COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

CASE PRESENTATION
PSH 3RD FLOOR B
NOVEMBER 28-DECEMBER 2, 2023

SUBMITTED BY:
Almocera, Jan Patrick D.
Alpuerto, Yenna Marie A.
Amoro, Aliana Margaret D.
Aro, Rence Roque L.
Asunto, Daryl Ann C.
Austria, Gia Lourdes Camille U.
Bangga, Merylle Hillary D.
Bianan, Brent Bryan B.
Permites, Ginta Morouah D.

BSN 3 N6G1

SUBMITTED TO:
Mrs. Marnellie Obeso, RN, MAN

December 2, 2023
UPPER GASTROINTESTINAL BLEEDING: GASTRIC ULCER, BODY FORREST CLASS
IIA, DIFFUSE EROSIVE GASTRITIS, DUODENITIS, BULB

1. Introduction

Etiology:
According to ICD-11 for Mortality and Morbidity, gastric ulcer presents a distinct
breach in the mucosa of the stomach which is a result of the effects of acid and pepsin in the
lumen. In the endoscopic or radiological view, there is an appreciable depth of the lesion.
When the break of epithelial lining is confined to the mucosa without penetrating through the
muscularis mucosae, the superficial lesion is called ‘erosion’.

Gastric ulcers affect the lining of the stomach. Five types of gastric ulcers occur,
based on their location and acid-secretory status (Cerulli & Iqbal, 2016). Common causes of
ulcers include infection with H. pylori, alcohol, aspirin, aspirin-containing medications, other
various medicines, such as NSAIDs.

2. Nursing Health History

● Signs and symptoms: Hematemesis approximately 1 tbsp. PTA
● Location: Gastrointestinal tract
● Timing: Once, 6 hours PTA
● Aggravating factors: History of gastric ulcer, poor diet management
● Alleviating factors: Proton pump inhibitor medication (Pantoprazole)
● Treatments tried: Immediate consultation to healthcare provider
3. Biographic data
● Chief complains
Patient was admitted to Perpetual Soccour Hospital with chief complaint of
hematemesis approximating to 1 tbsp.
● History of Present Illness
Patient had the onset of abdominal discomfort associated with one episode of
hematemesis approximately worth 1 tbsp.
● Past Medical History
Patient has a history of hypertension, taking ivabradine, amlodipine and clopidogrel
for the management of the condition. The patient also has a history of COPD, though
not exacerbated, taking tiotropium + olodaterol and salbutamol + ipratropium for
management. Patient has a history of CVD infarct MRS 1 in 2018 causing paralysis
to her left side extremities, ability to swallow and communicate was not affected. The
patient does not have any known allergies in terms of food and medication and has
no history of surgical procedures prior to admission. The patient doesn’t have history
of tobacco/drug use.
● Family history of illness (Genogram)
Patient’s significant other preferred not to disclose family history of illness.
● Activities of Daily Living
The patient was said to have decreased food intake for the past five years as stated
by her significant other, impairing her diet management. The patient enjoys watching
TV and enjoys sitting upright. The patient needs assistance in turning in bed and
getting out of bed, and has a cane on her bedside which supports her right hand
when she is seated. Patient was on NPO status, hence diet was not assessed.
 ● Social data
The patient’s social data was not entirely disclosed, however, throughout her
admission, only her daughter and her grandchild was present.
● Psychological data
The patient was alert, awake, and expressive throughout assessment, vital signs
taking, significant procedures, and interview. Patient communicates using eye-to-eye
contact and verbalizes her concerns and requests explicitly. The patient also has no
history of any mental condition or illness.

4. Gordon’s Assessment and Review of Systems

Gordon’s Criteria Before During

Admission Admission

HEALTH Client perceives She was worried

PERCEPTION herself as a about her
HEALTH healthy senior admission
MANAGEMENT citizen. She has because she
PATTERN a history of CVD was restricted
infarct back in from eating (on
2018 that NPO status)
paralyzed her since Monday,
left-side November 27,
extremities, but 2023. She
she remains compares her
positive towards ability to do
living the daily passive range of
even with her motion exercises
paralysis. Client and claims that
stated that she as soon as she
usually wakes was admitted,
up and tries to she has been
do tolerable extra careful
exercises on her about her
own. She has activities afraid
her vital signs to further
monitored at endanger
home; thus, she herself. She also
is monitors the
well-knowledgea results of her
ble about the vital signs and
normal ranges. acknowledges
SO claimed that them well. When
patient had poor client
diet experienced
management in unusuality, she
the past five immediately
years, leading to reported it.
her gastric ulcer.
NUTRITIONAL-M SO expressed Client was on
ETABOLIC that the client strict NPO
PATTERN had poor diet status, hence
management for diet was not
the past five thoroughly
years, but did assessed. She
not disclose was also on
what foods she CBS monitoring,
had during those to observe her
years. The blood sugar
patient doesn’t levels while on
have teeth NPO. Client did
anymore, hence not use dentures
she only uses throughout the
dentures. SO duration of our
noted that rotation. The
patient wakes up client’s weight
in the middle of was not
the night to drink proportional to
water and her height as
immediately she had an
returns back to average height.
sleep. When Her skin had
coughing, she obvious lesions.
also While drinking
continuously water, SO is
seeks for water. concerned about
her getting
aspiration
pneumonia, thus
constantly warns
her not to drink
water while
coughing. She
coughed a lot
when she was
already allowed
to drink water for
her HPN PO
medications.
 ELIMINATION Client is able to The client
PATTERN eliminate well eliminates using
without the use diapers and
of medications throughout the
to assist her days of rotation,
bowel and she was not able
urinary to eliminate fecal
elimination. wastes as she
was son strict
NPO status
following her
onset of
hematemesis.
She was
ordered to take
Bisacodyl
(Dulcolax) oral
and suppository
preparations
prior to
endoscopy
procedure,
which was held
prior our
rotation.

ACTIVITY-EXERC The client was The client fears

ISE PATTERN generally active of having a
and dislodged IV
participative. line, hence she
She exerts effort was extra
in performing careful with her
tolerable ADLs. movements. She
She wakes up finds herself
every morning unable to
and describes perform her
that she assists usual ROM
her left exercises, as
paralyzed hand she was thinking
in performing that her IV line
passive ROM contained a
exercises, hence needle the entire
it is able to raise time. She was
up and down. dependent to
She is capable her SO as she
of doing tasks was careful not
like feeding to further cause
herself but with exacerbation to
proper her existing
assistance, condition. She
gripping her willingly
bottle of water, participates in
assisting her the activities like
 paralyzed hands in changing
in doing passive positions, in vital
ROM exercises. signs taking,
dressing,
mobility in bed,
and transfer to
bedside chair.

SLEEP-REST The client has a Patient

PATTERN well-regulated expressed
sleep-rest feeling tired
pattern at home. because her
She wakes up in sleep patterns
the middle of the were interrupted
night to drink and she had a
water especially difficulty in
if she is getting back to
interrupted sleep after
because of getting
cough. Further interrupted. She
details were not no longer
assessed. remembers what
day it is,
because she
couldn’t
determine the
day and time
due to the
irregular sleep
pattern she had
since admission.

COGNITIVE-PER The client The patient can

CEPTUAL showed no easily respond
PATTERN difficulty in to queries and
hearing. She she can easily
can clearly point out her
express her concerns to the
thoughts and care provider.
consults her SO She was
regarding her assessed by the
concerns. When SO one time;
experiencing she easily
discomfort, she responded her
constantly name but got
verbalizes her her address
concerns. wrong. Her
responses don’t
come
automatically but
with given clues,
she can give out
full details and
 can engage in
conversations
well.

SELF-PERCEPTI The patient Since her

ON- describes admission to the
SELF-CONCEPT herself as institution, the
PATTERN elderly having a client was
positive outlook concerned about
in life. She has her inability to
generally eat or drink.
accepted her Although
condition but generally
makes do with communicative
what she and
currently has. participative, she
Since the worries about
paralysis of her her general
left side of the health status.
body, she was One time, she
never was anxious as
discouraged to the infusion
perform pump kept on
activities of daily alarming and
living. Although she expressed
she is no longer that the air might
of doing things get inside her
she normally did body if the line
before, she won’t be closed
claims of having as soon as
lived “kutob sa possible. She
mahimo”. reports
immediately and
notified me
regarding the
matter, to which
I referred
immediately to
the NOD as the
patient showed
anxiousness
and fear as the
infusion pump
alarm sounds
kept going.
ROLES-RELATIO This wasn’t During
NSHIPS thoroughly admission to
PATTERN assessed. PSH, the client
was
accompanied by
her daughter
and her
grandson.
Decisions were
made by her
daughter and
she was being
monitored by
another child
who works
abroad as a
nurse. They
immediately
sought medical
advice as soon
as they found
her vomiting
blood. She has
her children
supporting her
needs as well as
an insurance
covering her
medical
expenses.

SEXUALITY-REP The client was N/A

RODUCTIVE already 84 years
PATTERN old and
widowed, hence
this was not
further
discussed.
COPING-STRESS The client’s She greets
TOLERANCE children and everyone with a
PATTERN family monitors smile and
her conditions doesn’t show
well and signs of distress
supports her even when
needs, she admitted. She
continues to live shares a positive
according to her personality and
tolerance cooperates with
particularly in the procedures.
activities of the Though there
daily. She was an instance
shares a positive she showed her
outlook in life anxieties, when
despite her she understood
condition. what was
happening, she
easily calmed
down and gave
a sigh of relief.
She has
available
medications to
manage her
existing
conditions and
she is very
compliant with
all the medical
interventions
suggested to
her. She
verbalizes that,
“Kamo man
kamao ana, mao
salig rako
ninyo.”
 VALUES-BELIEF The client views The patient
PATTERN health as an plans to adhere
investment, she to treatment
is very compliant plans and
in terms of shares about no
participating in longer drinking
the activities that in the middle of
contribute to the night while
better her health coughing. She
condition. expressed
Although, SO understanding of
claimed that for the risks that
the past five come from
years, “wala aspiration
mana siyay pneumonia. She
tarong kaon sa plans to perform
lima ka tuig”. exercises as
The client and tolerated. The
her family are client asked her
devout Roman family members
Catholics. to offer mass for
her birthday
celebration.

5. Physical Assessment

PHYSICAL ASSESSMENT FINDINGS

General Survey The client was a gerontological patient

showing signs of decreased skin integrity
and turgor. She is constantly groomed by
her attending SO. She is ambulatory and
can do assisted transfer to her bedside
commode with a cane assisting her right
hand. She has L side paralysis, thus she is
depended to her care takers. She can
communicate well as her speech was not
affected by her paralysis. She can answer
details about herself. Her movements may
be limited but she can assist her paralyzed
extremities to do passive ROM exercises.

Skin and Nails The patient has visible lesions scattered

around her body. Some are small, some are
irregularly shaped. She has senile turgor
and upon assessment, her peripheral
extremities are cold to touch with increased
capillary refill time (> 3 seconds). Skin has
unusual discoloration especially on her
peripheral IV site. Skin was sensitive to
sensations except on her L side which was
affected by stroke.
 Head, Face, Neck Head is positioned on top of client’s body,
scalp had obvious lesions and client has a
thin white hair due to old age. Despite
paralysis on the left side of her body, she
does not have a facial droop. Client doesn’t
have presence of lice, parasites, but has
dandruff on her hair. Client can stretch her
mouth and expand her tongue. Client can
perform symmetrical facial expressions
easily and voluntarily purse lips. Client’s
neck was not palpated as only limited
assessment was permitted. The neck has
presence of lesions and no JVD was
observed. Client’s neck showed visible
carotid pulse but it was not palpated nor
auscultated.

Nose, Mouth, Throat Client’s nose had no discharges and was

not flaring, nares are symmetrical and nasal
septum is in the middle of the nose. The
client verbalized ability to smell though not
assessed thoroughly. Client’s oral mucosa
was dry as she was on strict NPO status for
5 days. The outer portions of her mouth had
white flakes and cracks were starting to
form due to lack of skin hydration. The
client can move mouth and tongue freely
without difficulty. There is no more teeth
visible. Gums are pink, tongue looked dry
but was not bleeding. No presence of
swelling or lesion upon inspection.

Ears and Eyes Sclera is anicteric and client has pink

peripheral conjunctiva. Peripheral vision
was not thoroughly assessed as well as
other EOM. Client can hear well and
respond to the queries given to her. No
unusual discharges noted. Further
assessment not done.

Lungs Client does not use accessory muscles to

assist in breathing and she was
non-dyspneic upon assessment.
Respiratory rate was within normal range.

Cardiovascular Carotid pulsations were noted. Client’s

radial pulse was easily pulsated as it was
strong enough to be palpated. She had
around > 90 bpm.

Musculoskeletal The client’s left side of the body was

already paralyzed. She assists her left arm
in performing passive ROM exercises. The
client was able to exert effort in pushing
 herself up against the bed, though it was
not enough to push her entire body to her
desired position.

Breasts Not assessed.

Abdomen Abdomen is distended. The client’s

abdomen skin color is generally paler than
other parts of her skin. Lesions noted. The
client’s abdomen was not palpated and
assessed thoroughly.

Neurologic Patient is well oriented with the location of

her admission, presence, and identity of her
care providers. Her body is relaxed and
maintains eye contact while having
conversations. She willingly shares a smile
everytime she faces a care provider. Her
speech is generally clear as well as her
pace and tone is normal. Her memory is
good though she needs cues to fully
remember exact details.

Genitourinary Not assessed

Anal area Not assessed

6. Anatomy and Physiology

 4 PARTS OF THE STOMACH

1. Cardiac
● The cardiac part of the stomach, also known as the cardiac region is the area located
near the opening of the stomach, where the esophagus connects to the stomach

Functions of the Cardiac

1. Reception of Food - The cardiac region receives food from the esophagus, acting
as a gateway to the stomach
2. Protection - The cardiac region helps prevent stomach acid and enzymes from
flowing back into the esophagus, thanks to the lower esophageal sphincter.
 3. Initiation of digestion - Although limited, some enzymes and chemical digestion
begins in this region due to the presence of mucous cells that secrete protective
mucus

2. Fundus
● The fundus is the upper portion of the stomach that lies above the level of the cardiac
(where the esophagus meets the stomach) and below the diaphragm

Functions of the Fundus

1. Intestinal Digestion - The fundus’s acidic environment and enzymatic activity initiate
the digestion of carbohydrates and fats
2. Acid Production - The fundus secretes hydrochloric acid, which plays a crucial role
in activating enzymes and creating an acidic environment for digestion.
3. Gastric Motility - The fundus contracts to help mix food with gastric secretions,
creating a semi-liquid mixture known as chyme, which is then gradually released into
the rest of the stomach for further processing.

3. Body
● The body region of the stomach is the middle portion between the fundus (upper
part) and the pylorus (lower part). The body region contains gastric glands that
secrete HCl, enzymes, and mucus
Functions of the Body
1. Storage - The body region can temporarily store food, allowing the digestive system
to process smaller amounts of food at a time, which can aid in more efficient
digestion and absorption.
2. Control of gastric Emptying - The body region controls the gradual release of
chyme into the small intestine through the pyloric sphincter
3. Initiation of Reflexes - The presence of food in the body region triggers sensory
signals that initiate digestive reflexes, stimulating the further secretion of gastric
juices and coordinating the movement of food through the digestive system

4. Pylorus
● The pylorus is the lower portion and the last section of the stomach that connects to
the small intestine. The Pylorus region of the stomach consists of two main parts: the
pyloric antrum, which is closer to the body region of the stomach; and the pyloric
canal, which is a narrow part that leads into the small intestine.

Functions of Pylorus
1. Enzymatic Activation - The pylorus ensures that chyme is released into the small
intestine at a controlled rate, allowing digestive enzymes from the pancreas and bile
from the gallbladder to mix with the chyme for further digestion
2. Acidic Chyme control - The pylorus helps prevent highly acidic chyme from the
stomach from entering the small intestine too quickly. This helps protect the delicate
lining of the intestine from potential damage
3. Prevents bacterial growth - The pylorus aids in preventing excessive bacterial
growth in the small intestine by regulating the flow of chyme. This helps maintain a
balanced microbial environment.
7. Pathophysiology
8. Laboratory and Diagnostic results
● Occult blood
Occult Blood POSITIVE

● CBC

Interpretation Results Units Reference

Value

WBC H 11.43 x10^9/L 4.10-10.9

Hemoglobin L 9.7 g/dL 12-16

Hematocrit L 30.0 % 36-46

RBC L 3.2 10^12/L 4.50-5.90

● Prothrombin Time

Percent H 101 % 70-100

activity

● Clinical Chemistry

Result Units Reference Interpretation

Value

Creatinine 1.36 mg/dL 0.55-1.02 H

BUN 28.00 mg/dL 7.0-18.0 H

● H. Pylori

H. pylori NEGATIVE

● Upper Gastro-Intestinal Endoscopy

Esophagus and GE Normal

Cardia (+) Erosions and erythema

Fundus (+) Erosions and erythema

Body (+) Big ulcer w/ non-bleeding visible

vessel where injection sclerotherapy w/
adrenaline 1:10,000 dilution injected the
ulcer
(+) Erosions and erythema
Antrum (+) Erosions and erythema

Pylorus Normal

Duodenal bulb (+) Erythema

Duodenal second portion Normal

9. Surgical management

Possible Gastrectomy
Gastrectomy is a medical procedure where all or part of the stomach is surgically removed.
Possible Laparoscopic Surgery
Laparoscopic surgery uses a long, thin tube with a camera lens attached to examine the
organs inside the abdominal activity to check for abnormalities, and to operate through
small incisions.
Gastric Bypass Surgery
Gastric bypass is a surgery that helps you lose weight by changing how your stomach and
small intestine handle the food you eat. After the surgery, your stomach will be smaller. You
will feel full with less blood.
Gastric bypass can be done in two ways. With open surgery, your surgeon makes a large
surgical cut to open your belly. The bypass is done by working on your stomach, small
intestine, and other organs. Another way to do this surgery is to use a tiny camera, called a
laparoscope. This camera is placed in your belly. The scope allows the surgeon to see your
stomach. This procedure is also called a Roux-en-Y gastric bypass. Your surgeon separates
the top part of your stomach to create a pouch about the size of a small egg. The surgeon
attaches the pouch to your small intestine. This bypasses most of your stomach and small
intestine.
 10. Drug study
Name of Drug Classification Mechanism of Action Indications and Nursing Responsibilities
Contraindications Side Effect

Generic Name: Anticholinergic Ipratropium functions as a Indications: - Headache Before:

Salbutamol + nonselective competitive - Chronic - Dizziness Check doctor’s order
Ipratropium Bronchodilators antimuscarinic agent. Its obstructive - Nausea Obtain the 5 right of administration
Trade/Brand Name: mechanism involves inducing pulmonary disease - dry mouth · Take vital signs
Airsupra + Ipravent bronchodilation by obstructing - bronchial asthma, - Tremors ·
Patient’s Dose: the acetylcholine-induced - chronic bronchitis, - constipation During:
1 neb q8h stimulation of guanylyl cyclase. - Reversible Monitored the patient’s vital signs
This inhibition reduces the obstructive airway especially Respiratory rate and
formation of cyclic guanosine disease oxygen
monophosphate (cGMP) at the Educated the patient about the drug
parasympathetic site. Contraindications: - Assess for Dizziness that may
- Hypersensitivity to affect gait
Salbutamol, on the other hand, salbutamol, After:
stimulates adenyl cyclase, an ipratropium or Document the due medication given
enzyme that promotes the fenoterol, atropine or Monitor for any sign of allergy
production of cyclic its derivatives. reaction
adenosine-3’, Hypertrophic
5’-monophosphate (cAMP). The obstructive
elevated cAMP levels activate cardiomyopathy,
protein kinase A, which, in turn, tachyarrhythmia.
hinders the phosphorylation of
myosin and decreases
intracellular ionic Ca
concentrations. This cascade of
events ultimately leads to the
relaxation of smooth muscle.
References: MIMS
Name of Drug Classification Mechanism of Action Indications and Side Effects Nursing Responsibilities
Contraindications

Generic Name: Calcium channel AmlodipineCalcium channel Indications: - Fatigue Before:

Amlodipine blockers blocker, works by inhibiting - HTN - Swelling Check doctor’s order
Trade/Brand Name: L-type calcium channels in -Coronary Artery - Palpitations Obtain the 5 right of administration
Aforbes vascular smooth muscle and Disease (CAD) - Flushing Take vital signs
myocardial cells. This inhibition -Chronic Stable During:
Patient’s Dose: leads to vasodilation, reducing Angina - Monitored the patient’s vital
10mg OD peripheral vascular resistance -Vasospastic Angina signs especially Bp and Pulse rate
and lowering blood pressure. Contraindications: - watchout for edema
- Hypersensitivity to -Educated the patient about the drug
any contents of the After:
drug - Document the due medication
- Severe hypotension given
Monitor for any sign of allergy
reaction

REFERENCES: Nursing drug handbook PG 1629 & MIMS

Name of Drug Classification Mechanism Mechanism of Indications and Side EffectsSide Nursing Responsibilities
Action Contraindications Effect (Before, During and After
Responsibilities
Generic Name: Therapeutic AmlodipineInhibits the binding Indications: - Bleeding Before:
Clopidogrel class: of the P2Y12 components of - To reduce the - Nose bleed · Check doctor’s order
antiplatelet ADP to its platelet receptor, rate of MI and stroke - Diarrhea · Obtain the 5 right of
Trade/Brand Name: drugs impeding ADP- mediated in patients with - Stomach pain administration
Artheogrel activation and established - Heartburn · Take vital signs
Pharmacologic subsequent platelet aggregation peripheral arterial ·
class: and irreversibly modifies the disease or history of During:
Patient’s Dose: Platelet platelet ADP receptor recent MI or stroke. - Monitored the patient’s vital
75mg OD aggregation - To reduce the signs especially Bp and Pulse rate
inhibitors rate of MI and stroke - Educated the patient about
in a patient's unstable the drug
angina/ non-St - Assess for bleeding
elevation MI. After:
Contraindications: - Document the due
- medication given
Hypersensitivity to Monitor for any sign of allergy
any contents of the reaction
drug
- Premature
interruption of
therapy may result in
stent thrombosis with
subsequent fatal or
nonfatal MI.
Use cautiously in
patient risk for
increased bleeding
from trauma, surgery.

REFERENCES: Nursing drug handbook PG 353 – 354

 Nursing Responsibilities
Name of Drug Classification Mechanism of Action Indications and Side Effects (Before, During and After
Contraindications Responsibilities)
Ivabradine PHARMACOTHERAPEUTIC Reduces spontaneous PO: Adults elderly: Occasional ( 10% -3%) BEFORE:
: pacemaker activity of the Initially 5mg twice
cardiac sinus node by daily for 14 days then Bradycardia,hypertension, Assessment:
Hyperpolarization-activated blocking HCN channels that adjust does to resting phosphenes, (visual
cyclic nucleotide-gated are responsible for cardiac heart rate of disturbances) severed. Patient Assessment and taking vital
(HCN) channel blocker. current, which regulates 50-60bpm. Further signs
heart rate. Does not affect their adjustments
ventricular respolazation or based on resting Medication Verification: Confirm the
CLINICAL: myocardial contractiity. Also heart rate and prescription for Ivabradine,
Reduces risk of worsening inhibits retinal current tolerability. checking the dosage, route, and
HE. involved in reducing bright Maximum: twice frequency.
in retina. Therapeutic Effect daily.

DURING:

● Timing: Administer the

medication at the prescribed
intervals.
● Vital Signs Monitoring:
●
AFTER:

Post-Administration Monitoring:
● Vital Signs:
Regularly monitor
vital signs, especially
heart rate and blood
pressure, to assess
the patient's
response to
ivabradine.
● Side Effects: Watch
for any side effects
such as visual
 disturbances,
dizziness, or other
symptoms and report
them promptly.
Patient Education:
● Potential Side
Effects: Reinforce
information about
potential side effects
and instruct the
patient to report any
concerning
symptoms.
● Missed Doses:
Provide guidance on
what to do if a dose
is missed and when
to take the next
scheduled dose.
Documentation:
● Record Keeping:
Document the
administration of
ivabradine, including
the time, dosage,
and any observed
effects or patient
responses.
● Vital Sign Trends:
Note trends in vital
signs over time,
especially changes
in heart rate and
blood pressure.
 REFERENCES: Nursing drug hand book 2023 PG 633 – 635

Name of Classficiation Mechanism of Action Indications and Side Effects Nursing Responsibilities
Drug Contraindications (Before, During and After
Responsibilities)

Tiotropium PHARMACOTHERAPEUTIC: Competitively and reversibly INDICATIONS: Frequent (16%-6%): BEFORE:

Anticholingeric (long-acting). inhibits action of acetylcholine Dry Mouth, sinusitis,
at muscarinic receptors in Long-term maintenance pharyngitis, Patient Assessment: Evaluate the
CLINICAL: Bronchodilator bronchial smooth muscle in treatment of bronchospasm dyspepsia, UTI, patient's medical history, including
Therapeutic Effect: Causes due to COPD. rhinitis. allergies and any
bronchodilation. contraindications to tiotropium.
Occasional Assess respiratory status,
CONTRAINDICATIONS: (5%-4%): including lung function and vital
Abdominal Pain, signs.
Hypersensitivity to peripheral edema,
tiotropium. History of constipation, Physical Assessment: Check for
hypersensitivity. epistaxis, vomiting, any signs of respiratory distress,
myalgia, rash, oral presence of cough, sputum
CAUTIONS: Narrow-angle candidiasis. production, or other symptoms
glaucoma, prostatic related to COPD or asthma.
hypertrophy, bladder neck
obstruction, moderate to Inhaler Technique: Educate the
severe renal impairment, patient on the correct use of the
history of hypersensitivity to tiotropium inhaler, emphasizing
atropine, myasthenia gravis. the need for slow and deep
inhalation.
Purpose of Medication: Explain
the purpose of tiotropium, its
benefits, and the importance of
adherence to the prescribed
regimen.

Side Effects and Reporting: Inform

the patient about potential side
effects and when to report
adverse reactions to healthcare
providers.

DURING:
Verify Patient Identity: Confirm the
patient's identity using at least two
patient identifiers (e.g., name and
date of birth) before administering
tiotropium.

Inhaler Administration:
● Instruct the patient to
exhale fully before inhaling
the medication.
● Administer tiotropium
according to the
prescribed dosage and
technique.
● Observe the patient's
inhalation technique to
ensure proper
administration.

Monitor for Adverse Reactions:

 ● Keep a watchful eye for
any immediate adverse
reactions, such as
coughing or signs of
respiratory distress.
● Assess for potential
systemic side effects, such
as changes in heart rate or
blood pressure.

Patient Comfort and

Understanding:
● Address any concerns or
questions the patient may
have during the
administration.
● Ensure the patient feels
comfortable and
understands the
importance of using the
medication as prescribed.
After:

Monitoring: Observe the patient

for any delayed adverse reactions
or side effects that may occur
after inhalation.
● Monitor respiratory status,
vital signs, and oxygen
saturation as needed.

Patient Education:
● Reinforce the importance
of continuing tiotropium
 therapy as prescribed,
even if symptoms improve.
● Provide information on
potential side effects that
may occur and actions to
take if they arise.
​

Documentation:
● Document the
administration of
tiotropium, including the
time, dosage, and any
observed effects or patient
responses.
● Note any patient education
provided and the patient's
understanding of the
instructions.

Follow-Up:
● Schedule follow-up
appointments to assess
the patient's response to
tiotropium therapy.
● Arrange for ongoing
monitoring of the patient's
respiratory status and
adjust the treatment plan
as needed.

REFERENCE: Nursing drug handbook 2023 PG

 S Side Effect Nursing Responsibilities
Mechanism Indications and (Before, During and After
Name of Classification of Action Contraindications Responsibilities)
Drug

AMPICILLIN/ PHARMACOTHERAPEUTIC Ampicillin inhibits bacterial cell Pharmacokinetics: FREQUENT: diarrhea, Assess patient for
SULBACTAM : Penicillin wall synthesis by binding to rash( most common) , infection at beginning
PCN-binding proteins. Subactam The addition of sulbactam urticaria, pain at IM and throughout
(UNASYN) CLINICAL: Antibiotic inhibits bacterial betalactamase, to ampicillin enhances the injection site, course of therapy.
protecting ampicillin from effects of ampicillin. thrombophlebitis with IV
degradation. Ampicillin is a administration, oral or Obtain a history
time-dependent antibiotic. vaginal candidiasis. before initiating
Its bacterial killing is theraphy to
Therapeutic Effect: Bactericidal largely related to the time OCCASIONAL: nausea, determine previous
in susceptible microorganisms. that drug concentrations vomiting, headache, use and reactions to
in the body remain above malase,urinary retention. penicillins or
the minimum inhibitory cephalosporins.
concentration. The CNS: Person with a
duration of exposure will -Seizures negative history of
thus correspond to how -Lethargy penicillin sensitivity
much bacterial killing will -Hallucinations may still have an
occur. This means that -Anxiety allergic response.
longer durations of -Depression
adequate concentrations Twitiching coma
are more likely to produce Obtain specimens for
therapeutic success. Derma: culture and sensitivity prior
However, when ampicillin -Skin rashes to initiating therapy. First
is given in combination GI: dose may be given before
with sulbactam, regrowth -Nausea receiving result.
of bacteria has been seen -Vomiting
when sulbactam levels -Diarrhea
fall below certain
concentrations. The two GU: Observe patient for
 drugs have similar -Oliguria signs and symptoms
pharmacokinetic profiles -Proteinuria of Anaphylaxis. Discontinue
that appear unchanged -Hematuria the drug and notify the
when given together. -Dysuria Physician immediately if
these occur. Keep
Hema: Epinephrine, an
-Anemia Antihistamine, and
Contraindications: -Increased bleeding time Resuscitation equipment
-Bone marrow close by in the even of an
Hypersenitivity to depression anaphylactic reaction.
penicillins or sulbactam.
Ampicillin/sulbactam is
contraindicated in Local:
individuals who have a -Pain at IV site
history of a
penicillinallergy.
Symptoms ofallergic
reactions may
range from rash to
potentially life-threatening
conditions, such as
anaphylaxis. Patients who
have asthma, eczema,
hives or hay fever are
more likely to develop
undesirable reactions to
any of the penicillins.

REFERENCE: Nursing drug hand book 2023 PG 68-69

Name of Drug Classification Mechanism of Action Indications and Side Effects Nursing Responsibilities
Contraindications

Generic Name: Therapeutic Indications: CNS Before:

class:
Pantoprazole Inhibits proton pump activity · Constipation; · Dizziness · Check doctor’s medication order.
Antiulcer drug/ bowel
Trade/Brand Name: GI agent By binding to · Headache · Check patients’ chart or medical
movement of
hydrogen-potassium adenosine history especially drugs that can
childbirth,
· Pantoloc Pharmacologic triphosphatase, located at the CV cause allergies to patient.
class: surgery, and
secretory surface of gastric
· Protonix endoscopic · Chest pain · Question history of GI disease,
parietal cells, to suppress
Proton pump examination ulcers, or GERD.
· Protonix IV inhibitors gastric acid secretion.
EENT
· Erosive · Check patient’s vital signs.
Patient’s Dose: Esophagitis · Rhinitis
· Educate client and SO about the
2 ampules in 80 cc drug
· Pathologic GI
PNSS 8cc/hr IV drip
Hypersecretory · Advise patient to take the
conditions · Vomiting
medication before breakfast.
· Diarrhea
Contraindications During:
:
· Abdominal pain
· Evaluate for therapeutic
· response (relief GI symptoms).
· Dyspepsia
Hypersensitivity
to drug ·
Metabolic
· Intestinal
obstruction · Hypoglycemia
After:
· Musculoskeletal
 Gastroenteritis · Monitor patient’s vital signs
· Hip, wrist, spine
Appendicitis fractures (with long · Check patient’s response to
References: Kluwer, term daily use) drugs.
W. (2022) Nursing
2022 drug handbook Skin · Assess patient continually and
(pp. 1154-1156). monitor its condition.
Wolter Kluwer health. · Rash
Inc Document in patient’s chart
· Pruritis

Others

· Reaction to
injection site
 Name of Drug Classification Mechanism of Action Indications and Side Effects Nursing Responsibilities
Contraindications

Generic Name: Therapeutic Amlodipine Thought to Indications: CNS: Before:

Bisacodyl class: stimulate colonic mucosa, Constipation; bowel · Dizziness Check the doctor’s medication order
Trade/Brand Name: Laxative producing parasympathetic movement of · syncope Assess patient's history of drugs
Dulcolax Pharmacologic reflexes that enhance childbirth, surgery, GI: and food allergies to.
Patient’s Dose: class: peristalsis and increase water and endoscopic · Nausea Assess history of GI disease, ulcers,
10 mg Stimulant and electrolyte secretion, examination · Vomiting or GERD.
2 Suppository IV – laxative thereby causing evacuation of Erosive Esophagitis · diarrhea (with Monitor patients vital signs
D5LR 1L @10 gtts/min colon. Pathologic high doses) Teach client and SO about the
Hypersecretory · abdominal pain effects of frequent use of the drug.
Reference: conditions · burning During:
Schull, P. D. (2013) sensation in rectum Check patient’s identity
Mc-Graw Hill: Nurse’s Contraindications: (with suppositories)
Drug Handbook Guide Hypersensitivity to · laxative Explain procedure to the patient
(pp. 150-151) drug dependence
Intestinal obstruction · protein-losing Ensure privacy and dignity.
Gastroenteritis enteropathy
Appendicitis Metabolic: After:
· hypokalemia · Assess stool frequency and
· fluid electrolyte consistency
imbalances Monitor patient for electrolyte
· tetany imbalances and dehydration.
· alkalosis
Musculoskeletal:
· muscle
weakness (with
excessive use)
11. NCP
12. Discharge plan
MEDICATIONS - Instructed the patient not to discontinue antibiotic
medication regimen unless the number of days
prescribed by their doctor has already been
completed.
- Advised patient not to miss prescribed medications
(for COPD and hypertension).

EXERCISE/
ENVIRONMENT - Engage in activities such as meditation, passive
range of motion exercises, and deep breathing
exercises to reduce stress levels and promote
mobility.
- Keep and ensure an environment free from smoke
because smoking can exacerbate COPD as well as
gastric ulcers and irritate the stomach lining.

TREATMENT - Eating smaller and more frequent meals helps to

reduce the amount of stomach acid produced and
prevents overloading the stomach.
- Avoid trigger foods like spicy, acidic, and fatty foods
that can irritate the stomach lining and worsen
symptoms.
- If Helicobacter pylori infection is present, follow the
prescribed antibiotic regimen and complete the full
course of treatment.
- Maintain hydration by taking sips of water as
tolerated throughout the day and avoid carbonated or
caffeinated beverages as these can worsen
symptoms.

HEALTH TEACHING - Educate the individual about the prescribed

medications, including their purpose, dosage, and
potential side effects.
- Encourage eating smaller, more frequent meals to
prevent overloading the stomach.
- Emphasises the importance of consuming a balanced
diet with plenty of fruits, vegetables, whole grains,
and lean proteins.
- Discuss the importance of staying hydrated and
limiting or avoiding caffeine and alcohol.
 - Encourage the individual to report any new or
worsening symptoms promptly.

OUT-PATIENT - Instructed the patient to continue with follow-up

medical checkups, as advised by the physician.
- Advised patient to seek consultation for any
unusualities experienced.

DIET - Advised patient to avoid any specific trigger foods

that worsen symptoms or cause discomfort. These
may vary from person to person but can include spicy
foods, fatty foods, and caffeine
- Advised patient to limit or avoid acidic foods and
beverages such as citrus fruits, tomatoes, coffee, and
carbonated drinks.
- Advised patient to choose foods that are easy to
digest and gentle on the stomach, such as cooked
vegetables, soft fruits, well-cooked grains, and lean
proteins.

SEXUALITY/ - Encouraged the patient to continue to have faith

SPIRITUALITY according to her religion and beliefs.
- Encouraged to maintain optimism in life, free from
stress, and communicate feelings and thoughts.

14. References
Peptic ulcers - Brigham and Women’s Hospital. (n.d.).
https://www.brighamandwomens.org/surgery/general-and-gastrointestinal-surgery/esophagus-and-sto
mach/peptic-ulcer#:~:text=Surgical%20Treatment&text=Gastrectomy%2C%20subtotal%20or%20par
tial%20gastrectomy,stomach%20to%20secrete%20digestive%20juices.
Gastric bypass surgery: MedlinePlus Medical Encyclopedia. (n.d.).
https://medlineplus.gov/ency/article/007199.htm#:~:text=Gastric%20bypass%20is%20surgery%20tha
t,feel%20full%20with%20less%20food.
Gastric Bypass Surgery for weight loss | Bariatric Services | OHSU. (n.d.).
https://www.ohsu.edu/bariatric-services/gastric-bypass-surgery-weight-loss#:~:text=What%20is%20g
astric%20bypass%20surgery,your%20stomach%20and%20upper%20intestine.