ACUTE PEPTIC DISEASE

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Group D jonal-james abdulrobert balancaremma concepcion cabigasarjane corpuzjessica may gaitedayana jacalan kara monina mampao lorica fritz nisnisan may angelie petallar cyndill seveses janel tomenio PRESENTS

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A CASE PRESENTATION ON Peptic Acid Disease

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DEMOGRAPHIC DATA   Name: Mr. MCDONALD Address: Purok 5, Robocon Linamon LDN Age: 29 years old Sex: Male Status: Married Religion: Islam Occupation: Driver

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HEALTH HISTORY Chief Complaint/s: hematemesis and fever B. Impression/Admitting Diagnosis: T/C Mallory Weiss Syndrome, acute tonsillopharyngitis C. Final Diagnosis: Acid Peptic Disease

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C. History of Present Illness: (Location, onset, character, intensity, duration, aggravation and alleviation, associated symptoms, previous treatment and result, social and vocational responsibilities) 4 days PTA, patient experienced swelling at left submandibular portion of the neck with fever and intermittent pain when chewing and swallowing. Self treatment included taking amoxicillin for 6 days until admission but S/Sx did not resolved. Positive for mumps. 6 hours PTA, pt experienced persistent vomiting with blood for a series of vomiting until 6th vomiting, hematemesis. Exacerbation of illness prompted family to seek treatment.

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D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illness, allergies, medication, habits, birth and development history, nutrition – for pedia) According to SO, patient was last hospitalized when he was 7 years old, diagnosed with fever and diarrhea. Reported complete immunization. No known allergies. No history of congenital defects.

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HEALTH HABITS

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FAMILY GENOGRAM GREEN COLOR - HPN YELLOW COLOR - GOITER RED COLOR - PROBLEM - PATIENT

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Patient’s Perception of… Present Illness: “Ok ra man. Ang sakit ra man sa ako kay akong bag-ang”, as verbalized by the patient. Hospital Environment: “Ok ra pud ang hospital. Limpyo daun maau mo-atiman ang mga nurses”, as verbalized by the patient.  Summary of Interaction: Patient is not interactive. He is disinterested. He is not paying attention that much when being questioned by the student nurse.

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PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS Date: January 19, 2009 Vital Signs: Temperature: 38.9° C Height: 5’3’’ Pulse: 80 bpm Weight: 65 kgs. Respiration: 22 cpm Blood Pressure: 110/70 mmHg Observation: Pt. received lying on bed, awake & coherent with newly hooked IVF #2 PLR 1 L hooked @ left arm, infusing well, @ 30 gtts/min.

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GORDON’S ASSESSMENT Name of Patient: Mr. McDonald Age: 29 y/o Sex: M Chief Complaints: Hematemesis & Fever Inclusive Dates: January 19-20, 2009 Impression/Diagnosis: T/C Mallory-Weiss Syndrome, Acute Tonsillopharyngitis R/O PTB, Mumps Allergies: NOne Date of Admission: January 19, 2009 Diet: NPO temporarily, then soft diet Type of Operation (if any): none

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ANATOMY AND PHYSIOLOGY

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PATHOPHYSIOLOGY

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SUMMARY OF INTRAVENOUS FLUIDS

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SUMMARY OF medications

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DRUG STUDY

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DIAGNOSTIC PROCEDURES

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MEDICAL MANAGEMENT

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SURGICAL MANAGEMENT

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NURSING MANAGEMENT

Nursing Care Plans : 

Nursing Care Plans

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Identified problem:Patient and SO reported unusual pattern of sleep during hospitalization compared before. Nursing Diagnosis: Acute pain related to irritated intestinal mucosa.

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Identified Problem: Body temperature of 38.2°C Nursing Diagnosis: Hyperthermia r/t possible dehydration

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Identified Problem: Patient and SO reported unusual pattern of sleep during hospitalization compared before. Nursing Diagnosis: Disturbed Sleep Pattern r/t internal factors (illness such as mumps and fever)

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Identified Problem: Patient reported tardiness. Nursing Diagnosis: Fatigue r/t prolonged bedrest

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Identified Problem: Patient stated boredom. Nursing Diagnosis: Deficient Diversional Activity r/t imposed activity restrictions/bedrest

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Identified Problem: Knowledge deficit Nursing Diagnosis: Deficient Knowledge regarding to disease process r/t lack of information/information misinterpretation.

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CONCEPT MAP

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Name: Mr. Mcdonald Age: 29 y.o Diagnosis: Acid Peptic Disease 6. Deficient Knowledge regarding to disease process r/t lack of information/information misinterpretation. S: “Wala lagi mi kabalo unsa jud ni iyang sakit. karon ra man gud ni siya nagsuka’g dugo,” as verbalized by the SO. O:   Observed questioning about patient’s condition SO and patient unable to answer question regarding patient’s illness Inaccurate follow through of instruction (patient went to toilet room despite order of CBR-TP) V/S: T= 37.3°C P= 74 bpm R= 19 cpm BP= 110/90 mm Hg 2. Hyperthermia r/t possible dehydration S:“Adtong using adlaw, gasigi lang ni siya’g suka, mga ika-unom siguro. Unya kaganiha naa nay dugo,” as verbalized by the SO. O: V/S : T= 38.2°C P= 80 bpm R= 22 cpm BP= 110/ 70 mm Hg Warm/flushed skin Restlessness noted Expressionless face Keeps on lying on bed (-) diaphoresis 1. Acute pain related to irritated intestinal mucosa. S: “Sakit man ako kuto-kuto ug sige ko suka suka pud” as verbalized by S.O.  P: felt Q: dull, stabbing pain R: localized pain S: 6/10 T: intermittent O: Guarded behavior Sleep disturbed Destructive behavior Reduced interaction with people and environment V/S: T= 37.3°C P= 80 bpm R= 22 cpm BP= 110/70 mm Hg 4. Fatigue r/t prolonged bedrest S: “Gikapoy na ko,” as verbalized by the patient. “ Gikapoy na siguro na siya day. Sige ra man gud na siya’g higda ug tulog,” as verbalized by the SO. O: Restless Keeps lying on bed Expressionless face General body malaise Drowsiness Inattentive Silent most of the time Slightly irritable V/S: T= 37.3°C P= 74 bpm R= 19 cpm BP= 110/90 mm Hg 5. Deficient Diversional Activity r/t imposed activity restrictions/bedrest S: “Boring kayo diri, gusto nako muuli,” as stated by the patient. O: Inattentive, Restless Lack interest, Silent most of the time Stays on bed most of the time Always lie on bed Takes a nap frequently Expressionless face Have a flat affect 3. Disturbed Sleep Pattern r/t internal factors (illness such as mumps and fever) S:  “Alas dos na sa kadlawon ko nakatulog. Nakamata kay 5 or 6 am,” as verbalized by the patient. “Sa amo, 8 pa gani, matulog na na siya, dayon mumata 5 or 6 sa buntag. Karon dili na,” as verbalized by the SO. O: Restless ,Keeps lying on bed Expressionless face,Frequent yawning, General body malaise V/S: T=38.2°C P= 80 bpm R= 22 cpm BP= 110/70 mm Hg

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DISCHARGE PLAN Patient’s Name: Mr. MCDONALD Date of Discharge : January 20, 2009 Condition Upon Discharge: good Nature: (v) Home per request ( ) Discharged against medical advise

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GROUP D

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THANK YOU!!!