NOOTAN COLLEGE OF

NURSING VISNAGAR

SUBJECT: clinical speciality-1

MEDICAL SURGICAL NURSING

TOPIC : HEALTH ASSESSMENT on

“Peptic ulcer”

Submiited to:- submitted by:-

Ms.Srushti Contractor Mr.Dharmendra Patel
Assit. Professor 1St year M.Sc nursing
NCN,Visnarar NCN,Visnagar
SR.NO CONTENT PAGE NO

1 PATIENT PROFILE 3

2 FAMILY HISTORY 4

3 MARITAL HISTORY 4

4 ENVIRONMENTAL HISTORY 5

5 SOCIOECONOMIC HISTORY 5

6 NUTRITIONAL HISTORY 6

7 PERSONAL HISTORY 7

8 HISTORY OF ILLNESS 10

9 PHYSICAL EXAMINATION 11-13

10 DIAGNOSTIC EVALUATION 14

11 MEDICAL MANAGEMENT 14

INDEX
PROFILE OF THE PATIENT

 NAME : Mr. Sureshbhai Patel

 AGE : 50 years

 SEX : Male

 ADDRESS : Sona Towen Kheralu Road Visnagar

 QUALIFICATION : 10th pass

 OCCUPATION : Shopkeeper Work

 MARITAL STATUS : Married

 RELIGION : Hindu

 INCOME : Rs 15000 per month.

 REGISTRATION NUMBER :5436

 WARD : Male Medical Ward

 BED NUMBER : 09

 DATE OF ADMISSION : 22/02/2018

 DIAGNOSIS : Peptic Ulcer

 NAME OF OPERATION : NA
FAMILY HISTORY
 FAMILY STATUS : He lives in a nuclear family

 NO OF FAMILY MEMBERS : His family comprises of 4 members

 HISTORY OF ANY CHRONIC ILLNESS : No history of any chronic

illness

 ANY COMMUNICABLE DISEASE IN FAMILY : No communicable

disease in family

 ANY CONGENITAL DISEASE IN FAMILY : No congenital disease in

family

 ANY HERIDITARY DISEASE IN FAMILY : There is no any hereditary

disease in family

 ANY DISABILITY IN FAMILY: There is no disability in the family.

FAMILY INFORMATION:

Name Of
Family Relationship Health
Sr.No Age/Sex Education Occupation
Member With Patient Status

Peptic
1 Suresh Bhai 50yrs/Male Self 10th Pass Shopkeeper
Ulcer
2 Kanchan Ben 48yrs/Female Wife Illiterate House-Wife Healthy

3 Deepak 30 Yrs/Male Son Graduate Clerk Healthy

4 Snehal 27yrs/Female Daughter Graduate ____ Healthy

FAMILY TREE: KEY WORDS:-

 Patient

Male

Suresh bhai(patient) kanchan ben(wife)

Female

Deepak Sonal

MARITAL HISTORY

 YEARS OF MARRIAGE : It has been 17 years of marriage life to

him.
 MARITAL RELATIONSHIP : The marital relationship is satisfactory
 STAYING TOGETHER : They stay together.
 ANY MARITAL DISCORD : There is no marital discord.
 NUMBER OF CHILDREN : He has a son who is 30 years old and a
Daughter of 27 years.
 HEALTH OF SPOUSE : Spouse is healthy.
 HEALTH OF CHILDREN : His children are healthy.
 ANY CONGENITAL DISEASE IN CHILDREN : There is no any
congenital disease

ENVIRONMENTAL HISTORY

 HOUSE : He owns his own house .

 LOCALITY : He lives in a village.
 TYPE OF HOUSE : His house is pakka type.
 VENTILATION : There is proper ventilation in the house.
  NUMBER OF DOORS AND WINDOWS : Doors:- 1
Windows:- 3
 BATHROOM : There is a separate bathroom in the house.
 LATRINE : There is inbuilt latrine in home.
WATER SUPPLY :There is a tape water supply in the house.
 KITCHEN :Kitchen is attached in the house.
 GARBAGE DISPOSAL FACILITY :There is adequate garbage
disposal facility.
 DRAINAGE :Drainage is closed.
 CLEANLINESS :House tends to be kept clean.

SURROUNDING :As he lives in village there are domestic animals around.

SOCIO-ECONOMIC HISTROY

 INCOME :His income is Rs 10000 per month.

 INDIVIDUAL :His income is rs 10000 per month.
 FAMILY :Including the family the income of month is rs 10000
per month.
 PER MONTH :Rs 10000/
 SOURCE OF INCOME : He works as clerk.
 LANGUAGE :He speaks gujarati language
 RELATIONSHIP WITH NEIGHBOURHOOD:The relationship with the
neighbourhood is good , maintained well, good communication.

NUTRITIONAL HISTORY:

 VEGETARIAN/NON VEGETARIAN : He partakes mixed diet. Both

vegetarian and non-vegetarian diet is consumed by the family and him
respectively.
 LIKE AND DISLIKE OF PATIENT: He has no dislikes as he said.
  NUMBER OF MEALS PER DAY : He eats 2 meals per day which
comprises of a heavy lunch and a supper in evening.
 FOOD ITEMS IN EACH MEAL:
Breakfatst:- bajra, milk, tea
Lunch:- bajra rotis , vegetables, pulses, buttermilk.
Dinner:- milk, roti, bhakri.
 NUMBER OF GLASSES OF WATER PER DAY : minimum 12 glasses
of water.
 BEVERAGES : He prefers tea .
 TEA/COFFEE : He prefers tea the most.
 FRUIT/JUICE : fruits he consumes as per season and occasionally.
 TYPE OF FOOD CONSUMED:

DIET BEFORE ILLNESS : Normal diet

DIET DURING ILLNESS : Soft diet(non-spicy).

PERSONAL HISTORY
1) HYGIENIC HABITS:-

 DENTAL CARE :Proper dental care taken by him. He brushes

his teeths daily.
 ORAL CARE :He cleans his teeth daily and make use of the
tongue cleaner daily.
 BATH FREQUENCY PER DAY: He baths twice a day
 SKIN :Proper skin care
 HAIR :His hairs are rough . he apply hair oil on daily basis.
 NAIL :He pairs his nails regularly.
 PERINEAL CARE :He cleans properly.
 CLEANLINESS OF DRESS :He puts on neat and tidy dress.
2) HEALTH HABITS:-

 SLEEP PATTERNS: He takes a normal pattern of sleep in

adequacy.
 DURATION OF SLEEP: He takes 8 hours of sleep.
 DURATION OF REST AT DAY TIME: In day time he sleep
sometimes and not daily.
 ANY SLEEP DISORDERS: He has no sleep disorders. He sleeps
well.

3) ELIMINATION HABITS:-

 BLADDER:
His bladder pattern is normal.
 BOWEL
FREQUENCY: He has not passed stool since 3 days after being
hospitalized. At home he passes regular stool.
AMOUNT OF STOOL: He has not passed stool in hospital. At home
he regularly passes stool.
CHARACTERISTICS: yellowish in colour. Semisolid in form.

4) OTHER HABITS:-

 SMOKING: he smokes cigarettes. He smokes 5 cigrattes per day. Its been

5 years since he smokes.
 TOBACCO CONSUMPTION: he consumes tobacco in smoke form
through cigarettes.
 TOBACCO CHEWING: he has no habit of chewing tobacco.
 ANY ADDICTION: he has no other addiction.
 SNUFF: he is not smelling snuff.
  EXERCISES: he is not doin any particular exercise. The only physical
activity is does is the work at his work place.

HISTORY OF ILLNESS

A) PAST MEDICAL OR SURGICAL HISTORY:-

 ILLNESS IN CHILDHOOD: he did not suffer from any illness in

childhood.
 ILLNESS IN ADULTHOOD: he did not suffer from any illness in
adulthood except for the condition of the peptic ulcer for which he is
admitted presently.
 ANY SURGERY IN PAST: he has not undergone any surgery in the
past.
 ANY TRAUMA OR INJURY IN PAST: he says that he did not suffer
any major trauma or injury in the past.
 DURATION OF ILLNESS: as he did not suffer from any major illness in
past.

B) PRESENT MEDICAL OR SURGICAL HISTORY:-

 REASON FOR SEEKING MEDICAL ASSISTANCE: patient was

admitted due to abdominal pain on 22/02/2018 . the pain was acute on
onset.
 ONSET OF ILLNESS: patient was diagnosed with peptic ulcer(gastric
ulcer) in sarvajanik hospital , gojariya.
 EFFECTS OF THE SYMPTOMS ON DAILY LIFE ACTIVITIES: due
to the symptoms the patient is unable to carry out his daily self care
activities.
 PATIENT KNOWLEDGE AND UNDERSTANDING OF DISEASE:
patient has no knowledge regarding the disease condition.
  FAMILY MEMBERS KNOWLEDGE AND UNDERSTANDING OF
THE DISEASE: family members have no knowledge regarding the
disease condition.
 PATIENT AND FAMILY MEMBERS PERCEPTION OF OUTCOME
OF DISEASE: patient and family members perceive to be a good
recovery after the treatment. They perceive that if untreated the disease
can prove to be fatal for the patient.

C) PRESENT COMPLAIN:-

Patient was admitted with the complain of abdominal pain along with nausea
and vomiting on 22/02/18 In gozariya sarvajanik hospital in male medical ward.
He is feeling better now.

PHYSICAL EXAMINATION

 GENERAL APPEARANCE :
 Body image: normal
 Health: Unhealthy
 Activity: less active
 VITAL SIGNS:
 TEMPEARTURE: 98.4 degrees fareinheit
 PULSE: 92 beats / minute
 RESPIRATION: 28 breaths / minute
 BLOOD PRESSURE: 120/70 mm/hg
 HEAD AND FACE:
 Scalp: clean
 Face: pale, fatigue, fear, anxiety
 EYES:
 Eyebrow: normal
 Eye lashes: no infection
 Eyelids: no any injury or oedema is present
 Eye balls: not sunken
 Conjunctiva: pale
  Sclera: no jaundiced
 Pupils: constricted
 Vision: react to light
 NOSE:
 External nares: Redness present
 Nostrils: no deviation from the normal . deviated septum
present.
 MOUTH & PHARYNX:
 Lips: dry
 odour of the mouth: not present
 Teeth: normal But yellowish colour is seen
 Mucus membrane: dry
 Tongue: pale and dry
 EAR:
 External ear: no discharge present
 Hearing: normal
 NECK:
 Lymph node: No any disease
 Thyroid gland: normal
 Range of motion: flexion, extension and rotatation can be
done
 CHEST:
 Thorax: expansion
 Breath sound: normal
 Heart: size: normal but decreased cardiac out put

 RESPIRATORY SYSTEM: the patient has breathlessness. The breathing

pattern is strained at times. Respiratory rate ranges from 28 to 30 breaths
per minute in his condition.

 CARDIOVASCULAR SYSTEM
 INSPECTION: normal shape of epigastrium and
pericordium
 PALPATION: normal on palpation of apex beat and no any
abnormality on palpation of pericardium carotid artery.
  PERCUSSION: no any fluid collection noticed on
percussion.
 AUSCULTATION: S1 & S2 sounds heard on auscultation.
 ABDOMEN:
 inspection: no skin rashes and scar found on inspection
 Auscultation: reduced bowel sound heard on auscultation
 Palpation: tenderness present on palpation and pain felt.
 Percussion : no any abnormal fluid collection noticed and no
presence of gas and masses in abnormality.

 NEUROLOGICAL SYSTEM: on neurological examination the

sensitivity and reflexes tend to be normal. No abnormality detected.

 INTGUMETARY SYSTEM: no any skin abnormalities , rashes, redness

or edema noticed .

 EXTREMITIES:
 Lower extremities: no any disorder , there is full range of
motion with flexion and extension.
 Upper extremities: can move both hands . there is full range
of motion with good flexion and extension.

 Genital and rectum:

 No enlarged inguinal lymph nodes, No hemorrhoids, no
enlargement of prostate glands.
 Bladder & Bowel Pattern: normal.
DAGNOSTIC EVALUATION:

SR NORMAL
NAME OF TEST DATE PATIENT FINDINGS
NO VALUE
1 Endoscopy 22/02/18 Perforation and ulcer
on the gastric mucosa. ----------

2 Stool antigen test 22/02/18 Positive for the

infection -----------

MEDICAL MANAGEMENT:

SR.
NAME OF DRUGS DOSE ROUTE TIME ACTION
NO

Proton
Inj Omeprazole 20 mg
1 intravenous 8AM#8PM pump
(Prilosec) bid
inhibitor
H2-receptor
2 Inj ranitidine 2cc bid intravenous 8AM#8PM
antagonist.

6AM#2PM#
3 Inj Metronidazole 500 mg tds intravenous Antibiotic
10PM
10AM#10P
4 Inj diclofenac 2cc bd intravenous Anelgesic
M