect oral cavity rendering nursing
pagkumakain, hindi hygiene as intervention and -health teach intervention and
ako makakagat ng manifested by health teaching, the patient about health teaching, the
mabuti”, as halitosis, tooth pt will demonstrate proper oral pt can demonstrate
verbalized by the enamel effective dental hygiene: effective dental
pt. discoloration, hygiene skills. >encourage hygiene skills.
excessive plaque, everyday brushing
Objective loose tooth, LTG after eating before LTG
-halitosis missing teeth. -After a week of bedtime -After a week of
-tooth enamel RNI and health >limit sweets RNI and health
discoloration teaching, the pt will -advice patient to teaching, the pt
-excessive plaque be encourage to seek a dental help was encourage to
-tooth fracture visit a dentist for a to have a denture visit a dentist for a
-loose tooth dental check up for so she can eat dental check up for
-missing teeth appropriate dental different foods. appropriate dental
care. care.
.
M- otivate Pt to have regular check up
E- ncourage Pt not to skip meals
L- essen work load and stress
E- ncourage Pt to eat nutritious food
(ex: Iron rich foods – malunggay, ampalaya,
internal organs)
N- o to vices such as drinking alcohol,
smoking and using of illegal drugs.
A- void spicy and sour foods