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Home , Indigestion

OUR LADY OF FATIMA UNIVERSITY College of Nursing

In Partial Fulfilment of Requirements for RLE 102

“ U p p e r Gastrointestinal bleeding”

A Individual Case Study

Presented To:

MA’AM AMY SANTOS MAN, RN

Submitted By: MAGAT, JESSIE BOY S.

GROUP of 2Y2-2c

September 24, 2012 I. INTRODUCTION

I as a nursing student of OLFU provide this case study as for the purpose of this case is to be familiar with upper GI bleeds as a direct result of stress related- mucosal disease,; How it is start, what are the causes and what are the ; especially how to prevent, treat and manage the patient by giving medication for treatment and providing rapport. .I chose this case study because this is the most interesting case I’ve encountered in the entire rotation and because some of the patients in Pedia ward 5west are having a dengue problem. I also fond to know about the important things to consider and word to discuss about this case. Upper gastrointestinal (GI) bleeding occurs when the inner lining (mucosa) of the , stomach, or proximal () is injured, exposing the underlying blood vessels, or when the blood vessels themselves rupture. Upper gastrointestinal bleeding (UGIB) is defined as hemorrhage that emanates proximal to the ligament of Treitz. It is a common and potentially life-threatening condition. More than 350,000 hospital admissions are attributable to UGIB, which has an overall mortality rate of 10%. Although more than 75% of cases of bleeding cease with supportive measures, a significant percentage of patients require further intervention, which often involves the combined efforts of gastroenterologists, surgeons, and interventional radiologists. Clinically, UGIB often causes (vomiting of blood) or (passage of stools rendered black and tarry by the presence of altered blood). The color of the vomitus depends on its contact time with the hydrochloric acid of the stomach. If vomiting occurs early after the onset of bleeding, it appears red; with delayed vomiting, it is dark red, brown, or black. -ground emesis results from precipitation of blood clots in the vomitus. (red blood per ) usually indicates bleeding distal to the ligament of Treitz. Occasionally, rapid bleeding from an upper GI source may result in hematochezia. Upper gastrointestinal bleeding (UGIB) is a significant and potentially life-threatening worldwide problem. Despite advances in diagnosis and treatment, mortality and morbidity have remained constant.1 Bleeding from the upper (GIT) is about 4 times as common as bleeding from the lower GIT. Typically patients present with bleeding from a peptic ulcer and about 80% of such ulcers stop bleeding. Increasing age and co-morbidity increase mortality. It is important to identify patients with a low probability of re-bleeding from patients with a high probability of re-bleeding. Upper GI bleeding can range in severity from clinically inapparent (insignificant) to large-volume, life-threatening bleeding. A variety of conditions can cause GI bleeding, and effective treatment depends on identification of the source of the bleeding and expeditious administration of therapy. Upper GI bleeding can be divided into two broad categories: variceal bleeding and non-variceal bleeding. Varices are dilated blood vessels found most frequently in the esophagus and stomach. Non- variceal upper gastrointestinal bleeding can be caused by a variety of conditions. Peptic ulcer is the most common cause. An ulcer bleeds when the blood vessels at the base of the ulcer are disrupted. Ulcers are most likely to occur in the stomach and duodenum and less frequently in the esophagus. Ulcers are caused most commonly by an with the bacterium or use of nonsteroidal anti- inflammatory drugs. Indeed, I choose this case because I want to learn why gastrointestinal bleeding occurs. To enhance my knowledge about GI bleeding. And as a health care provider I need to know more about the disease in order for me to establish rapport to my patient and how to deal with it.

II. PATIENT HEALTH HISTORY

A. Personal Data: Ms. Joselle Chua Ignacio is a 13-year-old female, Filipino. She is 2nd in the family siblings. She is a Roman Catholic. Ms. Joselle Chua Ignacio is currently residing in 3017 Taliptip, Bulacan-Bulacan. She is a currently studying as a high school student. Ms. Ignacio was admitted in the hospital on September 13, 2012 at exactly 11:05 pm. Her attending physician is Dr. Foronda, M.D. She stayed at 5th floor 5 west pedia wards.

B. Chief Complain: “Masaki tang aking tiyan, tapos parang may pumutok na ugat, tapos yung dumi ko may dugo ” as verbalized by the patient.

C. Principal Diagnosis: Upper Gastrointestinal Bleeding

D. History of Patient illness: Ms. Joselle Chua Ignacio never had undergone any procedure before. She felt prior to admission but can be slightly tolerated. She has been having on and off epigastric pain, associated with occasional melena, ¼ cup in amount. Ms. Ignacio has a difficulty in defecating. 1 day prior to admission, had only 1 episode of melena, 1 spoon in amount, prompting consult, hence admitted.

F. Past health History: The client stated that she has no previous hospitalization. She doesn’t have any allergies and past injuries, and have complete immunizations when she was a child. She doesn’t smoke and drink alcohol. She never undergoes any procedure. Upon assessment, the following data was obtained from patient X. BP= 130/90 mmHg; Temp. = 37.7C; Pulse rate= 55 bpm; Respiratory rate= 23 cpm.

G. Family History: The patient stated that her family has a history of Hypertension. She also stated that they don’t have history of , Tuberculosis and other hereditary disease.

H. Health- Perception/ Health Management Pattern The patient is almost generally the same as how every Filipino seeks health assistance. Without any problem regarding his health, She would not approach health workers not unless it is life threatening. He is pale to look at.

I. Nutritional/ Metabolic Pattern The patient eats three times a day. She said that he eats a fatty and salty diet and no limit when it comes to food. She said that “Hindi naman po ako mapili sa pagkain mahilig sa mga chips”. During his hospitalization, she is instructed with diet as prescribed by the physician. The patient consumed whole share of food with fair appetite. He usually drinks 5-6 glasses of water per day.

J. Elimination Pattern According to the patient, when she is at home, she had difficulty in defecating and when he push to do so, she has a black-tary color of stool. She said that every time she defecates, her stool has a blood. During her hospitalization he defecates three to four times a day. She urinates an average of 850 cc per shift (8 hours) with yellowish colored urine.

K. Sleep- Rest Pattern The patient sleeps for an average of 8 hours per day before his confinement. During his hospital stay, he usually sleeps for 5-6 hours and takes nap in the morning and afternoon. He said he had difficulty in sleeping because of the pain he felt in his abdomen.

L. Self-Perception/ Self-Concept Pattern “Ay gusto ko ng umuwi at gusto ng mga magulang kung uuwi narin” as verbalized. The patient verbalized that being hospitalized was not a change for him, but it affects to his family since they had a big problem in daily activities, physical and emotional stress.

M. Cognitive/ Perceptual Pattern Ms. Joselle Chua Ignacio is conscious, well oriented to time, place and person and is in a calm emotional state but gets irritable when discussing family matters with her parents. She exhibited appropriate behaviour and response when communicating and has not experienced any dizziness or tingling sensation.

N. Role/Relationship Pattern Ms. Joselle Chua Ignacio is is singel, a student and she is 2nd in the siblings. The patient lives with his family in 3017 Taliptip, Bulacan-Bulacan.and as for his hospitalization expenses, her family especially her father find ways just to pay the bill. Her family feels worried about the situation, her mother wants to stay with her as well as her father but they can’t because they need to work to earn money for his hospitalization.

O. Coping/ Stress-Tolerance Pattern “nakakapagod sa hospital at boring pa dito” as verbalized. Her vital support group is his family and significant others.

P. Value/ Belief Pattern Ms. Joselle Chua Ignacio is a Roman Catholic. She always goes to church every Sunday with his family. He thinks that God is vital to everyone and she trusts in God on whichever turn her condition will be. She says that hospitalization truly interferes, as he can’t go to church because of his illness.

Q. Physical Assessment  Skin: Uniform color with warm temperature, dry and smooth. No scars and hairs are evenly distributed.  Nails: Pale in color, long and slightly dirty, concave in shape with capillary refill of 3 seconds.  Head and Face: The skull is proportionate to body size, no tenderness. Hair is oily, thick and evenly distributed. Face is symmetrical and symmetrical facial movement.  Eyes: The client has straight normal eye condition; pupil is black in color and equal in size. Have thin eyebrows.  Ears: The shape is normal, hearing pattern is normal can hear whispered voice.  Nose and Sinuses: The nose is in septum is in midline, mucosa is pale; both patent but have watery secretion and sinuses are non tender.  Mouth: The lips are pale, symmetrical, pale mucosa, tongue is in midline.  Neck: The skin is uniform in color. Neck muscles are equal in size and no tenderness. Breast and Axilla. No masses, tenderness upon palpation.  Abdomen: Uniform in color, symmetrical movement, hypoactive bowel sound when percussion is dull for 3 clicks when palpate muscle guarding, usually urinary pattern is 850cc/shift.  Hearth and Neck Vessels: Apical pulse has 55bpm, cardiac sound (-) murmur noted, apical and radial pulse data 55bpm , blood pressure of 90/60, pulse pressure 83.

III. ANATOMY AND PHYSIOLOGY

The digestive tract (also known as the alimentary canal) is the system of organs within multicellular animals that takes in food, digests it to extract energy and nutrients, and expels the remaining waste. The major functions of the GI tract are ingestion, , absorption, and defecation. The picture to the right doesn't show the . The GI tract differs substantially from animal to animal. Some animals have multi-chambered stomachs, while some animals' stomachs contain a single chamber. In a normal human adult male, the GI tract is approximately 6.5 meters (20 feet) long and consists of the upper and lower GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the embryological origin of each segment of the tract.The first step in the digestive system can actually begin before the food is even in your mouth. When you smell or see something that you just have to eat, you start to salivate in anticipation of eating, thus beginning the digestive process. Food is the body's source of fuel. Nutrients in food give the body's cells the energy they need to operate. Before food can be used it has to be broken down into tiny little pieces so it can be absorbed and used by the body. In humans, proteins need to be broken down into amino acids, starches into sugars, and fats into fatty acids and glycerol. During digestion two main processes occur at the same time: * Mechanical Digestion: larger pieces of food get broken down into smaller pieces while being prepared for chemical digestion. Mechanical digestion starts in the mouth and continues in to the stomach. * Chemical Digestion: several different enzymes break down macromolecules into smaller molecules that can be more efficiently absorbed. Chemical digestion starts with saliva and continues into the intestines. Esophagus

The esophagus (also spelled oesophagus/esophagus) or gullet is the muscular tube in vertebrates through which ingested food passes from the throat to the stomach. The esophagus is continuous with the laryngeal part of the pharynx at the level of the C6 vertebra. It connects the pharynx, which is the body cavity that is common to both the digestive and respiratory systems behind the mouth, with the stomach, where the second stage of digestion is initiated (the first stage is in the mouth with teeth and tongue masticating food and mixing it with saliva). After passing through the throat, the food moves into the esophagus and is pushed down into the stomach by the process of peristalsis (involuntary wavelike muscle contractions along the G.I. tract). At the end of the esophagus there is a sphincter that allows food into the stomach then closes back up so the food cannot travel back up into the esophagus.

The GI System

The gastro-intestinal system is essentially a long tube running right through the body, with specialized sections that are capable of digesting material put in at the top end and extracting any useful components from it, then expelling the waste products at the bottom end. The whole system is under hormonal control, with the presence of food in the mouth triggering off a cascade of hormonal actions; when there is food in the stomach, different hormones activate acid secretion, increased gut motility, enzyme release etc. etc.

Nutrients from the GI tract are not processed on-site; they are taken to the liver to be broken down further, stored, or distributed.

The Stomach

The stomach is a 'j'-shaped organ, with two openings- the oesophageal and the duodenal- and four regions- the cardia, fundus, body and pylorus. Each region performs different functions; the fundus collects digestive gases, the body secretes pepsinogen and hydrochloric acid, and the pylorus is responsible for mucus, gastrin and pepsinogen secretion.

The stomach has five major functions;

 Temporary food storage  Control the rate at which food enters the duodenum  Acid secretion and antibacterial action  Fluidisation of stomach contents  Preliminary digestion with pepsin, lipases etc.

The Small Intestine

The small intestine is the site where most of the chemical and mechanical digestion is carried out, and where virtually all of the absorption of useful materials is carried out. The whole of the small intestine is lined with an absorptive mucosal type, with certain modifications for each section. The intestine also has a smooth muscle wall with two layers of muscle; rhythmical contractions force products of digestion through the intestine (peristalisis). There are three main sections to the small intestine;

 The duodenum forms a 'C' shape around the head of the pancreas. Its main function is to neutralise the acidic gastric contents (called 'chyme') and to initiate further digestion; Brunner's glands in the submucosa secrete an alkaline mucus which neutralises the chyme and protects the surface of the duodenum.  The jejunum  The . The jejunum and the ileum are the greatly coiled parts of the small intestine, and together are about 4-6 metres long; the junction between the two sections is not well-defined. The mucosa of these sections is highly folded (the folds are called plicae), increasing the surface area available for absorption dramatically. The Pancreas The pancreas consists mainly of exocrine glands that secrete enzymes to aid in the digestion of food in the small intestine. the main enzymes produced are lipases, peptidases and amylases for fats, proteins and carbohydrates respectively. These are released into the duodenum via the duodenal ampulla, the same place that bile from the liver drains into. Pancreatic exocrine secretion is hormonally regulated, and the same hormone that encourages secretion (cholesystokinin) also encourages discharge of the gall bladder's store of bile. As bile is essentially an emulsifying agent, it makes fats water soluble and gives the pancreatic enzymes lots of surface area to work on. structurally, the pancreas has four sections; head, neck, body and tail; the tail stretches back to just in front of the spleen.

The By the time digestive products reach the large intestine, almost all of the nutritionally useful products have been removed. The large intestine removes water from the remainder, passing semi-solid faeces into the rectum to be expelled from the body through the anus. The mucosa (M) is arranged into tightly-packed straight tubular glands (G) which consist of cells specialised for water absorption and mucus- secreting goblet cells to aid the passage of faeces. The large intestine also contains areas of lymphoid tissue (L); these can be found in the ileum too (called Peyer's patches), and they provide local immunological protection of potential weak-spots in the body's defences. As the gut is teeming with bacteria, reinforcement of the standard surfacedefences seems only sensible. The gallbladder is a pear shaped organ that stores about 50 ml of bile (or "gall") until the body needs it for digestion. The gallbladder is about 7-10cm long in humans and is dark green in appearance due to its contents (bile), not its tissue. It is connected to the liver and the duodenum by . The gallbladder is connected to the main through the gallbladder duct (cystic duct). The main biliary tract runs from the liver to the duodenum, and the cystic duct is effectively a "cul de sac", serving as entrance and exit to the gallbladder. The surface marking of the gallbladder is the intersection of the midclavicular line (MCL) and the trans pyloric plane, at the tip of the ninth rib. The blood supply is by the cystic artery and vein, which runs parallel to the cystic duct. The cystic artery is highly variable, and this is of clinical relevance since it must be clipped and cut during a . The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile emulsifies fats and neutralizes acids in partly digested food. After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect in fats.

IV. PATHOPYHSIOLOGY

V. DIAGNOSIS

A. Defination

Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon. Upper GI bleeds are considered medical emergencies, and require admission to hospitalfor urgent diagnosis and management. Due to advances in medications and , upper GI hemorrhage is now usually treated without surgery.

B. Risk & Pre-Disposing Factor

The condition tends to occur to Elderly, Coagulopathy is in an abnormality that affects blood coagulation patient that has . Treatment with blood thinner medication: Coumadin (Warfarin)Heparin, Daily use,Regular or heavy use of nonsteroidal anti- inflammatory medications: (Motrin, Advil)Naproxen (Anaprox, Naprosyn, Aleve) Ketoprofen (Orudis), ,Colorectal ,Gastric cancer,, ,Acid reflux disease

D. Signs and Symtoms Bleeding from the stomach can cause a host of signs and symptoms, some of which may clearly indicate a bleed while others can be vague and mistaken for other gastrointestinal conditions. Common signs and symptoms of stomach bleeding include:

 Vomiting of red, ‘fresh’ blood (hematemesis).  Vomiting of ‘old’, brown to black blood which resembles coffee grounds.  Presence of ‘fresh’ blood in the stool (hematochezia).  Black tarry stool due to the presence of ‘old’ blood (melena).  Epigastric pain (upper middle part of the abdomen, just below the breastbone) which may vary from sharp, stabbing pains to stomach cramps.  Dizziness/lightheaded feeling.

Not all these signs and symptoms of stomach bleeding may be present and the presence of blood in the vomit (hematemesis) is sufficient to make a differential diagnosis of upper gastrointestinal bleeding. Hematemesis may be due to bleeding elsewhere, including the mouth and upper respiratory tract, so it has to be differentiated from upper gastrointestinal bleeding with an upper GI endoscopy.

Other signs and symptoms of stomach bleeding includes:

 Other gastrointestinal symptoms including and .  General abdominal pain.  Fatigue and shortness of breath in chronic bleeding.  Fainting if there is significant blood loss.  Lack of appetite.  Loss of weight in chronic cases.  Low blood pressure ().  High heart rate (tachycardia).  Signs of shock in cases of significant blood loss.  Anemia.  Pallor.  Sweating.  Smell and taste of blood. This is subjective but is sometimes reported by patients with upper gastrointestinal bleeding.

VI. GROWTH AND DEVELOPMENT THEORY

A. Sigmund Freud’s Psychosexual Theory of Human Development  Genital (Puberty onwards): Ms. Joselle Chua Ignacio belongs to this stage because this stage develops energy directed towards full sexual maturity & function & development of skills to cope with the environment.

B. Erikson’s Stages of Psychosocial Development Theory  Adolescence (12–20 y/o Identity vs role confusion): Ms. Joselle Chua Ignacio belongs to this stage because this stage developes positive resolution like develops coherent sense of self and plans to actualize one’s abilities. While negative resolution develops feelings of confusion, indecisiveness, & possible anti-social behaviour.

C. Piaget’s Phases of Cognitive Development  Formal Operation (11+years): Ms. Joselle Chua Ignacio belongs to this stage because this stage develops Able to see relationships and to reason in the abstract

VII. LABORATORY EXAM

HEMATOLOGY REPORT

TEST RESULT UNIT REFERENCES RESULT WBC 6.1 10^3/uL 5.0-10.0 6.1 RBC 5.52 10^6/uL 4.2 -5.4 5.52 Hemoglobin 49 g/dL 12.0 – 16.0 49 Hematocrit 33.4 % 37.0 – 47.0 33.4 MCV 72.3 fL 82.0 – 98.0 72.3 MCH 20.4 Pg 27.0 – 31.0 20.4 MCHC 31.7 g/dL 31.5 – 35.0 31.7 RDW-CV 24.3 % 12.0 – 17.0 24.3 PDW 10.9 fL 9.0 – 16.0 10.4 MPV 9.3 fL 8.0 – 12.0 8.6 DIFFERENTIAL COUNT Lymphocyte 17.9 % 17.4 – 48.2 17.9 % Neutrophil % 65.0 % 43.4 – 76.2 65.0 Monocyte % 6.0 % 4.5 -10.5 6.0 Eosinophils % 1.0 % 1.0 – 3.0 1.1 Basophils % 0.1 % 0.0 – 2.0 0.1 Bands/stabs % 1.0 – 2.0 % PLATELET 331 10^3/uL 150 – 400 331

INTERPRETATION: An elevated WBC count occurs in infection, allergy, systemic illness, inflammation, tissue injury, and leukemia. A Low hemoglobin and hematocrit level indicates anemia. A low MCV number in a patient with a positive stool guaiac test (bloody stool) is highly suggestive of GI cancer. A low MCH indicates that cells have too little hemoglobin. This is caused by deficient hemoglobin production.

VIII. NURSING CARE PLAN

A. related to irregular defecation habit as manifested by Verbalization for help”, to help “Grabe mahirap dumumi”

BACKGROUND ASSESSMENT KNOWLEDGE DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

After 8 hours of nursing S: “Grabe Constipation is the most Constipation related to After 8 hours of nursing INDEPENDENT intervention, mahirap common digestive complaint It irregular defecation habit intervention the patient  Determine fluid intake  To evaluate client’s goals partially dumumi” as is a symptom rather than a will be able to: hydration status met.  Establish/ regain  Instruct the patient to  Prevent fullness verbalize by the disease and, despite its normal pattern of viod if there’s a feeling patient. frequency, often remains unrecognized until the patient bowel functioning of urgency  Participate in bowel  Note general O: develops sequelae, such as program a indicated oral/dental health  That can impact  Hard, anorectal disorders or  Demonstrate dietary intake formed diverticular disease. behaviour or DEPENDENT: stool lifestyle changes to  Hypoactive prevent recurrence  Apply lubricant bowel  To soften of problem sounds COLLABORATIVE:  Abdominal Encourage treatment of tenderness  To improve organ underlying causes. Distended function abdomen

B. Acute or chronic pain maybe related to chemical burn of gastric mucosa, oral cavity and physical response such as flex muscle spasm in the stomach wall as manifested by Verbalization for help”, to help “Napakasakit ng tiyan ko”

ASSESSMENT BACKGROUND KNOWLEDGE DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION (GRAMMAR TYPE)

S: “Napakasakit Acid, pepsin, and Acute or chronic After 4 hours Independent After 4 hours of ng tiyan ko” as helicobacter infection pain maybe of nursing nursing  Note reports of pain, verbalized by the play an important role in related to interventions  Pain is not always present, should be compared interventions, patient. the development of chemical burn including location, duration, with patient’s previous pain symptoms. The the patient was gastric ulcers. The gastric of gastric  The and intensity (0-10 scale). comparison may assist in diagnosis of etiology of able to verbalize

mucosal barrier overlies mucosa, oral Patient bleeding and development of complications. relief of pain O: cavity and the epithelium. The verbalize and  Hard, formed secretion of mucus and physical  Review factors that  Helpful in establishing diagnosis and treatment demonstrate s relief of stool bicarbonate provides a response such aggravate or alleviate pain. needs. relaxed body  Hypoactive first line defense in as flex muscle pain posture and be bowel sounds maintaining a near- spasm in the  Demonst able to sleep or  Note nonverbal pain cues.  Abdominal normal pH on the gastric stomach wall. rates  Non-verbal cues may be both physiological and rest properly.

tenderness epithelium and protects relaxed psychological and may be use in conjunction Distended the mucosal barrier with verbal cues to evaluate extent and severity body abdomen against acid. of the problem posture Gastromucosal  able to prostaglandins increase . sleep or the barrier’s resistance to  Provide small frequent  Food has an acid-neutralizing effect and dilutes ulceration. The integrity rest meals. the gastric contents. Small meals prevent of the barrier is properly. distention and the release of gastrin. enhanced by the rich blood supply of the  Identify and limit foods that  Specific foods that cause distress vary among mucosa of the stomach create discomfort. individuals. Spicy foods, alcohol, and coffee can and duodenum. precipitate dyspepsia.

 Assist with active and  Reduces joint stiffness, minimizing pain and passive range of motion discomfort. exercises.

 Provide frequent oral care  Halitosis from stagnant oral secretions is and comfort measures unappetizing and can aggravate . including back rub and position change.

Collaborative

 Provide and implement  Client may receive nothing by mouth initially. dietary modifications. When oral intake is allowed, food choices depend on the diagnosis and etiology of the bleeding.

 Use regular than skim milk,  Fat in regular milk may decreases gastric if milk is allowed. secretions. The calcium and protein content especially in skim milk increases secretions.

 Administer medications as  Helps relive acute or severe pain. indicated such as analgesics.

IX. DRUG STUDY

A. Ranitidine

NURSING GENERIC NAME INDICATION ACTION CONTRAINDICATION PRECAUTION/ ADVERSE REACTION CONSIDERATION Treatment and Inhibits the action Contraindicated in: PRECAUTION  Assess patient for Ranitidine prevention of of histamine at  Hypersensitivity, Severe and persistent headache. epigastric or heartburn, acid the H2 receptor Cross-sensitivity may abdominal pain and BRAND NAME indigestion, and site located occur; some oral ADVERSE RXN frank or occult blood Zantac sour stomach. primarily in gastric liquids contain Common: in the stool, emesis, parietal cells, alcohol and should  CNS: or gastric aspirate. DOSAGE resulting in be avoided in Confusion, dizziness, drowsiness,  Nurse should know 20 mg inhibition of patients with known that it may cause hallucinations, headache IV q8h gastric acid intolerance. false-positive results  CV: secretion. Use Cautiously in: for urine protein; In addition,  Renal impair- ment Arrhythmias test with ranitidine bismuth  Geriatric patients  GI: sulfosalicylic acid. citrate has some (more Altered taste, black tongue,  Inform patient that it antibacterial susceptible to constipation, dark stools, , may cause action against H. adverse CNS drug-induced , nausea drowsiness or pylori. reactions)  GU: dizziness.  Pregnancy or Decreased sperm count, impotence  Inform patient that Lactation increased fluid and  ENDO: fiber intake may Gynecomastia minimize  HEMAT: constipation. Agranulocytosis, Aplastic Anemia,  Advise patient to neutropenia, thrombocytopenia report onset of  LOCAL: black, tarry stools; Pain at IM site fever, sore throat;  MISC: diarrhea; dizziness; Hypersensitivity reactions, vasculitis rash; confusion; or hallucinations to health care professional promptly.  Inform patient that medication may temporarily cause stools and tongue to appear gray black.

B. Tranexamic Acid

PRECAUTION/ ADVERSE NURSING GENERIC NAME INDICATION ACTION CONTRAINDICATION REACTION CONSIDERATION A synthetic Contraindicated in: PRECAUTION  Unusual change in Tranexamic Acid Tranexamic acid is derivative of the  Allergic reaction to Mild to moderate renal bleeding pattern used for the amino acid lysine. It the drug or impairment, irregular should be BRAND NAME prompt and exerts its hypersensitivity menstrual bleeding, previous immediately Hemostan effective control of antifibrinolytic  Presence of blood history of thromboembolic reported to the hemorrhage in effect through the clots (eg, in the leg, disease, haematuria. Monitor physician. DOSAGE various surgical reversible blockade lung, eye, brain), closely in disseminated  For women who are 500 mg and clinical areas. of lysine-binding have a history of intravascular coagulation. taking Tranexamic IV q0.1h sites on blood clots, or are at Monitor LFT and eye acid to control plasminogen risk for blood clots examination regularly during heavy bleeding, the molecules. Anti-  Current long-term use. Discontinue if medication should fibrinolytic drug administration of disturbance in colour vision only be taken during inhibits endometrial factor IX complex occurs. Avoid IV inj rate >1 the menstrual plasminogen concentrates or anti- ml/minute due to risk of period. activator and thus inhibitor coagulant hypotension. Pregnancy,  Tranexamic Acid prevents fibrinolysis concentrates. lactation. should be used with and the breakdown extreme caution in of blood clots. The ADVERSE RXN CHILDREN younger plasminogen- Common: than 18 years old; plasmin enzyme  Diarrhoea, nausea, safety and system is known to vomiting, disturbances in effectiveness in cause coagulation colour vision, giddiness, these children have defects through lytic hypotension (after rapid not been confirmed. activity on IV inj), thromboembolic  The medication can fibrinogen, fibrin events. be taken with or and other clotting without meals. factors. By inhibiting  Swallow Tranexamic the action of Acid whole with plasmin plenty of liquids. Do (finronolysin) the not break, crush, or anti-fibrinolytic chew before agents reduce swallowing. excessive  If you miss a dose of breakdown of fibrin Tranexamic Acid, and effect take it when you physiological remember, then hemostasis. take your next dose at least 6 hours later. Do not take 2 doses at once.  Inform the client that he/she should inform the physician immediately if the following severe side effects occur: . Severe allergic reactions such as rash, hives, itching, dyspnea, tightness in the chest, swelling of the mouth, face, lips or tongue . Calf pain, swelling or tenderness . . Confusion . Coughing up blood . Decreased urination . Severe or persistent headache . Severe or persistent body malaise . Shortness of breath . Slurred speech . Slurred speech . Vision changes

X. DISCHARGE PLAN

MEDICATION  Discuss/instruct to the patient with their significant other the importance as  Patient with their significant other need to understand prescribe by the physician. the occurrence of the drug effects in order to when, what and whom to report on any symptoms present.  Emphasize on compliance to therapeutic and medication regimen and the information regarding side effect of the medications. ECONOMIC STATUS  Pinpoint the patient their capability to  This is to make sure that the compliance of the purchase the medications. medication will be achieved.

 The patient accessibility to the agency and  To have immediate interventions when signs and should be considered with regards to symptoms occur. follow-up.

 It is important to know patient ability to afford the expected expenses.  To ensures the patient adherence instructions.

TREATMENT  Encourage patient to have a vitamins  To have a fast recovery and to prevent complications. supplements.

 Compliance to medication regimen. HEALTH TEACHINGS  To monitor wound healing  Instruct the significant others to assess the patient’s incision and drainage system.

 Encourage the patient to prevent the stressful activity and have adequate rest.  To promote early recovery.

 Instruct the client and the significant others to monitor presence of infection and report immediately if signs and symptoms of  To monitor any signs of infection. infection occurs such as redness, foul- smelling drainage, temperature greater than 38.4 C.

OUT-PATIENT  Emphasize the patients to schedule for regular follow-up appointment, and discuss  To monitor any alternations in the patients status and the importance of regular check up care. ensure compliance to medication regimen. DIET  Instruct patient to eat high in protein such  For tissue repair and faster wound healing. as meat

 Instruct patient to eat high in carbohydrate.  For energy  Instruct patient to take vitamin K

 To prevent blood clot. SPIRITUALITY  Allow the patient to pray if possible all the time to God.  To provide and optimistic approach towards her problem.  Have faith in God.

XI. LEARNING EXPERIENCE

When I had my first exposure in the area, last September 10, 2012 I always endeavour to do what is finest and cool for my studies. I accomplished my requirements that were requested to make. It is conspicuous for me to build up what i had attained and be able to interpret what that is for. I was dazed because I was got carried away of my nervousness. Almost all of us were nervous to handle our patient and also with their chart because we were aghast to make our mistake. There were times that I get crap out when an accidental situation happened to one of our patient and I did not perceived what to do, but I was still thankful and glad that in spite of all the obstacle I had been through our Clinical Instructor who are always at our side to help, accompany and always intimate us what we should do to our patient.

Preparing this case study was a dare for me since it was my first time to alight upon this kind of disease. I gained more learning’s in this case study but comprising this, needs more patience’s and time. As what I achieved in my studies, I also learned to be sensitive to my patient’s feelings and my patient’s conditions in order for me to impart a therapeutic service that will nurture health and wellness on their sufferings. I also acquired trust and rapport up on patients needs effectively.

By doing this simple things makes me realize that each and every assessment of my patient or helping them through me, that I already step the new stage of my life as nursing student. As I take over my responsibility in our duty, but sometimes as I go along I encounter some difficulty during our service that can be manageable by helping each other with my group mate. And most of all I treat them as a family and I learn how to respect and socialize in one another. I learn also to strengthen my patience when it comes to tiring moments of our duty and above all this learning experience I had God is our staircase in our stairway of success. So God bless me and all the patient that I encounter.

XII.REFERENCES

Book sources:

1. Black, J. and Hawks, J. Medical-Surgical Nursing: Clinical Management for Positive Outcomes. Elsevier Health Sciences: Singapore. 2008 edition 2. Karch, Amy M. Lippincott’s Nursing Drug Guide. Lippincott Williams & Wilkins. Philadelphia. 2007 edition 3. Marilynn E. Doenges and Alice C. Murr: Nurses pocket guide, diagnoses, prioritized interventions and rationales. 4. Merriam Webster Dictionary. 2008 edition

Internet sources:

1. http://emedicine.medscape.com/article/417980-overview 2. http://scribd.com/GIbleeding.htm