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Upper gastro bleeding
Submitted by : Roldan Q. Vidad
ACKNOWLEDGEMENT
The proponents of this case study would like to extend their warmest gratitude to all the
people who made the success of this undertaking a reality.
First and foremost, to the Almighty Father, for His unceasing love and blessings; for
giving us enough power and fortitude to face all the hardships in the making of this work. To
Him be all glory and praise!
To our Clinical Instructors, Lasanas , for their invaluable time, knowledge and effort
rendered to us.
To the staff and personnel of Armed Forces of the Philippines Medical Center - V. Luna
General Hospital, especially in the ONCO ward for giving us the opportunity to complete this
endeavor. Thank you ma`am and sir.
INTRODUCTION
The first group of section 2D were given the opportunity to have a hospital exposure last
march 16 ,17 18 and 23 , 23, 25 2015 at AFP medical center – ONCO ward.
The patient, to be mentioned in this paper as EBD, was one of the patients admitted to the
onco ward. She was admitted due to diagnosed upper gastroinstestinal bleeding b.
Upper gastrointestinal bleeding (sometimes upper GI or UGI bleed or hemorrhage)
refers to bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from
the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in
altered form in the stool (melena). Depending on the severity of the blood loss, there may be
symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal
bleeding is considered a medical emergency and typically requires hospital care for urgent
diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers,gastric
erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well
as blood tests to determine hemoglobin concentration. In significant bleeding, fluid
replacement is often required, as well as blood transfusion, before the source of bleeding can be
determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy.
Depending on the source,endoscopic therapy can be applied to reduce rebleeding risk. Specific
medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such
as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to
need for surgery, although this has become uncommon as a result of improved endoscopic and
medical treatment.
Upper gastrointestinal bleeding affects around 50-150 people per 100,000 annually. Depending
on its severity, it carries an estimated mortality risk of 11%
I chose ESD as my subject primarily because her case posed as a very intricate case requiring
due understanding and knowledge. thus making this case a good avenue to broaden the
proponents’ knowledge about the disease and the surgical procedures involved.
OBJECTIVES
General Objective:
My main goal of is to be able to present the case study of our chosen client that would
provide a comprehensive discussion of the pathological mechanism of the disease to yield
significant information for the case study.
Specific Objectives:
In order to meet the general objective, the group aims to:
establish rapport to the patient and the patient’s significant others,
interpret the pertinent data gathered from the patient and her significant others,
state past and present health history of the patient,
define the complete diagnosis of the patient,
discuss the anatomy and physiology of the organ involved in the patient’s disease,
trace the pathophysiology of the patient’s disease,
obtain and rationalize the doctor’s order,
discuss the nature of the drugs given to the patient,
discuss the surgical procedure performed to the patient
present a specific, measurable, attainable, realistic and time-bounded nursing care plans
for the client,
justify the client’s prognosis according to the different criteria,
outline recommendations based on the case study’s findings.
PATIENT’S DATA
Personal Data:
Patients Name: “E,B`D”
Age: 72 years old
Gender: female
Birth date:
Birth Place
Civil Status
husban
Occupation :
October 18 1942
cavity
Married
N/A
N/A
City Address:
Family Income:
Socioeconomic class:
cavity
N/A
N/A
Nationality: Filipino
Religion [Denomination]: Roman catholic
Educational Attainment: N/A
Number of Siblings: 5
Ordinal Rank: N/A
Clinical/ Admitting Data:
Date of admission: January 26 2015
Time of admission: 9:30 am
Hospital & Hospital Number: N/A
Ward [Room & Bed Numbers]: ONCO ward (room A bed #5)
Attending Physician: N/A
Admitting Diagnosis: Upper gastroinstestinal bleeding related to peptic ulcer dse.
Pre-Op Diagnosis: Upper gastroinstestinal bleeding related to peptic ulcer dse.
Vital signs on admission:
Temperature:
Pulse Rate:
Respiratory Rate:
Blood pressure:
Source of Information:
37.3 Degrees Celsius
118 Beats per Minute
28 Cycles per Minute
130/80 mmHg
Patient, Patient’ daugther and Patient’s Chart
FAMILY BACKGROUND AND HEALTH HISTORY
HEALTH BACKGROUND
A. Family Background
`EBD` is a 72 years old male. He got 1 sibling. His father is not alive and his
mother is still living and is hypertensive. Among her 7 siblings, one is also hypertensive.
Out patient is married for 10 years. He is police officer. Her wife is a teacher. .
They have a 6 years old son and is currently in Grade 1 at Batangas elementary School.
The family lives in their owned house at Km. 7, Batangas
The family’s source of income his salary in her work as being a police officer. He
has a daily salary of P 7000/ day or about P 21000/month. From this, the family can
afford eating three times a day. Their usual diet is composed of fish and vegetables since
their son likes to eat vegetables. They only cook meat once or twice a week. Sometimes,
they also go to mall to have family bonding and time for fun.
This is the first time in their family that an above knee amputation. However,
B. Past Health History
The patient was hypertensive for 5 years. Highest Blood pressure IS 15/80. W/A
blood pressure 130 /80.the patient is also diabetic.
B. Effects/ Expectations of Illness to Self/ Family
This condition of the patient has really affected the family. This loss saddened the
family, most notably the patient.It could have been a lot better if this didn’t happen. How-
ever, as the patient verbalized, he couldn’t do anything about it since it’s God’s will.
His daughter has been very y supportive and provided all the support the patient
needed. Emotionally, the family support has been overwhelming. They really gave their
effort to help the patient cope up with this situation. Moreover, they didn’t have problem
in relation to finances since other family members and relative contributed in paying the
bill.
DEFINITION OF COMPLETE DIAGNOSIS
UPPER gastro bleeding related to peptic ulcer dse. S/p anterior circulation infarction right at herothrombotic in origin HCVD FC 11
PHYSICAL ASSESSMENT
I. Personal Data
Name: EBD Sex: female
Age: 72 years old Diagnosis: upper gastro bleeding
II. General Survey
The patient was assessed lying on bed in supine position, awake, conscious and coherent
and in respiratory distress. he was oriented to person, place and time and talks coherently.
Thoughts were coherent and with logical sequencing. IVF was attached to her. she was on NPO
diet.he had a dressing in the hypogastric area covered with binder.he was properly groomed but
slight body odor was noted. The patient has an endomorphic body structure and looked
according to her age. he was cooperative and responsive during the entire assessment.
III. Vital Signs
The patient has a body temperature of 37°C e. Respiration was assessed to be 28 cycles in
one full minute; her breathing was deep and in normal pace. Her pulse rate was 100 beats per
minute with a regular rhythm. Her cardiac rate is 103 beats per minute. Her blood pressure was
120/80 mmHg taking while he was lying supine on bed.
IV. The Integument
A. Skin
The patient’s skin is dry with poor skin turgor. Skin color is brown , the legs and
soles of the feet. Skin is warm to touch, which is uniform on both extremities. A surgical wound
covered by a sterile dressing is noted on the hypogastric area of the patient’s abdomen. Both the
right and left hands have scratches as it served as IV insertion sites.
B. Hair
Hair is evenly distributed over scalp. It is oily and black in color. Dandruffs are
present. Fine hairs are evenly distributed on both extremities.
C. Nails
Nails were unclean and not well trimmed with whitish to light pink nail beds, with
normal angle curvature, and with a capillary refill of 3 seconds. Fingernails and toenails were
pale. Surrounding tissues were intact; no lesions nor lacerations were observed.
V. The Head
A. Skull and Face
The patient’s head is normocephalic and proportional to body size. Presences of nodules
or masses are not noted. Facial features and movements are symmetrical. The patient is able to
raise her eyebrows, close her eyes, frown, and smile. Her face manifests a feeling of slight
tiredness.
B. The Eyes
The hair in the patient’s eyebrows is evenly distributed; skin is intact and
symmetrically aligned with equal movement and there was no noted scaling and flakiness of
skin. The eyelashes are equally distributed and curled slightly outward. Her eyelids close
symmetrically; discharges and discolorations were not noted. Her pupil size in both eyes are
equal, with a diameter of 3mm when dilated and 2mm when constricted; with brisk reaction to
light accomodation. According to her, when looking straight ahead, she can see objects in
periphery. There was no edema or tenderness noted over her lacrimal glands.
C. Nose and Sinuses
The external nose is symmetrical, straight and uniform in color. Nasal
flaring was not noted. Color is the same with the entire face; there was no tenderness noted upon
palpation. Lesions and tenderness were both absent. Nasal mucosa was pinkish. Both left and
right nares were patent, with no discharges; air could freely move in and out when the patient
breathes. The nasal septum is intact and in the midline without deviations. The frontal and
maxillary sinuses were non-tender upon palpation. Sense of smell was good. Patient was able to
differentiate water from that of alcohol, through scent.
D. Ears
Auricles are smooth, symmetrical and no discoloration noted. Her external pinna is
normoset; deformities, lesions or inflammations were not present. Pinna recoils after it is being
folded; it is firm and non tender. The ears were physically symmetrical in size and normoset
since boh are located in line with the outer canthus of his eyes. Normal voice tones are audible.
She was able to repeat whispered words and was able to hear ticking sound from the watch in
both ears.
E. Mouth and Oropharynx
There were no lesions and masses noted on the lips and they appear moist and
pinkish. Oral mucosa was pinkish and the tongue was located at the midline, pink in color,
slightly dry and furry with whitish coating. She was able to move her tongue freely. The gums
was pinkish, with no signs of bleeding. The uvula is in the midline and the mucosa surrounding it
is slightly pink. His tonsils were free from inflammation. Dental carries were present
VI. Neck
The muscles in her neck were equal in size. His neck movement was coordinated and
difficulty in moving was not noted. He was able to flex, hyperextend, laterally flex and rotate his
neck without distress. He can also turn his head on one side against the resistance of our hand
with the similar strength and shrug his shoulders up against the resistance of our hand with equal
strength. The trachea is in the midline. No lymph nodes were palpable.
VII. Chest and Lungs
The patient has a regular and normal breathing pattern; quiet and rhythmic respirations,
with respiratory rate of 28 cyles in one full minute. No tenderness and masses upon palpation.
No adventitious breath sounds on both left and right lung fields were heard during auscultation.
Tactile fremitus on both lungs are symmetrical. Posterior chest was not assessed.
VIII. Heart
A. Heart and Central Vessels
Point of maximum impulse and beat is auscultated at the 5 th intercoastal space left
midclavicular line. The patient has a cardiacrate of 103 beats per minute. Presence of abnormal
heart sounds were not noted upon auscultation.
B. Peripheral pulses
Peripheral pulses have regular rhythm strong. Her pulse rate is 100 beats
per minute. The skin is warm upon palpation and capillary refill time is 3 seconds.
IX. Abdomen
The patient’s abdomen has same color with his chest. The umbilicus is medially located
and shows signs of inflammation. Abnormal Bowel sounds are present upon auscultation. .
X. Genito-Urinary
The patient reported that there were no lesion, tenderness and masses in her perineum and
anus.
XI. Musculoskeletal
A. Upper Extremities
The patient’s radial and brachial pulses were regular but strong. Good range of
motion was noted. Palm is able to stay in both prone and supine in a good manner without
difficulty. He was able to exhibit strong hand grip on both arms. Client was able to extend
both arms. Reflex on the upper extremity was good.
B. Lower Extremities
The patient left leg is amputated while his right leg is normal.
ANATOMY AND PHYSIOLOGY
Stomach The stomach is a muscular sac that is located on the left side of the
abdominal cavity, just inferior to the diaphragm . In an average person, the stomach is about the size of their two fists placed next to
each other. This major organ acts as a storage tank for food so that the body has time to digest large meals properly. The stomach also
contains hydrochloric acid and digestive enzymes that continue the digestion of food that began in the mouth.
Small IntestineThe small intestine is a long, thin tube about 1 inch in diameter and about 10 feet long that is part of the lower gastrointestinal track. It is located just inferior to the stomach and takes up most of the space in the abdominal cavity. The entire small intestine is coiled like a hose and the inside surface is full of many ridges and folds. These folds are used to maximize the digestion of food and absorption of nutrients. By the time food leaves the small intestine, around 90% of all nutrients
have been extracted from the food that entered it.
Liver and GallbladderThe liver is a roughly triangular accessory organ of the digestive
system located to the right of the stomach, just inferior to the diaphragm and superior to the small intestine. The liver weighs about 3
pounds and is the second largest organ in the body. The liver has many different functions in the body, but the main function of the liver
in digestion is the production of bile and its secretion into the small intestine. The gallbladder is a small, pear-shaped organ located just
posterior to the liver. The gallbladder is used to store and recycle excess bile from the small intestine so that it can be reused for the
digestion of subsequent meals.
PancreasThe pancreas is a large gland located just inferior and posterior to the stomach. It is about 6 inches long and shaped like short, lumpy snake with its “head” connected to the duodenum and its “tail” pointing to the left wall of the abdominal cavity. The pancreas secretes digestive
enzymes into the small intestine to complete the chemical digestion of foods.
Large IntestineThe large intestine is a long, thick tube about 2 ½ inches in diameter
and about 5 feet long. It is located just inferior to the stomach and wraps around the superior and lateral border of the small intestine. The
large intestine absorbs water and contains many symbiotic bacteria that aid in the breaking down of wastes to extract some small amounts of nutrients. Feces in the large intestine exit the body through the anal
canal.
PATHOPYSIOLOGY
Vehicular accident
Serious infection that does
not get better with antibiotics
or other treatment
Above the knee amputation
January 31 1600 HAltered bleeding
Pale skin , fatigue , low body temperatureDoctors order with on going luparin drip D5W 240 cc – 10000 with teparin 13 cc/hr , continue PT, APIT every 6 ours >continuity patient accordingly
DOB 1700 H RR : 28 Administer oxygen Place the patient semi fowler position>relief DOB
Febraury 1 2000 Hhyperthemia
Temp: 40.2As assessed pt. closely>paracetamol 300 mg given as ordered>tepid sponge bath
Impaired skin integrity 2300 H D> post op dressing in the left leg , with external tarter at leg , A > assessed skin integrity , maintained and absence of aseptic technique , on daily wound care: monitored fr signs and symptoms of infectionR> No sign and symptoms of infection
Course in the ward
Assessment Diagnosis Planning Intervention Evaluation Subjected :
nahihirapan akong huminga “as
verbalize by the patient
Objected: RR:3302 sat: 89%
DOB relate to allergic
reaction of the blood
transfusion secondary to
blood loss
After 30 minutes nursing intervention the patient will experience lessened of difficulty of breathing.
>stop the blood transfusion as doctors order>administer 0xygen 2-3 L/m as doctor order>elevate the bed 30 %>monitored the Respiratory patterns including rate , depth and effort .
After 30 minutes nursing
intervention the patient will experience lessened of difficulty of breathing.