INTRODUCTION

This case study is about a 79-year old client who was admitted last
September 16, 2018 at Lipa Medix Medical Center with a diagnosis of hypovolemic
shock secondary to upper GI bleeding probably 20 to bleeding peptic ulcer disease
probably 20 to NSAID use; s/p TURP at Lipa City District Hospital. The main objective
of this case study is to provide students additional knowledge about the disease and
acquire appropriate nursing interventions and learn the complexities of real life
situations upon the exposure in the workplace.

This case study aims to:

 Provide factual information about hypovolemic shock, upper GI bleeding and

Melena, peptic ulcer, NSAIDS, Cystoclysis and TURP
 Relate disease process to the patient’s health condition
 Convey knowledge about complications and risk factors of hypovolemic
shock
 Identify possible treatment and proper nursing interventions to parturient with
hypovolemic shock

Specific Objectives:
 For us, G3A students be able to reflect on the entire course of treatment for
the patient, ranging from obtaining important information to diagnosis to
treating the medical condition.
 For the BSN students to be more aware of a certain disease uncommon to
them
 For the clinical instructors, this will serve as an additional guide to mold the
students in becoming better health care providers pertaining to the disease
 For the entire department of College of Nursing to play a central and critical
role in improving access and quality health care based on the primary health
care approach.

This case study was chosen and conducted because it is focused, reality-based,
relevant, and reflects evidence of best practices in nursing supported by research.
Purposes include employing out decision-making skills, using critical thinking to

1
analyze the situation, and developing cognitive reasoning abilities without harming the
patient.

According to Judi Marcin (2016), hypovolemic shock is a life-threatening

condition that results when you lose more than 20 percent (one-fifth) of your
body’s blood or fluid supply. This severe fluid loss makes it impossible for the
heart to pump a sufficient amount of blood to your body.

For adults, the clinical staging relating to loss of blood volume can be
classified as:

Class 1: Volume loss up to 15% of total blood volume, approximately 750 mL.
Heart rate is minimally elevated or normal. Typically, there is no change in blood
pressure, pulse pressure, or respiratory rate.

Class 2: Volume loss from 15% to 30% of total blood volume, from 750 mL to
1500 mL. Heart rate and respiratory rate become elevated (100 BPM to 120
BPM, 20 RR to 24 RR). Pulse pressure begins to narrow, but systolic blood
pressure may be unchanged to slightly decrease.

Class 3: Volume loss from 30% to 40% of total blood volume, from 1500 mL to
2000 mL. A significant drop in blood pressure and changes in mental status
occur. Heart rate and respiratory rate are significantly elevated (more than 120
BPM). Urine output declines. Capillary refill is delayed.

Class 4: Volume loss over 40% of total blood volume. Hypotension with narrow
pulse pressure (less than 25 mmHg). Tachycardia becomes more pronounced
(more than 120 BPM), and mental status becomes increasingly altered. Urine
output is minimal or absent. Capillary refill is delayed.

Signs and symptoms:

 Rapid heartbeat
 Quick, shallow breathing
 Feeling weak
 Being tired
 Confusion or wooziness

2
  Little or no urine output
 Low blood pressure
 Cold, clammy skin

Graham Rogers (2017) mentioned that upper gastrointestinal bleeding is bleeding in

the upper gastrointestinal tract, commonly defined as bleeding arising from
the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis)
or in altered form in the stool (melena) or black tarry stool. Depending on the severity of
the blood loss, there may be symptoms of insufficient circulating blood volume and shock.
It can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer
causes such as gastric cancer.

Peptic ulcers are sores that develop in the lining of the stomach, lower
esophagus, or small intestine. They're usually formed as a result of inflammation
caused by the bacteria H. pylori, as well as from erosion from stomach acids,
Grahan Rogers (2017).

Causes:

- A bacterium: Helicobacter pylori bacteria commonly live in the mucous layer that
covers and protects tissues that line the stomach and small intestine.

- Regular use of certain pain relievers: Taking aspirin, as well as certain over-the-
counter and prescription pain medications called nonsteroidal anti-inflammatory drugs
(NSAIDs) can irritate or inflame the lining of your stomach and small intestine. Peptic
ulcers are more common in older adults who take these pain medications frequently.

- Other medications: Taking certain other medications along with NSAIDs, such as
steroids, anticoagulants, low-dose aspirin, selective serotonin reuptake inhibitors
(SSRIs), alendronate (Fosamax) and risedronate (Actonel), can greatly increase the
chance of developing ulcers.

Moreover, Lynn Marks (2015) stated that nonsteroidal anti-inflammatory drugs,

or NSAIDS, are a drug class that reduce pain, decrease fever, prevent blood clots and, in
higher doses, decrease inflammation. NSAIDS block proteins, called enzymes, in the body
that help make prostaglandins. Prostaglandins are a group of naturally occurring fatty

3
acids that play a role in pain and inflammation. NSAIDs also can decrease inflammation,
such as fever, swelling, and redness.

Common side effects of the drugs include dizziness, nausea, and gastric irritation.
Uncommon side effects include raised liver enzymes, fluid retention, compromise kidney
function, asthma exacerbation and lastly, gastric ulcer or bleeding.

Furthermore, Patient S.P.M. s/p TURP was admitted with ongoing cystoclysis.
According to Jessa Cultura (2013), cystoclysis is defined as “continuous bladder irrigation”
or CBI. A continuous infusion of a sterile solution into the bladder, usually by using a three-
way irrigation closed system with a triple-lumen catheter. One lumen is to drain urine;
another is used to inflate the catheter balloon, and the final lumen carries the irrigation
solution. It is primarily used following genitourinary surgery including transurethral
resection of the prostate (TURP), a surgery used to treat urinary problems due to an
enlarged prostate.

Prevalence rate of Hypovolemic shock

According to Sharven Taghavi and Reza Askar (2018), patients with hypovolemic
shock have severe hypovolemia with decreased peripheral perfusion. If left untreated,
these patients can develop ischemic injury of vital organs, leading to multi-system organ
failure. The annual incidence of shock in United States of any etiology is 0.3 to 0.7 per
1000, being most common in the intensive care unit. While the incidence of hypovolemic
shock from extracellular fluid loss is difficult to quantify, it is known that hemorrhagic shock
is most commonly due to trauma. In one study, 62.2% of massive transfusions at a level
1 trauma center were due to traumatic injury. In this study, 75% of blood products used
were related to traumatic injury. Elderly patients are more likely to experience hypovolemic
shock due to fluid losses as they have a less physiologic reserve.

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 DEMOGRAPHIC DATA

Name : Pt. S.P.M

Sex : Male
Age : 79
Address : Purok 2 Brgy. Bolbok, Lipa City, Batangas
Date of birth : May 1, 1939
Civil status : Married
Educational Attainment : High school Graduate
Occupation : Retired/ worked as real estate agent
Religion : Catholic
Nationality : Filipino
Date and Time of Admission : September 16, 2018 at 3:30 AM
Attending Physician/s : Dr. Vergara, Dr. Santiago & Dr. T. Villa
Chief Complaint : The patient complaints of paleness, hematemesis approximately 5 episodes,
epigastric pain and 5 episodes of hematochezia with ongoing cystoclysis, S/P TURP September
14,2018)
Admitting Diagnosis : Hypovolemic Shock 2˚ to upper GI Bleeding probably 2˚ to Bleeding
Peptic Ulcer Disease probably 2˚ to NSAID use, S/P TURP on September 14, 2018

5
 MEDICAL HISTORY

A. History of Present Illness

The client is 79 year old with admitting diagnosis of Hypovolemic Shock 2° to upper GI
Bleeding probably 2° to Bleeding Peptic Ulcer Disease probably 2° to NSAID use, S/P TURP
September 14, 2018 at Lipa Medix Medical Center. He was directly admitted in the ICU with
cystoclysis on September 16, 2018 at 3:30 AM, assessed as pale – looking, soft non tender
abdomen and full and equal pulse. After the admission, the following episodes are seen on the
client; at 7:55 AM, the he developed an allergic reaction from the current blood transfusion started
3:40 AM represented by chills and rashes with BP of 90/60, resulting to the current blood
transfusion to put on hold. At 6:40 PM, the client had hematemesis about 930ml and BP of 70/40
and positive for pallor, at the same time, the doctor ordered fresh whole blood regulated fast drip,
blood pressure changed to 130/70 from 70/40. Lastly, at 10:08 PM, reoccurrence of hematemesis
about 475 ml with blood pressure 80/40. Client is given 3 units’ of fresh whole blood, ongoing 4 th
unit transfusion

In relation to the present condition, at 12 nn of September 15, 2018 admitted in LCDH, pt

S.P.M manifested episodes of epigastric pain, hematochezia approximately 500 ml and
hematemesis about 700 ml resulting to hypotension 80/50.

B. Past Medical History

On June 29, 2018, he was diagnosed of difficulty in urinating due to enlarged prostate
and on September 14, 2018 Medical Mission of Lipa City District Hospital, the client decided
to undergo TURP or Transurethral resection of the prostate, a urological procedure to treat
benign prostatic hyperplasia. The client did not experience being hospitalized during his
childhood days. According to him, salabat and oregano are his medicines whenever he had
fever and cough. Not until he reached 35, he decided to go to nearest hospital to check his
skin condition, which was diagnosed as psoriasis. He’s been taking Humira 40 mg
subcutaneously every other week, one week after the initial dose of 80 mg subcutaneously
but he decided to stop because of financial problem

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C. Genogram with Family Medical History

Client S.P.M has eight siblings, two sisters and six brothers. He is in the fourth order in the
family. Her mother died because of endometrial cancer, while his father died at natural death. Six
years ago, his older sister was cancer free from stage IIA breast cancer.

According to National Library of Medicine, A particular disorder might be described as “running

in a family” if more than one person in the family has the condition. Some disorders that affect
multiple family members are caused by gene mutations, which can be inherited (passed down

7
from parent to child). Other conditions that appear to run in families are not caused by mutations
in single genes. Instead, environmental factors such as dietary habits or a combination of
genetic and environmental factors are responsible for these disorders.

D. Social and Environmental Data

Client is currently living in Purok 2, Bolbok, Lipa City. He is living with his wife and son, who
is also married. He had 3 daughters and 4 sons who are living with their own family. They are all
professionals. Before, client S.P.M worked as real estate agent but later on he decided to retire
and open a sari - sari store with his wife. According to his children, patient S.P.M is well known to
their barangay because of his personality that enjoyed by many. He is also known for being self-
less because he believed that helping is a blessing to others and to yourself. When he was young,
his mother taught him how to share what they have.

In theory, parental warmth and responsivity is hypothesized to promote children’s prosocial

behavior because it gives children feelings of security, control, and trust in the environment.
Personality is usually described as a set of psychological characteristics that lead one to behave
in meaningfully consistent ways. Moreover, research suggests that myriad personality descriptors
can be captured by a smaller set of broad trait domains such as the well-known Big Five domains
of extraversion, agreeableness, conscientiousness, neuroticism, and openness (Costa & McCrae,
1985). Especially important for research on development is the fact that these overarching
descriptors of personality are not immutable but rather change in meaningful ways across the
years

E. Lifestyle

The client is non-smoker and non-alcoholic. He stated that he sleeps at around 9 PM after
watching his favorite tv series. He wakes up at 5:30 AM to have fresh air while drinking coffee,
after 30 minutes, walking and jogging around the street are his physical activities in the morning.
Part of his daily routine is to chat with their neighbors, especially about politics. He listens to radio
when he is bored At lunch time, he never forget to watch “Eat Bulaga” because it entertains him.
During Sundays, they would have family bonding.

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According Helen Sanders of Health Ambition, drinking coffee on an empty stomach, such as first
thing in the morning, stimulates hydrochloric acid production. This can be a problem because HCl
should only be produced to digest meals. If your body has to make HCl more often in response
to regular cups of coffee, it may have difficulty producing enough to deal with a large meal.

One study published in 2007 in the journal "Psychoneuroendocrinology" indicates, that coffee
may not be a good thing when it comes to work-related stress. Health care workers who drank
the most coffee had the greatest levels of the stress hormone cortisol in the evening after a day
at work. However, this cortisol increase was also linked to decision authority, and it may be that
those with the most responsibility also drank the most coffee. A second unpublished study at the
University of Bristol in the U.K. found that consumption of caffeinated coffee in a work environment
made men feel more stressed, although it tended to reduce stress for women.

According to the client, drinking coffee at morning boost his energy and adds to his relaxation. He
also stated that he can finished two mugs of coffee before and after eating breakfast. Furthermore,
when he was still a real estate agent, he can consumed 8 mugs of coffee in a day.

F. Nutrition and Diet

The client is fond of eating healthy foods and carbohydrate such as kakanin and rice.
According to him, he is not the type of person that who would risk to try new dishes. As 79
year old, he is more to eating vegetables and fish rather than meat. He believed that it would
be better to eat those things to prevent other diseases. Sometimes, they would use additives
such as Aji nomoto because at his age, he’s having difficulty in tasting the flavors.

According to W R Drucker, P L Howard, and S McCoy of NCBI, high protein diet does not
prolong tolerance to recurrent blood loss but there is a greatly reduced tolerance to shock
whose body weight was maintained on a low protein/high carbohydrate diet. The latter animals
also exhibited impaired refill of plasma volume and a paradoxical, continuing hyperglycemic
response during hypovolemia. This study suggests that although an abundant supply of blood
glucose is available as an energy source, glucose uptake in the peripheral tissues is inhibited
during hypovolemia by unknown mechanisms and thus homeostasis is curtailed. The protein
content of the diet may be a critical factor in carbohydrate use during shock.

9
G. Psychological

According to the client’s son, patient S.P.M has a positive outlook towards the challenges
in life. But, when the client was hospitalized, they began seeing their father to lose faith. There
were certain questions that bothers the patient including “Gagaling pa ba ako?” “Tatagal pa
ba ako, ano bang ginawa kong kasalanan bakit ako nagkaganito?”

Self-identity is often the subject of greatest change when confronted with an epiphanic
experience. It requires one to assess and reassess life and can be confronting as it may also
be rewarding. Experiencing a serious illness or being subjected to a life-threatening disease
is one of these moments. The effects of the illness may be debilitating and confronting and
the illness process often requires one to gain control over its effects by assuming some level
of ownership. This does not occur in all instances and a person may choose to have an
important other e.g. spouse, medical specialist, to take over this role. However, this role as
constructed through social interaction (W Karnilowicz, The psychology of chronic illness.)

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 DEVELOPMENTAL STAGES

I. Erik Erikson’s Theory of Psychosocial development

Erikson’s (1959) theory of psychosocial development has eight distinct stages,
taking in five stages up to the age of 18 years and three further stages beyond, well into
adulthood. During each stage, the person experiences a psychosocial crisis which could
have a positive or negative outcome for personality development. For Erikson (1963),
these crises are of a psychosocial nature because they involve psychological needs of the
individual (i.e. psycho) conflicting with the needs of society (i.e. social).

According to Erik Erikson’s Theory of Psychosocial Development, the patient

belongs to the range of 65 and older in the stage of Ego Integrity vs. Despair. During this
time, the patient begin to reflect back on his life as he approach the end of it. Patient
S.P.M. is proud of some aspects of his life; he raised seven children and has good
relationships with all of them and worked as real estate agent for several years. Like most
people, the client looks back on his life and sees both the things he is proud of as well as
the things he might regret. He made valuable contributions to society, successfully raised
a family and every time he thinks of his grandchildren he realizes that he has given
something to the world that will ultimately outlast him.

Moreover, the way he resolves that conflict of pride and disappointment

determines how he resolves the conflict of ego identity and despair. On one hand, he was
able to find satisfaction with his life and achievements, therefore he found ego integrity, a
feeling of being whole and complete.

II. Lydia Hall’s The Care, Cure, and Core Theory

Hall’s theory define Nursing as the “participation in care, core and cure aspects of
patient care, where CARE is the sole function of nurses, whereas the CORE and CURE
are shared with other members of the health team.” The major purpose of care is to
achieve an interpersonal relationship with the individual that will facilitate the development
of the core. The source of energy and motivation for healing is the individual care recipient,

11
 not the health care provider. Hall emphasizes the importance of the individual as unique,
capable of growth and learning, and requiring a total person approach.
As health care providers provide care onto patient S.P.M. at the basic needs
level, it presents them and the patient an opportunity for closeness. The patient
himself was able to share and explore his feelings to the team without any fright and
hesitance. Through such expression, the patient was capable of gaining self-identity
and further develop maturity. The motivation and energy achieved are necessary for
healing exist within patient S.P.M, rather than in the health care team.

III. Afaf Ibrahim Meleis’ Transitions Theory

In Meleis theory, she mentioned that people undergo several types and patterns
of transition, these include: awareness, engagement, change and difference, time span,
and critical points and events. First, a person’s awareness of change could mean that the
person may have begun his or her transition. Second, engagement is when the degree to
which a person demonstrates involvement in the process inherent in the transition.
Changes and differences are a property of transition when a person experiences his or
her identities, roles, abilities, and behaviors necessary to bring sense of movement. Time
span is then defined as an identifiable starting point, extending from the first signs of
anticipation. Lastly, critical points and events are defined as markers such as birth, death
or cessation.

During a therapeutic communication, patient had stated that since the time he
experienced pain leading to his condition at this time, he was not able to do tasks just like
before. Although at first, he has been thinking why these things happened to him, he still
learned to abide the challenges he continuously facing pertaining to his condition.
Furthermore, he believes God would not let him feel alone in his battle so he lifts himself
up by way also of his loved ones who constantly support him emotionally, physically, and
mentally.

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 PHYSICAL ASSESSMENT

Intensive Care Unit

Date Performed: September 17, 2018, 6:20AM

General Assessment: The patient appeared pale in general. He is lethargic where he shows
drowsiness, reduced alertness and the need for any verbal stimulation to only show response.
There are episodes of disorientation. Patient is able to do range of motions very slowly.
The following was taken during the day of our exposure:

Vital Signs:

TIME BLOOD TEMPERATURE PULSE RATE RESPIRATORY

PRESSURE RATE
6:00 AM 90/60mmHg 37.5°C 83 18
7:00AM 90/60mmHg 37.2°C 85 18
8:00AM 110/60mmHg 37.1°C 82 19
9:00AM 120/60mmHg 36.3°C 78 18
10:00AM 110/60mmHg 36.8°C 76 15
11:00AM 100/50mmHg 36.5°C 55 16
12:00NN 100/70mmHg 37.2°C 79 18
1:00PM 120/70 mmHg 37.6°C 84 17
2:00PM 110/60mmHg 36.2°C 85 16

Input: 3, 480cc (composed of IVF and cystoclysis)

Urine output: 850cc (upon endorsement of nurse from 8 hours duty prior to exposure)

Note:
(+) Hematochezia started and noticed at 2:15am. Stool appears to have blood in it. Also, bright
red liquid blood is excreted with the stool.
(+) Hematemesis at 2:30am (approx. 475ml). Vomit appears to be solely red liquid with few
clotted blood.

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BODY PART METHOD USED FINDINGS SIGNIFICANCE
Skin Inspection Pallor (+) Reduced blood flow
in body system

Reference: Paleness,
also known as pallor,
is an unusual lightness
of skin color compared
with the normal
complexion. Paleness
may be caused by
reduced blood flow
and oxygen or by a
decreased number of
red blood cells.
(https://www.healthline.com/
symptom/pallor)

Dry, scaly, white Hx of Psoriasis

patches on both legs Reference: The 5 most
common symptoms of
psoriasis include:
1. Rashes or patches
of red, inflamed skin…
2. Itchy, dry, painful
skin that can crack or
bleed.
3. Small areas of
bleeding where the
involved skin is
scratched.
4. Problems with your
fingernails and
toenails, including
discoloration and
pitting.
5. Scaly plaques on
top skin.
(https://www.webmd.com/skin-
problems-and-treatments/psoriasis/
psoriasis-signs-symptoms)

14
Head Inspection Symmetrical facial Normal
features
Palpation
No signs of tenderness,
lesions, lump or
depression
Hair Inspection Black, short coarse hair Normal balding pattern
Positive for hair thinning
or hair loss Reference: Gender,
age and genetics
affect hair distribution.
Hair should be evenly
distributed exceptions
are normal balding
patterns common to
men or persons of
advanced age. Hair
thins with age.
(https://healthassessmentsite.
wordpress.com/2016/05/09/skin-
hair-and-nails-assessment/)

No infestation
Scalp Inspection Dry scalp Normal

Palpation No wounds, dandruff

nor scaly patches
Eyes Inspection Pupils are black (+) Weakness related
Equal pupil size to eye reactivity
Round pupil shape
Reactive only slightly Reference: Weakness
Light makes pupil (that can be due to
constrict and dilate body injury, anatomical
although slowly or pathology, etc.) may
sluggishly affect a few or many
Accommodation shows muscles and develop
weak ability to see suddenly or gradually.
things far away and Weakness of specific
sometimes even close muscle groups can
up cause disorders of eye
movement, dysarthria,

15
 dysphagia, or
respiratory weakness.
(https://www.merckmanuals
.com/professional/neurologic-
disorders/symptoms-of-neurologic-
disorders/weakness

Pale conjunctiva (+) Reduced blood flow

in body system

Reference: Paleness
or pallor, is an unusual
lightness of skin color
compared with the
normal complexion.
Paleness, including the
conjunctiva that has
several blood vessels,
may be caused by
reduced blood flow
and oxygen or by a
decreased number of
red blood cells.
(https://www.healthline.com/
symptom/pallor)
Ears Inspection Parallel and Normal
symmetrical

No discharge or lesions

Palpation Tympanic membranes

and external auditory
canals normal

Sense of hearing: Able

to hear words and
correctly repeat
whispered word slowly
Nose Inspection Nasal mucosa normal Normal
Internal nares are clean

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 Sense of smell: Able to
smell odors
Mouth Inspection Dry lips (+) Possible signs of
Xerostomia dehydration

Reference: Xerostomia
is often (but not
always) associated
with hypofunction of
the salivary glands.
The main cause of this
is by the lack of
sufficient fluids in the
body that then can be
due to several
alterations to the
body’s metabolism.
(https://www.medicalnews
today.com/articles/187640.php)

No lesions and swelling

Slight pallor (+) Reduced blood flow

in body system

Reference: Paleness,
also known as pallor,
is an unusual lightness
of skin color compared
with the normal
complexion. Paleness
may be caused by
reduced blood flow
and oxygen or by a
decreased number of
red blood cells.
(https://www.healthline.com/
symptom/pallor)
Teeth Inspection Light yellow in color

17
 Use of dentures: (+) Teeth loss
Denture for entire upper Reference: Tooth loss
dental area is often associated
(incisors, cuspids and with aging. The nerves
molars) in the teeth become
smaller, and a person
Denture for bottom is less able to feel pain
dental area related to tooth decay
(entire molars, 3 or gum disease. Often,
cuspids and 1 incisior) the condition isn’t
treated until it’s too late
and the tooth is
beyond saving.
(https://www.miamiperio.
com/blog/aging-teeth)
Neck Inspection Palpable inflamed (+) Illness or infection
cervical and
Palpation submandibular lymph Reference: Swollen
nodes cervical lymph nodes
are nonthreatening.
However, it can occur
in reaction to infection,
injury, or cancer.
(Weber, Health Assessment in
Nursing)
Lung / Thorax Auscultation No abnormal breath Normal
sounds

Resonant on lung fields

Breast / Palpation / No lump or tenderness Normal

Chest Auscultation Normal apical rate

heard on intercostal
spaces

No third or fourth heart

sound heard on apex
Axillary Palpation Palpable inflamed (+) Illness or infection
axillary lymph nodes
Reference: This may
be due to the filtered

18
 accumulated germs or
cancel cells. Axillary
lymph nodes can
become enlarged in
many conditions
including infections,
lymphomas, and
breast cancers.
(https://www.verywellhealth-
com/axillary-lymph-nodes-
2252131

No lumps, rashes or
lesions present
Arms Palpation Pallor (+) Reduced blood flow
in body system

Range of motion: Reference: Paleness,

Inspection
Very slow but able to do also known as pallor,
range of motions like is an unusual lightness
flexion, extension, of skin color compared
abduction, adduction with the normal
and rotation complexion. Paleness
may be caused by
reduced blood flow
and oxygen or by a
decreased number of
red blood cells.
(https://www.healthline.com/
symptom/pallor)
Hands Inspection Capillary refill > 3 secs (+) Reduced blood flow
in body system
Palpation Pale/ whitish nail bed
Reference: Paleness,
also known as pallor,
is an unusual lightness
of skin color compared
with your normal
complexion. Paleness
may be caused by
reduced blood flow
and oxygen or by a

19
 decreased number of
red blood cells.
(https://www.healthline.com/
symptom/pallor)

IV site for insertion (+) Rehydration and

Intravenous fluid on Nutritional needs
R hand.
Reference: There are
several reasons why
there is a need to have
fluids administered
intravenously. For
instance, some
treatments rely on IV
delivery. Others
include rehydration,
medication
(https://www.healthline.com/
health/intravenous-fluid regulation
#purpose)
Abdomen Palpation Slight epigastric pain (+) Peptic ulcer
disease
(+) Upper GI Bleeding

Reference: Epigastric
pain is the most
common symptom of
both gastric and
duodenal ulcers. It is
characterized by a
gnawing or burning
sensation and occurs
after meals…
(https://emedicine.medscape.
com/article/181753-overview#a3)

Signs and symptoms

of an acute upper GI
bleeding include the
following:
- Hematemesis

20
 - Hematochezia
- Epigastric pain
- Heart burn…
(https://emedicine.medscape.
com/article/187857-overview#a1)

No altered bowel
sounds, rubs or
Auscultation vascular bruits

Tympanic abdominal
Percussion sound
Genitalia Inspection Three-way indwelling (+) Cystoclysis
Foley catheter inserted
Reference: It is a
process of flushing the
bladder with normal
saline. It is primarily
used following
genitourinary surgery
to keep the bladder
clear and free of blood
clots or sediment.
(https://medical-
dictionary.thefreedictionary.
com/continuous+bladder+
irrigation)

No signs of redness,
lesions or swelling

Frequent urge to
urinate

Rectum Inspection No signs of rectal Normal

bleeding, lumps nor
lesions
Legs Inspection Dry, scaly, white Hx of Psoriasis
patches on both legs Reference: The 5 most
common symptoms of
psoriasis include:

21
 1. Rashes or patches
of red, inflamed skin…
2. Itchy, dry, painful
skin that can crack or
bleed.
3. Small areas of
bleeding where the
involved skin is
scratched.
4. Problems with your
fingernails and
toenails, including
discoloration and
pitting.
5. Scaly plaques on
top skin.
(https://www.webmd.com/skin-
problems-and-treatments/psoriasis/
psoriasis-signs-symptoms)

Feet Inspection Dry, scaly, white Hx of Psoriasis

patches Reference: The 5 most
common symptoms of
psoriasis include:
1. Rashes or patches
of red, inflamed skin…
2. Itchy, dry, painful
skin that can crack or
bleed.
3. Small areas of
bleeding where the
involved skin is
scratched.
4. Problems with your
fingernails and
toenails, including
discoloration and
pitting.
5. Scaly plaques on
top skin.
(https://www.webmd.com/skin-
problems-and-treatments/psoriasis/
psoriasis-signs-symptoms)

22
Date Performed: September 18, 2018, 6:30AM

General Assessment: Patient have slight pink skin appearance. He is conscious and is oriented
to physical environment. He is able to response verbally and communicate.

Vital Signs:

TIME BLOOD TEMPERATURE PULSE RATE RESPIRATORY

PRESSURE RATE
6:00 AM 110/80mmHg 36.9°C 70 21
7:00AM 160/80mmHg 37.2°C 59 15
8:00AM 140/80mmHg 36.5°C 57 18
9:00AM 120/80mmHg 36.3°C 64 18
10:00AM 110/70mmHg 36.5°C 60 18
11:00AM 120/100mmHg 37.2°C 61 19
12:00NN 140/80mmHg 36.9°C 55 16
1:00PM 120/80mmHg 36.8°C 72 19
2:00PM 120/90mmHg 37.4°C 74 16

Input: 3, 100cc
Output: 750cc

BODY PART METHOD USED FINDINGS SIGNIFICANCE

Skin Inspection Dry, scaly, white Hx of Psoriasis
patches on both legs Reference: The 5 most
common symptoms of
psoriasis include:
1. Rashes or patches
of red, inflamed skin…
2. Itchy, dry, painful
skin that can crack or
bleed.
3. Small areas of
bleeding where the
involved skin is
scratched.

23
 4. Problems with your
fingernails and
toenails, including
discoloration and
pitting.
5. Scaly plaques on
top skin.
(https://www.webmd.com/skin-
problems-and-treatments/psoriasis/
psoriasis-signs-symptoms)

Head Inspection Symmetrical facial Normal

features
Palpation
No signs of tenderness,
lesions, lump or
depression
Hair Inspection Black, short coarse hair Normal balding pattern
Positive for hair thinning
or hair loss Reference: Gender,
age and genetics
affect hair distribution.
Hair should be evenly
distributed exceptions
are normal balding
patterns common to
men or persons of
advanced age. Hair
thins with age.
(https://healthassessmentsite.
wordpress.com/2016/05/09/skin-
hair-and-nails-assessment/)

No infestation
Scalp Inspection Dry scalp Normal

Palpation No wounds, dandruff

nor scaly patches
Eyes Inspection Pupils are black Normal
Equal pupil size
Round pupil shape
Reactive to light

24
 Light makes pupil
constrict and dilate
Accommodation shows
good ability to see
things close up
Ears Inspection Parallel and Normal
symmetrical
Palpation
No discharge or lesions

Tympanic membranes
and external auditory
canals normal

Sense of hearing: Able

to hear words and
correctly repeat
whispered word slowly
Nose Inspection Nasal mucosa normal Normal
Internal nares are clean

Sense of smell: Able to

smell odors
Mouth Inspection Dry lips (+) Dehydration
Xerostomia
Reference: Xerostomia
is often (but not
always) associated
with hypofunction of
the salivary glands.
The main cause of this
is by the lack of
sufficient fluids in the
body that then can be
due to several
alterations to the
body’s metabolism.
(https://www.medicalnews
today.com/articles/187640.php)

25
 No lesions and swelling

Teeth Inspection Light yellow in color

Use of Denture: (+) Teeth loss

Denture for entire upper Reference: Tooth loss
dental area is often associated
(incisors, cuspids and with aging. The nerves
molars) in the teeth become
smaller, and a person
Denture for bottom is less able to feel pain
dental area related to tooth decay
(entire molars, 3 or gum disease. Often,
cuspids and 1 incisior) the condition isn’t
treated until it’s too late
and the tooth is
beyond saving.
(https://www.miamiperio.
com/blog/aging-teeth)
Neck Inspection Palpable inflamed (+) Illness or infection
cervical and
Palpation submandibular lymph Reference: Swollen
nodes cervical lymph nodes
are nonthreatening.
However, it can occur
in reaction to infection,
injury, or cancer.
(Weber, Health Assessment in
Nursing)
Lung / Thorax Auscultation No abnormal breath Normal
sounds

Resonant on lung fields

Breast / Palpation / No lump or tenderness Normal

Chest Auscultation Normal apical rate

heard on intercostal
spaces

26
 No third or fourth heart
sound heard on apex
Axillary Palpation Palpable inflamed (+) Illness or infection
axillary lymph nodes
Reference: This may
be due to the filtered
accumulated germs or
cancel cells. Axillary
lymph nodes can
become enlarged in
many conditions
including infections,
lymphomas, and
breast cancers.
(https://www.verywellhealth-
com/axillary-lymph-nodes-
2252131

No lumps, rashes or
lesions present
Arms Palpation Normal

Range of motion:
Slow but able to do
range of motions like
flexion, extension,
abduction, adduction
and rotation
Hands Inspection IV site for insertion (+) Rehydration and
Nutritional needs
Palpation
Reference: There are
several reasons why
there is a need to have
fluids administered
intravenously. For
instance, some
treatments rely on IV
delivery. Others

27
 include rehydration,
medication
(https://www.healthline.com/
health/intravenous-fluid regulation
#purpose)
Abdomen Palpation Little episodes of (+) Peptic ulcer
epigastric pain disease
(+) Upper GI Bleeding

Reference: Epigastric
pain is the most
common symptom of
both gastric and
duodenal ulcers. It is
characterized by a
gnawing or burning
sensation and occurs
after meals…
(https://emedicine.medscape.
com/article/181753-overview#a3)

Signs and symptoms

of an acute upper GI
bleeding include the
following:
- Hematemesis
- Hematochezia
- Epigastric pain
- Heart burn…
(https://emedicine.medscape.
No altered bowel com/article/187857-overview#a1)
Auscultation sounds, rubs or
vascular bruits

Tympanic abdominal
Percussion sound

Genitalia Inspection No signs of redness, Normal

lesions or swelling

Urine appeared free Reference: In some

from clots and blood. cases, orange urine can

28
 indicate a problem with
any of the urinary system
or even the live,
especially if it includes
light-colored stools.
Dehydration, make it
much deeper in color,
can also make urine
appear orange.
(https://www.mayoclinic.
org/diseases-conditions/urine-
color/symptoms-causes/syc-
20367333)
Rectum Inspection No signs of rectal Normal
bleeding, lumps nor
lesions
Legs Inspection Dry, scaly, white Hx of Psoriasis
patches on both legs
Reference: The 5 most
common symptoms of
psoriasis include:
1. Rashes or patches
of red, inflamed skin…
2. Itchy, dry, painful
skin that can crack or
bleed.
3. Small areas of
bleeding where the
involved skin is
scratched.
4. Problems with your
fingernails and
toenails, including
discoloration and
pitting.
5. Scaly plaques on
top skin.
(https://www.webmd.com/skin-
problems-and-treatments/psoriasis/
psoriasis-signs-symptoms)

Feet Inspection Dry, scaly, white Hx of Psoriasis

patches

29
Reference: The 5 most
common symptoms of
psoriasis include:
1. Rashes or patches
of red, inflamed skin…
2. Itchy, dry, painful
skin that can crack or
bleed.
3. Small areas of
bleeding where the
involved skin is
scratched.
4. Problems with your
fingernails and
toenails, including
discoloration and
pitting.
5. Scaly plaques on
top skin.
(https://www.webmd.com/skin-
problems-and-treatments/psoriasis/
psoriasis-signs-symptoms)

30
 ANATOMY AND PHYSIOLOGY

The Circulatory System

The circulatory system, also called the cardiovascular system or the vascular system, is
an organ system that permits blood to circulate and transport nutrients(such as amino
acids and electrolytes), oxygen, carbon dioxide, hormones, and blood cells to and from
the cells in the body to provide nourishment and help in fighting diseases, stabilize
temperature and pH, and maintain homeostasis.

The arteries are part of the circulatory system, which is

responsible for the delivery of oxygen and nutrients
to all cells, as well as the removal of carbon
dioxide and waste products, the maintenance of
optimum blood pH, and the circulation of proteins and
cells of the immune system. They carry blood that is
oxygenated after it has been pumped from the heart.

The capillaries merge to bring blood into the venous

system. Blood flows from the heart through arteries,
which branch and narrow into arterioles, and then

31
 branch further into capillaries where nutrients and
wastes are exchanged.

The veins are blood vessels that carry blood toward the heart. Most veins carry
deoxygenated blood from the tissues back to the heart; exceptions are
the pulmonary and umbilical veins, both of which carry oxygenated blood to the heart.
Veins are less muscular than arteries and are often closer to the skin. There are valves
in most veins to prevent backflow.

The heart is a muscular organ in most animals, which

pumps blood through the blood vessels of the circulatory system.
Blood provides the body with oxygen and nutrients, as well as
assists in the removal of metabolic wastes.[2] In humans, the heart
is located between the lungs, in the middle compartment of
the chest.

The lymphatic system is part of the vascular system and an

important part of the immune system, comprising a large network
of lymphatic vessels that carry a clear fluid
called lymph directionally towards the heart. The other main
function is that of defense in the immune system.

32
The Digestive System

The digestive system is uniquely designed to turn the food humans eat into nutrients, which
the body uses for energy, growth and cell repair.

The mouth is the beginning of the digestive tract. In fact, digestion starts here
as soon as the meal is taken down. With the use of the tongue, foods then are
pushed into the throat (pharynx).

The esophagus is a muscular tube extending from the pharynx to

the stomach. By means of a series of contractions, called peristalsis, the
esophagus delivers food to the stomach.

33
 The stomach is a sac-like organ with strong muscular walls. In addition to
holding the food, it's also a mixer and grinder. The stomach secretes acid
and powerful enzymes that continue the process of breaking down the food.

In this case study, the patient was diagnosed with Peptic Ulcer. As mentioned, Peptic ulcers
are sores that develop in the lining of the stomach, lower esophagus, or small intestine.
Therefore, this part of the digestive tract is where the patient experienced defect or
limitation in a normal anatomical process.

The liver is a large, meaty organ that sits on the right upper side of the
stomach. The liver's main job is to filter the blood coming from the digestive
tract, before passing it to the rest of the body. The liver also detoxifies
chemicals and metabolizes drugs. As it does so, the liver secretes bile that
ends up back in the intestines. The liver also makes proteins important for
blood clotting and other functions.

The gallbladder is a small pouch that sits just under the liver. The
gallbladder stores bile produced by the liver. After meals, the gallbladder
is empty and flat, like a deflated balloon. Before a meal, the gallbladder
may be full of bile and about the size of a small pear.

Meanwhile, the pancreas is about 6 inches long and sits across the back
of the abdomen behind the stomach. It secretes enzymes into the small
intestine. These enzymes break down protein, fat, and carbohydrates
from the food we eat.

The spleen is an organ in the upper far left part of the abdomen, to the left
of the stomach. It acts as a filter for blood as part of the immune system.
Old red blood cells are recycled in the spleen, and platelets and white
blood cells are stored there.

34
 When it leaves the stomach, food is the consistency of a liquid or paste.
From there the food moves to the small intestine. The small intestine
continues the process of breaking down food by using enzymes
released by the pancreas and bile from the liver. The duodenum is
largely responsible for continuing the process of breaking down food,
with the jejunum and ileum being mainly responsible for the absorption
of nutrients nto the bloodstream.

In this study, the diagnosis considered upper gastrointestinal bleeding where patient
experienced epigastric pain that can possibly be determined by stomach or the duodenum.
The colon is a 5- to 6-foot-long muscular tube that connects the cecum
(the first part of the large intestine to the rectum (the last part of the large
intestine). It is made up of the cecum, the ascending (right) colon, the
transverse (across) colon, the descending (left) colon, and the sigmoid
colon (so-called for its "S" shape; the Greek letter for S is called the sigma),
which connects to the rectum.

Stool, or waste left over from the digestive process, is passed through the colon by means of
peristalsis (contractions), first in a liquid state and ultimately in solid form as the water is
removed from the stool.

It is the rectum's job to receive stool from the colon, to let you know there
is stool to be evacuated, and to hold the stool until evacuation happens.
When anything (gas or stool) comes into the rectum, sensors send a
message to the brain. The brain then decides if the rectal contents can
be released or not. If they can, the sphincters (muscles) relax and the
rectum contracts, expelling its contents. If the contents cannot be expelled, the sphincters
contract and the rectum accommodates, so that the sensation temporarily goes away.

The anus is the last part of the digestive tract. It consists of the pelvic
floor muscles and the two anal sphincters (internal and external
muscles). The lining of the upper anus is specialized to detect rectal
contents. It lets us know whether the contents are liquid, gas, or solid.

35
 THE INTEGUMENTARY SYSTEM

The skin is the largest organ of the body, with a total area of about 20 square feet. The skin
protects the body from microbes and the elements, helps regulate body temperature, and
permits the sensations of touch, heat, and cold.

Skin has three layers:

 The epidermis, the outermost layer of skin, provides a waterproof barrier and creates
our skin tone.
 The dermis, beneath the epidermis, contains tough connective tissue, hair follicles,
and sweat glands.
 The deeper subcutaneous tissue (hypodermis) is made of fat and connective tissue.

The skin’s color is created by special cells called melanocytes, which produce the pigment
melanin. Melanocytes are located in the epidermis.

Sweat glands that excrete wastes and regulate body temperature are also part of the
integumentary system. Somatosensory receptors and nociceptors are important
components of this organ system that serve as warning sensors, allowing the body to
move away from noxious stimuli.

36
The epidermis is the outermost of the three layers that make up
the skin, the inner layers being the dermis and hypodermis. The
epidermis layer provides a barrier to infection from
environmental pathogens and regulates the amount of water released
from the body into the atmosphere through transepidermal water loss.

The dermis or corium is a layer of skin between the epidermis (with

which it makes up the cutis) and subcutaneous tissues, that
primarily consists of dense irregular connective tissue and cushions
the body from stress and strain.

The subcutaneous tissue also called the hypodermis, hypoderm or

superficial fascia, is the lowermost layer of the integumentary
system. It lies between the dermis and underlying tissue or organ. It
serves as an insulation or padding of the body.

37
38
39
 LABORATORY RESULTS

Type of Examination: Urinalysis (UA)

Date Examined: September 15, 2018

A urinalysis is a test of your urine. A urinalysis is used to detect and manage a wide range
of disorders, such as urinary tract infections, kidney disease and diabetes. It involves checking
the appearance, concentration and content of urine. Abnormal urinalysis results may point to a
disease or illness.

NORMAL VALUES RESULT INTERPRETATION

Color Yellow YELLOW Normal

Character SLIGHTLY TURBID SLIGHTLY TURBID Normal

Creatinine 0.67 – 1.17 0.80 Normal

PH 4.5-8 6.0 Normal

Sugar 0 - 0.8 mmol/l (0 - 15 NEGATIVE Normal

mg/dL)

0-20 mg/dL is the

Albumin minimal detection NEGATIVE Normal
limit of protein

Epithelial Cells ≤15-20 squamous NEGATIVE Normal

epithelial cells/hpf

Bacteria NONE FEW Presence of bacteria in

the urine related to
Urinary Tract Infection
and prostate.

40
41
Type of Examination: Complete Blood Count (CBC)
Date Examined: September 15, 2018

A complete blood count (CBC) is a blood test used to evaluate your overall health and
detect a wide range of disorders, including anemia, infection and leukemia. A complete blood
count test measures several components and features of your blood, including: Red blood cells,
which carry oxygen. White blood cells, which fight infection. Hemoglobin, the oxygen-carrying
protein in red blood cells. Hematocrit, the proportion of red blood cells to the fluid component, or
plasma, in your blood. Platelets, which help with blood clotting.

BLOOD TYPE: A
RH TYPE: POSITIVE

CBC NORMAL VALUE RESULTS INTERPRETATION

WBC cell count can
double within hours
WBC ≤2-5 WBCs/hpf 11.00 after certain stimuli
such as post TURP
because of the large
bone marrow storage
and intravascular
marginated pools of
neutrophils.
Infections or
obstruction in the
urinary tract, prostate
or bladder may cause
an increased amount of
leukocytes.
Hemoglobin 11 – 16 11.6 (LCDH) Normal
pre-operative
9-14-2018

Hemoglobin is a protein
Hemoglobin 7.5 (MEDIX) in red blood cells that
post- operative carries oxygen
9-17-2018 throughout the body. Low
level of hemoglobin
indicates anemia,
Bleeding in digestive
tract, or post TURP
procedure.

42
Hematocrit 37 - 54 34.7 A low hemoglobin count
is associated with a
disease or condition that
causes few red blood
cells, blood loss,
enlarged prostate.

A high count of red blood

RBC 3.50 – 5.50 4.2 – 6.3 cells can indicate
infection, trauma,
enlarge prostate,
tumors, or kidney stones.

Neutrophils 50.0 – 70.0 82.7

Elevated count of
Neutrophils is caused
by Infection, bleeding
and medication that
can increase neutrophils
count one of which is
corticosteroids.

Lymphocytes 20 – 40 9.5 A low level of

lymphocytes indicates
that insufficient white
blood cells are being
made, cells are being
destroyed, cells are
caught in the lymph
nodes or spleen, or any
combination of these.

Monocytes 3.0 – 12.0 6.2 Normal

Eosinophils 1.2 0.5 – 5.0 Normal
Basophils 0.4% 0.0 – 0.5 Normal

Thrombocyte 150 – 450 85 10^9/L A low platelet count may

also be called
thrombocytopenia. This
condition can range
from mild to severe,
depending on its
underlying cause.

43
 symptoms can include
severe bleeding and
are possibly fatal if
they’re not treated.

MCV 80.0 – 100.0 93.2 fl Normal

MCH 27.0 – 34.0 31.2 pg Normal

MCHC 0.32 – 0.35 0.33 Normal

Radiological Society of North America, Inc. (RSNA)

https://www.radiologyinfo.org/en/info.cfm?pg=abdominus

44
National Institutes of Health's Web site

https://medlineplus.gov

45
ULTRASOUND RESULT FORM
Date Examined: July 29, 2018

Ultrasound imaging of the abdomen uses sound waves to produce pictures of the
structures within the upper abdomen. It is used to help diagnose pain or distention (enlargement)
and evaluate the kidneys, liver, gallbladder, bile ducts, pancreas, spleen and abdominal aorta.
Ultrasound is safe, noninvasive and does not use ionizing radiation. This procedure requires little
to no special preparation.

Kidneys, Urinary bladder & Prostate Ultrasound:

Both kidneys are normal in size exhibiting homogenous parenchyma. The right measuring about
8.58 x 3.88 x 3.88 cm/L x W x AP. The left, measuring about 9.35 x 4.85 x 4.48 cm (L x W x AP).
There is no evident lithiasis seen, both pelvocalyceal systems are not dilated.

The urinary bladder is physiologically distended showing smooth contour and outline.
No evident lithiasis seen. The wall is not thickened.

Trans-abdominal scarring shows an enlarged prostate gland measuring approximately 4.04

x 3.69 x 3.75 cm (L x W x AP) and weighting approximately 29.3 grams. The parenchymal echo
pattern is homogenous.

IMPRESSION:
Unremarkable kidneys and urinary bladder. Enlarged prostate gland (approx. wt.: 29.3 grams).
The parenchymal echo pattern is homogenous.

Radiological Society of North America, Inc. (RSNA)

https://www.radiologyinfo.org/en/info.cfm?pg=abdominus

46
 A 12-LEAD EKG
The primary purpose of the 12-lead EKG is to screen patients for cardiac ischemia, especially for
acute ST-elevation myocardial infarction. The standard 12-lead electrocardiogram is a
representation of the heart's electrical activity recorded from electrodes on the body surface. This
section describes the basic components of the ECG and the lead system used to record the ECG
tracings. ECG Waves and Intervals. A 12-lead EKG. The indications include:

1. Chest pain

2. Atypical chest pain

3. Epigastric pain

4. Back, neck, jaw or arm pain without chest pain

5. Palpitations

6. Syncope or near syncope

7. Pulmonary edema

8. Exertional dyspnea

9. Weakness

10. Diaphoresis unexplained by ambient temperature

11. Feel of anxiety or impending doom

12. Suspected diabetic ketoacidosis

ECK Learning Center

Utah USA
https://ecg.utah.edu/

47
 MEDICAL AND SURGICAL MANAGEMENT

Medical Management

DOCTOR’S ORDER RATIONALE

09/16/18
3:30 am

Please admit patient under Dr. D. To have a proper monitoring and planning
Vergara. and execution of interventions.

Secure consent for admission and To represent the ethical and legal expression
management. of the patient’s rights.

Ordered in preparation for a medical and

NPO
diagnostic procedure.

Diagnostics:

CBG To check blood glucose level.

To determine if there are abnormalities in the

CBC
blood cell counts.

To detect any alterations in the kidney and

Urinalysis
urinary tract.

12-lead ECG To measure the electrical activity of the heart.

To determine the ABO blood group and Rh

ABO typing
type for blood transfusion.

HBsAg To screen for Hepatitis B.

Serum Na, K To detect electrolyte imbalance.

Creatinine, BUN To assess kidney function.

48
 To evaluate the lungs, heart and chest wall
Chest x-ray and helps identify abnormalities and or
diseases.

To diagnose and detect a heart attack or any

Trop T quanti
heart-related conditions.

To help assess respirations by evaluating gas

ABG
exchange in the lungs.

To identify the cause of unexplained

PT, PTT, INR
bleeding.

To screen patients having prolonged bleeding

CT, BT
times.

To check if there is an abnormality and

SGPT, SGOT
severity of conditions of the liver.

Medications:

Norepinephrine 8mg + 250 cc PNSS To treat hypotension.

to run at 0.3mcg/kg/min Time: 3:30 am
BP: 80/50 mmHg

Tranexamic acid 500mg IV q6 To stop blood clots from breaking down and
reduce prolonged bleeding.

Omeprazole 80mg IV stat, then 40mg To help relieve epigastric pain.

IV q12

VS q1 and record An alteration in a patient’s vital signs can

provide objective evidence of the body’s
response to physical and psychological
stress or changes in physiological function.

49
 To monitor input and output and for
Maintain IFC
treatment.

I&O q shift and record To monitor or detect for fluid imbalances.

Refer to Dr. T. Villa for co-management. For gastrointestinal tract evaluation.

WOF: hyperthermia, chest To determine the extent of hypovolemic

pain/heaviness, dyspnea, sensorium shock and if internal hemorrhage is present.
changes.

3:40 am
Secure and transfuse 5 units of FWB x FD To restore the blood volume and components
properly typed and cross matched. and to maintain effective tissue perfusion.

Medications:

Start Voluven 500cc x 4 hours To treat or reduce hypovolemia.

Vitamin K 10mg IV q8 Helps in the formation of blood clots and

prevents further blood loss.

Somatostatin 250mcg stat To control non-variceal upper gastrointestinal

Somatostatin drip: Somatostatin + bleeding, including that peptic ulcers, in order
PNSS 1L x 24 hours for the endoscopist to have a clearer view of
varices because of less active bleeding.

IVF:
PNSS 1L fast drip 100cc, then To prime tubing before blood transfusion.
regulate to 90 cc/hr

Place on Trendelenburg position. To facilitate blood circulation back to the

brain that would divert blood from the lower
extremities to the central circulation,
augmenting cardiac filling by increasing right
and left ventricular preloads, stroke volume
and cardiac output.

50
 Regulate present blood transfusion to fast To restore or replace lost blood volume.
drip.

4:30 am
CP evaluation stands for the contemplated To assess the patient's pre-procedure cardiac
procedure. and pulmonary condition to avoid foreseeable
complications during procedure.

6:00 am
O2 at 2-3L/min via nasal cannula To aid in oxygen deprivation due to
continuous blood loss.

7:55 am

Diphenhydramine 50mg IV stat To prevent and treat any febrile non-

hemolytic and allergic reactions from the
blood transfusion.

8:01 am

Give hydrocortisone 100mg IV stat. To decrease the possibility of immune

reaction from the blood transfusion as the
patient have already shown sign of allergic
reaction in the form of rashes.

Hold gastroscopy until further order. To monitor patient until less bleeding is
present and contained and stabilize patient
before procedure.

9:40 am
Give hydrocortisone 10mg IV at 12 noon. Serves as a prophylaxis in preventing any
transfusion reaction.

Resume blood transfusion after 2nd dose To consume remaining FWB bag after being
of hydrocortisone. put on hold.

Facilitate blood transfusion. To monitor and detect signs and symptoms of

transfusion reaction.

For CP clearance. To assess the patient's pre-procedure cardiac

and pulmonary condition to avoid foreseeable
complications during procedure.

51
 For gastroscopy tomorrow 9 am. To detect if the source of bleeding is from the
upper gastrointestinal tract.

10:43 am
 Discontinue Voluven. To prevent fluid or circulatory overload
 Regulate blood transfusion for 4 hours, no because less bleeding is evident by this time.
interval.

2:25 pm

Regulate cystoclysis at 60 gtts/min. To flush the bladder with normal saline to

prevent or treat clot formation. Also, to
ensure the patency of the drainage system.

2:30 pm

Regulate cystoclysis at 60 cc/hr. To drain clot formations and fluids, and

bladder during acute urinary retention.

May wet lips only. Helps relieve mouth dryness during NPO.

May use D5W to inotropes. Promotes drug compatibility.

5:25 pm
IVF to follow: PNSS 1L x 90 cc/hr. To replenish fluid and prevent from
dehydration.

6:40 pm
Fast drip 300cc PNSS To check for blood pressure improvement
and prime tubing before blood transfusion.

(+) Hematemesis: 930mL

7:00 pm
Tranexamic acid 1gm IV stat Stops blood clots from breaking down and
reduce prolonged bleeding.

↑ Levophed to 1mcg/kg/min Treats events of acute hypotension.

Time: 6:40 pm
BP: 70/40 mmHg

Secure 3 more units of FWB. To obtain the completion of the transfusion

episode.

52
 Run 2 units fresh whole blood as fast drip To replace lost blood volume.
x 4 hours

Continue somatostatin drip. To control non-variceal upper gastrointestinal

bleeding, including that peptic ulcers, in order
for the endoscopist to have a clearer view of
varices because of less active bleeding.

↓ IVF to KVO while on blood transfusion. To prevent circulatory or fluid overload while
on blood transfusion.

Omeprazole 40mg IV now. To help relieve epigastric pain.

8:30 pm

Continue blood transfusions as ordered. To replace lost blood volume.

May go ahead with gastroscopy tomorrow. To detect if the source of bleeding is in the
upper gastrointestinal tract.

RBS  To check the blood glucose level.

 D5050 1 vial if RBS is less 100.  To increase blood glucose level.

Change mainline with D5LRS mix with To maintain nutrition and rehydration, and to
Suremine x 8°. prevent constipation when mixed with
Suremine.

10:08 pm
Fast drip another 200 mL PNSS stat. To check for blood pressure improvement
and prime tubing before blood transfusion.

SDTF: Norepinephrine 8mg in 250cc D5W To aid events of acute hypotension.

x 0.3mcg/kg/min. Time: 10:08 pm
BP: 80/40 mmHg

After fast drip of 200 mL PNSS, fast drip To replace lost blood volume.
ongoing fresh whole blood. (+) Hematemesis: 450mL

09/17/18
2:15 am
Fast drip 300cc IVF. To check for blood pressure improvement
and prime tubing before blood transfusion.

(+) Hematochezia

53
2:30 am

 Transfuse 1 unit FWB as fast drip now. To compensate with the blood loss.
 Transfuse another 2 units FWB for 4 Time: 2:30 am
hours. BP: 60/40
(+) Hematemesis: approx. 475mL

6:30 am

Standby 3 units FWB. To ensure availability of FWB when needed.

Give calcium gluconate 1 amp IV after 7th To prevent the occurrence of metabolic
unit of FWB. alkalosis and hypocalcemia in the event of
massive blood transfusion.

8:10 am
 Close cystoclysis. To check if bleeding is present, the color of
 Monitor urine output q1 and record. urine, and if the patient is able to urinate.

10:00 am
S/P Gastroscopy
For colonoscopy tomorrow 9 am. To detect if the source of bleeding is in the
lower gastrointestinal tract.

 Dulcolax 5 tabs once fully awake. To clear the bowel in preparation for the
 Surelax 1 sachet in 1 glass H2O q hourly colonoscopy.
x 5 doses.

Clear liquids then NPO post-midnight To give a good visualization of the colon.

↑ IVF at 6pm then regulate at 4pm until To replace fluid loss and prevent dehydration.
consumed.

Continue somatostatin drip. To control non-variceal upper gastrointestinal

bleeding, including that peptic ulcers.

54
 Vitamin K 1g IV q6. Helps in the formation of blood clots and
prevents further blood loss.

Request another 4 units FWB properly To ensure availability of FWB when needed.
typed and cross matched.

For surgical referral. To get a more accurate visualization of the

source of bleeding if failed to be seen in the
scope procedures.

Accomplish bleeding sheet. To keep track on the amount and duration of

blood volume loss.

10:22 am
Transfuse 1 more unit of FWB properly To replace lost blood volume.
typed and cross matched (BT #8).

Standby another 4 units of FWB properly To ensure availability of FWB when needed.
typed and cross matched.

55
Surgical Management
Gastroscopy

Gastroscopy is an examination of the upper digestive tract (the esophagus, stomach and
duodenum) using an endoscope — a long, thin, flexible tube containing a camera and a light —
to view the lining of these organs. It's also sometimes referred to as an upper gastrointestinal
endoscopy. Gastroscopy may be recommended to investigate signs and symptoms, diagnose,
and treat. It is a very safe procedure. Rare complications include bleeding, infection, tearing of
the gastrointestinal tract, and reaction to sedation.

A gastroscopy can be used to investigate:

 abdominal pain
 heartburn or indigestion
 persistently feeling and being sick
 dysphagia
 anemia, which may be caused by persistent internal bleeding
 severe bleeding, which may have caused a sudden, sharp pain in your abdomen, vomiting
blood or very dark or "tar-like" poo

A gastroscopy is also used to help confirm (or rule out) suspected conditions, such as:

 stomach ulcers
 gastro-esophageal reflux disease (GERD)
 celiac disease
 Barrett's esophagus
 portal hypertension
 stomach cancer and esophageal cancer

The client will need to stop drinking and eating up to eight hours before the procedure to ensure
your stomach is empty for the procedure. The client must tell the doctor about all the medications
and supplements taken before the procedure. During the procedure, a physician uses an
endoscope to examine the inside of the upper digestive system. After the procedure, the patient
may experience bloating and gas, cramping, and sore throat.

American Society of Gastrointestinal Endoscopy: Understanding Upper Endoscopy

56
Colonoscopy

A colonoscopy is an outpatient procedure used to detect changes or abnormalities in the

large intestine (colon) and rectum. During a colonoscopy, a long, flexible tube (colonoscope) is
inserted into the rectum. A tiny video camera at the tip of the tube allows the doctor to view the
inside of the entire colon. A colonoscopy is commonly used to evaluate gastrointestinal symptoms,
such as rectal and intestinal bleeding, or changes in bowel habits. Colonoscopies are also
performed for colorectal cancer screening in individuals without symptoms to check for colorectal
polyps or cancer. A screening colonoscopy is recommended for anyone 50 years of age and older
(45 for African Americans), and for anyone with parents, siblings, or children with a history of
colorectal cancer or polyps.

A colonoscopy poses few risks. Rarely, complications of a colonoscopy may include:

 Adverse reaction to the sedative used during the exam

 Bleeding from the site where a tissue sample (biopsy) was taken or a polyp or other
abnormal tissue was removed
 A tear in the colon or rectum wall (perforation)

The client will get written bowel prep instructions to follow at home before the procedure. The
bowel prep cleans out the intestine so the doctor can see everything clearly. During a
colonoscopy, an experienced doctor uses a colonoscope view the lining of the colon. The
colonoscope is inserted into the rectum and advanced through the large intestine. If necessary
during a colonoscopy, small amounts of tissue can be removed for analysis (a biopsy) and polyps
can be identified and entirely removed. In many cases, a colonoscopy allows accurate diagnosis
and treatment of colorectal problems without the need for a major operation.

The client may feel bloated or pass gas for a few hours after the exam, as you clear the air from
your colon. Walking may help relieve any discomfort. The client may also notice a small amount
of blood with your first bowel movement after the exam. Usually this isn't cause for alarm.
Recommend to consult the doctor if there is continuous pass of blood or blood clots or if persistent
abdominal pain or a fever is present. While unlikely, this may occur immediately or in the first few
days after the procedure, but may be delayed for up to one to two weeks.

American College of Gastroenterology. Colonoscopy Accessed 1/20/2015.

57
Anesthesia Used for the Procedures

Intravenous sedation is commonly used for gastroscopy and colonoscopy. The sedation
will be administered into a vein of the hand or arm. This will make the client drowsy and relaxed
but not unconscious. Sedation is used to help relieve or avoid the sensation of discomfort. The
client will be in a state called co-operative sedation: this means that, although drowsy, the client
will still hear what is said to him/her and will therefore be able to follow simple instructions during
the investigation. Sedation also makes it unlikely that the client will remember anything about the
procedure. The term “conscious sedation” also referred to as moderate sedation, is used to refer
to the most common combination of medications being administered, and is very adequate for
the sedation needs of most patients having a gastroscopy or colonoscopy.

Whilst sedated, the health care practitioners will check the breathing and heart rate so changes
will be noted and dealt with accordingly. For this reason, the client will be connected by a finger
probe to a pulse oximeter which measures the oxygen levels and heart rate during the procedure.
Sedation is very safe for most people having a gastroscopy or colonoscopy. Complications
associated with sedation are rare occurring in less than one in every 10,000 people. The most
common complications involve a temporary decrease in the rate of breathing or heart rate. By far,
the most common problem is a temporary decrease in the blood oxygen level that occurs when
breathing slows or subjects are not taking deep breaths. This can be corrected by giving extra
oxygen through a small nasal tube. If complications related to sedation occur, medicines can be
given by vein that reverse the effects of the sedation medications.

Please note that as the client will be having sedation, he/she must me reminded not to drive,
operate machinery or sign any legal documents for 24 hours following the procedure.

John J. Vargo, II, MD, MPH, FACG, Cleveland Clinic, Cleveland, OH – Published July 2005. Updated November

58
 IV SOLUTION

Date: September 15 – 18 2018

IV fluid therapy indications. IV fluid therapy is used to maintain homeostasis when enteral
intake is insufficient (e.g., when a patient is “nil by mouth” or has reduced absorption), and to
replace any additional losses and for medication and also The intravenous route is the fastest
way to deliver medications and fluid replacement throughout the body, because the circulation
carries them. Intravenous may be used for fluid replacement (such as correcting dehydration), to
correct electrolyte imbalances, to deliver medications, and for blood transfusions.

TYPES DESCRIPTION OSMOLARITY USE

PNSS 0.9% NaCl in Isotonic Increases circulating

- H2O plasma, volume
-Crystalloid Solution when red cells are
adequate.

D5LR Dextrose 5% in Hypertonic Replaces fluid and

Lactated Ringer’s Buffers Ph.

D5W Dextrose 5% in water Isotonic Replaces total fluid

crystalloid solution. volume. Helpful in
rehydrating and
excretory purposes.

Pharmaceutical Journal

A Royal Pharmaceutical Publication

https://www.pharmaceutical-journal.com

59
 8 Bags of FWB fresh whole blood transfused

Date: September 17, 2018

INDICATION

- It’s used in the treatment of massive bleeding in exchange transfusion. Internal bleeding
or as severe blood loss that may require hospitalization or a blood transfusion.

- One unit brings up hemoglobin levels by about 10g/L

CYSTOCLYSIS / BLADDER IRRIGATION

Data: September 17, 2018

INDICATION:

- It’s a process of flushing the bladder with normal saline to prevent or treat clot formation
post TURP procedure.

- Bladder irrigation may also be used to instill medications such as antibiotics for treating
bladder infections. This is done over a period of time and duns continuously.

Pharmaceutical Journal

A Royal Pharmaceutical Publication

https://www.pharmaceutical-journal.com

60

NAME OF DRUG CLASSIFICATION
GENERIC NAME:
 Catecholamine
Norepinephrine
 Neurotransmitters
DOSAGE:
8mg in 250 cc D5LR
MECHANISM OF
0.3 mcg / kg
ACTION:
Hormone that is released
FREQUENCY: by the adrenal medulla
Q8
and by the sympathetic
nerves and functions as a
neurotransmitter. It works
ROUTE OF
ADMINISTRATION: by constricting (narrowing)
IV
the blood vessels and
increasing blood pressure.
Norepinephrine is used to
treat life-threatening low
blood pressure
(hypotension) that can
occur with certain medical
conditions or surgical.
INDICATION AND NURSING
ADVERSE EFFECTS
CONTRAINDICATION RESPONSIBILITIES
Monitor for loss of glycemic
INDICATION: control when
Cardiovascular
Increased blood pseudoephedrine,
pressure, bradycardia, or Ischemic injury, phenylephrine, and other
bradycardia, arrhythmia,
heart block may occur blood pressure sympathomimetic are
increased, hypertension,
due to excessive alpha- administered to patients
pallor, stabbing
adrenergic receptor retrosternal pain. taking antidiabetic agents.
stimulation.
Nervous system
Monitor glucose level.
CONTRAINDICATION: Frequency not reported:
Norepinephrine should Headache Close monitoring of blood
not be used in patients GI pressure or the selection of
with peripheral or alternative therapeutic
Vomiting.
mesenteric thrombosis agents to the
due to the risk of Respiratory sympathomimetic agent
increasing ischemia and may be needed.
extending the area of Dyspnea
infarction, unless
administration is
necessary for a life-
saving procedure.
61
 INDICATION AND NURSING
NAME OF DRUG CLASSIFICATION ADVERSE EFFECTS
CONTRAINDICATION RESPONSIBILITIES
Tranexamic Acid Anti-fibrinolytic INDICATION: CNS Report unusual
Treatment of excessive change in bleeding
DOSAGE: Dizziness
bleeding resulting from pattern.
500 mg EENT
MECHANISM OF systemic or local hyper
ACTION: fibrinolysis, Visual abnormalities Report severe allergic
FREQUENCY:
coagulopathy in patients reactions such as
CV
Q6 Tranexamic acid with coagulopathy rash, hives, itching,
reducing conversion of undergoing or post- Hypotension, dyspnea tightness in
thromboembolism,
plasminogen to surgical procedures. the chest, swelling of
thrombosis
ROUTE OF
plasmin an enzyme the mouth, face, lips
ADMINISTRATION:
that degrades fibrin CONTRAINDICATION: GI and tongue.
IV
clots, fibrinogen and Patient with renal Diarrhea
other plasma impairment, hematuria Nausea
Vomiting
proteins. originating in the upper
urinary tract and
conditions associated
with increased thrombus
formation.

62
 INDICATION AND NURSING
NAME OF DRUG CLASSIFICATION ADVERSE EFFECTS
CONTRAINDICATION RESPONSIBILITIES
Omeprazole Anti-secretory INDICATION: NS Report severe
Proton pump inhibitor
headache, worsening
DOSAGE:
Short-term treatment Headache, dizziness, of symptoms, fever,
MECHANISM OF
80 mg asthenia, vertigo
for active duodenal chills.
40 mg ACTION: , insomnia, anxiety.
ulcer and epigastric
Gastric acid-pump pain. Take the drugs before
FREQUENCY:
inhibitor: Suppresses
Dermatologic meal.
gastric acid secretion
Stat
by specific inhibition of Frist line therapy for
Q6
the hydrogen- Rash, inflammation,
heartburn symptoms and
potassium ATPase urticarial, pruritus,
enzyme system at the Gastroesophageal reflux alopecia,dry skin. Instruct to swallow the
secretory surface of
ROUTE OF disease (GERD). capsules whole do not
the gastric parietal
ADMINISTRATION:
cells; blocks the final Short-term treatment of chew, open or crush
step of acid GI
IV active benign gastric them
production.
ulcer. Diarrhea, Abdominal pain,
nausea, Vomiting,
Constipation.
CONTRAINDICATION:
Hypersensitivity to
omeprazole or its
components.

63
 INDICATION AND NURSING
NAME OF DRUG CLASSIFICATION ADVERSE EFFECTS
CONTRAINDICATION RESPONSIBILITIES
Voluven Plasma expander INDICATION: CV Monitor V/S
Use as a plasma Respiratory Rate,
Hypotension,
DOSAGE: MECHANISM OF expander treatment of Pulse Rate, BP
500 cc thromboembolism,
ACTION: shock due to
thrombosis, Increased
FREQUENCY: The degree of plasma hypovolemia caused by Report severe allergic
intracranial pressure
volume expansion hemorrhage, surgery, reactions such as
Q4 seizures
intravascular and trauma, sepsis, or rash, hives, itching,
ROUTE OF
cardiovascular status. burns. dyspnea tightness in
ADMINISTRATION: GI
In patients who are NOTE: Dosage and the chest, swelling of
IV Diarrhea
hypovolemic, this infusion rate depend on the mouth, face, lips
Nausea
results in an amount of fluid loss Vomiting and tongue.
increase in cardiac and must be
NS
index, stroke work individualized.
index, arterial and
venous pressures. CONTRAINDICATION: Headache, dizziness,
asthenia, vertigo
Coagulopathy, , insomnia, anxiety.
intracranial bleeding,
surgery.

64
 INDICATION AND NURSING
NAME OF DRUG CLASSIFICATION ADVERSE EFFECTS
CONTRAINDICATION RESPONSIBILITIES
Vitamin K Blood-clotting Vitamin INDICATION  CV Evaluation of PT/INR will
be required to regulate
Rapid and weak pulse, dosage; report any unusual
MECHANISM OF Prevents further blood hypotension, cyanosis bleeding. Review a diet low
DOSAGE: ACTION: loss and formation of in vitamin K. No OTC
blood clots. Hypersensitivity medication without provider
10mg approval.
Combines with anti- Anaphylactic reactions
thrombin III to retard CONTRAINDICATION (IV route)
thrombin activity. Low-
FREQUENCY: molecular-weight Hypersensitivity to heparin: GI
heparin blocks factor severe thrombocytopenia;
Q8 Xa, factor lla. uncontrolled bleeding;
ulcers or any risk of Sensations of taste.
hemorrhage; liver or renal
disease.
ROUTE OF Respiratory
ADMINISTRATION:
Dyspnea
IV

65
 INDICATION AND NURSING
NAME OF DRUG CLASSIFICATION ADVERSE EFFECTS
CONTRAINDICATION RESPONSIBILITIES
Somastostatin Pituitary Hormones INDICATION: CV Report severe headache,
Somastostatin drip
increased intracranial worsening of symptoms,
MECHANISM OF Used to control upper pressure fever, chills.
ACTION: gastrointestinal bleeding Adrenal insufficiency,
DOSAGE:
including peptic ulcer. hypothyroidism Take the drugs before
250mcg stat
Enters target cells and Increased intracranial meal.
Somastostatin + PNSS 1L
x 24 hours binds to cytoplasmic pressure
receptors; initiates CONTRAINDICATION:
FREQUENCY: many complex seizures Instruct to swallow the
reactions that are Fungal infections pancreatitis capsules whole do not
Q1 x 24 hours
responsible for its Amoebiasis RESPIRATORY chew, open or crush them
anti-inflammatory, Hepatitis B Decreased respiratory
rate
ROUTE OF immunosuppressive Antibiotic-resistant infection.
ADMINISTRATION:
(glucocorticoid).
IV Contraindicated in patients
with acute critical illness
due to complications
following open heart or
abdominal surgery, multiple
accidental trauma or to
patients having acute
respiratory insufficiency.

66
 INDICATION AND NURSING
NAME OF DRUG CLASSIFICATION ADVERSE EFFECTS
CONTRAINDICATION RESPONSIBILITIES
Diphenhydramine Antihistamines INDICATION: CNS Monitor V/S
Antitussives Drowsiness, dizziness, Respiratory Rate,
DOSAGE: headache
To treat any febrile non Pulse Rate
50 mg CV
MECHANISM OF hemolytic and allergic
Hypotension, Palpitations.
ACTION: reaction from blood Raise side rails
FREQUENCY: GI
Antagonizes the transfusion.
Anorexia, dry mouth,
Stat effects of histamine at Constipation, nausea Instruct patient to
H1 – receptor sites; report excessive
Respiratory
does not bind to or CONTRAINDICATION: sedation, confusion or
Chest tightness, thickened
ROUTE OF
inactive histamine. Hypersensitivity; Acute bronchial secretions. hypotension.
ADMINISTRATION:
Significant CNS attacks of asthma
IV
depressant and anti- Use cautiously in severe
cholinergic properties liver disease; Seizure
disorders; Peptic ulcer.

67
 INDICATION AND NURSING
NAME OF DRUG CLASSIFICATION ADVERSE EFFECTS
CONTRAINDICATION RESPONSIBILITIES
Hydrocortisone Adrenocortical INDICATION: CNS Do not give IM
Glucocorticoid Vertigo injections if patient has
Decrease the possibility Headache thrombocytopenic
DOSAGE:
MECHANISM OF of immune reaction Insomnia purpura.
100mg
ACTION: from blood transfusion. Seizures Arrange for increased
Treatment for allergic CV dosage when patient
FREQUENCY:
Enters target cells and reaction. Hypotension is subject to unusual
Q2 binds to cytoplasmic Shock stress.
receptors; initiates CONTRAINDICATION: Heart failure secondary to
many complex fluid retention Give daily before 9am
ROUTE OF
reactions that are May cause Thromboembolism to mimic normal peak
ADMINISTRATION:
responsible for its gastrointestinal Cardiac arrhythmias diurnal levels and
IV
anti-inflammatory, perforation and secondary to electrolyte minimize HPA
immunosuppressive hemorrhage usually disturbances suppression.
(glucocorticoid). when in high doses or GI
for prolonged periods. Peptic or esophageal
ulcer
Pancreatitis
Abdominal distention
Nausea

68
 INDICATION AND NURSING
NAME OF DRUG CLASSIFICATION ADVERSE EFFECTS
CONTRAINDICATION RESPONSIBILITIES
Levophed Cardiac Stimulants INDICATION: CV Check the infusion site
Excluding Dopaminergic For the treatment of acute frequently for free-flow.
Hypotension, increased
DOSAGE: Agents hypotension, cardiogenic Peripheral
intracranial pressure
shock, sepsis, or septic vasoconstriction or
1mcg / kg thromboembolism,
shock. ischemia, tissue necrosis,
thrombosis, Increased
MECHANISM OF and/or gangrene in the
FREQUENCY: intracranial pressure
ACTION: CONTRAINDICATION: surrounding area can
Q2 seizures
Peripheral In patients with hypotension occur following
vasoconstriction by secondary to blood volume extravasation.
GI
acting on Alpha- deficits (hypovolemia)

ROUTE OF adrenergic receptors. It except to maintain Diarrhea

ADMINISTRATION: coronary and cerebral Nausea
is also inotropic Vomiting
IV stimulator of the heart artery perfusion until blood

and dilator of coronary volume replacement

arteries as a result of of therapy can be completed. If

the beta-adrenergic norepinephrine is continually

receptors. used to maintain blood

pressure in the absence of
blood volume replacement
therapy, many sequelae may
occur including severe
peripheral and visceral
vasoconstriction.

69
 INDICATION AND NURSING
NAME OF DRUG CLASSIFICATION ADVERSE EFFECTS
CONTRAINDICATION RESPONSIBILITIES
Dulcolax Stimulant laxative INDICATION: CNS -Assess for
Surelax Drossiness, dizziness,
Muscle stimulating contraindicated
fainting, sweating
DOSAGE: effects of barium. To conditions.
1 tab RESPIRATORY
MECHANISM OF clear the bowel in -Give as laxative as
1 Sachet Decreased respiratory
ACTION: preparation for the rate temporary measure.
Enzyme systems colonoscopy. -Arrange to
FREQUENCY: CV
X1 involved in . Palpitations discontinue
X5
neurochemical administration as soon
GI
ROUTE OF transmission and CONTRAINDICATION: as levels are within
Excessive bowel activity,
ADMINISTRATION:
muscular excitability Allergy to magnesium perianal irritation normal limits and
PO works by stimulating products. desired clinical
Metabolic
the nerve endings in Abdominal Pain Magnesium intoxication response is obtained.
the wall of large bowel Acute surgical abdomen Hypocalcemia with tetany

( colon) and rectum. Intestinal and biliary tract

70
71
72
73
74
75
 PROGNOSIS

Upon last exposure, September 18, 2018, the patient is conscious and coherent. Although weak
he is able to respond and communicate well. During interaction the patient showed a slight
development of anxiety regarding his current medical condition and recovery. The last doctor’s
order required the client shall undergo exploratory laparotomy due to idiopathic bleeding on his
gastric system.

76
REFERENCES

American Society of Gastrointestinal Endoscopy: Understanding Upper Endoscopy

American College of Gastroenterology. Colonoscopy Accessed 1/20/2015.

John J. Vargo, II, MD, MPH, FACG, Cleveland Clinic, Cleveland, OH – Published July 2005.

77