`I. PATIENT ASSESSMENT DATA BASE A.

GENERAL DATA Patients Name Address Age Sex Birth Date Rank of the Family Nationality Civil Status Date of Admission Order of Admission Attending Physician : : : : : : : : : : : JG Malasique, Pangasinan 52 Female January 14, 1959 Mother Filipino Married August 13, 2011 Medical Ward Dr. Revera

B. CHIEF COMPLAINT Cough accompanied by chest pain C. HISTORY OF PRESENT ILLNES Patient complained of abdominal pain which was associated with heartburn D. PAST HEALTH HISTORY / STATUS Childhood Illnesses: Cough and cold, fever Immunization: BCG, DPT, Hepa B, Measles, OPV Major Illnesses: None Current Medications: Paracetamol Allergies: None

E. FAMILY ASSESSMENT Name RG RG RG LG LG F. SYSTEM REVIEW 1. HEALTH PERCEPTION She prioritize other things inside the house like washing the clothes, cleaning the house and cooking. Whenever one of the family get sick, she just give medicine like paracetamol for fever and sometimes she using herbal medicine. : Relation Husband Daughter Son Daughter Daughter Age 53 30 27 24 16 Sex Male Female Male Female Female Occupation Farmer Housewife N/A N/A N/A Educl Attainment High School Graduate College Graduate High School Graduate High School Graduate Elementary Graduate

2. NUTRITIONAL-METABOLIC PATTERN Usual Daily Menu Food - vegetable, rice, fish and some fruits Water - 1-3 cup of water a day Beverages- N/A

3. ELIMINATION PATTERN BOWEL HABITS Color: Normal Odor: Fishy odor Consistency: 1-2 times Laxative use if any: None

BLADDER

Color: Yellow Odor: Aromatic Alterations if any: None

4. ACTIVITY AND EXERCISE PATTERN Self care ability __0___ Feeding __0__ Bathing __0___ Bed Mobility

__0___ Dressing __I___ Toileting __II_ Home Maintenance

__0__ Grooming __0_ Cooking _____ others

LEGEND 0 - full care I - requires use of equipment II - requires assistance or supervision from others III requires assistance or supervision from another and equipment and a device IV- dependent: doesnt participate 5. COGNITIVE PERCEPTUAL PATTREN Hearing: Patient hearing is clear Vision: Patient vision is clear Sensory Perception: She respond actively Learning Styles: She watches news daily 6. SLEEP REST PATTERN Sleep Habits: N/A Special sleeping problem: N/A Hours of sleep: 7 hours Sleeping Alterations: Waking up during urination Sleeping Aids: N/A

7. SELF PERCEPTION AND SELF CONCEPT PATTERN Feelings about current state: N/A Description of self: N/A Known capabilities and weaknesses: sometimes she is lying in bed Self Worth: the family was caring for her 8. ROLE RELATIONSHIP PATTERN Perception of major roles and responsibilities in the family: Mother Perception of major roles and responsibilities at work: Sometimes shes helping his husband in the farm Perception of major roles and responsibilities: 9. SEXUALITY REPRODUCTIVE PATTERN Menstrual History Age of onset of menarche: 14 years old Number of menstrual days: 3 days Number of pads every menstruation: 4 times Presence of PMS, dysmenorrheal and other menstrual problem: For both sexes Contraception: N/A Sexual activities: sexually active Special health reproductive problems: N/A History of sex abuse: N/A 10. COPING STRESS TOLERANCE PATTERN Perception of stress and problems in life: sometimes the patient was in stress Coping method and support system used: N/A 11. VALUE BELIEF PATTREN Value goals and philosophical beliefs, religious and spiritual beliefs: patient is a roman catholic, she believe in god. G. HEREDO FAMILIAL ILLNESS Maternal: Diabetes Paternal: Anemic H. DEVELOPMENTAL HISTORY THEORIST AGE SEX PATIENT DESCRIPTION

Erick Erickson

18 months to 3 years

Male

Basing on this theory, he is still belongs to Infancy based on Eriksons theory the child developmental task is the TRUST vs. MISTRUST Because an infant is utterly dependent; the

development of trust is based on the dependability and quality of the childs caregivers. If a child successfully develops trust, he or she will feel safe and secure in the world. Caregivers who are inconsistent, emotionally unavailable, or rejecting contribute to feelings of mistrust in the children they care for. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable. As observed the child had already built trust to his mother and father wherein he only allows his mother and fatherto cuddled and feed him.

Basing on this theory, Jimmy Mendaros Segmund Freud 1 month to 1 year Male belongs to the oral stage wherein an infants pleasure centers are in the mouth. This is also the infant's first relationship with its mother; it is a nutritive one.

James Fowler

0 to 3 years

Male

Interprets the environment by mental image

Male Jean Piaget 1 to 2 years

Infant unable to formulate concepts about self and the environment

I. PHYSICAL ASSESSMENT A. General Survey Over all appearance and grooming: Patient was properly good in appearance Actual height and weight vs. ideal body weight: Normal height but obese Symptoms and distress: Back pain Posture, gait: Normal posture Affect and mood: N/A Relevance and organization of thought: N/A

B. VITAL SIGNS Temp: 35.3 oC CR: 120 bpm/min RR: 21 cpm/min BP: 140/100 C. REGIONAL EXAM 1, Hair Head and Face Long fine, black, wavy hair 2. Eyes Has normal symmetry of the eye. Pupils are black in color. Pupils equally round. Iris is flat and round. Both eyes move coordinate and in unison with parallel alignment. 3. Ears No lesions, some wrinkles. 4. Nose The nose is symmetrical with no dermities. Some wrinkles. 5. Mouth and throat Mouth was proportional and symmetrical. Lips were slight dry with no presence of ulcerations, sores or lesions. 6. Neck and Lymph nodes There is no masses and lesions noted. Neck and head is centered. Head movement is coordinated and smooth movements were done with no discomfort. The trachea is in central placement in midline of the neck upon palpation. 7. Skin Skin slightly dry, rough and wirth skin turger. No bruises or discoloration observed.

8. Nails Finger nails are untrimmed and dirty 9. Thorax and Lungs Chest is symmetric and spine 10. Breast and axilla N/A 11. Abdomen N/A 12. Extremities Extremities are proportion 13. Genitalia N/A

II. PERSONAL / SOCIAL HISTORY Habits / Vices: N/A Caffeine: 2 cups Smoking: N/A Alcohol: N/A Tea: N/A Drugs: N/A Lifestyle: N/A Social affiliation: N/A Rank in the family: Mother Educational Attainment: N/A III. ENVIRONMENTAL HISTORY They live in a small barangay quite far from the town. They belong to a lower class of living. They live at the farm whom they got their income.

IV. PEDIATRIC HISTORY A. Maternal and Birth History Date of Birth Birth Weight Type of Delivery

V. INTRODUCTION
Epigastric pain is pain that is localized to the region of the upper abdomen immediately below the ribs. Often, those who experience this type of pain feel it during or right after eating or if they lie down too soon after eating. It is a common symptom of gastroesophageal reflux disease (GERD) or heartburn. It may be associated with the gastric contents moving upward into the back of the throat, causing inflammation and a burning pain. Epigastric pain may also occur with conditions that cause inflammation of the digestive organs, such as gastritis and pancreatitis. Pregnant women may experience epigastric pain due to increased abdominal pressure and hormonal changes that slow the digestive process. Epigastric pain can also arise from conditions that impair the normal digestive process, such as peptic ulcers, hiatal hernias, or gallstones. In these cases, it may occur frequently after meals, and it may become chronic.

VI. Anatomy and Physiology of Digestive System ANATOMY

 PHYSIOLOGY
The epigastrium (or epigastric region) is the upper central region of the abdomen. It is located between the costal margins and the subcostal plane. The umbilical region, in the anatomists' abdominal pelvic nine-region scheme, is the area surrounding the umbilicus (navel). This region of the abdomen contains part of the stomach, the head of the pancreas, the duodenum, a section of the transverse colon and the lower aspects of the left and right kidney. The hypogastrium (alternative names including hypogastric region, pubic region and suprapubic region) is an area of the human abdomen located below the navel. The pubis bone constitutes its lower limit. hypochondriac region either of the abdominal regions that are in superior lateral locations, one on the left (left hypochondriac region) and one on the right (right hypochondriac region) of the epigastric REGION; called also hypochondrium. lateral region either of the abdominal regions that are in central lateral locations, one to the left (left lateral region) and one to the right (right lateral region) of the umbilical REGION; called also flank and lumbar region iliac region the junctional region betwen the abdomen and thigh; either of the abdominal REGIONS lateral to the suprapubic(hypogastric) region. Called also groin and iliac or inguinal REGION.

VII. Pathophysiology

FATTY FOODS

CHOLESTEROL INCREASED
PHOSPHOLIPIDS IN BILES

EPIGASTRIC PAIN

IMPAIRED GALL BLADDER MOTILITY

CRYSTALLIZES AND FORM NIDUS

STONE FORMS

Generic Name: Tramadol Brand Name:ULTRAM ER Dosage: The recommended dose of tramadol is 50-100 mg (immediate release tablets) every 4-6 hours as needed for pain. The maximum dose is 400 mg/day. Indication: Ultram is indicated for the management of moderate to moderately severe pain.
Mechanism of Action Side Effects Contraindication Adverse Reaction Nursing Consideration

Tramadol is a manmade (synthetic) analgesic (pain reliever). Its exact mechanism of action is unknown but similar morphine. Like morphine, tramadol binds to receptors in the brain (opioid receptors) that are important for transmitting the sensation of pain from throughout the body to.

Tramadol is generally well tolerated, and side effects are usually transient. Commonly reported side effects include nausea, constipation, dizziness, headache, drowsiness, and vomiting. Less commonly reported side effects include itching, sweating, dry mouth, diarrhea, rash, visual disturbances, and vertigo. Some patients who received tramadol have reported seizures.

Ultram should not be administered to patients who have previously demonstrated hypersensitivity to tramadol or in cases of acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids or psychotropic drugs.

> Ultram was administered to 550 patients during the double-blind or open-label extension periods in U.S. studies of chronic nonmalignant pain. Of these patients, 375 were 65 years old or older. TABLE 1 reports the cumulative incidence rate of adverse reactions by 7, 30 and 90 days for the most frequent reactions (5% or more by 7 days). The most frequently reported events were in the central nervous system and gastrointestinal system.

Tramadol lowers the seizure threshold. It also synergizes with SSRI's and tricyclics, and may have a stronger effect on epileptics. Ergo, seizure warning. Tramadol is about 10% as effective as MS when delivered IM/IV. As such, it does not have demonstrate the powerful anti-shock properties of MS.

Generic Name: Ranitidine Brand Name: ZANTAC Dosage: Usual oral doses for treating ulcers and GERD are 150 mg twice daily or 300 mg at bedtime. The maintenance dose is 150 mg daily. Indication: Used in the treatment of peptic ulcer disease (PUD), dyspepsia, stress ulcer prophylaxis, and gastroesophageal reflux disease (GERD).
Mechanism of Action Side Effects Contraindication Adverse Reaction Nursing Consideration

Ranitidine is an oral drug that blocks the production of acid by acid-producing cells in the stomach. It belongs to a class of drugs called H2 (histamine-2) blockers that also includes cimetidine (Tagamet), nizatidine (Axid), and famotidine (Pepcid). Histamine is a naturally-occurring chemical that stimulates cells in the stomach (parietal cells) to produce acid.

- constipation; - diarrhea; - headache; - stomach pain; - upset stomach; - vomiting;

Ranitidine is contraindicated in patients known to have hypersensitivity to ranitidine bismuth citrate or any of its ingredients.

Similar to other H2 antagonists, adverse reactions during ranitidine therapy are infrequent. Adverse reactions during ranitidine therapy occur rarely and are usually mild and transient.

Renal and Hepatic patients are not a good candidate for this med. No anti-inflamatories should be given. This includes aspirin and the like. Antacids should be taken one hour before or one hour after ranitidine, as they inhibit the effectiveness. Avoid stomach and GI irritants -- this includes smoking and ETOH Watch for signs of GI bleeds.

Generic Name: Famotidine Brand Name: PEPCID Dosage: The recommended adult oral dose for treating duodenal ulcers is 40 mg once daily at bedtime or 20 mg twice daily. Indication: For the treatment of peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD).
Mechanism of Action Side Effects Contraindication Adverse Reaction Nursing Consideration

. Histamine is a chemical made by the body that stimulates cells lining the stomach to produce acid. Famotidine belongs to a class of medications called H2-blockers that blocks the action of histamine on stomach cells, thus reducing production of acid by the stomach

- constipation; - diarrhea; - difficulty breathing or swallowing; - dizziness; - fussiness (in babies who take famotidine); - headache; - hives; - hoarseness; - itching; - skin rash; - swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs;

> Hypersensitivity to any component of these products. Cross sensitivity in this class of compounds has been observed. Therefore, Famotidine should not be administered to patients with a history of hypersensitivity to other H2-receptor antagonists.

.CNS:Headache,mala ise, dizziness, somnolence, insomnia Dermatologic:Rash GI: Diarrhea, constipation, anorexia, abdominal pain Other: Muscle cramp, increase in total bilirubin, sexual impotence

Allergy to famotidine; renal failure; lactation, pregnancy, hepatic impairment Physical: Skin lesions; liver evaluation, abdominal exam, normal output; renal function tests, serum bilirubin

X. LIST OF IDENTIFIED PROBLEMS 1. Diarrhea related to toxin 2. Hypertermia related to infection

3. Fluid volume Deficit related to active fluid volume loss 4. Risk for Impaired skin integrity related to altered fluid status 5.Knowledge deficit related to lack of knowledge

XI. NURSING CARE PLAN Assessment

SUBJECTIVE: Bakit kaya madalas ako mahilo? (Why do I always feel dizzy?) as verbalized by the patient. OBJECTIVE: Request for information. Agitated behavior Inaccurate follow through of instructions. V/S taken as follows: T: 37.2 P: 84 R: 18 BP: 180/110

Diagnosis
> Risk for prone behavior related to lack of knowledge about the disease

Scientific Background
. High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body. High blood pressure does not mean excessive emotional tension, although emotional tension and stress can temporarily increase blood pressure. Normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called "prehypertension

Planning
After 8 hours of nursing interventions, the patient will verbalize understanding of the disease process and treatment regimen.

Intervention
INDEPENDENT: Define and state the limits of desired BP. Explain hypertension and its effect on the heart, blood vessels, kidney, and brain. Assist the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol. Reinforce the importance of adhering to treatment regimen and keeping follow up appointments. Suggest frequent position changes, leg exercises when lying down.

Rationale
> Provides basis for understanding elevations of BP, and clarifies misconceptions and also understanding that high BP can exist without symptom or even when feeling well. These risk factors have been shown to contribute to hypertension. Lack of cooperation is common reason for failure of antihypertensive therapy. Decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing.

Evaluation
After 8 hours of nursing interventions, the patient was able to verbalize understanding of the disease process and treatment regimen.

Assessment
SUBJECTIVE: Sumasakit ang sikmura ko pgkatapos kumain (Ive been experiencing abdominal pain immediately after eating) as verbalized by the patient

Diagnosis
Acute pain r/t Chemical burn of gastric mucosa

Scientific Background
Chemical burn of gastric mucosa

Planning
After 8 hours of nursing intervention the patient will verbalize relief of pain.

Intervention
Independent Note reports of pain, including location, duration, intensity (010 scale)

Rationale
> Pain is not always present, but if present should be compared with patients previous pain symptoms. This comparison may assist in diagnosis of etiology of bleeding and development of complications.

Evaluation
Demonstrated relaxed body posture and be able to sleep/rest appropriately.

Damage to the G.I lining

Acute pain

>Demonstrate relaxed body posture Review factors and be able to that aggravate or sleep/rest alleviate pain. appropriately.

OBJECTIVE: Abdominal guarding Restlessness facial grimacing pain scale of 6 out of 10 V/S taken as follows T: 37.5C P: 65 R: 14 BP: 110/ 80

Identify and limit foods that create discomfort such as Helpful in spicy or establishing carbonated drink. diagnosis and treatment needs. Encourage small, frequent meals Encourage patient FOOD HAS AN ACID NEUTRALIZING to assume EFFECT AND DILUTES position of THE GASTRIC comfort. CONTENTS. COLLABORATIVE Provide and implement prescribed dietary modifications. Administer medications as indicated Analgesics, e.g., morphine sulfate

Assessment
Subjective: sobrang sakit ng bandangibaba ng bythe patient.Objective:Fac ial grimaceNarrowed focusGuardingbehavi or

Diagnosis
Acute painrelated toabdominalconditio n(probablycholelithia sis)as evidencedby positivefacial grimace,narrowedfocu s andguardingbehavior

Scientific Background
Fatty food, Cholesterol, Increased phospholipids in biles, Crystallizes and form nidus Stone forms Impairedgallbladdermotility Epigastric pain

Planning
After 8 hrs. of nursinginterventionsth e patient pain will berelieved orcontrolled

Intervention Rationale
Observe anddocument loc ation of thepain, scale (0-10)and character of the pain y Promote bed rest y >Providesinfor mation about diseasepro gression,develo pment of complication s andeffectivenes s of intervention y

Evaluation
After 8 hrs. of nursinginterve ntionsthe patient painwas relieved orcontrolled.

Controlenvironm To reduces entaltemperature intraabdominalp y ressure y Encourage use of relaxationtech To nique minimizedermald y iscomfort y Administermedica tion asindicated To promotes such rest,redirectsatt asanticholinergic, ention, sedatives,narcotic mayenhance coping. y To reduce severepain/prom otesrest and relaxessmooth muscles

VIII. LABORATORY AND DIAGNOSTIC EXAMINATION

HEMATOLOGY cholesterol triglycerides Direct HDLC LDL VLDL amylase Results 4.1 1.80 .5 2.78 .82 38. mmol/L mmol/L mmol/L mmol/L mmol/L U/L 5.2 .11-232 1.6 3.88 .91 28-100

XIII. DISCHARGE PLAN Clients with epigastric pain are instructed to take the following plan for discharge: Medication should be given to be taken regularly as prescribed, on exact dosage, time and frequency. Diet which is prescribed should be followed avoid fatty foods. To include fruits especially banana in diet. Health Teachings as follows: Importaance of proper hygiene Proper handwashing Eat nutrritious foods and fruits Increase oral intake should be conveyed