8/3/2019 Case Pres Gastritis)

1/21

CAPITOL UNIVERSITYCollege of Nursing

Cagayan de Oro City

A Case StudyOn

Gastritis with 2nd degree anemia

In Partial FulfillmentOf the course

RLE 7

Submitted to:

Clinical InstructorMrs. Maria Rica Adane,RN

Submitted by:

Cantil, Maria Renee

RLE 7 Group 7THFS 3:00-11:00 pm

8/3/2019 Case Pres Gastritis)

2/21

TABLE OF CONTENTS

I. Introduction

II. Clients Profile

III. Anatomy and Physiology

IV. Pathophysiology

V. Diagnostic Procedures and Lab Results

VI. Drug Study

VII. Nursing Care Plans

VIII. Discharge Plan

IX. Learning Insights

X. Reference

8/3/2019 Case Pres Gastritis)

3/21

I. INTRODUCTION

I have chosen to study Gastritis with a second degree anemia because Ive got

so interesting to know if how it affects to people and of course all of the corresponding

complications of this because this is a very common disease that Filipinos mostly have.

Gastritis is not a single disease, but several different conditions that all have

inflammation of the stomach lining. Gastritis can be caused by drinking too much

alcohol, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin

or ibuprofen, or infection with bacteria such as Helicobacter pylori(H. pylori). Sometimes

gastritis develops after major surgery, traumatic injury, burns, or severe infections.

Certain diseases, such as pernicious anemia, autoimmune disorders, and chronic bile

reflux, can cause gastritis as well.

The most common symptoms are abdominal upset or pain. Other symptoms are

belching, abdominal bloating, nausea, and vomiting or a feeling of fullness or of burning

in the upper abdomen. Blood in your vomit or black stools may be a sign of bleeding in

the stomach, which may indicate a serious problem requiring immediate medical

attention.

Gastritis is diagnosed through one or more medical tests. The doctor eases an

endoscope, a thin tube containing a tiny camera, through your mouth (or occasionally

nose) and down into your stomach to look at the stomach lining. The doctor will check

for inflammation and may remove a tiny sample of tissue for tests. This procedure to

remove a tissue sample is called a biopsy. The doctor may check your red blood cell

count to see whether you have anemia, which means that you do not have enough red

blood cells. Anemia can be caused by bleeding from the stomach. This test checks for

the presence of blood in your stool, a sign of bleeding. Stool test may also be used to

detect the presence ofH. pyloriin the digestive tract.

Treatment usually involves taking drugs to reduce stomach acid and thereby help

relieve symptoms and promote healing. (Stomach acid irritates the inflamed tissue in the

stomach.) Avoidance of certain foods, beverages, or medicines may also be

recommended.

If your gastritis is caused by an infection, that problem may be treated as well.

For example, the doctor might prescribe antibiotics to clear up H. pyloriinfection. Once

the underlying problem disappears, the gastritis usually does too. Talk to your doctor

before stopping any medicine or starting any gastritis treatment on your own.

8/3/2019 Case Pres Gastritis)

4/21

8/3/2019 Case Pres Gastritis)

5/21

Cognitive-perceptual pattern:

Patient recognizes everyone and expresses affection to them. She is coherent.

Role-relationship pattern: (while confined)

The family of the patients is supportive, they find resources to support the

financial needs specially in procuring medicines for the patient.

PHYSICAL ASSESSMENT

ASSESSMENT DATAASSESSMENT FINDINGS

BEFORE (SEPT 23, 09)SKIN

Color

Temperature

Turgor

Texture

Lesion

Integrity

Others

warm

36.4 C

Fair skin turgor

Moist skin

(-) Lesions/Rash

Intact

NAILS

Color

Texture

Shape

Others

Dusky

Smooth

Concave

Poor capillary refill = 3 sec

HAIR

Color

Texture

Distribution

Quantity

Others

black

Coarsely dry

Evenly distributed

moderate

HEAD

Shape

Size

Configuration

Headache

Round

Normocephalic

Symmetrical

None

ASSESSMENT DATA

8/3/2019 Case Pres Gastritis)

6/21

EARS

Hearing

Tinnitus

Vertigo

Earaches

Infection

DischargesS

Others

Can hear whispered voice

None

No vertigo

No earaches

No infection

No discharges

NOSE AND SINUSES

Frequent colds

Nasal stiffness

Nose bleed

Sinus trouble

None

None

None

Sinuses are non tender

MOUTH & THROAT

Condition of teeth

Bleeding gums

Tongue

Throat

Hoarseness

Mucous membrane

Incomplete teeth

No bleeding

Tongue is at midline,

Throat Non-tender

None

Pinkish

ASSESSMENT DATA ASSESSMENT FINDING

NECK

Symmetry

Condition of trachea Thyroid

Lymph nodes

Symmetrical

in the midline

(+) non-palpable

8/3/2019 Case Pres Gastritis)

7/21

LUNG

Symmetry

Shape

Respiratory movements

# of breath

Symmetrical

A:P diameter 1:2

Asymmetrical, use of accessory muscles, (+)

wheezing

24 cpm

AUSCULTATION:

Character of respiration (-) rales on upper lung lields

Decrease breath sounds on left lung field

HEART AND NECK VESSELS:

Apical Pulse

Cardiac Sounds

Apical/Radial pulse data

Blood pressure

Pulse pressureAny special procedure

Done

74 bpm

(+) murmurs,harsh, occasional rales

110/80 mmHg

65 bpm ( full pulses)none

ASSESSMENT DATA ASSESSMENT FINDING

ABDOMEN:

Symmetry

Contour

Skin Lesion

Masses

Bowel Sounds

Tenderness

Others

Symmetrical( flat and feat)

protuberant

none

(-) Masses

Normoactive bowel sounds

none

8/3/2019 Case Pres Gastritis)

8/21

MUSCULOSKELETAL SYSTEM:

Posture

ROM

Muscle Strength

abnormal postures arent present

active-passive

4/5

HEAD AND NECK:

Facial muscle symmetry

Swelling

Scars

Discoloration

Weakness

ROM

Posterior neck cervical spine

Muscle spasm

Crepitus

Symmetrical

None

None

None

(+) Weakness

can turn head from side to side

Non-tender

(-) Spasm

(-) Crepitus heard

MOTOR SYSTEM:

Muscle tone

Ability to move extremities against gravity

Spasticity, flaccidity or rigidity, tremors, lies

Without hypertrophy or atrophy

Muscle strength is 4/5

none

MENTAL STATUS:

LOC

Long term memory

Short Term Memory

conscious

organized

organized

8/3/2019 Case Pres Gastritis)

9/21

III. Anatomy & Physiology

Human Digestive System Diagram:

Human Digestive System Diagram

The Human Digestive System Pictureabove,

shows the relative positioning of various

organs in the abdomen. Notice how thesmall

intestine snakes back and forth, and how

thelarge intestine also curves to accommodate

it's

length in the small space of the abdomen.A truly remarkable machine

- The Human Digestive System.

A. Digestion of food begins in the mouthwith chewing and the action of saliva.

Food is physically broken into small pieces

with the teeth and tongue and then swallowed.

B. The swallowed food travels down along tube called the esophagus into the

stomach.Food is moved down the esophagus by

wavelike muscular contractions.

C. The stomach is a highly flexiblemuscular bag about the size of an apple.

Food is mixed with acids to help break it

down further. The acids also destroy most

bacteria (if any) in the food.Food is gradually turned into a liquid, which

is released into the small intestine in small

amounts.

D. The small intestine is a thin tube of upto 7 meters long, which is so ingeniouslymade, that it presents an enormous

surface area from which it extracts

nutrients from the mixture.

Nutrients move across the small intestine wall into the bloodstream, where they are

transported to the cells of the body, to be used

for energy and building and repairing the body.

E. The large intestine is about 1.5 meterslong, containing undigested material

including fibre, bacteria and other wastesthat have been passed from the smallintestine.

It's here, that water is extracted (recycled)

and the waste material is finally processedbefore elimination.

8/3/2019 Case Pres Gastritis)

10/21

The Digestive Process:

The start of the process - the mouth: The digestive process begins in the mouth. Food is

partly broken down by the process of chewing and by the chemical action of salivary

enzymes (these enzymes are produced by the salivary glands and break down starches

into smaller molecules).

On the way to the stomach: the esophagus - After being chewed and swallowed, the

food enters the esophagus. The esophagus is a long tube that runs from the mouth to

the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force

food from the throat into the stomach. This muscle movement gives us the ability to eat

or drink even when we're upside-down.

In the stomach - The stomach is a large, sack-like organ that churns the food and bathes

it in a very strong acid (gastric acid). Food in the stomach that is partly digested and

mixed with stomach acids is called chyme.

In the small intestine - After being in the stomach, food enters the duodenum, the first

part of the small intestine. It then enters the jejunum and then the ileum (the final part of

the small intestine). In the small intestine, bile (produced in the liver and stored in the

gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner

wall of the small intestine help in the breakdown of food.

In the large intestine - After passing through the small intestine, food passes into

the large intestine. In the large intestine, some of the water and electrolytes (chemicals

like sodium) are removed from the food. Many microbes (bacteria like Bacteroides,

Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in

the digestion process. The first part of the large intestine is called the cecum (the

appendix is connected to the cecum). Food then travels upward in the ascending colon.

The food travels across the abdomen in the transverse colon, goes back down the other

side of the body in the descending colon, and then through the sigmoid colon.

The end of the process - Solid waste is then stored in the rectum until it is excreted via

the anus.

Digestive System Glossary:

anus - the opening at the end of the digestive system from which feces (waste) exits the

body.

appendix - a small sac located on the cecum.

ascending colon - the part of the large intestine that run upwards; it is located after the

cecum.

bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and

secreted into the small intestine.

cecum - the first part of the large intestine; the appendix is connected to the cecum.

8/3/2019 Case Pres Gastritis)

11/21

chyme - food in the stomach that is partly digested and mixed with stomach acids.

Chyme goes on to the small intestine for further digestion.

descending colon - the part of the large intestine that run downwards after the transverse

colon and before the sigmoid colon.

duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach

to the jejunum.

epiglottis - the flap at the back of the tongue that keeps chewed food from going down

the windpipe to thelungs. When you swallow, the epiglottis automatically closes. When

you breathe, the epiglottis opens so that air can go in and out of the windpipe.

esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle

movements (called peristalsis) to force food from the throat into the stomach.

gall bladder - a small, sac-like organ located by the duodenum. It stores and releases

bile (a digestive chemical which is produced in the liver) into the small intestine.

ileum - the last part of the small intestine before the large intestine begins.

jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum

and the ileum.

liver - a large organ located above and in front of the stomach. It filters toxins from the

blood, and makes bile (which breaks down fats) and some blood proteins.

mouth - the first part of the digestive system, where food enters the body. Chewing and

salivary enzymes in the mouth are the beginning of the digestive process (breaking

down the food).

pancreas - an enzyme-producing gland located below the stomach and above the

intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and

proteins in the small intestine.

peristalsis - rhythmic muscle movements that force food in the esophagus from the

throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what

allows you to eat and drink while upside-down.

rectum - the lower part of the large intestine, where feces are stored before they are

excreted.salivary glands - glands located in the mouth that produce saliva. Saliva contains

enzymes that break down carbohydrates (starch) into smaller molecules.

sigmoid colon - the part of the large intestine between the descending colon and the

rectum.

stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical

and mechanical digestion takes place in the stomach. When food enters the stomach, it

is churned in a bath of acids and enzymes.

transverse colon - the part of the large intestine that runs horizontally across theabdomen.

http://www.enchantedlearning.com/subjects/anatomy/lungs/label/http://www.enchantedlearning.com/subjects/anatomy/lungs/label/http://www.enchantedlearning.com/subjects/anatomy/lungs/label/

8/3/2019 Case Pres Gastritis)

12/21

V. LABORATORY AND DIAGNOSTIC RESULT

X-Ray Report

Name: Guro, Dayangkira Record number: 10-173

Age: 72 YOAddress: Kalilangan, Bukidnon Date: 1/6/10Examination: Chest PA Physician: Dr. Refre

Findings:

Lungs clear. Diaphragmatic leaves depressed. Calcareous depositsthoracic spine. Heart not enlarged. Lipping in thoracic spine. Trachea soft tissueremarkable. Calcific densifies in right apex.

Impression:

Pulmonary HyperactionAtherosclerosis, thoracic aortaSpondylosis, thoracic spineREesidual Kochs calcifications in right apex.

Peripheral Smear Report

Name: Guro, Dayangkira Accession No: PS 10-06

Age/Sex: 72YO/ F Room No: 342

Attending Physician: Dr. Refre Date signed: 1/8/10

Findings:

The erythrocytes are exhibiting mild anisocytosis, with few microlytic cells/hypochronic cells, and occasional target cells seen. The leukocytes are normal inmorphology, however, they appears to be scarcity of lymphocytes. The plateletsare adequate and normal in granularity.Comments/ Suggestions/ Recommendations:

MICROLYTIC HYPOCHROMIC ANEMIA, MILD LYMHOCYTOPENIAPLATELETS ADEQUATE.

8/3/2019 Case Pres Gastritis)

13/21

Name: Guro, Dayangkira Age/Sex: 72YO/FRequested by: Dr. Refre Date: 1/7/10

Tests SI Unit Results: Normal Range:Blood ureanitrogen 41.04 15.0-45.o mg/dlALAT(SGPT) 26.2 F: up to 32.0 u/L

M: up to 41u/L

STOOL EXAMINATION

Name: Guro, Dayangkira Age/Sex: 72YO/F

Service: Date: 1/7/10

Consistency: Formed Color: brownish

Ascaris: none Pus cells: none

Amoeba: sees Hookworm: none

Other parasites: Trichuris: sees

* Occult Blood: Positive

8/3/2019 Case Pres Gastritis)

14/21

Ultrasound/ Mammography Report

Name: Guro, Dayangkira

Address: Kalilangan, Bukidnon

Examination: Ultrasound of whole abdomen.

Findings:

Small cysts in the liver with biggest one having a diameter of 1.7

cms. In medial aspect of right lobe. Gallbladder is of normal size with no echoes

with in lumen. No dilated billiary ducts. Pancreas and spleen are of normal size

and echo pattern with no focal masses. Right kidney measures 9.3 x 38cms with

corticomedullary thickness of 14cms and the left measures 9.3 x 3.5 cms with

corticomedullary thickness of 1.6 cms. Normal echo pattern with no stones nor

focal masses. Atheromatous abdominal aorta. No abdominal masses. Uterus is

retroverted and measures 5.6 x 2.6x 2.4 cms. No adnexal mass.

Impression:

Small hepatic cysts with biggest one having a diameter of 17 cmsAtherosclerotic, Thoracic spine

Spondylosis, thoracic spine

Residua Kocks calsification,right apex

8/3/2019 Case Pres Gastritis)

15/21

VIII. HEALTH TEACHINGS/DISCHARGE PLAN

M Medication

Medications includes Albuterol Ipatropium, Hydrocortisone, Paracetamol

Provide client and the significant others with the list of the drugs, its dosage,

route, classification, Indications and side effects.

Instruct client and the health care provider at home regarding the timing and

frequency of the drugs.

Provide information regarding adverse effects of the drugs that need to be

reported immediately.

E Exercise

Proper exercise is being recommended within normal range.

T Treatment

Given medications for her gastritis and vitamins supplementation.

H Health teachings

Compliance in maintenance of care when at home.

Increase fluid intake

Avoid taking medication like anti-inflammatory drugs and aspirin that could trigger

stomach inflammation unless prescribed.

Maintainance of proper hygiene is recommended.

Strictly avoid intake of acidic beverages and foods to avoid gastric irritation

Always have the patient proper rest and sleep.

Avoid crowded places.

O Out-patient

Tell the client and significant others to go back for follow-up check-up to his

physician and to report any abnormalities noted to make any immediate

management and to see any improvement regarding the clients health.

Provide family with the contact numbers of hospitals and physician in case ofemergency.

8/3/2019 Case Pres Gastritis)

16/21

D Diet

Teach the client to eat healthy foods that are rich in protein and take the vitamins

prescribed, also to increase fluid intake to 2 3 L/day.

Soft diet is being recommended.

High fiber foods are being recommended also.

Instruct the family regarding the clients diet modification and follow promptly.

S Spiritual

Tell the client to always pray and if possible, attend the mass every Sunday with

assistance to her family.

Always trust Gods will. Never blamed God of your condition and always take it

as a blessing either it is good or bad.

RECOMMENDATION

This nursing care plan is tailored to fit the needs of the patient concerned. We

strongly believe that following this care plans will address the specific problems that the

patient and significant other/s will face as they go through the whole healing process.

As their student nurses, we will be able to carry out interventions that are needed

not only to present solutions to the following problems but also to prevent the occurrence

of such problems. We can aid in promoting health but we cannot do it alone, the need for

cooperation is greatly needed in the part of the patient and its significant other/s as well.

The healing process will not limit only inside the hospital setting but it will expand

further into the patients home upon discharge. That is why we came out with health

teachings and discharge plans to cover this part of the healing process and make it easy

for the significant other/s to apply these learning when the need arises. I recommend

that the patient and its significant other/s will serve this care plan as a guide for them to

carry out procedures and that, following the teachings given will help the patient deal

with his recuperation process.

8/3/2019 Case Pres Gastritis)

17/21

IX. LEARNING EXPERIENCE

One of the splendid moment in my life is having been assigned in COMC Station

3. Asking why?I t is because I do really thought that it is more difficult in here and we

wont learn many procedures in here but everything changes when I was assigned in

here under our very skillful clinical instructor, Maam Adane. I have learned and

experienced such events that Im sure will never forget. Ambitiously, I do really feel often

that I am already a nurse. I did enjoyed every procedure that I have done and I was

always been so eager to learn more and perform more procedures. My experiences here

in COMC are something that I could really treasure because of what I have learned in

this hospital. Many opportunities have come in my way and I actually become more

competitive by applying all that I have learned in COMC. I do also feel so grateful

because of those opportunities because not even all student nurses have been lucky

enough to be assigned in COMC and experienced what I had experienced. Of course

having been in my new groupmates, Im always so happy being with them. We also used

to help each other that I can really tell anyone that we have already developed our

teamwork and not being selfish.

Regarding this case, I find it very interesting to study because almost of us

Filipinos have a very good appetite that we dont mange to watch our diet. It is been

known and a very common disease that anyone can have. I do also hope that this case

study would help to encourage everyone who will read how hard to have a gastritis with

its corresponding complications wherein they would realize that this disease is more

about having a discipline and awareness in all our eating pattern.

8/3/2019 Case Pres Gastritis)

18/21

. As we go on through our journey. God, please guide my paths, to have

patience, respect and prosperity all the time especially in our profession. This is a

priceless legacy.

References:

DavisDrug Guide for Nursing II Edition

Nursing Care Plan 6th Edition (FA Davis)

Essentials of Human Anatomy and Physiology 8th Edition Elaine Marieb

www.mims.com

www.nursing.ning.com

http://www.mims.com/http://www.nursing.ning.com/http://www.mims.com/http://www.nursing.ning.com/

8/3/2019 Case Pres Gastritis)

19/21

8/3/2019 Case Pres Gastritis)

20/21

8/3/2019 Case Pres Gastritis)

21/21