CAPITOL UNIVERSITY College of Nursing Cagayan de Oro City

A Case Study On Gastritis with 2nd degree anemia

In Partial Fulfillment Of the course RLE 7 Submitted to: Clinical Instructor Mrs. Maria Rica Adane,RN Submitted by: Cantil, Maria Renee

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

TABLE OF CONTENTS I. II. III. Introduction Clients Profile 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

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 of H. pylori in 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. pylori infection. 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.

II. CLIENTs PROFILES ` Patient X is a 72 years old female, Filipino, an Islam from Kalilangan, Bukidnon. She is born in Butongan, Wao, Lanao del Sur on May 10, 1937. Admitted for the first time in Cagayan de oro medical center due to shortness of breath and vomiting. The client was the informant during the interview, with a reliability of 95%. HISTORY OF PRESENT ILLNESS 5 days PTAonset of cough; productive of yellowish to greenish sputum associated with occasional and moderate fever. Initially sought consult at Bukidnon Provincial Hospital and was managed as CAP with anemia second degree-----received here for further management.. PRE-HOSPITALIZATION Health Perception-health management pattern: Patient X is an old adult that is dependent to her childrens care. Childrens perception is necessary for the well being of the patient. Activities of Daily Living: Patient eats according to her tolerable diet. She stays to there house most of the time doing household chores. Patient occassionaly drinks water, amounting to 3 glasses per day, urinates 4-5 times per day, defecates 1-2 times everyday. Nutritional metabolic pattern: (While confined) While patient was confined, she was recommended and followed-up with a soft diet and was restricted to eat acidic foods that could trigger her gastric irritation. Increased fluid intake was also recommended. Elimination pattern: (while confined) Patient defecate once or thrice a day with soft brownish stools. Activity exercise pattern: (while confined) Patient is able to walk, with minimal restriction because of her non-healing wound at her left leg. Patient is dependent to her children with all needs during the confinement. Sleep-rest pattern: (while confined) Patient sleeps about 6- 8 hours per day, with afternoon naps. And easily awakens when significant others becomes noisy.

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 FINDINGS BEFORE (SEPT 23, 09) warm 36.4 C Fair skin turgor Moist skin (-) Lesions/Rash Intact

ASSESSMENT DATA SKIN Color Temperature Turgor Texture Lesion Integrity Others NAILS Color Texture Shape Others HAIR Color Texture Distribution Quantity Others HEAD Shape Size Configuration Headache

Dusky Smooth Concave Poor capillary refill = 3 sec black Coarsely dry Evenly distributed moderate

Round Normocephalic Symmetrical None

ASSESSMENT DATA

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 MOUTH & THROAT Condition of teeth Bleeding gums Tongue Throat Hoarseness Mucous membrane None None None Sinuses are non tender Incomplete teeth No bleeding Tongue is at midline, Throat Non-tender None Pinkish

ASSESSMENT DATA NECK Symmetry Condition of trachea Thyroid Lymph nodes

ASSESSMENT FINDING Symmetrical in the midline (+) non-palpable

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 HEART AND NECK VESSELS: Apical Pulse Cardiac Sounds Apical/Radial pulse data Blood pressure Pulse pressure Any special procedure Done ASSESSMENT DATA ABDOMEN: Symmetry Contour Skin Lesion Masses Bowel Sounds Tenderness Others ASSESSMENT FINDING Symmetrical( flat and feat) protuberant none (-) Masses Normoactive bowel sounds none 74 bpm (+) murmurs,harsh, occasional rales 110/80 mmHg 65 bpm ( full pulses) none (-) rales on upper lung lields Decrease breath sounds on left lung field

MUSCULOSKELETAL SYSTEM: Posture abnormal postures arent present ROM Muscle Strength active-passive 4/5

HEAD AND NECK: Facial muscle symmetry Swelling Scars Discoloration Weakness ROM Posterior neck cervical spine Muscle spasm Crepitus MOTOR SYSTEM: Muscle tone Ability to move extremities against gravity Spasticity, flaccidity or rigidity, tremors, lies none Without hypertrophy or atrophy Muscle strength is 4/5 Symmetrical None None None (+) Weakness
can turn head from side to side

Non-tender (-) Spasm (-) Crepitus heard

MENTAL STATUS: LOC Long term memory Short Term Memory conscious organized organized

III. Anatomy & Physiology Human Digestive System Diagram:

A. Digestion of food begins in the mouth

with 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 a long tube called the esophagus into the stomach. Food is moved down the esophagus by wavelike muscular contractions. C. The stomach is a highly flexible muscular 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 up to 7 meters long, which is so ingeniously made, that it presents an enormous surface area from which it extracts nutrients from the mixture. Nutrients move across the small intestine Human Digestive System Diagram wall into the bloodstream, where they are The Human Digestive System Picture transported to the cells of the body, to be used for energy and building and repairing the body. above, E. The large intestine is about 1.5 meters shows the relative positioning of various long, containing undigested material organs in the abdomen. Notice how the including fibre, bacteria and other wastes small that have been passed from the small intestine snakes back and forth, and how intestine. the large intestine also curves to accommodate It's here, that water is extracted (recycled) and the waste material is finally processed it's length in the small space of the abdomen. before elimination. A truly remarkable machine - The Human Digestive System.

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.

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 the lungs. 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 the abdomen.

V. LABORATORY AND DIAGNOSTIC RESULT X-Ray Report Name: Guro, Dayangkira Age: 72 YO Address: Kalilangan, Bukidnon Examination: Chest PA Record number: 10-173 Date: 1/6/10 Physician: Dr. Refre

Findings: Lungs clear. Diaphragmatic leaves depressed. Calcareous deposits thoracic spine. Heart not enlarged. Lipping in thoracic spine. Trachea soft tissue remarkable. Calcific densifies in right apex. Impression: Pulmonary Hyperaction Atherosclerosis, thoracic aorta Spondylosis, thoracic spine REesidual Kochs calcifications in right apex.

Peripheral Smear Report Name: Guro, Dayangkira Age/Sex: 72YO/ F Attending Physician: Dr. Refre Findings: The erythrocytes are exhibiting mild anisocytosis, with few microlytic cells/ hypochronic cells, and occasional target cells seen. The leukocytes are normal in morphology, however, they appears to be scarcity of lymphocytes. The platelets are adequate and normal in granularity. Comments/ Suggestions/ Recommendations: MICROLYTIC HYPOCHROMIC ANEMIA, MILD LYMHOCYTOPENIA PLATELETS ADEQUATE. Accession No: PS 10-06 Room No: 342 Date signed: 1/8/10

Name: Guro, Dayangkira Requested by: Dr. Refre Tests Blood urea nitrogen ALAT(SGPT) SI Unit Results: 41.04 26.2

Age/Sex: 72YO/F Date: 1/7/10 Normal Range: 15.0-45.o mg/dl F: up to 32.0 u/L M: up to 41u/L

STOOL EXAMINATION Name: Guro, Dayangkira Service: Consistency: Formed Ascaris: none Amoeba: sees Other parasites: * Occult Blood: Positive Age/Sex: 72YO/F Date: 1/7/10 Color: brownish Pus cells: none Hookworm: none Trichuris: sees

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 cms Atherosclerotic, Thoracic spine Spondylosis, thoracic spine Residua Kocks calsification,right apex

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 of emergency.

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.

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.

. 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:

Davis Drug 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