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    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

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    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

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    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.

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    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

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    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

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    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

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    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

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    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.

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    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.

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    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/
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    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.

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    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

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    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

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    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.

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    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.

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    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.

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    . 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/
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