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LICEO DE CAGAYAN UNIVERSITY R.N. PELAEZ BLVD.

, CARMEN, CAGAYAN DE ORO CITY COLLEGE OF NURSING

A CARE STUDY ON

HYPERTENSION - T/C ACUTE GASTRITIS

In Partial Fulfillment Of the Requirements Of NCM501 204 Related Learning Experience (RLE)

Submitted By: Fantonial, Michelle Labajosa, Jona Mae Gani, Ramuadee O. Macahilos, Ronnieza Mae M.

Submitted To: Mr. Michael Chua, R.N Clinical Instructor

August 03, 2008

TABLE OF CONTENTS
I. Introduction y y y Overview of the Disease Objectives Scope and Limitation

II. Health History y Patients Profile y Health History y History of Present Illness III. Developmental Data IV. Medical Management y Doctors Order y Laboratory Results y Drug Study V. Anatomy & Physiology VI. Pathophysiology VII. Nursing Assessment y Nursing System Review Chart y Nursing Assessment II VIII. Nursing Management y Actual Nursing Management(SOAPIE) IX. Health Teachings X. Referrals & Follow-Up XI. Documentation

I. INTRODUCTION
A. OVERVIEW OF THE DISEASE

Blood pressure is the product of cardiac output multiplied by peripheral resistance. Cardiac output is the product of the heart rate multiplied by the stroke volume. In normal circulation, pressure is exerted by the flow of blood through the heart and blood vessels. High blood pressure, known as hypertension, can result from a change in cardiac output, a change in peripheral resistance, or both.

Hypertension is defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) as a systolic blood pressure greater than 140 mmHg and a diastolic pressure greater than 90 mmHg. JNC7 defines a blood pressure of less than 120/80 mmHg diastolic as normal, 120 to 129/80 to 89 mmHg as pre-hypertension and 140/90 mmHg or higher as hypertension.

Primary hypertension also known as essential hypertension denotes a high blood pressure from an unidentified cause. This accounts for the majority of cases recorded in the hospitals revolving around 90 to 95% of the population. The remaining 5 to 10% of this group have secondary hypertension, a high blood pressure related to identified causes. These causes include narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism (mineralocorticoid hypertension), certain medications, pregnancy, and coarctation of the aorta.

Hypertension is sometimes called the silent killer because people who have it are often symptom-free. Once identified, elevated blood pressure should be monitored at regular intervals, because hypertension is a lifelong condition. It often accompanies other risk factors for atherosclerotic heart disease, such as dyslipidemia (abnormal blood fat levels), obesity, diabetes mellitus, metabolic syndrome, and a sedentary lifestyle.

Gastritis (inflammation of the gastric or stomach mucosa) is a common GI problem. Acute gastritis is often caused by dietary indiscretion the person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDS), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may caused the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis or obstruction. Acute gastritis also may develop in acute illnesses, especially when the patient has had major traumatic injuries; burns, severe infection; hepatic, renal, or respiratory failure; or major surgery. Gastritis may be the first sign of an acute systemic infection.

Symptoms of gastritis may occur as a rapid onset of abdominal discomfort, headache, lassitude, nausea, anorexia, vomiting, and hiccupping, which can last from a few hours to a few days.

B. OBJECTIVES OF THE STUDY

At the end of 1 day duty:

y y

The group will be able to thoroughly assess and identify the priority needs of the client. To demonstrate basic understanding of the patients disease condition, appropriate care, action, diagnostic examinations and medications given.

y y y y

To provide appropriate and effective nursing care of client with Essential Hypertension. To intervene efficiently and effectively on clients needs. To come up with desirable outcomes for the clients welfare. To grasp optimal learning in this case and to hone the skills in providing better nursing care in the clinical setting.

To develop the ideal attitude of a nurse through this case study.

C. SCOPE AND LIMITATION OF THE STUDY

This study will act as a baseline data as well as a guide for coming up with a good, reliable, accurate and comprehensive research paper dealing with issues commonly experienced by patients in the hospital setting.

The primary concern of the study is health maintenance and detection of actual and potential health problem that could further exacerbate the clients disease condition. Nursing process is utilized including the appropriate use of NCP and independent nursing interventions. The clients history of present illness including family history is being scrutinized to detect any possible health problem or knowledge deficit regarding family care.

This study was conducted in the Orthopedic Ward Station 4 of Polymedic General Hospital during our 2 days duty in the said institution. The hospital exposure was scheduled last July (Monday and Tuesday). The gathered data was limited only to the information given by the patient, the significant others, patients chart and other observations noted. This study mainly focuses on Mr. Z, male, 50 years old and a resident of Domingo A. Velez St. Cagayan de Oro City. He was admitted due to epigastric pain and headache. The following methods were used during the data gathering:  Asking questions using the PONR guidelines  Subjective cues from the patient  Using the four primary techniques in physical examination such as:     Inspection Palpation Percussion Auscultation

II. HEALTH HISTORY


A. PATIENTS PROFILE

Name: Date of Birth: Age: Sex: Civil Status: Height: Weight: Occupation: Income: Wife: Occupation: Children: Address: Religion: Allergies: Date of Admission: Time Admitted: Chief Complaint: Admitting Diagnosis: Attending Physician: Vital Signs: Temperature: Pulse Rate: Respiratory Rate: Blood Pressure:

Mr. Z

50 years old Male Married 53 186 lbs

Mrs. Z

6 children

Islam No known food and drug allergies July 18, 2009 7:30 pm Epigastric pain and headache Essential hypertension, T/C Acute Gastritis Dr. Edmilao 37.40C 73 bpm 18 cpm 140/80 mmHg

B. HEALTH HISTORY

Family History: Diabetic on patient fathers side Past-medical history: hypertensive, diabetic, non-asthmatic, Non-alcoholic drinker and smoker. No known food and drug allergy. Second time admission with the same diagnosis

C. HISTORY OF PRESENT ILLNESS This is a case of Mr. Z, 50 years old, male and presently residing in _____________was admitted in Polymedic General Hospital Station 4 last July 18, 2009 at around 7:30 in the evening. An hour prior to admission, patient had sudden onset of dimming of vision, then momentarily loss of consciousness for about 2 to 3 minutes, has a (-) history of neither trauma nor vomiting. And thus seek for an admission in this institution.

III. DEVEOPMENTAL DATA


A. Erick Erickson (Psychosocial Theory)

Mr. Zs age belongs to the adulthood stage of Erik Erikssons theory of stages of development. The central task that he ought to resolve at this stage is to resolve generativity versus stagnation. With Mr. Zs case, he verbalized that drinking and smoking is very bad in our health. With this, he was able to accept ones own lifes uniqueness and worth. Furthermore, he also said that he was happy to raise his children and watch them grow with their respective families now. He also verbalized that he is not afraid to die at this point in his life because according to him, his task of being a father to his children and a husband to his wife has been done.

B. Jean Piaget (Cognitive Developmental Theory)

It refers to the manner in which people learn to think, and use language. It involves a persons intelligence, perceptual ability, and ability to process information. Cognitive development represents a progression of mental abilities from illogical to logical thinking, from simple to complex problems solving, and from understanding concrete ideas to understanding abstract concepts. As we observed, Mr. Z could talk and communicate well able to answers our questions correctly, he was still able to think logically.

C. Robert Havighurst (Developmental Task)

Since Mr. Z is already 50 years old, he belongs to the late maturity stage of Robert Havighursts Developmental task theory. Basing on our assessment and interview with him, he has been adjusting well with his decreasing physical strength and health.

IV. MEDICAL MANAGEMENT


A. DOCTORS ORDER

DX ORDER July 19, 2009 July 20, 2009 July 21, 2009

RATIONALE

B. LABORATORY RESULTS

July 18, 2009 COMPLETE BLOOD COUNT WBC 11.51 x 10^g/L DIFFERENTIAL COUNT NEUTROPHILS LYMPHOCYTES EOSINOPHILS 84.0% 7.8% 0.4% BLOOD CHEMISTRY POTASSIUM URIC ACID 3.12 meq/L 10.16 meq/L 3.50 5.80 1.0 6.0 54.0 62.0 20.0 40.0 1.0 6.0 5.0 10.0

July 19, 2009 FECALYSIS OCCULT BLOOD POSITIVE

BLOOD CHEMISTRY TOTAL CALCIUM 7.46 mgs/dL 8.10 10.40

LIPID PROFILE FASTING BLOOD SUGAR 121.40 mgs/dL 70.00 99.00

July 21, 2009 HEMATOLOGY WBC 4.95 DIFFERENTIAL COUNT NEUTROPHILS MONOCYTES EOSINOPHILS 48.1 12.9 6.9 54.0 62.0 4.0 10.0 1.0 6.0 5.0 10.0 x 10^g/dL

C. DRUG STUDY Generic Name Brand Name Date Ordered Classification July 18, 2009 Analgesic Celecoxib

Dose/ Frequency/ 200 mg 1 tab P.O Route Mechanism Action of Analgesic and anti-inflammatory activities related to inhibition of the cox2 enzyme, which is activated in inflammation to cause the sign&symptoms associated with inflammation. Specific Indication Contraindication Management of acute pain Contraindicated with allergies to sulfonamides, celecoxib, NSAIDS or aspirin Side Effects Headache, dizziness, insomnia, fatigue, tiredness

Nursing Precaution Administer drug with food or after meals if GI upset occurs

Generic Name Brand Name Date Ordered Classification

Omeprazole Omepron July 18, 2009 Antacid/ Anti-ulcer

Dose/ Frequency/ 20 gm 1 tab P.O Route Mechanism Action of Gastric acid-pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells, blocks the final step of acid production. Specific Indication Contraindication Side Effects Contraindicated with hypersensitivity to omeprazole or its components Headache, dizziness, anxiety, dry skin, diarrhea, abdominal pain, nausea, vomiting Nursing Precaution Administer before meals. Caution pt. to swallow capsules whole, not to open, chew, or crush them. Treatment of active benign gastric ulcer

Generic Name Brand Name Date Ordered Classification

Allopurinol

July 18, 2009 Antigout drug

Dose/ Frequency/ 300 mg 1 tab P.O Route Mechanism Action of Inhibits the enzyme responsible for the conversion of purines to uric acid, thus reducing the production of uric acid with a decrease in serum and sometimes in urinary uric acid levels, relieving the signs and symptoms of gout.

Specific Indication Management of the signs and symptoms of primary and secondary gout. Contraindication Side Effects Nursing Precaution Contraindicated with allergy to allopurinol Headache, drowsiness, neuritis, diarrhea, abdominal pain, nausea, vomiting Administer the drug after meals

Generic Name Brand Name Date Ordered Classification Dose/ Route Mechanism Action Specific Indication Contraindication

Paracetamol Biogesic July 18, 2009 Antipyretics

Frequency/ 500 mg 1 tab every 4 hours P.O PRN

of Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever. Relief of fever, minor aches, and pain. Contraindicated with anemia, cardiac, and pulmonary disease.

Hypersensitivity, used cautiously in hepatic disease, alcohol abuse, malnutrition. Side Effects Allergic skin reactions & GI disturbances, hepatic failure, renal failure, rash. Nursing Precaution If in case of drug overdose, acetylcysteine is the antidote.

Generic Name Brand Name Date Ordered Classification Dose/ Route

Hydrite

July 18, 2009 Antidiarrheal

Frequency/ 1 tab + 200 cc water P.O TID

Mechanism of Action Specific Indication Replacement of fluid and electrolytes losses associated with acute diarrhea Contraindication Side Effects Nursing Precaution Should be used only in severe dehydration if IV therapy is not given.

Generic Name Brand Name Date Ordered Classification Dose/ Route Mechanism of Action Specific Indication Contraindication Side Effects Nursing Precaution

Flagyl

July 18, 2009 Antibacterial/ Antibiotic

Frequency/ 500 mg

Inhibits DNA synthesis in specific anaerobes, causing cell death. Acute infection with susceptible anaerobic bacteria Contraindicated with hypersensitivity to metronidazole. Headache, dizziness, diarrhea, nausea, vomiting Take full course of drug therapy, take the drug with food if GI upset occur.

Generic Name Brand Name Date Ordered Classification Dose/ Route Mechanism of Action Specific Indication

Amoxicillin Himox

Antibiotic

Frequency/ 500 mg 1 cap TID (6-12-6)

Inhibits synthesis of cell wall of sensitive organisms causing cell death. Infection due to susceptible strain of E.coli

Contraindication

Contraindicated with allergies to penicillins, cephalosporins, and other allergies

Side Effects Nursing Precaution

Lethargy, seizures, gastritis, stomatitis Take this drug around the clock.

Generic Name Brand Name Date Ordered Classification

Mucosta

Cytoprotectives

Dose/ Frequency/ Route 100 mg 1 tab TID (6-12-6) Mechanism of Action Specific Indication Contraindication Side Effects Nursing Precaution Treatment of gastric mucosal lesions Hypersensitivity to any of the drug components Constipation, diarrhea, nausea, vomiting Administer this drug after meals

Generic Name Brand Name Date Ordered Classification

Kalium Durules

Oral electrolytes/ Hydrating solutions

Dose/ Frequency/ Route 1 tab OD P.O Mechanism of Action Specific Indication Contraindication Side Effects Nursing Precaution Administer this drug after meals Hypokalemia, as prophylaxis during treatment with diuretics Renal insufficiency, hyperkalemia

V. ANATOMY & PHYSIOLOGY


Anatomy of the Heart The heart is a hollow, muscular organ located in the center of the thorax, where it occupies the space between the lungs (mediastinum) and rests on the diaphragm. It weighs approximately 300 g (10.6 oz). The heart pumps blood to the tissues, supplying them with oxygen and other nutrients. The pumping action of the heart is accomplished by the rhythmic contraction and relaxation of its muscular wall. During systole (contraction of the muscle), the chambers of the heart becomes smaller as the blood is ejected. During diastole (relaxation of the muscle), the heart chambers fill with blood in preparation for subsequent ejection. A normal resting adult heart beats approximately 60 to 80 times per minute. Each ventricle ejects approximately 70 ml of blood per beat and has an output of approximately 5 L per minute. The heart is composed of three layers. The inner layer, or endocardium, consists of endothelial tissue and lines the inside of the heart and valves. The middle layer, or myocardium, is made up of muscle fibers and is responsible for pumping action. The exterior layer of the heart is called the epicardium. The heart is encased in a thin, fibrous sac called the pericardium, which is composed of two layers. Adhering to the epicardium is the visceral epicardium. Enveloping the visceral pericardium is the parietal pericardium, a tough fibrous tissue that attaches to the great vessels, diaphragm, sternum, and vertebral column and supports the heart in the mediastinum. The space between these two layers (pericardial space) is filled with about 30 ml of fluid, which lubricate the surface of the heart and reduces friction during systole.

Heart Chambers

The four chambers of the heart constitute the right- and leftsided pumping systems. The right side of the heart, made up of the right atrium and right ventricle, distributes venous blood (deoxygenated blood) to the lungs via the pulmonary artery (pulmonary circulation) for oxygenation. The right atrium receives blood returning from the superior vena cava (head, neck,

and upper extremities), inferior vena cava (trunk and lower extremities), and coronary sinus (coronary circulation). The left side of the heart, composed of the left atrium and left ventricle, distributes oxygenated blood from the pulmonary circulation via the pulmonary veins. The varying thicknesses of the atrial and ventricular walls relate to the workload required by each chamber. The atria are thin-walled because blood returning to these chambers generates low pressures. In contrast, the ventricular walls are thicker because they generate greater pressures during systole. The right ventricle contracts against low pulmonary vascular pressure and has thinner walls than the left ventricle. The left ventricle, with walls two-and-a-half times more muscular than those of the right ventricle, contracts against high systemic pressure. Because the heart lies in a rotated position within the chest cavity, the right ventricle lies anteriorly (just beneath the sternum) and the left ventricle is situated posteriorly. The left ventricle is responsible for the apical beat or the point of maximum impulse (PMI), which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space.

Heart Valves

The four valves in the heart permit blood to flow in only one direction. The valves, which are composed of thin leaflets of fibrous tissue, open and close in response to the movement of blood and pressure changes within the chambers. There are two types of valves: Atrioventricular and Semilunar.

Atrioventricular Valves

The valves that separate the atria from the ventricles are termed atrioventricular valves. The tricuspid valve, so named because it is composed of three cusps or leaflets, separates the right atrium from the right ventricle. The mitral or bicuspid (two cusps) valve lies between the left atrium and left ventricle. Normally, when the ventricles contract, ventricular pressure increases, closing the atrioventricular valve leaflets. Two additional structures, the papillary muscles and the chordae tendineae, maintain valve closure. The papillary muscles, located on the sides of the ventricular

walls, are connected to the valve leaflets by thin fibrous bands called chordate tendineae. During systole, contraction of the papillary muscles causes the chordate tendineae to become taut, keeping the valve leaflets approximated and closed.

Semilunar Valves

The two semilunar valves are composed of three half-moon-like leaflets. The valve between the right ventricle and the pulmonary artery is called the pulmonic valve. The valve between the left ventricle and the aorta is called the aortic valve.

Coronary Arteries The left and right coronary arteries and their branches supply arterial blood to the heart. These arteries originate from the aorta just above the aortic valve leaflets. The heart has large metabolic requirements, extracting approximately 70% to 80% of the oxygen delivered (other organs extract, on average, 25%). Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. The left coronary artery has three branches. The artery from the point of origin to the first major branch is called the left main coronary artery. Two branches arise off the left main coronary artery: the left anterior descending artery, which courses down the anterior wall of the heart, and the circumflex artery, which circles around to the lateral left wall of the heart. The right side of the heart is supplied by the right coronary artery, which progresses around to the bottom or inferior wall of the heart. The posterior wall of the heart receives its blood supply by an additional branch from the right coronary artery called the posterior descending artery. Superficial to the coronary arteries are the coronary veins. Venous blood from these veins returns to the heart primarily through the coronary sinus, which is located posteriorly in the right atrium.

Cardiac Muscle

The myocardium is the middle, muscular layer of the atrial and ventricular walls. It is composed of specialized cells called myocytes, which form an interconnected network of muscle fibers. These fibers encircle the heart in a figure-of-eight pattern, forming a spiral from the base of the heart to the apex. During contraction, this muscular configuration facilitates a twisting and compressive movement of the heart that begins in the atria and moves to the ventricles. The sequential and rhythmic patter n of contraction, followed by relaxation of the muscle fibers, maximizes the volume of blood ejected with each contraction. This cyclical pattern of myocardial contraction is controlled by the conduction system.

Physiology of the Heart

Cardiac Electrophysiology

The cardiac conduction system generates and transmits electrical impulses that stimulate contraction of the myocardium. Under normal circumstances, the conduction system first stimulates contraction of the atria and then the ventricles. The synchronization of the atrial and ventricular events allows the ventricles to fill completely before ventricular ejection, thereby maximizing cardiac output. Three physiologic characteristics of two specialized electrical cells, the nodal cells and the Purkinje cells, provide this synchronization. Automaticity: ability to initiate an electrical impulse Excitability: ability to respond to an electrical impulse Conductivity: ability to transmit an electrical impulse from one cell to another

Both the sinoatrial (SA) node and the atrioventricular (AV) node are composed of nodal cells. The SA node, the primary pacemaker of the heart, is located at the junction of the superior vena cava and the right atrium. The SA node in a normal resting adult heart has an inherent firing rate at 60 to 100 impulses per minute, but the rate can change in response to the metabolic demands of the body.

The electrical impulses initiated by the SA node are conducted along the myocardial cells of the atria via specialized tracts called intermodal pathways. The impulses cause electrical stimulation and subsequent contraction of the atria. The impulses are then conducted to the AV node, which is located in the right atrial wall near the tricuspid valve. The AV node coordinates the incoming electrical impulses from the atria and after a slight delay (allowing the atria time to contract and complete ventricular filling) relays the impulse to the ventricles. Initially, the impulse is conducted through a bundle of specialized conducting tissue, referred to as the bundle of His, which then divides into the right bundle branch (conducting impulses to the left ventricle). To transmit impulses to the left ventricle, the largest chamber of the heart, the left bundle branch divides into the left anterior and left posterior bundle branches. Impulses travel through the bundle branches to reach the terminal point in the conduction system, called the Purkinje fibers. These fibers are composed of Purkinje cells, specialized to rapidly conduct the impulses through the thick walls of the ventricles. This is the point at which the myocardial cells are stimulated, causing ventricular contraction. The heart rate is determined by the myocardial cells with the fastest inherent firing rate. Under normal circumstances, the SA node has the highest inherent rate (60 to 100 impulses per minute), the AV node has the second-highest inherent rate (40 to 60 impulse per minute), and the ventricular pacemaker site have the lowest inherent rate (30 to 40 impulses per minute). If the SA node malfunctions, the AV node generally takes over the pacemaker function of the heart at its inherently lower rate. Should both the SA and AV nodes fail in their pacemaker function, a pacemaker site in the ventricle will fire at its bradycardic rate of 30 to 40 impulses per minute.

Cardiac Action Potential The nodal and Purkinje cells (electrical cells) generate and transmit impulses across the heart, stimulating the cardiac myocytes (working cells) to contract. Stimulation of the cardiac working cells occur due to the exchange of electrically charged particles, called ions, namely sodium, potassium, and calcium, as they enter and exit the cell. Sodium rapidly enters into the cell through sodium fast channels, in contrast to calcium, which enters the cell through calcium slow channels. In the resting or polarized state, sodium is the primary extracellular ion, whereas potassium is the primary intracellular ion. This difference in ion concentration means that the

inside of the cell has a negative charge compared to the positive charge on the outside. This relationship changes during cellular stimulation, when sodium or calcium crosses the cell membrane into the cell and potassium ions exit into the extracellular space. This exchange of ions creates a positively charged intracellular space and a negatively charged extracellular space that characterizes the period known as depolarization. Once depolarization is complete, the exchange of ions reverts back to its resting state; this period is known as repolarization. The repeated cycle of depolarization and repolarization is called the cardiac action potential which has five phases. y Phase 0: Cellular depolarization is initiated as positive ions influx into the cell. During this phase, the working cells (atrial and ventricular myocytes) rapidly depolarize as sodium moves into the cells through sodium fast channels. The myocytes have a fast response action potential. In contrast, the cells of the SA and AV node depolarize when calcium enters these cells through calcium slow channels. y Phase 1: Early cellular repolarization begins during this phase as potassium exits the intracellular space. y Phase 2: This phase is called the plateau phase because the rate of repolarization slows. Calcium ions enter the intracellular space. y Phase 3: This phase marks the completion of repolarization and return of the cell to its resting state. y Phase 4: This phase is considered the resting phase before the next depolarization.

Cardiac Output

Cardiac Output refers to the amount of blood pumped by each ventricle during a given period. The cardiac output in a resting adult is about 5 liters per minute but varies greatly depending on the metabolic needs of the body. Cardiac output is computed by multiplying the stroke volume by the heart rate. Stroke volume is the amount of blood ejected per heartbeat. The average resting stroke volume is about 70 ml, and the heart rate is 60 to 80 beats per minute (bpm). Cardiac output can be affected by changes in either stroke volume or heart rate.

Control of Heart Rate

The heart rate is affected by central nervous system and baroreceptor activity. Baroreceptors are specialized nerve cells located in the aortic arch and in both right and left internal carotid arteries (at the point of bifurcation from the common carotid arteries). The baroreceptors are sensitive to changes in blood pressure (BP). During elevations in BP (hypertension), these cells increase their rate of discharge, transmitting impulses to the medulla. This initiates parasympathetic activity and inhibits sympathetic response, lowering the heart rate and the BP. The opposite is true during hypotension (low BP). Hypotension results in less baroreceptor stimulation, which prompts a decrease in parasympathetic inhibitory activity in the SA node, allowing for enhanced sympathetic activity. The resultant vasoconstriction and increased heart rate elevate BP.

Control of Stroke Volume

Stroke volume is primarily determined by three factors: preload, afterload, and contractility. Preload refers to the degree of stretch of the cardiac muscle fibers at the end of diastole. The end of diastole is the period when filling volume in the ventricles is the highest and the degree of stretch on the muscle fibers is the greatest. The volume of blood within the ventricle at the end of the diastole determines preload, which directly affects stroke volume. Afterload, the amount of resistance to ejection of blood from the ventricle, is the second determinant of stroke volume. The resistance of the systemic BP to left ventricular ejection is called systemic vascular resistance. The resistance of the pulmonary BP to right ventricular ejection is called pulmonary vascular resistance. There is an inverse relationship between afterload and stroke volume. Contractility refers to the force generated by the contracting myocardium under any given condition. Contractility is enhanced by circulating catecholamines, sympathetic neuronal activity, and certain medications. Increased contractility results in increased stroke volume.

Anatomy of the Gastrointestinal Tract The gastrointestinal (GI) tract is a 23- to 26-foot-long pathway that extends from the mouth to the esophagus, stomach, small and large intestines, and rectum, to the terminal structure, the anus. The esophagus is located in the mediastinum anterior to the spine and posterior to the trachea and heart. This hollow, muscular tube, which is approximately 25 cm in length, passes through the diaphragm at an opening called the diaphragmatic hiatus. The remaining portion of the GI tract is located within the peritoneal cavity. The stomach is situated in the left upper portion of the abdomen under the left lobe of the liver and the diaphragm, overlaying most of the pancreas. A hollow muscular organ with a capacity of approximately 1500 ml, the stomach stores food during eating, secretes digestive fluids, and propels the partially digested food, or chime, into the small intestine. The small intestine is the longest segment of the GI tract accounting for about two thirds of the total length. It folds back and forth on itself, providing approximately 7000 cm of surface area for secretion and absorption, the process by which nutrients enter the bloodstream through the intestinal walls. The large intestine consists of an ascending segment on the right side of the abdomen, a transverse segment that extends from right to left in upper abdomen, and a descending segment on the left side of the abdomen. The GI tract receives blood from arteries that originate along the entire length of the thoracic and abdominal aorta and veins that return blood from the digestive organs and the spleen. Both the sympathetic and parasympathetic portions of the autonomic nervous system innervate the GI tract. In general, sympathetic nerve stimulation exerts an inhibitory effect on the GI tract, decreasing gastric secretion and motility and causing the sphincters and blood vessels to constrict. Parasympathetic nerve stimulation causes peristalsis and increase secretory activities. The sphincters relax under the influence of parasympathetic stimulation except for the sphincter of the upper esophagus and the external anal sphincter, which are under voluntary control.

Functions of the Digestive System Primary functions of the GI tract are as follows: y y y The breakdown of food particles into the molecular form for digestion. The absorption into the bloodstream of small nutrient molecules produced by digestion. The elimination of undigested unabsorbed foodstuffs and other waste products.

Chewing and Swallowing

The process of digestion begins with the act of chewing, in which food is broken down into small particles that can be swallowed and mixed with digestive enzyme. Eating or even the sight, smell, or taste of food can cause reflex salivation. Approximately 1.5 L of saliva is secreted daily from the parotid, the submaxillary, and the sublingual glands. Ptyalin, or salivary amylase, is an enzyme that begins the digestion of starches. Water and mucus, also contained in saliva, help lubricate the food as it is chewed, thereby facilitating swallowing. Swallowing begins as a voluntary act that is regulated by the swallowing center in the medulla oblongata of the central nervous system (CNS).

Gastric Function The stomach, which stores and mixes food wit secretions, secretes a highly acidic fluid in response to the presence or anticipated ingestion of food. This fluid, which can total 2.4 L/day, can have a pH as low as 1 and derives its acidity from hydrochloric acid (HCL) secreted by the glands of the stomach. The function of this gastric acid is twofold: to break down food into more absorbable components and to aid in the destruction of most ingested bacteria. Pepsin, an important enzyme for protein digestion, is the end product of conversion of pepsinogen from the chief cells.

VI. PATHOPHYSIOLOGY
Acute Gastritis- It is the inflammation of the gastric or stomach mucosa. It is often caused by dietary indiscretion the person eats food that is irritating, too highly seasoned, or contaminated with disease causing microorganisms.

Predisposing Factors:  Age  Acid-base imbalance  Low buffer system Lifestyle

Precipitating Factors: > Smoking > Skipping meal

> Environment > Spicy foods > Ingestion of alcohol

(Smoking, too much ingestion of alcohol, skipping meals, intake of spicy foods)

Hypersecretion of gastric juice

Erodes the surface epithelial (usually superficial)

s/sx: abdominal discomfort, epigastric tenderness

Failure of feedback mechanism

Alteration in the protective mucosal layer

s/sx: nausea & vomiting

Inflammation and ulceration

s/sx: stomach pain

VII. NURSING ASSESSMENT


NURSING SYSTEM REVIEW CHART Date: 07/03/09 Name: Mr. Z Vital Signs: Pulse: 64bpm BP: 140/70mmhg Temp: 37.6C Height: 57 EENT: impaired vision blind pain reddened drainage gums hard of hearing deaf burning edema lesion teeth Asses eyes, ears, nose throat for abnormality no problem RESP asymmetric tachypnea apnea rales cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea labored wheezing pain cyanotic Asses resp, rate, rhythm, depth, pattern, breath sounds, comfort no problem CARDIO VASCULAR arrhythmia tachycardia numbness diminished pulses edema fatigue irregular bradycardia murmur tingling absent pulses pain Asses heart sounds, rate rhythm, pulse, blood pressure, clrc., fluid retention, comfort no problem GASTRO INTESTINAL TRACT obese distention mass dysphagia rigidly pain Asses abdomen, bowel habits, swallowing, bowel sounds, comfort no problem GENITO-URINARY and GYNE pain urine color vaginal bleeding hermaturia discharge nocturia Asses urine freq., color, control, odor, comfort/ Gyn-bleeding, discharge no problem NEURO paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision grip Asses motor function, sensation, LOC, strength, Grip, gait, coordination, orientation, speech, no problem MUSCULOSKELETAL and SKIN appliance stiffness itching petechiae hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed atrophy pain ecchymosis diaphoretic moist Asses mobility, motion. Gait, alignment, joint function /skin color, texture, turgor, integrity no problem

Weight: No oppurtunity _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________

_ _

NURSING ASSESSMENT II
SUBJECTIVE COMMUNICATION: Comments: Hearing Loss Wala man koy problema sa visual changes akong pandungog ang ako denied lang panan-aw medyo halap
as verbalized by the patient.

OBJECTIVE glasses languages contact lens hearing aide R L speech difficulties Pupil size 2-3mm Reaction: Pupil Equally Round and Reactive to Light and Accommodation

OXYGENATION: dyspnea smoking history ________________ cough sputum denied CIRCULATION back pain leg pain numbness of extremities denied NUTRITION Diet _Diabetic diet __ N V Character recent change in weight, appetite swallowing difficulty denied ELIMINATION: Usual bowel pattern once a day constipation remedy Date of last BM 07- 03- 09

Comments: Wala koy ubo ug plema, as verbalized by the patient. Resp. regular irregular Description: RR is within normal range R Normal and symmetrical chest expansion L Normal and symmetrical chest expansion

Comments: Medyo hawoy akong lawas as verbalized by the patient.

Heart Rhythm regular irregular Ankle edema _____NONE_______________ Car Rad DP Fem Pulse R___________+_____+_______+___ L_______+____+_______________ Comments: all pulse sites were palpable. if applicable dentures Full Upper Lower none Partial With Patient

Comments: Maayo man ang akong pagkaon. as verbalized by the patient.

Comments: Patient s bowel is formed stool and brown in color.

urinary frequency 130cc a day urgency dysuria hematuria Incontinence

Bowel sounds No bowel sounds Present yes no

Urine* (color, consistency, Odor) Yellowish in color, aromatic in odor Briefly describe the patients ability to follow treatments ( diet, meds, etc.) for chronic health problems (if present) The pt. is cooperative and can follow treatments what is given to him.

polyuria diarrhea foly in place character denied ________________ MGT. OF HEALTH & ILLNESS: alcohol denied Dili ko gainom ug ilimnon nga makahubog. SBE Last Pap Smear: none LMP : N/A

NURSING ASSESSMENT II

SUBJECTIVE SKIN INTEGRITY Dry Itching Other Denied Wala koy gibati nga katol2x sa panit as verbalized by the patient.

OBJECTIVE Dry Cold Pale Flushed Warm Moist Cyanotic * Rashes, ulcers, decubitus (describe size, location, drainage) Left diabetic wound at the left toes noted.

ACTIVITY/SAFETY convulsion Comments: dizziness Kinahanglan ko limited motion alalayan kay diko of joints kabakod kung ako ra Limitation in as verbalized by the ability to patient. ambulate bathe self other denied COMFORT/SLEEP/AWAKE: pain Comments: (location, Maayo man hinuon ang frequency akong pagkatulog , as remedies) verbalized by the nocturia patient. sleep difficulties denied COPING: Occupation: unemployed Members of household: 3 members Most supportive person: Jocelyn Padero (daughter)

LOC and orientation : The patient was oriented to place, time and person.. Gait: Walker Cane Other steady unsteady __________________ sensory and motor losses in face or extremities ______numbness of extremities_____ ROM limitations patient can sit but with assistance.

facial grimaces guarding other signs of pain no other signs of pain side rail release form signed ( 60 + years) __________nONE__________

Observed non-verbal behavior : The patient was conscious and coherent The person and his phone number that can be Reached any time : No Oppurtunity

SPECIAL PATIENT INFORMATION ( USE LEAD PENCIL) _____PT/OT 65 kgs. Daily weight __140/70 _BP q shift ____ Irradiation ___ Neuro vs _____ Urine Test ___CVP/SG. Reading _____ 24 hours Urine Collection Date Ordered 07-03-09 07-03-09 07-03-09 Diagnostic Exams CBC Urinalysis Creatinine Date Done 07-03-09 07-03-09 07-03-09 Date Ordered 07-03-09 07-03-09 I.V Fluids / Blood D5LR 1L @ 20 gtts/min. D5LR 1 L @ 20 gtts/min. DateDisc. 07-04-09

VIII. NURSING MANAGEMENT


S Sakit akong tiyan as verbalized by the patient

 Moaning  Irritability  Scattered movement

A Acute pain related to irritated stomach mucosa

At the end 30 minutes of nursing intervention, patient will be able to report relieve of pain.

Independent: 1.  2.  I 3.  4.  Monitored vital signs Usually altered in acute pain Assessed for referred pain as appropriate To help determine possibility of underlying condition or organ dysfunction requiring treatment Provided comfort measures To provide non-pharmacological pain management Encouraged adequate rests period To prevent fatigue

Dependent: 1. Administered analgesic as prescribed by the doctor  For treatment of mild to moderate pain

At the end of 30 minutes of nursing intervention, my objective was met; patient was able to report pain was relieved.

Wala kayo koy gana magkaon as verbalized by the patient

 Diarrhea  Lack of interest in food  Bitter tongue taste

A Imbalanced nutrition less than body requirements related to inadequate intake of nutrients

At the end 3 hours of nursing intervention, patient will be able to interact with the interventions given

Independent: 1.  2.  3.  4.  5.  Assess wt., age, strength, activity, rest level Provides comparative baseline Encouraged client to choose food that are appealing To stimulate appetite Promote pleasant, relaxing environment To enhance intake of food Promote adequate/ timely fluid intake Limiting fluid 1 hour before meal decreases possibility of early satiety Prevent/minimize unpleasant odors/sights May have a negative effect on appetite

At the end of 3 hours of nursing intervention, my objective was met; patient was able to response to the interventions given.

Dili kayo ko ganahan mo inom ug tubig ug uban pa as verbalized by the patient

 Refusal to drink beverages

A Risk for imbalance fluid volume related to insufficient fluid intake

At the end 4 hours of nursing intervention, patient will be able to increase fluid intake & follow interventions given

Independent: 1.  2.  3.  4.  Administer IV fluids To promote fluid replacement & management Weigh daily or as indicated and evaluated They are related to fluid status Monitor vital signs To observed and note any deviations Note presence of vomiting, liquid stool To include in losses in output calculation

At the end of 4 hours of nursing intervention, my objective was met; patient was able to response on the interventions given.

IX. HEALTH TEACHINGS


Patient was instructed to comply with the medications given by the doctor:  Omeprazole 20 g 1 tab on once a day  Allopurinol 300 mg 1 tab once a day MEDICATIONS  Hydrite 1 tab + 200 cc water 3x a day  Flagyl 500 mg once a day  Amoxicillin 500 mg 1 cap 3x a day  Mucosta 100 mg 1 tab 3x a day  Kalium Durules 1 tab once a day Patient was instructed to plan for rest periods in a day and avoid or learn to EXERCISE cope with stressful situations. Avoid strenuous activity that may cause fatigue.

Patient was instructed to comply with the drug regimen, promote a healthy TREATMENT lifestyle changes which includes adequate nutrition, cessation from smoking, decreased alcohol consumption, and stress reduction strategies.

OUTPATIENT

Patient was instructed to have a follow-up check up 1 week after discharge from the hospital for further evaluation.

DIET

Patient was instructed to follow a low fat, salt, and purine diet. And to avoid acidic and spicy food intake. Increase fluid intake for 8-10 glasses/day. Eat nutritious foods such as green leafy vegetables and fruits.

X. REFERRALS & FOLLOW-UP


Before the patient was about to be discharged, I was able to impart my health teachings to him including proper nutrition, compliance to medications and good personal hygiene. I advised the client to have a quarterly physical examination. It's important to have a thorough physical exam every quarter in addition to his regular diabetes checkups. This is an opportunity to check for complications of diabetes and to screen for conditions such as cardiovascular and kidney diseases.

XI. BIBLIOGRAPHY