ULCER like DYSPEPSIA

Presented By: Salimo, Axl Rose P. Salisi, Kevin John R.

I. Introduction
The development of ovarian cysts is a common condition in which one or more cysts f orm on the ovary or ovaries of a woman's reproductive system. An ovarian cyst consists of a sac filled with fluid, blood, or tissue. Ovarian cysts are generally not dangerous and often go away by themselves within weeks to a few months. However, some ovarian cysts can remain and cause serious problems to health or fertility. During ovulation (the process during which the egg ripens and is released from the ovary) the ovary produces a hormone to make the follicles (sacs containing immature eggs and fluid) grow and the eggs within it mature.

I. Introduction
Ovarian cysts can develop due to a woman's changing hormones that normally occur during the monthly menstrual cycle. There are many types of ovarian cysts, including endometriomas, dermoid cysts, and functional cysts. Cysts vary in size, from the size of a pea to the size of a softball.

I. Introduction
But with this case, the patient was diagnosed with ovarian new growth that is benign. Benign cysts can cause pain and discomfort related to pressure on adjacent structures, torsion, rupture, hemorrhage (both within and outside of the cyst), and abnormal uterine bleeding. They rarely cause death. There are often no symptoms of ovarian cysts, but sometimes they can result in abdominal pain, infertility and other health problems.

I. Introduction
The focus of this case is the abdominal pressure made by the growth of the cyst, thus causes epigastric pain, upon the recognition of the person of the pain a diagnostic test, maybe an ultrasound or endoscopy procedure might tell what or how big the affectation of the cyst to the digestion of the person. ON this case, dyspepsia was the associated diagnosis in the ovarian new growth.

I. Introduction
Dyspepsia is derived from Greek word and means difficult to digest. Dyspepsia (indigestion) is best described as a functional disease. Sometimes, it is called functional dyspepsia. It pertains to the muscular organs of the alimentary tract-oesophagus, stomach, small intestine, gallbladder, and colon. It is called functional, because it involves either the muscles of the organs or the nerves that control the organs are not working normally, and, as a result, the organs do not function normally.

I. Introduction
Ulcer like dyspepsia is a type of indigestion that may be caused by peptic ulcer. The symptoms are often similar to dyspepsia caused by ulcers such as bloating and epigastric pain or discomfort. Some causes of this disease is the presence of infection like H. pylori, some are due to other diseases maybe a growth from adjacent internal structures and some are from the persons eating habits like eating too fast or skipping important meals.

II. DEMOGRAPHIC PROFILE

Name: Patient M
Age: Gender: Female 33 years old

Usual Source of Medical Care: Maxicare

Physician: Height: 1.68 m Dr. Quino

Address:

Batangas

Sambat, Tanauan City,

Weight: 63 kg
BMI: 22.34 Growth, erosion Admitting Diagnosis: Ovarian New Ulcer like - Dyspepsia Final Diagnosis: Dyspepsia with gastric

Date of Birth: April 3, 1979

Admission date
and time: January 16, 2013, 2:18 PM

III. REASON FOR SEEKING HEALTH CARE

Chief Complaint: Epigastric pain

IV. PRESENT HISTORY OF ILLNESS

Eleven days prior to admission, Patient M was noted to have episodic, burning to colicky epigastric pain. Negative for vomiting, diarrhea and dyspepsia.
Since before, Patient M has a habit of skipping breakfast and eating a lot at lunch and dinner. She also has a high intake of coffee, 5 cups per day. She prefers drinking coffee than water. Few Hours prior to admission Patient M had 6 episodes of epigastric pain after eating chicken and rice @ KFC. Together with her husband, she consulted DMMC Hospital-ER and was admitted.

V. PAST HEALTH HISTORY

Past health history
According to Patient M, she had completed her immunization status. On her elementary days, she experienced sore eyes, mumps, chicken pox and measles and relieved without consulting a physician but with assistance of alternative therapy like using herbal plants. She was hospitalized last 2002 but with a diagnosis of typhoid fever and was able recover after a week of hospital stay.

V. PAST HEALTH HISTORY

Patient M also undergone two surgical operations (Dilatation and Curettage) with a two year interval, this is because of an ectopic pregnancy and an ultrasound that revealed that the fetus in her womb had no heart beat respectively. According to her she has irregular menstrual cycle sometimes it would be continuous for a month then for some months there would be amenorrhea. Allergies
She is not allergic to drugs, animals, insects, food or other agents. Accidents and Injuries fatal. There were no reports of patient being involved in major accidents or injuries that might have been

VI. COURSE IN THE WARD

This is a case of a 33/F, married, currently residing at Sambat, Tanauan City, Batangas. Patient came in at our institution with a chief complaint of epigastric pain. History started 11 days prior to admission. Patient complained of epigastric pain. Patient took nothing for relief. Persistence of symptoms prompted consult and subsequent admission. Upon admission, Patient was subjected for radiologic work ups for the abdomen that revealed left posterior cul de sac cystic mass probably left ovarian origin. No medications were given at the emergency department.
No other remarks were known. An intravenous fluid of D5 NB 1 L to run for 8 hours was hooked to Patient M.

VI. COURSE IN THE WARD

Impression: Ovarian New Growth, Ulcer like Dyspepsia
The time of interaction with patient was last January 17 - 18, 2013, exactly the second and third day of the patient from her admission.

VII. FAMILY HISTORY

VII. FAMILY HISTORY

Family History Interpretation According to Patient M, They have a history of liver disease and her father died because of a liver complication. Her Mother has asthma and her siblings are all alive and well. No other serious diseases happen to have occurred to her family except for simple common colds that relieved by subsequent medical consultation.

VIII. PHYSICAL EXAM

General appearance & mental status Patient M, a 33 year old female client, was admitted on January 16, 2013 in Daniel Mercado Medical Center. Upon assessment, the patient was laying on bed and is awake, conscious, coherent & responsive. She complains of epigastric pain with a pain scale of 3 out of 10. Patient M was received with an ongoing intravenous fluid of D5 NB 1 liter to run for eight hours and at a desired rate of 41- 42 drops per minute. The client can ambulate by herself. She is 1.68 m in height and weighs 63 kg. She has a BMI of 22.34 which is normal for her age.

VII. FAMILY HISTORY

Vital Signs BP- 110/60mmHg RR- 19 cpm; regular rhythm Skin PR- 72 bpm; irregular rate and rhythm Temp- 36.8C

The color of the skin is brown and is moist. The patient has good skin turgor. No wounds or lesions are noted.
Eyes

Eyes have symmetrical lids and normal periorbital area. Pink palpebral conjunctiva is noted, and sclera is observed to be anicteric. Dark circles under the eyes were noted

VII. FAMILY HISTORY

Chest and Lungs The patient has regular breathing at the rate of 19 cpm. Symmetrical chest expansion was noted. Heart and Breast

The patient has symmetrical, rounded shape breast with smooth surface. She has a capillary refill time of 2 seconds. Her pericardial area is flat and heart sound is irrregular in rate and rhythm with a rate of 72 bpm.

VII. FAMILY HISTORY

Abdomen The patient experiences epigastric pain and it was also her chief complaint. Pain scale of 3/ 10 was given by the patient. There is sometimes pressure in her abdomen forcing her to limit her movements. Guarding behavior was also noted in the patient. Back and Extremities Patient M can ambulate by herself, but assistance is still encouraged to avoid any injuries. She has negative bipedal edema. Weakness upon movement is noted. Movement is also limited.

VII. FAMILY HISTORY

Behavior Patient M was cooperative the whole time. She answers every question well and her words are understandable but moderate in pace, she yawns from time to time and looked drowsy.

IX. FUNCTIONAL ASSESSMENT

HEALTH PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION
Even though Patient M born in an urban place she still believes in Patient Ms beliefs and health practices superstition such as dwarfs, enkantos stays the same. She added that it is not and aswangs. Thus, she sometimes bad if we believe in both herbal and use herbal medicines for some health scientific medicine. matters.

Health ManagementHealth Perception

IX. FUNCTIONAL ASSESSMENT

HEALTH PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION Patient M eats 2-3 times a day. She prefers Due to her hospitalization Patient M realized to eat pork, chicken and fish but would how poor her eating habits were. She said sometimes eat vegetables. Patient M has a that she would start to tone down her coffee habit of skipping breakfast and eating a lot intake and starts to eat the right time, but at lunch and dinner. She also has a high she only consumes 25% of her food in the intake of coffee, 5 cups per day. She food tray given in the hospital. prefers drinking coffee than water.

Nutritional- Metabolic

IX. FUNCTIONAL ASSESSMENT

HEALTH PATTERN BEFORE HOSPITALIZATION Patient M regularly voids every morning after her cup of coffee. DURING HOSPITALIZATION Since hospitalization Patient M is not able to defecate.

Elimination

Activity-Exercise

During her hospitalization, she was not Patient M is a housewife and her able to exercise; she would only daily household chores served as her ambulate when she would go to the activities. She sometimes fetches her bathroom. She stays on bed at all daughters from their school. times.

IX. FUNCTIONAL ASSESSMENT

HEALTH PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION According to her, she has ample time to rest although sometimes experienced Patient M sleeps everyday in a range sleep disruption due to time of of 6-8 hours. A cup of coffee before procedure and treatments and stress her sleep is her daily routine. brought about by her condition. She yawns frequently and appears drowsy.

Sleep-Rest

IX. FUNCTIONAL ASSESSMENT

HEALTH PATTERN BEFORE HOSPITALIZATION She graduated college with a degree of Business Administration Major in Marketing. Often times, she is the one teaching her children their homework. DURING HOSPITALIZATION Patient M appeared coherent, alert and responsive during our interview. She reads the daily newspaper given in the hospital. But she took a break from teaching her daughters their homework.

Cognitive-Perceptual Pattern

IX. FUNCTIONAL ASSESSMENT

HEALTH PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION Patient M has a good relationship with regards to his family and relatives. She lives nearby her mother in law. Her mother is in Pangasinan During her hospital stay she would often to have 2-3 together with her brother and sisters. Ever since, visitors from time to time. She said that nothing she is known friendly in their neighborhood. She changes in her role and relationship with her friends would only stay at home and go out sometimes to and family. fetch her daughters from school. Other than that, her neighbor hence no problem about her attitude as verbalized by the patients husband.

Role-Relationship Pattern

IX. FUNCTIONAL ASSESSMENT

HEALTH PATTERN Self-perception Self-concept BEFORE HOSPITALIZATION DURING HOSPITALIZATION
Patient M has a good perception in herself. She is Patient M is a little worried about her condition. She proud to be a mother of her two kids. And said hope to feel better to be able to be back to her that every problem makes her stronger as a normal routine. person. Because of her hospitalization, she copes with her According to her, whenever a stressful event condition by following her physician and listening to comes in her way, she manages it than ignoring it; the health instructions given by the nurse for her she said that things like that are inevitable thus faster recovery. She thinks that at the end of the day she faces it positively. she will be good and recover.

Coping- Stress

IX. FUNCTIONAL ASSESSMENT

HEALTH PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION

Value- Belief Pattern

Patient M is a Roman Catholic; she Patient M said that she prays whenever goes to Church with her family. She a procedure would be done to her. She stated that she believes in the power finds strength and courage when she of a superior being. prays and talks to the Lord.

X. REVIEW OF ANATOMY AND PHYSIOLOGY

X. REVIEW OF ANATOMY AND PHYSIOLOGY

Vagina: A muscular passageway that leads from the vulva (external genitalia) to the cervix. Cervix: A small hole at the end of the vagina through which sperm passes into the uterus. Also serves as a protective barrier for the uterus. During childbirth, the cervix dilates (widens) to permit the baby to descend from the uterus into the vagina for birth.

X. REVIEW OF ANATOMY AND PHYSIOLOGY

Uterus: A hollow organ that houses the baby during pregnancy. During childbirth, the uterine muscles contract to push out the baby. Each month, unless a fetus has been conceived, the uterine wall sheds its lining (see The Menstrual Cycle and Ovulation below). Ovaries: Two organs that produce hormones and store eggs. Each ovary releases one egg per month. Fallopian tubes: Muscular tubes that eggs released from the ovaries must traverse to reach the uterus.

X. REVIEW OF ANATOMY AND PHYSIOLOGY

The Menstrual Cycle and Ovulation Each month a womans body goes through a menstrual cycle. A woman can become pregnant only during ovulation, a severalday phase in the middle of the menstrual cycle when one of the ovaries releases an egg.

X. REVIEW OF ANATOMY AND PHYSIOLOGY

The Menstrual Cycle and Ovulation If the ovulated egg is fertilized by a mans sperm following sexual intercourse, it will implant in the endometrium, the lining of the uterus that becomes the placenta during pregnancy. The placenta nurtures the fertilized egg as it develops and grows into a baby.

XI. PATHOPHYSIOLOGY

XI. PATHOPHYSIOLOGY

XI. PATHOPHYSIOLOGY

XII. LABORATORY RESULTS

XII. LABORATORY RESULTS

Patient Name: Patient M
Analyte MCHC Analyte

Order Date: January 16, 2013

Result 30.80 Result Unit g/dL Unit Schillings Diffrential

Room No. 329

HEMATOLOGY
Normal Range 31.00-37.00 Normal Range Remarks Low Remarks

Date of Birth: April 3, 1979 Age: 33 Sex: Female

Eosinophils

0.240

0.000-0.060

High

XII. LABORATORY RESULTS

Patient Name: Patient M Order Date: January 16, 2013 Room No. 329
HEMATOLOGY Date of Birth: April 3, 1979 Age: 33 Sex: Female Interpretation: Low MCHC - May indicate anemia.

High eosinophils - May indicate immunologic response or increase acidity of blood.

XII. LABORATORY RESULTS

Patient Name: Patient M
Analyte Color: Transparency: Reaction: Specific Gravity:

Order Date: January 16, 2013

Result

Room No. 329

URINALYSIS
Remarks Normal May indicate presence of bacterial infection. Urine is acidic. Low

Date of Birth: April 3, 1979 Age: 33 Sex: Female

Macroscopic
Light Yellow Slightly Turbid 6.5 1.005

XII. LABORATORY RESULTS

Patient Name: Patient M
Analyte Albumin Sugar Analyte Microscopic CAST Hyaline Analyte

Order Date: January 16, 2013

Result Chemical Result Result

Room No. 329

URINALYSIS
Remarks Negative Negative

Date of Birth: April 3, 1979 Age: 33 Sex: Female

Negative

XII. LABORATORY RESULTS

Patient Name: Patient M
Analyte

Order Date: January 16, 2013

Result Microscopic CELL

Room No. 329

URINALYSIS
Remarks

Date of Birth: April 3, 1979 Age: 33 Sex: Female

PUS Cells

2-3

Pus in the urine may indicate urinary tract infection. Normal RBC in the urine is < 5, this can only indicate that the RBC level is increased.

Red Blood Cells

0-1

XII. LABORATORY RESULTS

Patient Name: Patient M
Analyte
Amorphous Urates

Order Date: January 16, 2013

Result Microscopic CRYSTAL
Moderate Microscopic EPITHELIUM

Room No. 329

URINALYSIS
Remarks
Presence of amorphous in the urine indicates yeast infection.

Date of Birth: April 3, 1979 Age: 33 Sex: Female

Squamous

Many

Presence of epithelial cells in the urine indicates the exposure of the specimen with skin flora.

XII. LABORATORY RESULTS

X- RAY (AP/ PA/L/O) Interpretation: Minimal free fluid, pelvic adrexae left posterior cul de sac cystic mass probably left ovarian origin. Normal sized anteverted uterus. Normal right ovary sonogram. Interpretation: Left ovarian new growth

XII. LABORATORY RESULTS

Patient Name: Patient M Order Date: January 17, 2013 Room No. 329
COLONOSCOPY Date of Birth: April 3, 1979 Age: 33 Sex: Female Impression: Gastric erosion, antrum

XIII. JUSTIFICATION OF NURSING PROBLEMS

Nursing Diagnosis Prioritization Rationale

Acute epigastric pain related to abdominal condition (ulcer like dyspepsia) as manifested by positive facial grimace, guarding behaviour, weakness and limited movement and a verbal report of moderate pain, 3/10.

Addressing the acute epigastric pain felt by the patient is the highest priority. In order to intervene well with the patient, it is essential to relieve the patient out of discomfort.

XIII. JUSTIFICATION OF NURSING PROBLEMS

Nursing Diagnosis Prioritization Rationale
Next is the sleep deprivation, which is the second complaint of Patient M. During student nurse patient interaction it is evidently to see the lack of sleep of the patient. The verbalization of Patent M of her increase desire to sleep was taken into consideration that if the patient was able to rest, the better the efficacy of the interventions.

Sleep deprivation related to abdominal pain secondary to underlying condition (ulcer like dyspepsia) as manifested by positive drowsiness, weakness, dark circles under the eyes and a verbal report of desire to sleep.

XIII. JUSTIFICATION OF NURSING PROBLEMS

Nursing Diagnosis Prioritization Rationale
This nursing problem takes the third priority because of the questions raised by the patient about the result of her colonoscopy report. It is imperative for the patient to focus on being well when she all she thinks about is what gastric erosion means as being reflected by the result of the colonoscopy report. Answering the inquiry of the patient also places the interaction on both parties to build a stronger rapport.

Deficient knowledge related to unfamiliarity with information resource as manifested by positive weakness, poor eating habits, patient asking questions and colonoscopy report revealed presence of gastric erosion at antrum.

XIII. JUSTIFICATION OF NURSING PROBLEMS

Nursing Diagnosis Prioritization Rationale Even Patient M, asks questions it was observed that in the beginning of the regimen she was very eager and cooperative with the health providers. This nursing problem took the fourth priority because the readiness of the patient for any therapeutic regimen was evident since from the start and it became a must for the health providers to maintain that readiness exhibited by Patient M.

Readiness for enhanced therapeutic regimen management related to underlying condition (ulcer likedyspepsia) as manifested by cooperativeness and willingness to all therapeutic interventions and procedures.

XIII. JUSTIFICATION OF NURSING PROBLEMS

Nursing Diagnosis Prioritization Rationale
This nursing problem took the last priority because this problem only exists when Patient M experiences discomfort. The discomfort brought by the pain was the reason and when the pain is relieved and the patient rested through therapeutic interventions the patient is very much able to eat and get her adequate nutritional needs.

Risk for imbalanced nutrition: less than body requirements related to self impose decrease intake probably secondary to abdominal discomfort.

XIV. NURSING CARE PLAN #1

Subjective: Sumasakit pa din yung sa may tiyan ko as verbalized by the patient.
Objective: Facial grimace Guarding behaviour
ASSESSMENT

Acute epigastric pain After 2 hour of Independent: Independent: After 2 hours of related to abdominal nursing interventions, 1. Assessed patients 1. To assess the nursing interventions, condition (ulcer like the patient will be condition. degree of severity. the goal was met, the dyspepsia) as able to report that the patient was relieved manifested by positive pain is relieved as that 2. Reviewed patients 2. For background from her pain as facial grimace, can be evidenced by a chart. information of the evidenced by the guarding behaviour, pain scale of 0-2 out patient. following: weakness and of ten.

NURSING DIAGNOSIS

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

XIV. NURSING CARE PLAN #1

Weakness and limited limited movement and After 2 hour of 3. Establish rapport movement a verbal report of nursing interventions, with the patient. Pain scale 3/10 moderate pain, 3/10. the patient will be Vital signs: able to report that the Temperature - 36.8C pain is relieved as that Pulse Rate - 72bpm can be evidenced by a Respiratory Rate - 19 pain scale of 0-2 out 4. Noted cpm of ten. characteristics of pain Blood Pressure from the patient. 110/60 mmHg
ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION

3. Rapport building Kirot- kirot na lang reduces anxiety of kaag nagalaw ako, 1 patient during nurse- out of 10 na lang as patient interaction. verbalized by the patient. 4. To know the progression of the pain that affects patient condition.

RATIONALE

EVALUATION

XIV. NURSING CARE PLAN #1

ASSESSMENT NURSING DIAGNOSIS PLANNING

5. Provided quiet and 5. To promote comfortable relaxation and reduce environment. tension. 6. Encouraged 6. To divert the diversional activities attention of patient (watch TV, read from the pain. newspaper, and listen to relaxing music).

IMPLEMENTATION

RATIONALE

EVALUATION

XIV. NURSING CARE PLAN #1

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION 7. Encouraged adequate rest periods. 8. Instructed patient to perform warm compress as indicated. RATIONALE 7. To prevent fatigue. EVALUATION

8. To promote vasodilatation that promotes circulation thus 9. Monitored vital signs reduces pain. and documented. 9. To monitor condition of patient through her vitals.

XIV. NURSING CARE PLAN #1

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE 10. Checked IVF D5 NB 10. To promote adequate 1L x 8 hours and hydration. regulated at desired rate 41- 42 gtts/min. Dependent: Dependent: 1. Omeprazole reduces 1. Administered gastric pain. Omeprazole 40 mg IV as ordered. Collaborative: Collaborative: 1. To reduce gastric 1. Reminded patient to workload. follow soft diet as prescribed by dietician. EVALUATION

XIV. NURSING CARE PLAN #2

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Sleep deprivation Hindi pa ako related to nakakatulog, gusto abdominal pain ko matulog as secondary to verbalized by the underlying patient. condition

After 8 hours of Independent: nursing 1. Assessed interventions the patients condition. patient will be able to report improved 2. Reviewed patients chart. sleep that can be evidenced

Independent: After 8 hours of 1. To assess the nursing degree of severity. interventions the goal was met, the 2. For background patient was able to information of the report improved patient. sleep as

XIV. NURSING CARE PLAN #2

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Objective: (ulcer like dyspepsia) by a 2-3 hour sleep 3. Establish rapport 3. Rapport building evidenced by the Dark circles under the as manifested by within the shift. with the patient. reduces anxiety of following: eyes positive drowsiness, patient during nurse- Nakatulog ako Weakness weakness, dark circles patient interaction. kanina 9- 12 (3 Drowsy under the eyes and a 4. Instructed patient . hours), okay na Pain scale - 3/10 verbal report of desire to avoid caffeinated 4. Caffeine properties naman, nakapahinga Vital signs: to sleep. substances/ foods. inhibit sleep. kahit papaano as Temperature - 36.8C verbalized by the patient.

XIV. NURSING CARE PLAN #2

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Pulse Rate - 72bpm Respiratory Rate - 19 cpm Blood Pressure 110/60 mmHg

5. Promoted physical 5. To increase desire activities during day to sleep. time. 6. Provided calm environment.

6. For more conducive place for sleep.

XIV. NURSING CARE PLAN #2

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE 7. Adjusted lightings to 7. To relax the eyes of dim. patient and thus promote sleep. 8. Reduced noise in the room as much as possible (decrease volume of TV, requested visitors to keep their voice down). 8. To promote sleep. EVALUATION

XIV. NURSING CARE PLAN #2

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE 9. Instructed patient about 9. To orient patient about monitoring schedules times of disruption of her (Vital signs= Every four sleep. hours) 10. Kept patient safe. 10. Safety is the number one goal of the nurse. 11. To reduce discomfort. EVALUATION

11. Positioned patient comfortable.

XIV. NURSING CARE PLAN #2

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE 12. Instructed patient to 12. To continue the leave warm compress while reduction of pain this sleeping. inhibits the sleep of the patient. 13. Monitored patients vital signs every four 13. To monitor condition hours. of patient through her vitals. EVALUATION

XIV. NURSING CARE PLAN #2

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE 14. Checked IVF D5 NB 14. To promote adequate 1L x 8 hours and regulated hydration. at desired rate 41- 42 gtts/min. Collaborative: 1. Collaborated with maintenance personnel about quietly entering the room. Collaborative: 1. To avoid noise and disruption of patients sleep. EVALUATION

XIV. NURSING CARE PLAN #3

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Deficient Ano ba yung knowledge related gasgas daw sa to unfamiliarity sikmura ko? as with information verbalized by the resource as patient. manifested by

After 8 hours of Independent: Independent After 8 hours of nursing 1. Provided 1. Information can nursing interventions, the explanations decrease anxiety, interventions, the patient will be able of/reasons for test thereby reducing patient was able to to verbalize procedures and sympathetic understand her understanding of preparation needed. stimulation. condition as her condition. evidenced by:

XIV. NURSING CARE PLAN #3

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Objective: positive weakness, Asking questions poor eating habits, Weakness patient asking Poor eating habits questions and Colonscopy Report: colonoscopy report Gastric erosion at revealed presence of antrum gastric erosion at antrum.

2. Reviewed disease 2. Provides knowledge Sa pagkain ko pala process/prognosis. base from which ang pinaka patient can make importanteng bagay informed choices. ngayon sa sakit ko, magaagahan na ako at magbabawas ng kape,

XIV. NURSING CARE PLAN #3

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

3. Encouraged 3. Effective questions, communication expression of and support at this concern time can diminish anxiety and promote healing.

XIV. NURSING CARE PLAN #3

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

4. Instructed patient to 4. Prevents and limits avoid food/fluids high recurrence of gastric in fats (e.g., whole attacks. milk, ice cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans,

XIV. NURSING CARE PLAN #3

ASSESSMENT NURSING DIAGNOSIS . PLANNING IMPLEMENTATION onions, carbonated beverages), or gastric irritants (e.g., spicy foods, caffeine, citrus). RATIONALE EVALUATION .

5. Recommended resting in semi-Fowlers position after 5. Promotes flow of food meals. and general relaxation during initial digestive process.

XIV. NURSING CARE PLAN #3

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

6. Suggested patient 6. Promotes gas limit gum chewing, formation, which can sucking on straw/hard increase gastric candy, or smoking distension/discomfort.
7. Monitored patients 7. To monitor vital signs and condition of patient documented. through her vitals.

XIV. NURSING CARE PLAN #3

ASSESSMENT NURSING DIAGNOSIS

PLANNING

8. Checked IVF D5 NB 8. To promote 1L x 8 hours and adequate hydration. regulated at desired rate 41- 42 gtts/min.
Collaborative: Collaborative: 1. Reminded patient to 1. To reduce gastric follow soft diet as workload. prescribed by dietician.

IMPLEMENTATION

RATIONALE

EVALUATION

XIV. NURSING CARE PLAN #4

XIV. NURSING CARE PLAN

XVI. PROGRESS NOTES

EXERCISE: Perform passive ROM exercise like flexion, extension of the extremities. Brisk walking every morning. Avoid straining, do not lift heavy object HEALTH TEACHING: Encourage participation in recreation and regular exercise program Provide appropriate level of environmental stimulation (e.i; music, TV/ radio, personal possessions and visitors) Suggest use of sleep aid/ promote normal sleep/rest.

XVI. PROGRESS NOTES

OPD:
DIET: Attend follow up check up next Friday (January 25, 2013).

Eat a well balanced diet High fiber diet like vegetables and fruits. Folic Acid and Iron rich foods such as : leafy green vegetables, asparagus, legumes, oranges and orange juice, liver, and whole Avoid gastric stimulants such as: Bell pepper, spicy preservatives ans caffeine and caffeinated foods.

grains sauces,

XVII. PROGNOSIS
Best Case Scenario for Patient M

Patient M, after her discharge was very cautious about her condition. She followed the prescription of her physician about the foods to be eaten and to be avoided. She also took her medications on time and performed activities optimal for her ability. She does not skip her breakfast and only drinks 1-2 cups of coffee per day and increased her intake of water. Upon her follow up check up, the physician encouraged Patient M to continue this healthy food lifestyle and said that Patient M was already well.

XVII. PROGNOSIS
Worst Case Scenario for Patient M
Patient M, after her discharge was very careless about her condition. She skips her meals and eats whenever she wants to. She also drinks the same amount of coffee a day which more than 5 cups. Patient M also forgets to drinks her medications on time and was lying on bed most time of the day. Four days after her discharge she was not able to fetch her children for school and said that she was so sick to get up. She was brought to the hospital and was subjected for another colonoscopy and the gastric erosion found before got worse and bigger. Patient M was again admitted and was subjected surgery to correct the erosion in her digestive tract.