I.

GENERAL PROFILE/INFORMATION

a. Name: Mr. VP

b. Age: 67

c. Sex: Male

d. Marital Status: Married

e. Occupation: Farmer

f. Address: 23 Road Side Alno, La Trinidad Benguet

g. Religion: Roman Catholic

h. Date of Admission: April 9, 2010

i. Admitting physician: Dave Diomampo, M.D.

j. Admitting Diagnosis: Gastric Outlet Obstruction se4condary to Gastric mass t/c

malignancy

k. Principal Diagnosis: Gastric Adenocarcinoma

II. CHIEF COMPLAINTS

- The patient was admitted at the said hospital due to epigastric pain, nausea and vomiting
and diarrhea since the last week of December. Pain described as dull and intermittently
occurring.

III. HISTORY OF PRESENT ILLNESS

- Three months prior to admission, the patient experienced epigastric pain which he rated
as 3/10 (where 1 as the lowest and 10 as the highest) that occurs intermittently. And on
January the pain became more painful and he also experienced nausea and vomiting and
diarrhea. He then went to the Rural Health Center for check-up and was given
medications which he cannot remember. His condition improved about a week but the
same symptoms occurred again.

The same symptoms continued until hours prior to admission which then he cannot
tolerate and rated the pain as 10/10 (where 1 as the lowest and 10 as the highest). Then he
decided to be admitted at BGHMC.

IV. PAST MEDICAL HISTORY

- No other hospital admissions.

V. SOCIAL AND ENVIRONMENTAL HISTORY

-The patient works as a farmer. His ethnic background is Ibaloi thus, he often join in any
occasions wherein ‘watwat’ is given after the occasion. Sometimes, his neighbors would
even save some for him.

1
 He is a smoker and able to consume 20 sticks or almost a pack of the cigarette per day.
He had been smoking for 34 years. He is also an alcoholic beverage drinker. He drinks
once or twice a week.
The patient and his family do not have beliefs that could affect their reactions and
preferences with regards of interventions or status.

VI. FAMILY HISTORY

-His family has a history of hypertension and diabetes mellitus.
Before, his father was suspected of having tuberculosis because he vomited blood. He
died and did not have the chance to be treated at the hospital. However the patient did not
manifest any signs of tuberculosis. No history of cancer (CA) and coronary artery disease
(CAD).

VII. PHYSICAL EXAMINATION

A.GENERAL SURVEY

Mr. P., a 67 year old farmer, was admitted to the surgical unit of Baguio General
Hospital for treatment of gastric outlet obstruction related to gastric mass. April 13, he
underwent total gastrectomy. When received, he has an intravenous infusion of Amino
Acid Solution regulated at 40 gtts/min. The said IV solution was then followed by an IVF
of D5LRS 1 liter with the same regulation. When assessed, he has an incision at the
midline of the abdomen, with dressings dry and intact. He is conscious and coherent and
able to perform activities of daily living such as eating and attending bathroom needs
without assistance yet, moves slowly.
The patient was complaining of pain. When asked to rate his pain on a scale of 1-
10 (10 being the most severe and 1 as the least), he gave an answer of 6/10 described as
moderate stabbing pain on his incision site. The scale increases most whenever he is
remains supine at bed. He assumes position of greatest comfort to decrease pain
sensation, often at side-lying or sitting position.
Other assessment includes his weight of 37.0 kg and his height was 154 cm taken
on April 15.

B.HEENT

The patient’s head is proportionate to body size. Black- colored hair with some
noted grey colored ones are evenly distributed over scalp. Presence of flakes was noted
by parting the hair in several areas. No signs of other infestation such as lice, nits noted.
Absence of nodules or masses was noted upon palpation of the skull. No local
deformities from a trauma were noted.
No bulging masses or injuries in the head and face noted; with an equal hair
distribution and good grooming is practiced. No evidence of parasites on the scalp.
Eyes are symmetrical in level with each other. Pupils are equally round and reactive to
light accommodation. There were no noted signs of periorbital edema or sunken eyeballs.
The ear has a proportionate color with the head and face. There are no visible lumps or
lesions seen. It is firm and not tender upon palpation. No ear discharges noted. By having
a conversation, the patient requests to repeat the statements, leans forward or turns the
head toward the speaker for a clearer hearing. Thus, he has a diminished hearing acuity in
both ears due to aging process.
The nose is symmetrical, no deformities and lesions noted. No nasal discharge or
flaring noted. Air moves freely as the client breathes through the nares.
The neck is symmetrical; no distension and bulging noted. Color is proportionate to head
and face. Lymph nodes are not palpable. No reported throat problems.

2
C. RESPIRATORY SYSTEM

The patient has a respiratory rate ranging from 16- 22 bpm. Respiration described
as neither too shallow nor too deep. Symmetrical chest wall expansion noted. No
presence of any abnormal breath sounds was noted upon auscultattion. (-) crackles, (-)
wheezing, (-) ronchi. Respiratory excursion noted as 4cm which is in the range of the
normal 3-5cm thoracic expansion.

D. CARDIOVASCULAR SYSTEM

The patient's pulse rate ranges from 60- 75 bpm. His radial pulse was used.
Rhythm is normal and regular, no bounding or irregularities noted. His blood pressure is
120/80 mmHg. No verbalized dizziness noted. His heart sounds heard through a
stethoscope are loud and distinct.

E. GASTROINTESTINAL SYSTEM

He underwent a surgical procedure known as total gastrectomy. Diet includes

candies and sips of water during the first 2 days of our shift.
During the first 2 days of assessment, the patient has a clear bowel sounds due to
decreased intestinal motility or peristaltic activity upon auscultation. Third day of
assessment, bowel movement occurred with the stool described as watery and reddish in
color. The patient verbalized no pain felt when passing-out the stool. Since bowel
movement occurred, clear to general liquid diet was then ordered.
The abdomen was flat and non- distended.

F. GENITO-URINARY SYSTEM

The patient verbalized no difficulty in urinating. He voids 2-3 times in a day in

the comfort room within the patient's room. Amount ranges from 150-250cc during an 8
hour shift. Urine is described as yellow-colored. No other urinary problems were noted.

G. MUSCULO- SKELETAL SYSTEM

The patient experiences no contractures and tremors. He is able to ambulate

slowly and without assistance to a verbalized distance of approximately 6 meters from
bed to the comfort room. He also verbalized that a mild pain he experience to his joints
contributes to a decreased speed. In further assessing the patient, there was a noted
decrease in the arm and leg circumference due to decreased muscle mass. He is able to
perform range of motion exercises when encouraged to do so.

H. INTEGUMENTARY SYSTEM

The patient is brownish in complexion and is proportionate to his entire body. His
temperature ranges from 36.7-37.4 degree Celsius. No signs of edema and dehydration
noted. He is able to differentiate cold and warm stimuli. Hair is evenly distributed over
scalp. No presence of infection such as lice, with no scalp lesions. Pink nail beds with an
angle of 160 degrees, no clubbing noted. His capillary refill is 1 second. Scars of
microabrasions were noted on the lower extremities.
He has a 7 inches incision at the midline of the abdomen that is covered with a
dry and intact surgical dressing after the surgical procedure.Dressings dry and intact,
no unusual discharges noted.

3
VIII. DIAGNOSTICS
Date and time the Diagnostic procedure Description of the
diagnostic procedure diagnostic procedure
conducted
April 14 2010 Upper GI endoscopy An upper
gastrointestinal (UGI)
endoscopy is a procedure
that allows your doctor
to look at the interior
lining of your esophagus,
your stomach, and the
first part of your small
intestine (duodenum)
through a thin, flexible
viewing instrument
called an endoscope. The
tip of the endoscope is
inserted through your
mouth and then gently
moved down your throat
into the esophagus,
stomach, and duodenum.
4
Significance/purpose of Implications of the Highlight the significant
the procedure findings findings
Main purpose of an Esophagus: Multiple
endoscopy is to allow the esophageal ulcers,
physician to observe proximal to distal
what is happening within Endoscopic Diagnosis
the body. The procedure Stomach; Dilated and - Esophagitis, severe
can help the physician to filled with the food, with complete gastris outlet
identify signs that an a nodular mass at the obstruction secondary to
organ is not functioning posterior wall of te mid- gastric mass, to consider
as it should, is enlarged, body extending to the malignancy
or in some other manner antrum causing complete
is not as it should be. At obstruction of th antrum
the same time, an
endoscopy can be used to Duodenum: not assessed
evaluate any type of
abnormal growths
present in or around an
organ, such as a tumor,
ulcers, inflammation,
infection, or bleeding.
COMPLETE BLOOD COUNT

Examination Result Normal range Significance

Hemoglobin 109L 140-180g/L LOW
Hematocrit .38L .40-.54g/L LOW
WBC count 6.0 5.0-10. Normal
Differential count
Neutrophils .40 .50-.70 LOW
Lymphocytes .31 .20-.40 Normal
Midcells .09 .03-.09 Normal
Eosinophils .03 .02-.07 Normal
Monocytes 0.6 0.0 - 13.0 Normal
Red cell count 2.85x1012/L 3.0 -5.0x1012/L LOW
Platelet count 245,000 mm3 140,000 - 390,000 mm3 Normal

IX. MEDICAL DIAGNOSIS

- Status Post- Total Gastrectomy

5
X. COMPREHENSIVE PATHOPHYSIOLOGY AND MANAGEMENT

LEGENDS: RISK FACTORS

•Lifestyle(smoking, alcohol intake)
-NURSING PROBLEM • Diet(Salty & Smoked Foods, Nitrates)
• Occupation(Coal Mining, Agriculture)
-NURSING INTERVENTIONS • Male Gender
• Age(Uncommon in those younger than age 40)

Exposure to Carcinogen

Mutation of the tumor Suppressor Genes(p53) of Gastric Cells

Uncontrolled Cell Division of Abnormal Cells

Formation of Gastric Mass

(MALIGNANT)

GASTRIC
ADENOCARCINOMA

Epigastric Pain Nausea & Vomiting Anorexia Weight Loss Early Statiety

TOTAL GASTRECTOMY

6
 Instillation of Anesthesia
Open Surgical Procedure before start of operation

Midline Incision of the Abdomen

Release of Chemical mediators

(especially prostaglandins)
Site of Bacterial Invasion

Enhanced pain-provoking effect of bradykinin Decreased gastric motility

Post Op or peristaltic activity
Medications
Increased sensitivity of pain receptors

Adverse CNS reaction Decreased or inadequate

intake of nutrients
(Candies & sips of water)
to prevent risk for
Drowsines, dizziness, etc.
aspiration

IMPAIRED TISSUE RISK FOR INJURY PAIN

INTEGRITY RISK FOR IMBALANCED
INFECTION NUTRITION

Weakness
7

IMPAIRED TISSUE
INTEGRITY
> Assess skin/tissues,
bony prominences,
pressure areas and
wounds.
> Assess blood supply
and sensation (nerve
damage) of affected area
and evaluate pulses.
> Note poor hygiene/
health practices (e.g. lack
of cleanliness, poor
dental care, etc.).
> Inspected wound daily
or as appropriate for
changes (e.g. signs of
infection/complications
or healing).
> Provided appropriate
protective and healing
devices (e.g. heel
protectors, adding/
cushions, splints, etc.).
> Maintained affected
limbs in functional
alignment using pillows.
RISK FOR IMBALANCED
RISK FOR INJURY PAIN INFECTION NUTRITION
> Observe patients > Assessed PQRST scale
> v/s taken and recorded, >Monitor vital signs and
general health status of pain.
especially the record
> Assess for the presence > Assessed vital signs.
temperature > Assess patient’s weight
of adverse effects of the > Observe for nonverbal
> monitor incision site > Monitor/ explore
drugs cues indicating the level
> assess nutritional status attitude towards
> assess for factors that of pain
> assess clinical eating/food
may increase the risk for > Promoted deep
manifestations of > Monitor laboratory
injury breathing exercises
infection values
> monitor and record v/s >Administered
> examine incision site > Monitor Input and
>assist in treatment that analgesics as prescribed
and suture line, noting Output
may result to risk for >Created a quiet, non-
changes in appearance > Attend needs by
injury disruptive environment
and foul odor placing items where the
> assist in performing with dim lights and
> handle patient gently patient can reach (e.g
exercise or simple comfortable temperature
and keep linens dry and tissue)
activity when possible.
wrinkle-free > Ensure safety by
> ensure safety by > Provided comfort
> wash hands before placing pillow on the
raising side rails measures like touch,
having contact with the sides
>provide any assistive repositioning.
incision site > Assist patient with
devices (such as cane)
> change dressing meals as needed
during ambulation
aseptically > Promote pleasant and
> provide meticulous relaxing environment,
care of incision including socialization
> administer medications when possible.
as indicated.
8
XI. TREATMENT/MANAGEMENT

A. DRUG STUDY

9
Trade and Classification of Mechanism of Side Effects Nursing
Generic Names Drugs Action Interventions
Omepron Antisecretory Gastric acid- CNS; headache, Assessment:
pump inhibitor: dizziness, 1. History
Omeprazole Suppresses asthenia, vertigo, :hypersensitivity
gastric acid insomnia, to omeprazole or
ORDER: secretion by apathy, anxiety, any of its
IV 40 mg, OD specific paresthesias, components;
inhibition of the dream pregnancy,
hydrogen- abnormalities lactation
potassium 2. Physical: skin
ATPase enzyme Dermatologic: lesions; reflexes;
system at the rash, urinary output;
secretory surface inflammation, abdominal
of the gastric urticaria, examination;
parietal cells; pruritus, respiratory
blocks the final alopecia, dry auscultation
step of acid skin
production. Interventions:
GI: diarrhea, 1. Administer
abdominal pain, before meals.
nausea, 2. Administer
vomiting, antacids with, if
constipation, dry needed.
mouth, tongue 3. Have regular
atrophy medical follow-
up visits.
Respiratory: URI 4. Report severe
symptoms, headache,
cough, epistaxis worsening of
symptoms, fever,
chills.

Teaching points:
1. Take the drug
before meals.
Swallow the
capsules whole;
do not chew,
open, or crush
them. This drug
will need to be
taken for up to 8
wk (short-term
therapy) or for a
prolonged period
(> 5 yr in some
cases).
2. Have regular
medical follow-
up visits.
These side
effects may
occur: Dizziness
(avoid driving or
performing
hazardous tasks);
headache
(request
medications);
nausea, vomiting,
diarrhea
(maintain proper
10 nutrition);
symptoms of
upper respiratory
tract infection,
 B. IV FLUIDS
Component of the Classification of the
Effects or Uses Significance
Fluids Fluids
1. Provides
electrolytes and
D5LRS calories, and is a
Increases the
-sodium chloride, source of water for
interstitial space
potassium chloride, hydration.
Hypertonic osmolarity which then
calcium chloride, and 2. It is capable of
causes fluid to leak
sodium lactate in inducing diuresis
out of the cells.
distilled water. depending on the
clinical condition of
the patient.

C. SURGERIES
Date and time of Surgical Description of Surgical Results
procedure conducted. procedure
April 13, 2010 Total Gastrectomy Total removal of the stomach
-is the surgical removal of all and the removal of the gastric
part of the stomach. This mass found.
surgery is performed as a
treatment for stomach cancer
and may also be indicated for
a bleeding gastric ulcer, a
perforation(hole) in the
stomach wall

XII. NURSING DIAGNOSIS

1. Acute Pain r/t tissue trauma secondary to total gastrectomy

2. Imbalanced Nutrition: Less than body requirements r/t inadequate intake of nutrients

3. Impaired tissue integrity r/t surgical incision

4. Risk for Infection r/t site of bacterial invasion

6. Self-care deficit: Hygiene/bathing r/t weakness

7. Anxiety r/t surgical intervention/procedure

8. Activity intolerance r/t generalized weakness secondary to surgery

9. Risk for constipation related to effects of medications, surgery, dietary change, and
immobility

10. Risk for injury r/t drug-induced adverse CNS reactions such as dizziness and
drowsiness

Prioritization:

1. Acute Pain r/t tissue trauma secondary to total gastrectomy

2. Risk for injury r/t drug-induced adverse CNS reactions such as dizziness and
drowsiness

11
3. Risk for Infection r/t site of bacterial invasion

4. Imbalanced Nutrition: Less than body requirements r/t inadequate intake of nutrients

5. Impaired tissue integrity r/t surgical incision

12