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    Ward Class

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    AYESSA JOELLE FOMOKAO
    - The patient, a 62-year-old female, presented with weakness, vomiting, and weakness in both lower extremities. Diagnostic tests showed high levels of segmenters and low levels of lymphocytes and red blood cells, indicating a possible infection or inflammatory disorder. Tests also showed high creatinine and BUN levels, signifying poor kidney function. She received pantoprazole and metaclopramide to treat nausea, vomiting, and reduce stomach acid. Her nursing problems included impaired comfort due to acute pain, impaired physical mobility due to weakness, and risk for electrolyte imbalance from vomiting.

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    Ward Class

    Uploaded by

    AYESSA JOELLE FOMOKAO
    77 views7 pages
    - The patient, a 62-year-old female, presented with weakness, vomiting, and weakness in both lower extremities. Diagnostic tests showed high levels of segmenters and low levels of lymphocytes and red blood cells, indicating a possible infection or inflammatory disorder. Tests also showed high creatinine and BUN levels, signifying poor kidney function. She received pantoprazole and metaclopramide to treat nausea, vomiting, and reduce stomach acid. Her nursing problems included impaired comfort due to acute pain, impaired physical mobility due to weakness, and risk for electrolyte imbalance from vomiting.

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    -WARD-CLASS-

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    - The patient, a 62-year-old female, presented with weakness, vomiting, and weakness in both lower extremities. Diagnostic tests showed high levels of segmenters and low levels of lymphocytes and red blood cells, indicating a possible infection or inflammatory disorder. Tests also showed high creatinine and BUN levels, signifying poor kidney function. She received pantoprazole and metaclopramide to treat nausea, vomiting, and reduce stomach acid. Her nursing problems included impaired comfort due to acute pain, impaired physical mobility due to weakness, and risk for electrolyte imbalance from vomiting.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    77 views7 pages

    Ward Class

    Uploaded by

    AYESSA JOELLE FOMOKAO
    - The patient, a 62-year-old female, presented with weakness, vomiting, and weakness in both lower extremities. Diagnostic tests showed high levels of segmenters and low levels of lymphocytes and red blood cells, indicating a possible infection or inflammatory disorder. Tests also showed high creatinine and BUN levels, signifying poor kidney function. She received pantoprazole and metaclopramide to treat nausea, vomiting, and reduce stomach acid. Her nursing problems included impaired comfort due to acute pain, impaired physical mobility due to weakness, and risk for electrolyte imbalance from vomiting.

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    You are on page 1of 7

    -ACUTE GASTRITIS-

    Keana Trisha G. Domingo BSN 3A


    PATIENT DETAILS:

    Name of Patient: 262 Civil Status Married Age  

    Address Fatima, General Santos City Nationality Filipino Sex Female

    Date of
    Religion Roman Catholic  February 06, 2023
    Admission

    Time of
    Date of Birth   10:35AM
    Admission

    Attending
     Dr. Jonathan Vincent S. Paez Consultant  
    Physician
    PATIENT HEALTH HISTORY

    •Initial Vital Signs: •Chief Complaint: Weakness, Vomiting, and Weakness of both lower
    extremities since last night.
    • Temperature: 37
    •History of Present Illness:
    Degree Celsius
    Night PTA, patient had onset of weakness of both legs
    • Pulse Rate: 90
    Early Morning PTA, had vomiting for 3 episode associated with
    • Respiratory Rate: 22 inability to stand or walk
    • Blood Pressure: 130/70 (+) Vomiting at ER with brownish content
    • 02 Sat: 97% •History of Past Illness:
    • Height: 150 cm S/P CVA/Infarct

    • Weight: 50 kg DM with Neuropathy and Retinopathy


    •Family Health History: No Data Available
    • BMI: 22.2
    •Allergies: None
    DIAGNOSTIC TESTS

    Date Diagnostic Normal Values Results Significant


    Ordered Test
    03/06/23 CBC High level of segmenters and low level of
    Segmenters 0.500-0.7000 g/L 0.80 (H) lymphocytes may be an indicator of a infection,
    Lymphocytes 0.1800-0.4200 g/L 0.08 (L) an inflammatory disorder or a cancer. Low
    Hematocrit 0.3500-0.4900/L 0.32 (L) Hematocrit, Hemoglobin and RBC Count may
    Hemoglobin 120.0000-150.0000 g/L 108 (L) indicate anemia.
    RBC Count 4.000-5.400 x 10 ^ 12/L 3.75 (L)
    03/06/23 Creatinine 0.55-1.02mg/dL (Female) 3.53 (H) High level of Creatinine may be a sign of poor
    kidney function.
    03/06/23 BUN 9.8-20mg/dL (>50 years old) 74.1 (H) High level of BUN means that the kidney
    (Female) aren’t working well.
    MEDICAL MANAGEMENT/ MEDICATIONS:

    Medical Treatments/Procedures:
    Surgery:
    • Gastroscopy

    Medication:
    • Pantopranzole – To reduce the amount of stomach acid your body makes.
    • Metaclopramide – To treat nausea and vomiting.
    NURSING PROBLEM

    • Impaired Comfort related to acute pain as manifested by


    diaphoresis, grimace, restlessness, weakness, and nausea
    and vomiting.
    • Impaired Physical Mobility related to cute pain as
    manifested by difficulty of moving, poor balance,
    weakness, and presence of oxygen support.
    • Risk for Electrolyte Imbalance related to vomiting and
    diaphoresis.
    THANK
    YOU!

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