Download - Bleeding Peptic Ulcer_CS
LICEO DE CAGAYAN UNIVERSITY R.N.P. Blvd., Carmen, Cagayan de Oro City
C O L L E G E O F N U R S I N G
A family Care Study
With
PEPTIC ULCER DISEASE
Submitted to:
Clinical Instructor
As Partial Requirement for NCM501202
Submitted by:
NCM501202 Student
January 18, 2007
Table of Contents
I. INTRODUCTION ----------------------------------------------------1 – 2
II. HEALTH HISTORY -------------------------------------------------3 – 4
III. DEVELOPMENTAL DATA ---------------------------------------5 - 6
IV. MEDICAL MANAGEMANT ---------------------------------------7 - 17
V. ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY----------18 - 22
VI. NURSING ASSESSMENT ----------------------------------------23 -25
VII. NUSING MANAGEMENT -----------------------------------------26 -35
VIII. REFERRALS AND FOLLOW-UP--------------------------------36
IX. EVALUATION AND IMPLICATIONS---------------------------37
X. BIBLIOGRAPHY -----------------------------------------------------38
I. INTRODUCTION
Overview of the Case
Too much stress, too much spicy food, and you may be headed for an ulcer or
so the thinking used to go.
A peptic ulcer is an ulcer of one of those areas of the gastrointestinal tract that
are usually acidic. A more general term, peptic ulcer disease (PUD), is also in use.
Most ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that
lives in the acidic environment of the stomach. Ulcers can also be caused or
worsened by drugs such as Aspirin and other NSAIDs. Contrary to general belief,
more peptic ulcers arise in the duodenum (first part of the small intestine, just after
the stomach) than in the stomach. About 4 % of stomach ulcers are caused by a
malignant tumour, so multiple biopsies are needed to make sure. Duodenal ulcers
are generally benign.
The common belief was that peptic ulcers were a result of lifestyle. Doctors
now know that a bacterial infection or medications — not stress or diet — cause most
ulcers of the stomach and upper part of the small intestine (duodenum). Esophageal
ulcers may also occur and are typically associated with the reflux of stomach acid.
Although stress and spicy foods were once thought to be the main causes of
peptic ulcers, doctors now know that many ulcers are caused by the corkscrew-
shaped bacterium Helicobacter pylori (H. pylori).
H. pylori lives and multiplies within the mucous layer that covers and protects
tissues that line the stomach and small intestine. Often, H. pylori causes no
problems. But sometimes it can disrupt the mucous layer and inflame and erode
digestive tissues, producing an ulcer. One reason may be that people who develop
peptic ulcers already have damage to the lining of the stomach or small intestine,
making it easier for bacteria to invade and inflame tissues.
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The most common ulcer symptom is gnawing or burning pain in the abdomen
between the breastbone and the belly button. The pain often occurs when the
stomach is empty, between meals and in the early morning hours, but it can occur at
any other time. It may last from minutes to hours and may be relieved by eating food
or taking antacids. Less common symptoms include nausea, vomiting, or loss of
appetite. Sometimes ulcers bleed. If bleeding continues for a long time, it may lead to
anemia with weakness and fatigue. If bleeding is heavy, blood may appear in vomit
or bowel movements, which may appear dark red or black.
Objective of the Study
The objectives of this care study aims to:
1. Develop knowledge, which would make us or the readers aware on what are
the possible causative agents and the signs & symptoms manifested by the
patient on having this specific condition
2. Know the possible actions that would help alleviate or even prevent a certain
problem related to the condition of the patient for the prevention of possible
complications
3. Even give some interventions to those problems that were observed to the
patient, but are not related to its diagnosis.
4. Have a correct nursing care rendered to the patient on the entire therapy
5. Identify what are the uses of the drugs being prescribed by the patients
physician during the entire hospitalization
Scope and limitation of the Study
This study focuses mainly on the patient’s specific condition, which is bleeding
peptic ulcer and even focused more on the condition of the patient before and upon
admission to further evaluate what are the possible nursing and medical interventions
would be applied to the patient on the entire course of therapies.
II. HEALTH HISTORY
Patients Profile
The name of the patient was, male; 74 years old; a Roman Catholic; and a
Filipino citizen. He is married to Mrs. and have three siblings namely; and presently
residing at.
He was born on the. He is five feet four inches in height and 100 pounds in
weight
He is negative on food and drug allergies. His chief complains were
Hematochezia and Hemoptysis. He was diagnosed by his physician Dr. Bacal, with
T/C bleeding peptic ulcer disease.
Personal Health History
My patient has not received any blood from the past. He has no known food
and medicine allergies. He had experienced having a cough when the time he
stopped smoking and it gone out to be more severe on the following days. As his
watcher said that he was hospitalized for several times because of his condition. , is
susceptible to many diseases since the patient was to old and have vices that
precipitates lots of diseases and complications. The patient also told me that when
there were times that there is pain on his stomach, he sometimes skip his meals. As
we all know, that, skipping a meal will lessen our body’s nutrients/strength and would
become prone to diseases when the nutritive status of our body is altered. And due
to tiredness and inadequate nutrients on his body, the patient would become weak
and alters his daily activities. The above factors made my patient a susceptible
individual to a certain disease.
History of Present Illness and Chief Complains
, presently residing in was admitted at Cagayan de Oro Polymedic General
Hospital due to Hematochezia ( cause: bleeding in colon/rectum and results to loss of
blood higher in the digestive tract or through defecation of bloody stools (melena);
and also hemoptysis ( coughing up of blood from respiratory tract. Bloodsteaked
3 1
2
sputum often is presented in minor upper respiratory infection or bronchitis). The
patient was experiencing severe pain on his abdominal area when he does not eat
his meals. Since the cause the discomforts felt by the patient on his abdomen, as
well as the bloody stools during defecation, and with laboratory examination taken by
(e.g. CBC), the patient is then positive with a peptic ulcer disease. He was also noted
with acute bronchitis; the patient was not able to talk clearly because of his
productive cough or retained secretions/bronchospasm that obstructs the airway of
the patient, that’s why he has dyspnea and some manifestations of hyperventilation
and tachypnea, these was the cause why the patient has ineffective airway clearance
during his hospitalization. Few minute prior to admission the patient encountered
dizziness and brought patient to his room on a stretcher (condition upn admission)
The result of his physical assessment was that he is febrile and is in
respiratory distress. His vital signs during the first day of assessment were,
temperature: 36.3oc; pulse rate: 88bpm; respiration rate: 28 cpm; and blood pressure:
140/70 mmHg. There was no skin lesions observed upon admission. Dr. Bacal’s
admitting diagnosis to was Bleeding Peptic Ulcer Disease
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III. DEVELOPMENTAL DATA
The stage of older adulthood is considered to begin at 65 years of age. Many
physical, psychological, and social changes occur during later adulthood. The critical
transition comes at the time of retirement for both the husband and the wife. In old
age persons are moving toward completion of their life cycles. Old age can be a
time when a person can enjoy his/her time with his/her grandchildren and leisure
time activities, and forget about things caused him/her a great deal of stress and
anxiety in the past three or four decades . During this stage a person must adapt to
changing physical abilities. This stage is characterized by increased wisdom although
many other things are lost such as health, friends, family and independence. The
aging process of people in this stage of development varies greatly. Ego integrity Vs
despair represents this stage in the psychosocial theory. The developmental tasks of
the older adult are: adjusting to decreases physical strength and loss of health,
adjusting to retirement and reduced income, coping with death of a husband or wife
and preparing for one's own deatheating periods.
According to Erik Erickson’s Psychosocial Development Theory lies on the
stage 8 (integrity vs. Despair), wherein, ego integrity is the ego's accumulated
assurance of its capacity for order and meaning. And despair is signified by a fear of
one's own death, as well as the loss of self-sufficiency, and of loved partners and
friends.
This stage is focused on reflecting back on the person’s life, that is, those who
are unsuccessful during this phase will feel that their life has been wasted and will
experience many regrets. The individual will be left with feelings of bitterness and
despair.
Those who feel proud of their accomplishments will feel a sense of integrity.
Successfully completing this phase means looking back with few regrets and a
general feeling of satisfaction. These individuals will attain wisdom, even when
confronting death.
In general, this is the patients time for reflecting on and reviewing how he met
previous challenges and lived his life. Adjusting to decreasing physical strength and
health; Adjusting to retirement and reduced income; Establishing an explicit affiliation
with one's age group; and Meeting social and civil obligations are the right ways on
how to establish a satisfactory physical living arrangements on his kind of stage.5
IV. MEDICAL MANAGEMANT
December 3, 200612:10 AM
Please admit to Medical Ward
TPR every four hours
For – CBC and Chest PA
(#1 IVF therapy)
Combivent 1 neb every 6 hours
Esomemeprazole (Nexium) 20mg 1 tab BID, PO
For further medical management and monitoring
For baseline data of interventions and close monitoring of patients vital signs
CBC- includes absolute number of percentages of erythrocytes, leukocytes,platelets, hemoglobin and hematocrit in blood sample. Used to evaluate blood if it is potential for infection or other disorders/abnormalities.
This medication is an intravenous (IV) solution used to supply water, calories, and electrolytes
Relaxes bronchial uterine and vascular smooth muscle by stimulating beta2 receptors that helps to prevent or treat broncho-spasm in patient with severe obstructive airway disease
Proton Pump Inhibitor that reduces gastric acid secretion and decreases gastric acidity that helps eradicate Helicobac- ter Pylori.
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Sucralfate (Iselpin) 1g/10ml BID, PO
Isoptin 240 mg 1 tab OD, PO
Administer O2
Short term treatment of ulcer (duodenal).Maintenance therapy for duodenal ulcer
Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. For management of hypertension
For oxygen therapy of the patient since the patient cannot breath normally during admission.
December 4,2006
Lactulose (Dupholac), 20cc BID
Cefixime (Tergeof) 200mg BID, PO
Produces an osmotic effect in colon, resulting distention promotes peristalsis. For or to treat constipation
Stable in the presence of beta-lactamase enzyme. Used for acute bronchitis and acute exacerbations of chronic bronchitis
December 5,2006
IVF TF with D5NSS at 20 gtts / min
This medication is an intravenous (IV) solution used to supply water, calories, and electrolytes (e.g., sodium, chloride) to the body. 8
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December 6, 2006
On going IVF # 5 D5NSS @ 20 gtts / min.
Terminate when consume (IVF to consume)
December 7, 2006
Discontinue Nebulization
May Go Home Tomorrow
Discontinue Isoptin
Resume spiriva 1 cap OD inhalation
This medication is an intravenous (IV) solution used to supply water, calories, and electrolytes (e.g., sodium, chloride) to the body.
The Patient is done with the Intravenous therapy and should continue his therapy with his medications.
This indicates that patient has alleviated his respiratory conditions and has change its conditions unlike before
This indicate that the patient is in good condition and return to its functional level.
The blood pressure of the patient was back on its normal ranges on a couple of days of admission. So the specific drug was discontinued.
For the total wellness of his bronchospasm.
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LABORATORY RESULTS
RADIOGRAPHIC REPORT
(CHEST PA)
December 4, 2006
The lungs are clear. The heart is enlarged (CTR:067) exhibiting inferolateral
displacement of the cardiac apex. There are crescentic calcifications in the aortic
knob.
The midline structures are not displaced. The costophrenic sulci and
hemidiaphragms are intact. The rest of the included structures are unremarkable.
CU cardiomegaly is considered. ECG correlation suggested
Atheromatous aorta
?
DPBR, Radiologist
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HEMATOLOGY REPORT
Lab no. : 600066002
Date Received: 12-04-06 (5:58)
Date Reported: 14-04-06 (7:18)
TEST RESULT UNIT REFERENCE
WHITE BLOOD CELLS
RED BLOOD CELLS
HEMOGLOBIN
HEMATOCRIT
MCV
MCH
MCHC
DIFFERENTIAL COUNT
Lymphocyte
Neutrophil
Monocyte
Eosinophils
Basophils
PLATELET
23.31
4.40
13.2
39.7
94.7
30.1
32.0
7.5
89.2
7.4
.9
.2
189
10^3/uL
10^6/uL
g/dL
%
fL
pg
g/dL
%
%
%
%
%
10^3/uL
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
17.4 – 48.2
43.4 – 76.2
4.5 – 10.5
1.0 – 3.0
0.0 – 2.0
150 - 400
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DRUG STUDY
Generic Name
Brand Name
Date ordered Classification Dose/
Frequency/ Route
Mechanism of Action
Indication Contraindication Side Effects Nursing Precaution
Verapami Isoptin December 3, 2006
Anti-hypertensive
240mg/ 1tab od/ PO
Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction.
Management of hypertension
Hypersensitivity, sick sinus syndrome
BP less than 90 mmHg
CHF, severe ventricular dysfunction
Anxiety, confusion,Dizziness, headache, nervousness, blurred vision, polyuria, vomiting
Use cautiously in severe hepatic impairement- geriatric patient.
History of serious ventricular arrhythmias.
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Generic Name
Brand Name
Date ordered Classification Dose/
Frequency/ Route
Mechanism of Action
Specific Indication
Contraindication Side Effects Nursing Precaution
Sucralfate Iselpin December 3, 2006
Antiulcer drugs
1 gram qid/ PO(befire meals at HS)
Unknown. Probably adheres to and protects surface of ulcer by forming a barrier.
Short term treatment of ulcer (duodenal)
Maintenance therapy for duodenal ulcer
Use cautiously to patient with chronic renal failure
Dizziness, headache, vertigo, constipation, nausea, gastric discomfort, diarrhea, dry mouth
Drug is minimally absorbed and causes few adverse effect
Drug contains Aluminum but isn’t classified as Antacid. Monitor patients renal insufficiency for aluminum toxicity
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Generic Name Brand Name Date ordered Classification Dose/
Frequency/ Route
Mechanism of Action
Specific Indication
Contraindication Side Effects Nursing Precaution
Esomepra-zole
Nexium December 3, 2006
Antiulcer drugs
20mg/ 1 tab bid/ PO
Proton Pump Inhibitor that reduces gastric acid secretion and decreases gastric acidity
Helicobacter Pylori eradication
Hypertensive to drug or some components of esomeprazole or omeprazole
Headache, dry mouth, diarrhea, nausea, abdominal pain, vomiting, and constipation
Give at least one hour before meals
Monitor GI symptoms for improvement or worsening.
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Generic Name
Brand Name Date ordered Classification Dose/
Frequency/ Route
Mechanism of Action
Specific Indication
Contraindication Side Effects Nursing Precaution
Combivent Salbutamol Sulfate
December 3, 2006
Broncho-dilators
1 neb q 6o
Relaxes bronchial uterine and vascular smooth muscle by stimulating beta2 receptors.
To prevent or treat broncho-spasm in patient with severe obstructive airway disease
Hypertensive to drug or ingredients
Use extended release tablets cautiously in patient with GI narrowing
Dizziness, headache, heartburn, nausea, vomiting, cough, increase sputum, tachycardia
Drug may decrease sensitivity of spirometry used for dx of asthma
Patient may use tablet and aerosol together monitor for signs of toxicity.
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Generic Name Brand Name Date ordered Classification Dose/
Frequency/ Route
Mechanism of Action
Specific Indication
Contraindication Side Effects
Nursing Precaution
Lactulose Dupholac December 4, 2006
Laxatives 20cc/ bid/ PO
Produces an osmotic effect in colon, resulting distention promotes peristalsis.
For or treat constipation
Patient with a low galactose diet
Use cautiously in patient with diabetes mellitus.
Abdominal cramps, belching, diarrhea, gaseous distention, flatulence, nausea, vomiting
Minimize sweet taste dilute with water or give with food.
Monitor sodium level for hypernatremia, especially when giving in higher doses to treat hepatic encephalopathy.
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Generic Name
Brand Name
Date ordered Classification Dose/
Frequency/ Route
Mechanism of Action
Specific Indication
Contraindication Side Effects Nursing Precaution
Cefixime Tergeof December 4, 2006
Cephalosporin / antibiotic
200mg/ bid/ PO
Stable in the presence of beta-lactamase enzyme
Used for acute bronchitis and acute exacerbations of chronic bronchitis.
Hypertensive to drugs or other cephalosporin drugs.
Flatulence, elevated alkaline phosphatase level.
Once reconstituted, keep suspension at room temperature where it maintains potency for 14 days.
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V. ANATOMY & PHYSIOLOGY AND PATHOPHYSIOLOGY
Digestive System, organs for changing food chemically into simple soluble substances absorbable by tissues. This process involves catalytic reactions between ingested food and enzymes secreted into the intestinal tract (see Intestine). Digestion of fatty substances appears to involve the assembly of bile salts, phospholipids, fatty acids, and monoglycerides that can pass through intestinal cells. Other nutrients such as iron and vitamin B12 are absorbed by specific “carrier proteins” that make them transferable by the intestinal cells. The process described here is typical of all vertebrates except ruminants.
Digestion includes both mechanical and chemical processes. The mechanical processes include chewing to reduce food to small particles, the churning action of the stomach, and intestinal peristaltic action. These forces move the food through the digestive tract and mix it with various secretions. Three chemical reactions take place: conversion of carbohydrates into such simple sugars as glucose (see Sugar Metabolism), breaking down of protein into such amino acids as alanine, and conversion of fats into fatty acids and glycerol (see Fats and Oils). These processes are accomplished by specific enzymes.
When food is eaten, the six salivary glands produce secretions that are mixed with the food. The saliva breaks down starches into dextrin and maltose, dissolves solid food to make it susceptible to the action of later intestinal secretions, stimulates
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secretion of digestive enzymes, and lubricates the mouth and oesophagus for the passage of solids.
Stomach and Intestinal Action
Gastric juice in the stomach contains agents such as hydrochloric acid and some enzymes, including pepsin, rennin, and traces of lipase. (The surface of the stomach itself is thought to be protected from acid and pepsin by its mucous coating.) Pepsin breaks proteins into peptones and proteoses. Rennin separates milk into liquid and solid portions; lipase acts on fat. Another function of stomach digestion is gradually to release materials into the upper small intestine, where digestion is completed. Some constituents of gastric juice become active only when exposed to the alkalinity of the small intestine; secretion is stimulated by chewing and swallowing and even by seeing or thinking of food (see Reflex). The presence of food in the stomach also stimulates production of gastric secretions; these in turn stimulate the production of digestive substances in the small intestine.
The most extensive part of digestion occurs in the small intestine; here most food products are further hydrolysed and absorbed. Predigested material supplied by the stomach is subjected to the action of three powerful digestive fluids: pancreatic fluid, intestinal juice, and bile. These fluids neutralize the gastric acid, ending the gastric phase of digestion.
Intestinal juice is secreted by the small intestine. It contains a number of enzymes; its function is to complete the process begun by the pancreatic juice. The flow
19
of intestinal juice is stimulated by the mechanical pressure of food partly digested in the intestine.
The water-soluble substances, including minerals, amino acids, and carbohydrates, are transferred into the venous drainage of the intestine and through the portal blood channels directly to the liver. Many of the fats, however, are resynthesized in the wall of the intestine and are picked up by the lymphatic system (see Lymph), which carries them into the systemic blood flow as it returns through the vena caval system (see Heart), bypassing an original passage through the liver (see Circulatory System).
Excretion
Undigested material is formed into a solid mass in the colon by reabsorption of water into the body. If colonic muscles propel the excretory mass through the colon too quickly, it remains semi-liquid. The result is diarrhoea. Insufficient activity of the colonic musculature, on the other hand, produces constipation. The stool is held in the rectum until excreted through the anus.
Many disorders of absorption are collectively called malabsorptive states, the most profound and difficult being a condition known as spruce.
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PATHOPHYSIOLOGY
Definition:
Peptic Ulcer
A circumscribed breaks or ulcerations of the gastrointestinal mucosa and
underlying tissues caused by gastric secretions that have low pH(acid)
Predisposing Factors
Blood Type (tends to strike with type “A” blood; duodenal ulcers tends to afflict
type “O” Blood.
Genetic Predisposition/ Factors
Normal Aging
Exposure to irritants (alcohol use and tobacco smoking)
Physical trauma
Emotional stress or psychosomatic factors (e.g. chronic anxiety)
Precipitating Factors
Epigastric Pain which is burning
Piercing and periodic
Hyperacidity
Nausea or vomiting
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Schematic Diagram
HCl = Pepsin Irritants(Alcohol and tobacco)
Increase or excessive mucous or gastric acid secretions (caused by secretions stress or stimulants)
Damage of mucous membrane
PEPTIC ULCER DISEASE
S/s: Pain (burning, Aching, or gowning)Epigastric Tenderness
Bleeding at the site (GIT)Passage of tarry stools (melena)
May occur
Complications: pyloric or duodenal obstruction,
hemorrhage and perforation22
VI. NURSINS ASSESSMENT
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EENT: Impaired vision blind pain reddened drainage gums hardof hearing deaf burning edema lesions teethassess eyes ears nose throat for abnormalities no problemRESP: Asymmetric tachypnea apnea rales cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea labored wheezing pain cyanoticasses resp. rate, rhythm, depth, pattern, breath sounds, comfort noproblemCARDIO VASCULAR Arrhythmia tachycardia numbness diminished pulse edema fatigue irregular bradycardia murmur tingling absent pulses painassess heart sounds, rate rhythm, pulse, blood pressure, circ., fluid retention, comfort no problemGASTRO INTESTINAL TRACT Obese distention mass dysphagia rigidly painassass abdomen, bowel habits, swallowing, bowel sounds, comfort no problemGENITO-URINARY Pain urine color vaginalbleeding hematuria discaharge noctoriaAssess urine freq., control, color, odor, comfort/gyn-bleeding, discharge no problemNEURO Paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision gripassess motor function, sensation, LOC, strength, grip, gait, coordination, orientation,speech, no problemMUSCULOSKELETAL and SKIN Appliance stiffness itching petechiae hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed atrophy pain ecchymosis diaphoretic moistassess mobility, motion, gait, alignment, joint function/skin color, texture, turgor, integrity noproblem
Place an (x) in the area of abnormality. Comment at the space provided indicate the location of the problem in the figure if appropriate, using (x)
Pain at OD
O2 administration (nasal Cannula)
Tachypnea (RR 28cpm)Hyperventilation
Pain @ Right Knee / Leg(Arthritis)
IVF D5NSS 1l infusing at Right hand @ 20gtts/min
Abdominal Pain
Body is Weak
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EENT: Impaired vision blind pain reddened drainage gums hardof hearing deaf burning edema lesions teethassess eyes ears nose throat for abnormalities no problemRESP: Asymmetric tachypnea apnea rales cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea labored wheezing pain cyanoticasses resp. rate, rhythm, depth, pattern, breath sounds, comfort noproblemCARDIO VASCULAR Arrhythmia tachycardia numbness diminished pulse edema fatigue irregular bradycardia murmur tingling absent pulses painassess heart sounds, rate rhythm, pulse, blood pressure, circ., fluid retention, comfort no problemGASTRO INTESTINAL TRACT Obese distention mass dysphagia rigidly painassass abdomen, bowel habits, swallowing, bowel sounds, comfort no problemGENITO-URINARY Pain urine color vaginalbleeding hematuria discaharge noctoriaAssess urine freq., control, color, odor, comfort/gyn-bleeding, discharge no problemNEURO Paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision gripassess motor function, sensation, LOC, strength, grip, gait, coordination, orientation,speech, no problemMUSCULOSKELETAL and SKIN Appliance stiffness itching petechiae hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed atrophy pain ecchymosis diaphoretic moistassess mobility, motion, gait, alignment, joint function/skin color, texture, turgor, integrity noproblem
Place an (x) in the area of abnormality. Comment at the space provided indicate the location of the problem in the figure if appropriate, using (x)
Pain at OD
O2 administration (nasal Cannula)
Tachypnea (RR 28cpm)Hyperventilation
Pain @ Right Knee / Leg(Arthritis)
IVF D5NSS 1l infusing at Right hand @ 20gtts/min
Abdominal Pain
Body is Weak
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Briefly describe the patient's ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). Medications ordered by the doctor are always available and given at the right time but not similar to his diet. He seldom eat food because of his condition, as the patient stated
MGT. OF HEALTH & ILLNESS: Alcohol denied (amount, frequency)____as patient verbalized that he doesn’t drink alcoholic beverages any more __ SBE Last Pap Smear _____N/A__________ LMP: _________N/A_____________________
Comments __________ Bowel sound___________________________ ______Audible________________________ Abdominal Distension___________________ Present yes no ___________________ Urine* (color.,___________________ consistency, odor)___________________ _____________________________________ _____________________________________ _____________________________________ *if they are in place?
ELIMINATION:Usual bowel pattern urinary frequency____2 x per day___ ____Every Hour______ Constipation urgency Remedy dysuria_December 5, 2006_ hematuria Date of last BM incontinence________________ polyuria Diarrhea foly in place Character denied________________
Dentures none Full Partial With PatientUpper
Lower
NUTRITION:Diet___________________________________ N V Comments__________Character ____________________ Recent change in ____________________ wieght,appetite ____________________ Swallowing ____________________ difficulty _____________________ Denied _____________________
Heart rhythm regular irregular Ankle edema ___________________________Pulse Car. Rad. DP Fem.* R _+______+_______+______+_____+______L _+______+_______+______+_____+______Comments:_all pulses are palpable or noted during the assessment (positive) * if applicable
CIRCULATION: Chest pain Comments___________ ____________________ Leg pain ____________________ ____________________ Numbness of ____________________ Extremities ____________________ ____________________ Denied ____________________
Resp. regular irregularDescribe: __Patient exhibits hyperventilation a manifestation of tachypnea on patient_______
R _side is symmetrical during inhalation/exhalation L _side is symmetrical during inhalation/exhalation
OXYGENATION: Dyspnea Comments___________ Smoking history ___________________ _____________ __________________ cough __________________ sputum __________________ denied ___________________
Glasses languages Contact lens hearing aide R L Pupil Size ___3.0mm__ speech difficulties Reaction ____PERRLA_____
COMMUNICATION: Hearing loss Comments___________ Visual changes ____________________ Denied ____________________ ____________________ ____________________
OBJECTIVESUBJECTIVE
“maayo raman akong paminaw, sakit lang usahay akong tuo nga mata”
“gahanga- kon ko tungod sa akong ubo na grabe ang plema panalagsa”
“gapaminhod usahay and akong tiil ug usahay pud musakit tungod aning arthritis na hinungdan nganu galisod kog lakaw usahay”
Diet as Tolerated
“Dili nagyud kau ko g,a kaun wala man gyud koy gana bisag unsa nga pagkaun na ihatag sa akoa”
“sige ko ug kalibang ug tae na basa as verbalizad by the patient. Still his stool is black, tarry/bloody (melena), and wet (characteristics)
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12-04-06 Chest X-Ray12-04-06
Date disc.
(Still Infused)
I.V. Fluids/Blood
D5NSS 1L @20 gtts/min
Date ordered
12-05-06
Date done
12-04-06
Diagnostic/ laboratory Exams
Complete Blood Count
Date ordered
12-04-06
SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)______100 lbs ___ Daily Weight _____N/A_______PT/OT _____N/A__________140/70 mmHg__ BP q Shift _____N/A____ Irradiation_____N/A________ Neuro vs. _____N/A____ Urine Test _____N/A____________N/A________ CVP/SG. Reading _____N/A____ 24 hour Urine collection
Observed non- verbal behavior Always touching his jaw during my assessment when he speaks and even after coughing. The person and his phone number that can be reached any time ___________________________________________________________________
COPING:Occupation _________None _____________Members of household ___Melsa, Rebbeca Fe, Lenthi Ann____________________________Most supportive person ____ Rebbeca Fe __________________________________________
Facial grimaces Guarding Other signs of pain __there were no other signs of pains felted by the patient during my assessment_____________________________________________Side rail release form signed ( 60 + years)_________________________________________
COMFORT/SLEEP/AWAKE: Pain Comments __________ (location) ___________________ Frequency ____________________ Remedies) ____________________ Nocturia ____________________ Sleep difficulties ____________________ Denied ____________________
LOC and orientation _The patient is still aware of the time, date and place______________________________ Gait: walker cane other Steady unsteady____________________ Sensory and motor losses in face or extremities _______________________________ ROM limitations __cannot extremely move his right leg or even his lower extremities because of his arthritis__________________________________________________________________________________________________________________________________________________________________________
ACTIVITY/ SAFETY: Convulsion Comments ___________ Dizziness ____________________ Limited motion ____________________ Of joints ____________________ ____________________ Limitation in ____________________ Ability to ____________________ Ambulate ____________________ Bathe self ____________________ Other ____________________ Denied ____________________
Dry cold pale Flushed warm Moist cyanotic*ashes, ulcers, decubitus (describe size, location, drainage) __tenderness/ ulcerations or rashes are not noted during the assessment
SKIN INTEGRITY: Dry Comments ___________ ____________________ Itching ____________________ ____________________ Other ____________________ ____________________ Denied ____________________
OBJECTIVESUBJECTIVE
“wala man koy katol-katol sa akong panit, wla pud koy problema anang mga samad samad sa akong panit”
“gabatiun kog kalipong dili napud ko tanto maka lakaw lakaw. Kung magkaun ko taman rako lingkod sa akong bed o sa akong higdaanan mukaun ug ga diapers na gali ko kay lisod na kau maglakaw-lakw ”
“sigi ko ug ihi-ihi sa gabie, dili pud ko katulog ug tarong kay gaubuha ko ug mau”
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VII. NURSING MANAGEMENT
IDEAL NURSING MANGEMENT
ACTIONS/INTERVENTIONSDiarrhea Management (NIC)IndependentObserve and record stool frequency, characteristics,amount, and precipitating factors.
Promote bedrest, provide bedside commode.
Remove stool promptly. Provide room deodorizers.
Identify foods and fluids that precipitate diarrhea, e.g.,raw vegetables and fruits, whole-grain cereals,condiments, carbonated drinks, milk products.
Restart oral fluid intake gradually. Offer clear liquidshourly; avoid cold fluids.
Administer medications as indicated:Antidiarrheals, e.g., diphenoxylate (Lomotil),Loperamide (Imodium), anodyne suppositories;
RATIONALE
Helps differentiate individual disease and assessesseverity of episode.
Rest decreases intestinal motility and reduces themetabolic rate when infection or hemorrhage is acomplication. Urge to defecate may occur withoutwarning and be uncontrollable, increasing risk ofincontinence/falls if facilities are not close at hand.
Reduces noxious odors to avoid undue patientembarrassment.
Avoiding intestinal irritants promotes intestinal rest.
Provides colon rest by omitting or decreasing the stimulusof foods/fluids. Gradual resumption of liquids mayprevent cramping and recurrence of diarrhea; however,cold fluids can increase intestinal motility.
Decreases GI motility/propulsion (peristalsis) anddiminishes digestive secretions to relieve cramping anddiarrhea. Note: Use with caution in UC because they mayprecipitate toxic megacolon.
NURSING DIAGNOSIS: DiarrheaMay be related to
Inflammation, irritation, or malabsorption of the bowelPresence of toxinsSegmental narrowing of the lumen
Possibly evidenced byIncreased bowel sounds/peristalsisFrequent, and often severe, watery stools (acute phase)Changes in stool colorAbdominal pain; urgency (sudden painful need to defecate), cramping
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Bowel Elimination (NOC)
Report reduction in frequency of stools, return to more normal stool consistency.Identify/avoid contributing factors
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NURSING DIAGNOSIS: Fluid Volume, risk for deficientRisk factors may include
Excessive losses through normal routes (severe frequent diarrhea, vomiting)Hypermetabolic state (inflammation, fever)Restricted intake (nausea/anorexia)
Possibly evidenced by[Not applicable; presence of signs and symptoms establishes an actual
diagnosis.]DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Hydration (NOC)
Maintain adequate fluid volume as evidenced by moist mucous membranes, good skin turgor, and capillaryrefill; stable vital signs; balanced I&O with urine of normal concentration/amount.
ACTIONS/INTERVENTIONSFluid/Electrolyte Management (NIC)Independent
Monitor I&O. Note number, character, and amount ofstools; estimate insensible fluid losses, e.g., diaphoresis.Measure urine specific gravity; observe for oliguria.
Assess vital signs (BP, pulse, temperature).
Observe for excessively dry skin and mucous membranes,decreased skin turgor, slowed capillary refill.
Weigh daily.
Maintain oral restrictions, bedrest; avoid exertion.
Observe for overt bleeding and test stool daily for occultblood.
RATIONALE
Provides information about overall fluid balance, renalfunction, and bowel disease control, as well as guidelinesfor fluid replacement.
Hypotension (including postural), tachycardia, fever canindicate response to and/or effect of fluid loss.
Indicates excessive fluid loss/resultant dehydration.
Indicator of overall fluid and nutritional status.
Colon is placed at rest for healing and to decreaseintestinal fluid losses.
Inadequate diet and decreased absorption may lead tovitamin K deficiency and defects in coagulation,
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Note generalized muscle weakness or cardiacdysrhythmias.CollaborativeAdminister parenteral fluids, blood transfusions asindicated.
Administer medications as indicated:Antidiarrheal (Refer to ND: Diarrhea);
potentiating risk of hemorrhage.
Excessive intestinal loss may lead to electrolyteimbalance, e.g., potassium, which is necessary for proper
skeletal and cardiac muscle function. Minor alterations inserum levels can result in profound and/or life-threateningsymptoms.
Reduces fluid losses from intestines.
NURSING DIAGNOSIS: Pain, acuteMay be related to
the effect of gastric acid secretion on damaged tissue Possibly evidenced by
Reports of colicky/cramping abdominal pain/referred painGuarding/distraction behaviors, restlessnessFacial mask of pain; self-focusing
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Pain Level (NOC)
Report pain is relieved/controlled.Appear relaxed and able to sleep/rest appropriately.
ACTIONS/INTERVENTIONSPain Management (NIC)IndependentEncourage patient to report pain.Assess reports of abdominal cramping or pain, notinglocation, duration, intensity (0–10 scale). Investigate andreport changes in pain characteristics.
Note nonverbal cues, e.g., restlessness, reluctance to
RATIONALE
May try to tolerate pain rather than request analgesics.Colicky intermittent pain occurs with Crohn’s diseasePredefecation pain frequently occurs in UC with urgency,which may be severe and continuous. Changes in paincharacteristics may indicate spread of disease/developingcomplications, e.g., bladder fistula, perforation, toxicmegacolon.
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move, abdominal guarding, withdrawal, and depression.Investigate discrepancies between verbal and nonverbalcues.
Review factors that aggravate or alleviate pain.
Encourage patient to assume position of comfort, e.g.,knees flexed.
Provide comfort measures (e.g., back rub, reposition) anddiversional activities.
Observe/record abdominal distension, increasedtemperature, decreased BP.CollaborativeImplement prescribed dietary modifications, e.g.,commence with liquids and increase to solid foods astolerated.
Administer medications as indicated, e.g.:Analgesics;Anti-ulscer drugs;
Body language/nonverbal cues may be both physiologicaland psychological and may be used in conjunction withverbal cues to determine extent/severity of the problem.
May pinpoint precipitating or aggravating factors (such asstressful events, food intolerance) or identify developingcomplications.
Reduces abdominal tension and promotes sense ofcontrol.
Promotes relaxation, refocuses attention, and mayenhance coping abilities.
May indicate developing intestinal obstruction frominflammation, edema, and scarring.
Complete bowel rest can reduce pain, cramping.Pain varies from mild to severe and necessitatesmanagement to facilitate adequate rest and recovery.Note: Opiates should be used with caution because theymay precipitate toxic megacolon.
Relieve spasms of GI tract and resultant colicky pain.
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ACTUAL NURSING MANAGEMENT
“Subjective”
The patient complained of difficulty of breathing because of his cough and
even verbalized that his throat was very painful when he will swallow food
“Objective”
The patient manifests tachypnea or hyperventilation during the assessment.
With a respiration Rate of 28 cpm, with a productive cough noted and shows
facial grimace upon respiration or coughing.
“Assessment”
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Ineffective airway clearance related to increased production of secretions,
retained secretions and bronchospasm.
“Planning”
At the end the interventions given to the patient, he would somehow perform
with himself the skills or techniques on how to lessen, ease, or prevent
dyspnea, cough or hyperventilation. The patient will also learn about the
reason of the condition, how it occurs and how it would be prevented and
what are the uses of the medications given by his physician.
“Implementation”
Assist patient to assume position of comfort (e.g. elevate the head part of the
bed).- Elevation of head facilitates respiratory function by use of gravity;
however patients in severe distress will seek the position that most eases
breathing.
Keep environment to a minimum (e.g. dust, smoke, and feather pillow)-
Precipitator of allergic reaction of respiratory reaction that can trigger or
exacerbate onset of acute episode
Encourage or assist with abdominal or pursed lips breathing exercise.-
provide patient with some means to cope with control dyspnea and reduces
air trapping
Increase fluid intake to 3000mL/day within cardiac tolerance. Provide
warm/tepid liquids recommended intake of fluid between, instead of during
meals.- hydration helps reduces the viscosity of secretions, facilitating
expectoration using warm liquids may decrease bronchospasm . Fluids
during meals can increase gastric distention and pressure on the diaphragm.
Administer medications as prescribed by his doctor such as bronchodilator
(e.g. ventolin, combivent)- this medication relaxes smooth muscles and
reduce local congestion, reducing airway spasm, wheezing, and mucus
production.
“Evaluation”
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At the end of a couple of interventions done to the patient, he reports reduced
difficulty in breathing that is, retained secretions are somehow lessened and
coughing was also reduced. And he will be able to prevent bronchospasm if
he continue using or performing the interventions for the wellness of his
health
“Subjective”
The patient has a complaint of bloody and dark colored stool (melena). Also
verbalized that he coughs or cough-up blood with sputum on it. And also
experiences burning epigastric pain or discomfort on his abdominal part or
area.
“Objective”
Was diagnosed with bleeding peptic ulcer disease; on his complete blood
count results found out that his hemoglobin was deceased and this is a sign
for blood loss. And regarding his discomforts felt on his abdomen, wherein
he show facial grimace when pains is felt.
“Assessment”
Increase risk of anemia due to acute GI bleeding related to ulcer
Acute pain related to pyloric obstructions complication of peptic ulcer
“Planning”
At the end of the interventions done to the patient, he will be able to perform
specific interventions with him self on how to lessen or prevent the
discomforts felt by the patient and how to manage of having a regular or
normal characteristics of stools upon defecation. By teaching patient the
methods to minimize symptoms while maintaining adequate nutrition and also
teaching patient about necessary life style changes aimed at decreasing
stress and minimizing effectiveness of coping mechanism.
“Implementation”
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Provide small and frequent meals- Food prevents distenson and release of
gastrins and has an acid neutralizing effect. Patient should eat meals on a
regular basis.
Institute measures to neutralize or buffer hydrochloric acid, inhibit acid
secretion and decreases the activity of pepsin
Administer antacids as prescribed by the physician to reduce acidity and
even anti ulcer drugs (e.g. esomeprazole)- to treat peptic ulcer or eradicate
helicobacter pylori.
Diet regulation through the use of bland foods and restriction of irritating
substances such as nicotine, caffeine, alcohol, spices, and gassy foods.
To have some bed rest to reduce physical activity and promote comfort to the
patient.
Encourage hydration to reduce anticholinergic side effects and dilute the
hydrochloric acid in the stomach
“Evaluation”
At the end of a several interventions, the patient somehow reports reduced
pain; the patient verbalizes appropriate diet modification and even
demonstrates compliance with the prescribed medication regimen in order to
reach the total health and wellness.
“Subjective”
The patient complained of pain on his right leg and even numbness, and
wasn’t able to walk with him self because of the pains and even because of
his condition, as he verbalized.
“Objective”
Has limitation on his range of motion: right leg, when tenderness is felt.
There is facial grimace when patient wants to move his leg or when pain
occurs. He was not able to ambulate by himself.
“Assessment”
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Acute Pain related to joint tenderness due to arthritis on right leg
“Planning”
The patient would somehow perform the techniques on how to exercise or
practice moving his affected area with himself and even would tolerate the
pain for a short period of time. And even the patient would be aware on what
are the significance of the said interventions and how it affects his total
condition or how it can help him on the entire course of health teachings.
“Implementation”
Elevate the affected portion or the foot of the patient with pillows under it. So
hat it would promote blood circulation.
To practice exercising his leg joints by extension or flexion of knees(range of
motion exercise)
Apply heat and colds to or on the affected area to provide relief or comfort to
the area by constriction / dilation of blood vessels
Promote rest and position of comfort to ease joint pains and encourage diet
rich in nutrients – dense food such as fruit, vegetables or legumes
Administer medications as prescribed by his doctor such as analgesics - this
drug reduces pains felt by the patient.
“Evaluation”
At the end of a couple of interventions done to the patient, he reports reduced
difficulty in breathing that is, retained secretions are somehow lessened and
coughing was also reduced. And he will be able to prevent bronchospasm if
he continue using or performing the interventions for the wellness of his
health
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VIII. REFERRALS AND FOLLOW-UP
It is important to comply regularly its medication as prescribed by his attending
physician and to continue and finish its entire therapeutic regimen. And explain to the
patient the use and side effects of the medications so that he will be aware of its effects
such as bronchodilators for the treatment of his cough that helps alleviate or prevent
bronchospasm (e.g. ventolin for Nebulization) and even anti-ulcer drugs to prevent
reoccurrence of the disease (e.g. Sucralfate).
35
He should practice moving his lower extremities to promote blood circulation and even
to improve the range of motion of his foot or feet so that he could somehow, able to
ambulate with him self in later times. To perform bed exercise such as leg exercise,
since patient is always on bed and have limitations on his physical activity because his
still weak.
The patient was instructed to avoid over work for the following days and must
have adequate bed rest to regain energy or strength. By means of anticipating the
needs on the course of healing and curing process the patient must then focused to
himself by not always depending on the interventions that are not highly needed just to
ease or prevent any health problem regarding his condition . But he should focus
entirely on how to prevent the problem on his actions by himself.
Environmental sanitation is needed to provide a healthy and therapeutic way of
curing himself. Smoking and alcohol consumption must be prevented totally by the
patient so that his problem would not be worse again..
Upon discharged, he must come back to the hospital one week after, for the
follow-up check-up to confirm if the patients condition is really restored. Also to know if
there are complications sited during the check up to know if patients condition have
worsen or not.
And lastly, he should take note of the foods that are irritating to his GI tract to
prevent reoccurrence of abdominal pain and even should eat adequate amount of foods
every meals. Eating nutritious food would somehow help the patient on regaining some
strengths or energy to his body, such as green leafy vegetables, fruits, and foods rich in
protein.
IX. EVALUATION AND IMPLICATIONS
At the end of my hospital duty, I as a student nurse was able to render care to my
patient to help him resolve his problem regarding health. Through observing the
patient’s status, I was able to identify some problems during my assessment. Because
of a couple of interventions or health teachings applied and imparted to the patient, I
was able to lessen its respiratory pattern on the patients problem of breathing
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(ineffective Airway Clearance); alleviated pains felt by the patient due to the effects of
the peptic ulcer or to the arthritis; and even have defecated a normal characteristics of
stool.
Patient was willing to pursue his medical therapy just to promote health and
wellness for the betterment of his condition. During the treatment, the patient was able
to develop or enhance health awareness on his disease and with this knowledge
instilled to his mind, he was then aware on how the disease was transmitted and what
are the proper ways or interventions done just to minimize or prevent this disease from
getting worst.
I have also made the patient realize the importance of completing the course of
therapy by taking the medicines prescribed or ordered to him by his physician. In
addition, eating healthy or nutritious foods that were prescribed to him by the health
providers was further been explained to him especially the benefits he will gain in eating
these nutritious foods.
In general, the patient was very cooperative to what health measures
administered to him by the health providers.
Moreover, these several interventions given to the patient made his body
functions different than as before
X. BIBLIOGRAPHY
Lippincott Williams and Wilkins, Nursing 2006 Drug Handbook, 26th Edition,
Barbara Kozier et al, Fundamentals of Nursing, 7th Edition,
Lippincott Williams and Wilkins, Nursing 2004 Drug Handbook, 24rd Edition,
Mosby’s Pocket Dictionary of Medicine, Nursing Allied Health, 4 th Edition,
Published in Elsevier Science (Singapore) PTE LTD
Microsoft ® Encarta ® Premium Suite 2005. © 1993-2004 Microsoft
Corporation. All rights reserved.
37
Mosby’s Comprehensive Review of Nursing, 13th Edition by:
Saxton,Nugent,Pelikan
http://www.cnn.com/HEALTH/library/DS/00583.html
Smeltzer & Bare, medical Surgical Nursing, 10th ed. Vol. 1, Lippincott
Williams & Wilkins, Philadelphia, USA pp.1015-1051
Mosby’s MEDICAL ENCYCLOPEDIA, the definitive health reference
http://www.wrongdiagnosis.com/p/peptic_ulcer/symptoms.htm
http://en.wikipedia.org/wiki/Peptic_ulcer
http://www.emedicine.com/med/topic1776.htm
http://www.gicare.com/pated/ecdgs09.htm
http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=8
LICEO DE CAGAYAN UNIVERSITY R.N.P. Blvd., Carmen, Cagayan de Oro City
C O L L E G E O F N U R S I N G
A Care Study
Moesis L. Labuntog
38
Submitted to:
Ms. Asterie Revelo, RNClinical Instructor
As Partial Requirement for NCM501202
Submitted by:
Librea, Celso R.NCM501202 Student
January 18, 2007