PILAR COLLEGE OF ZAMBOANGA CITY, INC.

R.T Lim Blvd., Zamboanga City

Tertiary Department

Care of Client with Duodenal Ulcer, UTI, Stage 1

Hypertension
 Members:
Abdukarim, Nawiira S.

Abdurajan, Daisy Walda J.

Ahadain, Wadzra M.

Ahiyas, Chay Rey V.

Alingco, Shelo Mith G.

Asim, Marissa K.

Askalani, Abdut-Tawab G.

Bacalucos, Hyde R.

Cambonga, Ryka Patricia M.

Del Prado, Ryan Boy V.

Fernandez, Rose Lain E.

Panelist:
Mrs. Crisitine R. Al-sundal RN,MN
Mr. Fhahad Abdulakarin RN
Mrs. Milagrosa Alvarez RN,MN

Adviser
Mrs. Ma. Jocelyn L. Toribio RN, MAN
October 18, 2021
 TABLE OF CONTENTS
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Pathophysiology and Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Patient's Profile and History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Gordon's 11 Functional Health Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Cephalo-caudal Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Drug Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Comprehensive Nursing Care Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Health Teaching Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Conclusions and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Exhibits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

FIGURES
Figure 1. Anatomy of the Duodenum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 2. The Human Urinary System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 3. Anatomy of the Kidney……………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 4. Anatomy of the Blood Vessels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Figure 5. Anterior View of the Human Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 6. Blood Pressure Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure 7. Pathophysiology of Duodenal Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Figure 8. Pathophysiology of Urinary Tract Infection (UTI) . . . . . . . . . . . . . . . . . . . . 28
Figure 9. Pathophysiology of Stage 1 Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Figure 10. Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Figure 11. Conceptual Framework of Kolkaba’s Comfort Theory . . . . . . . . . . . . . . . 56
TABLES
Table 1 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Table 2 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Table 3 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Table 4 (LAB RESULT ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Table 5 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..43
Table 6 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Table 7 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Table 8 (LABRESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Table 9 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Table 10 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Table 11 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Table 12 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Table 13 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Table 14 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Table 15 (LAB RESULT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Table 16(Ciprofloxacin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Table 17 (EsomeprazoleSodium) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Table 18 (Cimetidine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Table 19 (Nursing Care Plan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Table 20 (Nursing Care Plan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Table 21 (Nursing Care Plan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Table 22 (Health Teaching Plan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
 EXECUTIVE SUMMARY

A Peptic Ulcers are open sores or lesions that commonly occur in the upper
digestive tract. Individually, peptic ulcers are described by where they are found. A
duodenal ulcer is a sore that forms in the lining of the duodenum, the beginning of the
small intestine. Symptoms include pain in the stomach or abdomen that might come and
go, have indigestion, feel very full and bloated after eating, might feel like vomiting and
lose weight. Urinary tract infections are common infections that happen when bacteria
enter and infect the urinary the urethra, bladder, vagina or kidneys can be affected.

Repeated infections can affect the way the kidneys function and lead to high
blood pressure and other issues. High blood pressure or Hypertension is when your blood
pressure is regularly higher than recommended levels. Her orders upon admission include
NPO, strict Input and Output monitoring, repeat urinalysis and FBS in the morning, do
LFT's and electrolytes, give oxygen @ 2 L/min via nasal cannula PRN for dyspnea and
IVF NaCl and D5%LR alternately for a total of 2,500 mL/ day and Urine for C and S.
The primary drugs that were given to the patient are: Ciprofloxacin (Ciprobay),
Esomeprazole Sodium (Nexium) and Cimetidine (Tagamet).

This study concluded that the early detection of signs and symptoms,
accompanied by an adequate evaluation and prognosis, is a fundamental tool to improve
outcomes. Patient’s unhealthy lifestyle choices such as consuming too much salty foods,
coffees and taking over the counter drug (NSAID) can precipitate the development of
Duodenal Ulcer. The past and current medical history of the Patient contributed to the
existing condition. Drugs that are given to the patient like ciprofloxacin, esomeprazole
sodium, and cimetidine help improve the patient's condition with oxygen therapy and IVF
for comfort.

This case study recommends that team members needs well collaborated and
coordinated health team approach for the management and treatment of the condition.
Appropriate assessment of signs and symptoms is a vital key to avoid risks and
complications and give interventions for proper diagnosis. Health education for patients
and their families helps to better understand the state of health, the options and its

i
consequences. Lastly, Individualized care plans focus heavily on each patient's problems
and how they affect them. This will allow the patient's illnesses to be compared and offer
a broader view.
 INTRODUCTION

A Peptic Ulcer is an open sore that occurs in the upper digestive tract. Peptic
ulcer disease occurs most often in people between the ages of 40 and 60. It is relatively
rare in women of childbearing age, but it has been observed in children and even in
infants. After menopause, the incidence of peptic ulcer disease in women is almost the
same as in men. Peptic ulcers can occur if too much acid is not secreted There are two
types of peptic ulcers, a gastric ulcer, which forms in the lining of the stomach,
esophageal ulcers are ulcers that develop inside the esophagus and a duodenal ulcer,
which forms in the upper part of the small intestine.

Duodenal ulcers occur when there is a disruption to the surface of the mucosa of
the duodenum. Normally, a thick layer of mucus protects the stomach lining from the
effect of its digestive juices. Bacteria, stomach acid and digestive enzymes can then
damage the wall itself, as a result it can reduce this protective layer, allowing stomach
acid to damage the tissue. The stomach is full of strong acid, which breaks down and
digests the food eaten. Helicobacter pylori commonly infects the stomach which may be
acquired through ingestion of food and water. The H. pylori bacteria stick to the layer of
mucus in the digestive tract and cause inflammation (irritation), which can cause this
protective lining to break down. People who take or are dependent on non-steroidal anti-
inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen are more likely
to develop duodenal ulcers. In fact, after H. pylori, NSAID use is the other leading cause
of this disease. Other risk factors known to increase your risk of developing duodenal
ulcers include ages between 40 or 60, alcohol use, history of stomach ulcer, smoking,
serious injury, or physical trauma. Intake of milk and drinks containing caffeine can
increase the secretion of HCl. In addition, excessive secretion of HCl in the stomach may
contribute to the formation of peptic ulcers, and stress may be associated with its
increased secretion. Stress and spicy foods can make stomach ulcers worse.

A rare condition known as Zollinger-Ellison syndrome causes cancerous and non-

cancerous tumors to develop. These tumors release hormones that cause extremely high
levels of stomach acid, which can lead to stomach and duodenal ulcers. A person with
duodenal ulcers may experience stomach or abdominal pain (these can come and go and

1
are relieved by eating or taking an antacid), indigestion, feel very full and bloated after
eating, vomiting, nausea and weight loss. In rare cases, ulcer can cause serious
complications. If the person with duodenal ulcer experience severe stomach pain that
does not go away, and vomit or stool looks bloody or black, this is an emergency.

A Urinary tract infection (UTI) is an infection in any part of the urinary system,
especially the kidneys, ureters, bladder, and urethra. Most UTIs are caused by bacteria
that enter the urethra and then the bladder. The infection most commonly develops in the
bladder, but can spread to the kidneys. Most of the time, your body can get rid of these
bacteria. However, certain conditions increase the risk for having UTIs. Infection limited
to the bladder can be painful and uncomfortable. However, if a urinary tract infection
spreads to the kidneys, serious consequences can occur. Women are at higher risk of
developing a urinary tract infection than men. Factors that can increase the risk of UTIs
include a previous UTI, sexual activity, changes in the bacteria that live inside the vagina,
or vaginal flora. For example, menopause or the use of spermicides can cause these
bacterial changes, pregnancy, age (older adults and young children are more likely to get
UTIs), structural problems in the urinary tract, such as enlarged prostate, poor hygiene,
for example, in children who are potty-training. Symptoms typically include needing to
urinate often, having pain when urinating and feeling pain in your side or lower back.
Most UTIs can be treated with an antibiotic.

High blood pressure, also known as hypertension, is high blood pressure that is
above normal. Tissues and organs need the oxygenated blood that your circulatory
system carries throughout the body. When the heart beats, it creates pressure that pushes
blood through a network of tube-shaped blood vessels, which include arteries, veins and
capillaries. This pressure, blood pressure, is the result of two forces:

The first force (systolic pressure) occurs as blood pumps out of the heart and into
the arteries that are part of the circulatory system. The second force (diastolic pressure) is
created as the heart rests between heart beats. The blood pressure will change throughout
the day based on the activities. It is a major risk factor for stroke, myocardial infarction,
vascular disease, and chronic kidney disease.

2
 High blood pressure usually has no symptoms. The only way to know if a person
has it is through regular blood pressure checks by the health care provider. Symptoms of
severe hypertension can include headache, shortness of breath, nosebleeds, hot flashes,
dizziness, chest pain, blurred vision, and blood in the urine. These symptoms require
immediate medical attention. There are two main types of hypertension: primary and
secondary hypertension. Primary or essential high blood pressure is the most common
type of hypertension. Most people with this type of blood pressure develop over time as
they age. Secondary hypertension is caused by another disease or by the use of certain
medications. It usually improves after treating this condition or stopping the drugs that
cause it. Symptoms of severe hypertension can include headache, shortness of breath,
nosebleeds, hot flashes, dizziness, chest pain, blurred vision, and blood in the urine.
These symptoms require immediate medical attention.

3
 DISEASE MANAGEMENT

DUODENAL ULCER

1. MEDICAL-SURGICAL MANAGEMENT: (IN GENERAL)

PPI

-  Proton pump inhibitors were used to block the stomach acid by preventing the proteins
actions known as the proton pumps. By reducing the stomach acid, the duodenal could
further be prevented from getting ulcer.

ANTIBIOTICS

-Antibiotics are effective at killing the bacteria and often used as treatment for stomach
and duodenal ulcers.

The standard approach to treatment is called triple therapy. This combines

two Antibiotics to knock out the infection and a Proton Pump Inhibitor (PPI) to help
with healing by reducing stomach acids.

*MEDICATIONS:

Combination drug therapy includes:

*Triple therapy

- PPI with two antibiotics (Metronidazole(flagyl) and Clarithromycin (biaxin)

PPI includes Omeprazole (prilosec), Esomeprazole

*Vagotomy

*Antrectomy

*Bilroth I (gastroduodenostomy)

*Bilroth II (gastrojejunostomy)

4
NURSING INTERVENTIONS

*Relieving Pain

*Reducing Anxiety

*Maintaining Optimal Nutritional Status

*Monitoring and Managing Potential Complications

1. MEDICAL MANAGEMENT: (FOR THE PATIENT’S CASE)

*Cimetidine (Tagamet)
* Esomeprazole Sodium (Nexium)
NURSING INTERVENTIONS:

*Monitor improvement of GI symptoms to help determine if the drugs are successful

*Advice patient to avoid foods that can cause increase in GI irritations

*Health teaching about stress reduction and relaxation techniques

UTI

1. MEDICAL MANAGEMENT (IN GENERAL)

ANTIBIOTICS

Antibiotics are safe, antimicrobial medications and usually the first line of treatment that
stamp out a bacterial urinary tract infection by killing or blocking the germs that cause it.

MEDICATIONS:

*Antibiotics (such as Nitrofurantoin, Fluoroquinolone,Penicillin or Cephalosporin)

*Urinary analgesic agent (Phenazopyridine)

NURSING INTERVENTIONS

*Relieving Pain and discomfort

*Monitoring and Managing Potential Complications

5
*Educating Self-Care

2. MEDICAL MANAGEMENT: (FOR PATIENT’S CASE)

*Ciprofloxacin (ciprobay)

NURSING INTERVENTIONS

*Instruct patient not to take or eat a lot of caffeine products within 6 hours before or 2
hours after medication

*Watch for signs and symptoms of serious adverse reaction

*Ensure that the patient is well hydrated

*Instruct patient to report any adverse reactions

HYPERTENSION

1. MEDICAL MANAGEMENT: (IN GENERAL)

*BETA-BLOCKERS

Drugs from the beta blocker group work by suppressing the effect of the epinephrine or
adrenaline hormone, which is a hormone that plays a role in blood flow, thereby making
the heart beat slower and less work, as well as blood pressure down. In addition, the drug
also helps dilate blood vessels so that blood circulation goes smoothly.

*VASODILATORS

Vasodilators are used to treat high blood pressure (hypertension). By widening the

arteries, these drugs allow blood to flow through more easily, reducing blood pressure.

*ACE INHIBITORS

Angiotensin-converting-enzyme inhibitors are a class of medication used primarily for

the treatment of high blood pressure. They work by causing relaxation of blood vessels as
well as a decrease in blood volume, which leads to lower blood pressure and decreased
oxygen demand from the heart.

6
*ANGIOTENSIN II RECEPTOR BLOCKERS

The angiotensin II receptor blockers lower blood pressure by blocking the

AT1 receptors. Therefore they have similar effects to angiotensin converting enzyme
(ACE) inhibitors, which inhibit the synthesis of angiotensin II by ACE.

MEDICATIONS:

*Beta-Blockers ( such as, metropolol, propanolol)

*Alpha1- Blockers (doxazosin, prasozin, terazosin)

*Vasodilators (hydralazine, minoxidil)

*ACE Inhibitors (benazepril, captopril)

*Angiotensin II Receptor Blockers (such as eprosartan, losartan)

*Calcium Channel Blockers (diltiazem extended release)

NURSING INTERVENTIONS

*Increasing Knowledge

*Promoting Adherence to the Therapeutic Regimen

* Enhancing Self-Care

*Promoting home, Community-based, and Transitional care

2. MEDICAL MANAGEMENT: (FOR PATIENT’S CASE)

*ANGIOTENSIN II RECEPTOR BLOCKERS (Losartan(cozaar))

NURSING INTERVENTIONS

*Monitor blood pressure and heart rate

*Monitor side effects

*Explain the importance of lifestyle modification

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 SIGNIFACANCE OF THE STUDY

This study regarding Duodenal Ulcer associated with UTI and Stage 1 Hypertension will
be of great benefit to the following:

Patient: Provide awareness of disease process to motivate and encourage patient

becoming self-reliant in managing duodenal ulcer disease that will help in maximizing
the quality of life and prevent another occurrence of complication.

Patient’s Family: Encourage for Planning and preparing better to strengthen the
relationship and helping patient in managing and making adjustment in all aspect as well
as providing what patient needs. Develop good support system, guiding and maintaining
good and healthy environment.

Nursing Students: Improve the knowledge, skills and attitude in rendering quality
standard and evidence-based nursing care to the patient with similar conditions and this
study will serve as guidelines and basis for related studies preference in the future.

Academe: Provide understanding about the disease condition and also, serve as a
contribution of knowledge to the faculty and students, use this as a push-on to help widen
their awareness about this particular disease.

Community: Serve as a guide to those in the same concern by encouraging their self to
maintain their health in a good status at the same time do well in acquiring good healthy
lifestyle by prioritizing their health.

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 ANATOMY AND PHYSIOLOGY

DUODENUM

The duodenum has been described as a C-shaped or horseshoe-shaped segment of

the small intestine. It is located below the stomach. This portion of the small intestine
received its name due to its size; in Latin, duodenum translates to 12 fingers, which is the
approximate length of the organ.1 the duodenum can be separated into four segments.
Each segment has a different anatomy (shape) and performs a different based function.
The lining of the duodenum is comprised of four layers—each with its own specialized
function.

The duodenum’s “C” shape surrounds the pancreas, where it receives pancreatic
enzymes for digestion. The duodenum also connects to the liver via a structure called the
hepatoduodenal ligament. This junction is where the duodenum receives bile to mix with
chyme, an important part of the chemical digestive process described in more detail
below.

Figure 1. Anatomy of the Duodenum

9
URINARY

The urinary system's function is to filter blood and create urine as a waste by-
product. The organs of the urinary system include the kidneys, renal pelvis, ureters,
bladder and urethra. The body takes nutrients from food and converts them to energy.
After the body has taken the food components that it needs, waste products are left
behind in the bowel and in the blood.

Figure 2. The Human Urinary System

KIDNEY

The kidney and urinary systems help the body to eliminate liquid waste called
urea, and to keep chemicals, such as potassium and sodium, and water in balance. Urea is
produced when foods containing protein, such as meat, poultry, and certain vegetables,
are broken down in the body. Urea is carried in the bloodstream to the kidneys, where it
is removed along with water and other wastes in the form of urine. Other important
functions of the kidneys include blood pressure regulation and the production of
erythropoietin, which controls red blood cell production in the bone marrow. Kidneys
also regulate the acid-base balance and conserve fluids.

10
 Figure 3. Anatomy of the Kidney

BLOOD VESSELS

The excessive pressure on your artery walls caused by high blood pressure can
damage your blood vessels as well as your organs. The higher your blood pressure and
the longer it goes uncontrolled, the greater the damage.

Vessels transport nutrients to organs/tissues and to transport wastes away from

organs/tissues in the blood. A primary purpose and significant role of the vasculature is
its participation in oxygenating the body. Deoxygenated blood from the peripheral veins
is transported back to the heart from capillaries, to venules, to veins, to the right side of
the heart, and then to the lungs. Oxygenated blood from the lungs is transported to the left
side of the heart into the aorta, then to arteries, arterioles, and finally capillaries where the
exchange of nutrients occurs. Loading and unloading of oxygen and nutrients occur
mostly in the capillaries.

11
 Figure 4. Anatomy of the Blood Vessels

HEART

The heart is made up of four chambers: two upper chambers known as the left
atrium and right atrium and two lower chambers called the left and right ventricles. It is
also made up of four valves: the tricuspid, pulmonary, mitral and aortic valves.

The right atrium receives non-oxygenated blood from the body’s largest veins — superior
vena cava and inferior vena cava — and pumps it through the tricuspid valve to the right
ventricle. The right ventricle pumps the blood through the pulmonary valve to the lungs,
where it becomes oxygenated. The left atrium receives oxygenated blood from the lungs
and pumps it through the mitral valve to the left ventricle. The left ventricle pumps
oxygen-rich blood through the aortic valve to the aorta and the rest of the body.

12
 Figure 5. Anterior View of the Human Heart

Blood Pressure readings

Blood pressure numbers of less than 120/80 mm Hg are considered within the
normal range. If your results fall into this category, stick with heart-healthy habits like
following a balanced diet and getting regular exercise. Elevated blood pressure is when
readings consistently range from 120-129 systolic and less than 80 mm Hg diastolic.
People with elevated blood pressure are likely to develop high blood pressure unless
steps are taken to control the condition. Hypertension Stage 1 is when blood pressure
consistently ranges from 130-139 systolic or 80-89 mm Hg diastolic. At this stage of high
blood pressure, doctors are likely to prescribe lifestyle changes and may consider adding
blood pressure medication based on your risk of atherosclerotic cardiovascular disease
(ASCVD), such as heart attack or stroke. Hypertension Stage 2 is when blood pressure
consistently ranges at 140/90 mm Hg or higher. At this stage of high blood pressure,
doctors are likely to prescribe a combination of blood pressure medications and lifestyle

13
changes. This stage of high blood pressure requires medical attention. If your blood
pressure readings suddenly exceed 180/120 mm Hg, wait five minutes and then test your
blood pressure again. If your readings are still unusually high, contact your doctor
immediately. You could be experiencing a hypertensive crisis.

Figure 6. Blood Pressure Chart

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 DEFINITIONS OF TERMS

Antrectomy- An antrectomy is the resection, or surgery, of the main stomach referred to

as antrum. The antrum may be the lower third from the stomach that lies between
patient’s body from the stomach and also the pyloric canal, which empties to the first the
main small intestine (World Laparoscopy Hospital).

Duodenal Ulcer- A duodenal ulcer is a sore that forms in the lining of the duodenum.
Your duodenum is the first part of your small intestine, the part of your digestive system
that food travels through straight after it leaves your stomach (Health Direct, 2020).

Stage 1 Hypertension- is a systolic pressure ranging from 130 to 139 mm Hg or a

diastolic pressure ranging from 80 to 89 mm Hg (Mayo Clinic, 2021).

Urinalysis- Urinalysis is the physical, chemical, and microscopic examination of urine. It

involves a number of tests to detect and measure various compounds that pass through
the urine (MedlinePlus, 2021).

Urinary Tract Infection- A urinary tract infection (UTI) is an infection in any part of
your urinary system — your kidneys, ureters, bladder and urethra. Most infections
involve the lower urinary tract — the [ CITATION Tuc21 \l 1033 ].

Vagotomy- A vagotomy is a type of surgery that removes all or part of your vagus nerve.
This nerve runs from the bottom of your brain, through your neck, and along your
esophagus, stomach, and intestines in your gastrointestinal (GI) tract (Jewell, T. 2018).

15
 REVIEW OF RELATED LITERATURE

Duodenal Ulcer

Duodenal ulcers are part of a broader disease state categorized as peptic ulcer disease.
Peptic ulcer disease refers to the clinical presentation and disease state that occurs when
there is a disruption in the mucosal surface at the level of the stomach or first part of the
small intestine, the duodenum. Anatomically, both the gastric and duodenal surfaces
contain a defense system that includes pre-epithelial, epithelial, and subepithelial
elements. Ulceration occurs from damage to the mucosal surface that extends beyond the
superficial layer. While most duodenal ulcers present with dyspepsia as the primary
associated symptom, the presentation can range in severity levels, including
gastrointestinal bleeding, gastric outlet obstruction, perforation, or fistula development
(Quinones et al, 2021). According to the study made by Singh et al. (2020) people
engaged in manual works having poor socioeconomic status are, accordingly, more prone
to develop perforation. Also, ingestion of NSAIDS and steroids, smoking and alcohol
consumption may also increase the risk of duodenal ulcer perforation. This study also
indicates that dietary habit seems to play a role in the pathogenesis of peptic ulcer and
complications. Spicy foods and irregular diet may increase the risk of duodenal ulcer and
perforation development. Moreover, the incidence of perforation is more common in
patients with type O blood group. A study conducted by Noola et al (2016) titled "A
clinical study of duodenal ulcer perforation" shows that the highest incidence of duodenal
ulcers was found in 40 – 49 years of age (25%) followed by 20 – 29 years (21.67%), 30 –
39 years (20%), and 50 – 59 years (15%).

The mechanisms of ulcer formation are diverse and include excessive gastric acid
secretion and the use of non-steroidal anti-inflammatory drugs (NSAIDs). In recent years,
the incidence of non- Hp non-NSAIDs-related ulcers has been on the rise (Hou and
Zhang, 2015). Other non- Hp bacteria may participate in the development of two
common ulcers. (Kuna et al, 2019) The estimated prevalence of peptic ulcer disease in
the general population is 5–10%, but recent epidemiological studies have shown a

16
decrease in the incidence, rates of hospital admissions, and mortality associated with
peptic ulcer. This is most likely secondary to the introduction of new therapies and
improved hygiene, which resulted in a decline in Helicobacter pylori (H. pylori)
infections.

Stage 1. Hypertension

Hypertension Stage 1 is when blood pressure consistently ranges from 140-159

systolic or 90-99 mm Hg diastolic (Hinkle & Cheever 2018). At this stage of high blood
pressure, doctors are likely to prescribe lifestyle changes and may consider adding blood
pressure medication based on your risk of atherosclerotic cardiovascular disease
(ASCVD), such as heart attack or stroke (AHA,2021). High blood pressure is a major
risk factor for chronic heart disease, stroke, and coronary artery disease. Elevated blood
pressure is positively correlated with the risk of stroke and coronary heart disease. In
addition to coronary artery disease and stroke, complications include heart failure,
peripheral vascular disease, kidney dysfunction, retinal hemorrhage, and visual
impairment (Singh et al., 2017).

According to Oguanobi (2021) there are several barriers to hypertension control

and these barriers are largely responsible for the observed increase in the incidence of
complications in patients who are hypertensive in spite of the continuous progress of their
antihypertensive strategies. In many countries, primary health care facilities play a vital
and significant role in the detection, risk factor assessment, and management of
hypertension.

Furthermore, one key patient-related factor that determines control of

hypertension is the adherence to recommended therapy. However, patients are often
worried about the lifelong nature of essential hypertension and the requirement for
prolonged therapy and life style modifications and consequently resort to endless search
for the cures in alternative medicines, food supplements, and local remedies. Adherence
to hypertension treatment is also influenced by socio-cultural and economic factors that
includes adverse traditional and cultural practices, illiteracy, and as well as poverty.

17
 Globally, an estimated 26% of the world’s population (972 million people) has
hypertension, and the prevalence is expected to increase to 29% by 2025, driven largely
by increases in economically developing nations (Alexander, 2020). According to Mills
et al. (2020) Hypertension is the leading cause of cardiovascular disease and premature
death worldwide. Owing to the widespread use of antihypertensive medications, global
mean blood pressure (BP) has remained constant or has decreased slightly over the past
four decades.

By contrast, the prevalence of hypertension has increased, especially in low- and

middle-income countries (LMICs). Estimates suggest that 31.1% of adults (1.39 billion)
worldwide had hypertension in 2010.

The prevalence of hypertension among adults was higher in LMICs (31.5%, 1.04
billion people) than in high-income countries (28.5%, 349 million people). Variations in
the levels of risk factors for hypertension, such as high sodium intake, low potassium
intake, obesity, alcohol consumption, physical inactivity and unhealthy diet, may explain
some of the regional heterogeneity in hypertension prevalence. Despite the increasing
prevalence, the proportions of hypertension awareness, treatment and BP control are low,
particularly in LMICs, and few comprehensive assessments of the economic impact of
hypertension exist. Future studies are warranted to test implementation strategies for
hypertension prevention and control, especially in low-income populations, and to
accurately assess the prevalence and financial burden of hypertension worldwide (Talaei
et al, 2018).

Urinary Tract Infection

According to the study made by Demillie Beyene (2014) Urinary tract infection
(UTI) is a common bacterial infection known to affect the different parts of the urinary
tract and the occurrence is found in both males and females. Despite the fact, that both
the genders are susceptible to the infection, women are mostly vulnerable due to their
anatomy and reproductive physiology. The infection is usually caused as a consequence
of bacterial invasion of the urinary tract including the lower and the upper urinary tract.

18
Among the bacterial species Escherichia coli account to 80% to 85% of the infection
followed by Staphylococcus species that constitutes to 10% to 15%. In addition, bacterial
species Klebsiella, Pseudomonas, Proteus and Enterococcus species plays a minor role in
conferring the infection. A variety of parameters are related to UTI which include age,
parity, gravidity, pregnancy and association of diseases augment the condition of the
infection.

The prevalence of UTI increases with age, and in women aged over 65 is
approximately double the rate seen in the female population overall. Etiology in this age
group varies by health status with factors such as catheterization affecting the likelihood
of infection and the pathogens most likely to be responsible. In younger women,
increased sexual activity is a major risk factor for UTIs and recurrence within 6 months is
common.

In the female population overall, more serious infections such as pyelonephritis

are less frequent but are associated with a significant burden of care due to the risk of
hospitalization. Etiology in older postmenopausal women varies depending on their
health status, residential status (institutionalized or not), age, the presence of diabetes
mellitus, history of/current catheterization, spinal cord dysfunction, and a history of
antibiotic use (Medina and Castillo, 2019).

Infections of the urinary tract are the second most common type of infection in the
body. Although most urinary tract infections can be effectively treated with antibiotics,
recurrence of urinary tract infections is a common problem and can sometimes be very
bothersome. They also stated that another possible mechanism of common urinary tract
infections is the survival of bacteria in the bladder through the progression of intracellular
bacterial communities (Kuo et al., 2017). Early studies showed that E. coli can replicate
intracellularly, form a loose group of bacteria, and then escape into the lumen of the
bladder.

In females, short distance between anus and vagina, facilitates ascending rectal
normal flora to enter urethra and causing recurrent urinary tract infection or RUTI, so
whipping genital area from front to back is important to prevent it (Al-Khikani, 2020).

19
According to this study, many females suffer from RUTI with a high rate in which this
stays a major challenge, requiring long-term prophylactic therapy in order to prevent it.
This study also indicated that persistent sexual intercourse is considered the biggest risk
factors for RUTIs in women. Females then are encouraged to prevent spermicidal
contraceptives and vaginal douching that may irritate and hurt the vagina that facilitates
the entry and colonization of bacteria inside the urinary tract. Moreover, post-menopausal
women have greater rates of UTI due to pelvic prolapse, the loss of estrogen and little
lactobacilli in the vaginal flora. Estrogen helps a generation of lactobacillus in the vagina,
reduces pH, as well as avoids vaginal colonization by pathogenic bacteria.

20
 PATHOPHYSIOLOGY

A peptic ulcer may be referred to as a gastric, duodenal, or esophageal ulcer,

depending on its location. A peptic ulcer is an excavation that forms in the mucosa of the
stomach, in the pylorus which is the opening between the stomach and duodenum, in the
duodenum or in the esophagus. The cause is the erosion of a circumscribed area of the
mucosa. This erosion may extend as deeply as the muscle layers or through the muscle to
the peritoneum or the thin membrane that lines the inside of the wall of the abdomen.
Peptic ulcers are more likely to occur in the duodenum than in the stomach. Accordingly,
women and men have about equivalent lifetime risk of developing peptic ulcers.
However, duodenal ulcers are more common in men during the age of 40-50 years old.

There are several risk factors and causes of peptic ulcer or peptic ulcer disease.
Before, stress and anxiety were thought to be causes of peptic ulcers, but research has
revealed and documented that most peptic ulcers result from infection with the gram-
negative bacteria, H. pylori, which may be acquired through ingestion of food and water.
Person-to-person transmission of the bacteria also occurs through close contact and
exposure to emesis. However, most infected people do not develop ulcers. The
predisposition to ulcer formation depends on certain factors, such as the type of H. pylori
and other as yet unknown factors. The use of NSAIDs such as ibuprofen and aspirin are
also a major risk factor for peptic ulcers. It is believed that smoking and alcohol
consumption may be risks, although the evidence is inconclusive. There is no evidence
that the ingestion of milk, caffeinated beverages, and spicy foods are associated with the
development of peptic ulcers. Familial tendency may also be a significant predisposing
factor. People with blood type O are more susceptible to the development of peptic
ulcers. There also is an association between peptic ulcer disease and chronic obstructive
pulmonary disease, cirrhosis of the liver, and chronic kidney disease. Peptic ulcer disease
is also associated with Zollinger–Ellison syndrome (ZES). ZES is a rare condition in
which benign or malignant tumors form in the pancreas and duodenum that secrete
excessive amounts of the hormone gastrin. The excessive amount of gastrin results in
extreme gastric hyperacidity and severe peptic ulcer disease.

21
 Peptic ulcers occur mainly in the gastroduodenal mucosa because this tissue
cannot withstand the digestive action of gastric acid or HCl and pepsin. The erosion is
caused by the increased concentration or activity of acid–pepsin or by decreased
resistance of the normally protective mucosal barrier. A damaged mucosa cannot secrete
enough mucus to act as barrier against normal digestive juices. The exposure of the
mucosa to gastric acid or HCl, pepsin, and other irritating agents like NSAIDs or H.
pylori, leads to inflammation, injury, and subsequent erosion of the mucosa. Patients with
duodenal ulcers, accordingly, secrete more acid than normal, while patients with gastric
ulcers tend to secrete normal or decreased levels of acid. When the mucosal barrier is
impaired, even normal or decreased levels of HCl may result in the formation of peptic
ulcers.

On the other hand, Duodenal ulcers occur with numbers of risk factors including
age, sex or gender, family history of ulcers, people with blood type O, tobacco use,
abusive alcohol consumption, stress, Helicobacter pylori bacterial infection, presence of
gastrinoma, and frequent use or intake of non-steroidal anti-inflammatory drugs or
NSAIDs.

However, accordingly, there are most common and major causes that results to
duodenal ulcers. One is the Helicobacter pylori infection. H. pylori causes inflammation
in the walls of the duodenum which stimulates G-cells that in return results to increased
levels of gastrin produced and also a destruction of delta cells that decreases
somatostatin. The stimulation of both cells will then lead to an increased levels of acid
production. Furthermore, with H. pylori infection, particularly in the gastric mucosa, the
bacteria releases adhesions that would help them adhere to the foveolar cells that
functions to produce mucus to protect the stomach from the acid, and with this adhesion,
this will eventually destroy the gastric mucosal lining. H. pylori also happens to release
proteases that cause damage to mucosal cells. Most of the time, this damage starts in the
antrum that finds its way to eventually affect the duodenum and its lining.

The second cause is the presence of Zollinger-Ellison syndrome that occurs when
there is an existence of a tumor called gastrinoma. Gastrinoma is a neuroendocrine tumor
usually located in the duodenal wall and the pancreas and it causes secretion of abnormal

22
amounts of gastrin that stimulates the parietal cells releasing excess hydrochloric acid
causing increased acid production that overwhelms normal defense mechanism allowing
the development of a duodenal ulcer. The last of the most common causes of duodenal
ulcer are the non-steroidal anti-inflammatory drugs. NSAIDs inhibit the enzyme called
cyclooxygenase 1 or cox 1 that is involved in the synthesis of inflammatory
prostaglandins. With prolonged use of NSAIDs, there will be a reduced level of
prostaglandins leaving the mucosal layer susceptible to damage and causing an ulcer to
develop overtime.

23
 Non-modifiable risk factors: Modifiable risk factors:
-Age (40-49 years old) -Sex (Male) -Smoking -H. pylori infection -Gastrinoma
-Family history (of ulcers) -Blood type O -Alcohol abuse -Frequent use of NSAIDs
-Stress -History of Duodenal Ulcer

Helicobacter pylori (H. pylori) Non-steroidal anti-inflammatory drugs Zollinger-Ellison syndrome (ZES)
Infection (NSAIDs) overuse

Colonize gastric Inhibit COX 1 enzymes Secretes abnormal levels of

mucosa gastrin

Reduced levels of prostaglandins

Inflammation of the antrum Release
adhesions Stimulation of parietal cells
and proteases
Gastric mucosa becomes
Stimulation of G-cells and susceptible to damage
destruction of D-cells
Excess release of hydrochloric
acid
Damage of gastric mucosa
Increased gastrin,
decreased somatostatin
Gastric Ulcer

Increased acid production

Damage of the duodenal
mucosa

24
DUODENAL ULCER
Figure 7. Pathophysiology of Duodenal Ulcer
 Urinary tract infections or UTIs are caused by pathogenic microorganisms in
the urinary tract. The most common causative agent is E. coli or Escherichia coli. UTIs
are generally classified as infections involving the upper or lower urinary tract and
further classified as uncomplicated or complicated, depending on other patient-related
conditions.

Lower UTIs include bacterial cystitis or inflammation of the urinary bladder,

bacterial prostatitis or inflammation of the prostate gland, and bacterial urethritis which is
an inflammation of the urethra. Acute or chronic nonbacterial causes of inflammation in
any of these areas can be misdiagnosed as bacterial infections. Upper UTIs are much less
common and include acute or chronic pyelonephritis or an inflammation of the renal
pelvis, interstitial nephritis referred to as an inflammation of the kidney, and kidney
abscesses. Upper and lower UTIs are further classified as uncomplicated or complicated,
depending on whether the UTI is recurrent and the duration of the infection. Most
uncomplicated UTIs are community acquired, whereas, complicated UTIs usually occur
in people with urologic abnormalities or recent catheterization and are often acquired
during hospitalization.

In Lower Urinary Tract Infection, this happens when there is a bacterial

invasion in the lower urinary tract. For infection to occur, bacteria must gain access to the
bladder, attach to and colonize the epithelium of the urinary tract to avoid being washed
out with voiding, evade host defense mechanisms, and initiate inflammation. Many UTI
cases result from fecal organisms ascending from the perineum to the urethra and the
bladder and then adhering to the mucosal surfaces.

Furthermore, a urethrovesical reflux, which is an obstruction to free-flowing

urine, this is backward flow of urine from the urethra into the bladder that also causes an
infection in the lower urinary tract. With coughing, sneezing, or straining, the bladder
pressure increases, which may force urine from the bladder into the urethra. When the
pressure returns to normal, the urine flows back into the bladder, bringing into the
bladder the bacteria from the anterior portions of the urethra. Urethrovesical reflux is also
caused by dysfunction of the bladder neck or urethra. The urethrovesical angle and
urethral closure pressure may be altered with menopause, that increases the incidence of

25
infection in postmenopausal women. Reflux is most often noted in young children, and
treatment is based on its severity.

Additionally, there is a ureterovesical or vesicoureteral reflux which refers to the

backward flow of urine from the bladder into one or both ureters. When the
ureterovesical valve is impaired by either congenital causes or ureteral abnormalities, the
bacteria may reach the kidneys and eventually destroy them.

On the other hand, in Upper Urinary Tract Infection, or pyelonephritis is a

bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both
kidneys. Causes involve either the upward spread of bacteria from the bladder or spread
from systemic sources reaching the kidney via the bloodstream. Pathogenic bacteria from
a bladder infection can ascend into the kidney, resulting in pyelonephritis.

Accordingly, an incompetent ureterovesical valve or obstruction occurring in the

urinary tract increases the susceptibility of the kidneys to infection because static urine
provides a good medium for bacterial growth. Bladder or prostate tumors, strictures,
benign prostatic hyperplasia, and urinary stones are some potential causes of obstruction
that can lead to infections. Systemic infections such as tuberculosis can spread to the
kidneys and result in abscesses.

In general, Urinary Tract Infection or UTI, has risk factors that include age, sex,
family history, congenital defects, pregnancy, uncircumcised male, instrumentation such
as catheterization, sexual activities, urinary stones, residual urine, urinary stasis, urinary
reflux, and poor hygiene. The most common causative agent of UTI, accordingly, is
Escherichia coli. As these bacteria invades the lower urinary tract, initial contamination
occurs leading to its colonization in the urethra and the bladder triggering an
inflammatory response. With presence of inflammation, neutrophils are then recruited to
this area. This event continues as bacteria multiply and evade the immune system with
their virulent factors. For an instance, E. coli bind to cells in the lower urinary tract and
they hide from immune cells. There is a biofilm formation wherein bacterium stick to
each other and they adhere to surfaces allowing survival of themselves. This will then
lead to Lower UTI, and if left untreated, this will eventually make the bacteria ascend

26
towards the kidneys and colonize the kidneys as well causing now Upper UTI.
Furthermore, if this upper UTI is left untreated, the bacteria then spread to the circulation
via the renal veins causing septic shock in worse cases.

27
Non-modifiable: Modifiable:
-Age -Sex (Female) - Instrumentation (Catheterization) - Diabetes
-Family history -Congenital defect - Pregnancy - Sexual activity
-Impaired Immune System - Residual urine (200 mL or more) - Poor hygiene

Most common causative agent: Escherichia Coli (E.Coli)

Contamination of the Lower urinary tract

Colonization of bacteria in the urethra and bladder

Inflammation in the lower urinary tract

Neutrophil infiltration

Bacteria multiply and evade the immune system

Biofilm formation

LOWER URINARY TRACT INFECTION

Ascension of bacteria towards the kidney/s

Colonization of bacteria in the kidney/s

UPPER URINARY TRACT INFECTION

Figure 8. Pathophysiology of Urinary Tract Infection (UTI)

28
 Hypertension can result from increases in cardiac output, increases in peripheral
resistance, or both. Increases in cardiac output are often related to an expansion in vascular
volume. Hypertension is a multifactorial condition as in most cases, it has no precise cause that
can be identified. Because hypertension can be a sign, it is most likely to have many causes. For
hypertension to occur there must be a change in one or more factors affecting peripheral
resistance or cardiac output. In addition, there must also be a problem with the body’s control
systems that monitor or regulate pressure. The tendency to develop hypertension is inherited;
however, genetic profiles alone cannot predict who will and who will not develop hypertension.

There are many causes of hypertension that have been suggested and this include
increased sympathetic nervous system activity related to dysfunction of the autonomic nervous
system, increased renal reabsorption of sodium, chloride, and water related to a genetic variation
in the pathways by which the kidneys handle sodium, increased activity of the renin–
angiotensin–aldosterone system, resulting in expansion of extracellular fluid volume and
increased systemic vascular resistance, decreased vasodilation of the arterioles related to
dysfunction of the vascular endothelium, resistance to insulin action, which may be a common
factor linking hypertension, type 2 diabetes, hypertriglyceridemia, obesity, and glucose
intolerance, and activation of the innate and adaptive components of the immune response that
may contribute to renal inflammation and dysfunction.

The two stages of hypertension include Stage 1 Hypertension wherein the systolic
pressure ranging from 140 to 159 mm Hg or a diastolic pressure ranging from 90 to 99 mm Hg
and Stage 2 Hypertension which is more-severe hypertension, this is a systolic pressure of 160
mm Hg or higher or a diastolic pressure of 1000 mm Hg or higher.

Furthermore, there are two main types of high blood pressure, known as the primary and
the secondary high blood pressure or hypertension. Primary, or essential, hypertension is the
most common type of high blood pressure. For most people, this develops over time as they get
older. Secondary high blood pressure is caused by another medical condition or use of certain
medicines. Certain conditions that may cause secondary hypertension include kidney disease,
adrenal disease, thyroid problems and obstructive sleep apnea.

29
 Moreover, hypertension can be caused by certain risk factors that include age, family
history, ethnicity, obesity, sedentary lifestyle, stress, diabetes, sleep apnea, smoking, and alcohol
abuse. Primary hypertension, although as an unknown cause, it can probably can be caused by a
sedentary lifestyle or obesity which are developed because of habits, hypersensitive sympathetic
nervous system which increases sympathetic nervous system activity leading to an increased
release of norepinephrine causing vasoconstriction that increases the total peripheral resistance
thus causing hypertension. Also, an increased in sensitivity of renin-angiotensin-aldosterone axis
causing an excessive production of renin thus increasing angiotensin II causing high blood
pressure. Lastly, if there is a decreased sodium excretion there will be an increased sodium
retention leading to an elevated blood levels and vasoconstriction and later on leading to the
development of hypertension.

For secondary hypertension, this is developed commonly from complications of renal

disease conditions. These conditions include glomerulonephritis, diabetic nephropathy, and
polycystic kidney disease that will eventually cause a damage in the kidney or kidneys causing
disruption of its functions leading to hypertension. More of the conditions include renal artery
stenosis, vasculitis, and fibromuscular dysplasia that cause a narrowed blood vessel particularly
the renal arteries causing a decreased blood flow to the kidneys leading to a decreased urine
production that results to build up of water and
sodium eventually causing hypertension.

30
Non-modifiable risk factors: Modifiable risk factors:
-Advancing adult age (>65 years old) - Sex (Male) -Obesity -Diabetes mellitus -Smoking
-Ethnicity (African-Americans) -Family History -Sedentary Lifestyle -Alcohol abuse -Stress

Autonomic Nervous System Increased activity of RAAS Dysfunction of the

dysfunction
Vascular Endothelium
Increased Renin secretion
Increased Sympathetic
Nervous System activity Decreased secretion of
Increased Angiotensin I Nitric Oxide

Releases an increased Increased Angiotensin II Systemic Decreased vasodilation

norepinephrine level vasoconstriction of the arterioles
Increased Aldosterone levels
Vasoconstriction
Increased systemic
Sodium and Water retention vascular resistance

Elevated blood volume

Increased blood pressure

Prehypertension

STAGE 1 HYPERTENSION

Figure 9. Pathophysiology of Stage 1 Hypertension

31
 PATHOGENESIS

MODIFIABLE FACTORS:

-Consuming too much

-Increased blood
salty foods and coffee
sugar
-Taking OTC drugs
-Constipation
-Elevated blood sugar
NON-MODIFIABLE RISK FACTORS:
MODIFIABLE - Hx: UTI
RISK FACTORS: - Age
(6 months ago)
ALT=52 U/L , - Menopause
- Female
AST=43 U/L
ALP=121 U/L ,
Albumin=5.9 g/dL,
Total Protein=8.4 gdL Disruption to the surface of Impairment of body’s natural
GGT=57 U/L Damage to the kidney
(BUN – 23mg/dl duodenal mucosa defense, allowing growth and
(Liver Failure) Creatinine – 2.12 mg/dl) accumulation of bacteria.

 Abdominal pain
 Abdominal Fullness E. coli gains entry to the
Decrease kidney function urinary tract
 Nausea/Vomiting
 Weight loss
 Dark stools
Fluid retention due to an Inflammation of the urethral
elevated Na+ lining (flank pain, difficult
urinating)
Duodenal Ulcer
Increased blood pressure
WBC increased to fight off
bacteria (11,000 u/L), turbid
Stage 1 Hypertension urine, and fever.
32
Figure 10. Pathogenesis
Urinary Tract Infection
 PATIENT’S PROFILE
Patient’s Name: Mrs. S

Age: 50 years old

Sex: F

Citizenship: Filipino

Religion: Seventh Day Adventist

Occupation: House Wife

Admitting Diagnosis: Duodenal Ulcer, UTI, Stage 1 Hypertension

Chief Complaint: Abdominal Distention, abdominal pain, chest pain after eating, pain on
the lateral side of her abdomen.

Past History: Patient had medical history of UTI 6 months ago, and was treated with
antibiotics for 2 weeks without hospitalization. She’s used in taking over the counter
drugs like ibuprofen and aspirin for pain and joint swelling.

Present History: The patient was brought to the hospital 3 days ago and claimed that she
is experiencing abdominal distention, abdominal pain, chest pain after eating, and pain on
the flank area. She also claimed that she’s experiencing nausea and vomiting, bitter taste
in the mouth, noticeable weight loss, very dark stools, difficult urination and loss of
appetite.

33
 GORDON’S 11 FUNCTIONAL MODEL

Gordon’s 11 Health Functional Pattern

1. Health Perception- Health Management Pattern

The patient admitted she is used to taking over-the-counter drugs like ibuprofen
and aspirin for pain and joint swelling. She has a medical history of UTI 6 months
ago and was treated with antibiotics for 2 weeks without hospitalization. She eats
three times a day and usually sleeps an average of 5 hours. Her husband said that
days before the admission his wife was complaining of difficult urination and was
very irritable at home but refused to see a doctor.

2. Nutrition and Metabolic Pattern

Mrs. S, claimed to eat three times a day, her favorite food is fried fish with
“suka”, she loves chips, native foods like “biko”, and “balut”. She drinks about 3-4
glasses of water per day and 3-4 cups of native coffee almost every day. She also
complains of hypoactive bowel movements at times. Upon admission, she claimed to
have lost weight and appetite for food. Her body weight is 51 kg with a BMI of 19.3
which is considered normal but lower than the ideal body weight of 58.5 kg. She
verbalized “ta duele mio bariga y pecho akabar kome” “(My stomach and chest hurt
after eating”). She was advised to be on NPO and prescribed NaCl alternate with
D5% LR for a total of 2,500 ml/day, IVF, and Cimetidine (Tagamet) 300 mg in 500
mL NSS to run at 25 mg/h continuous IV infusion. At present she was advised to
have a low protein soft diet, she was able to take 45% of her breakfast, with 1
episode of nausea early in the morning. She still complain of abdominal cramps, but
“hinde mas gayot bien duele egual del primero” as Mrs. S verbalized.

3. Elimination Pattern
She complains of constipation with some dark stools recently. Upon admission,
she claimed to have nausea and vomiting, her stools were now very dark and

34
 urination was still difficult. Her urine output, 6 hours since admission is 180 ml
(measured in a urinal).
She also vomited twice, each is about 50-80 ml, and the vomitus was greenish-
yellowish fluids believed to be gastric in origin.
Urinalysis was done and the urine color was amber and turbid. At present, her 24
hours input is 2,800 mL and her urine output is 1, 600 mL (measured in a urinal). Her
latest urine analysis showed that the urine was color-amber and minimally turbid.

4. Activity and Exercise Pattern

Mrs. S said she enjoys watching “teleserye” and Netflix at home. She also enjoys
the computer and cellular phones often for online communication with her son and
grandchildren. She keeps a small garden at home and cooks for her family well.
According to her, she goes to church every Saturday and reads the Bible with some
friends once a week. No data was obtained regarding exercise, but at present she can
move within the room with some assistance from the watcher.

5. Sleep and Rest Pattern

According to Mrs. S, she usually sleeps an average of 5 hours per night. She
sleeps late from watching movies, but sometimes she spends extra time until morning
to finish some movie marathon. No further data regarding current sleep and rest
patterns.

6. Cognition and Perception Pattern

Mrs. S was conscious, responsive, coherent and oriented, she could answer
questions correctly and she was able to raise and lower her arms when instructed.
She can recognize her husband and the reason why she was brought to the hospital
but kept asking what her illness was and if she will be operated.

7. Self-perception and Self-concept Pattern

Her husband claimed that Mrs. S was a loving and caring wife. Three days since
admission Mrs. S, verbalized “No kyere pa yo muri. Kyere pa yo mira ta gradua mio

35
 mga apo” (“I am not ready to die, I still want to see my grandchildren graduate”). No
further data was mentioned.
8. Roles and Relationship Pattern
Mrs. S claimed that she is a high school graduate and a housewife since her
married life. She is married to her husband for 24 years and she has one son who is
now married. She also has grandchildren which she keeps in touch through online
communication. No further data was mentioned.

9. Sexuality and Reproductive Pattern

She claimed to have “regular, monthly menstruation” before she menopause at the
age of 47. Mrs. S, also confided that she had a history of Gonorrhea around 10 years
back and blamed her husband for the infection. She said she was treated by a private
physician with penicillin injection at that time. She has 1 son which she delivered
normally in the hospital. There are no reports of any unusual bleeding at present. She
also claimed that she is not very much sexually active as she used to be.

10. Coping and Stress Tolerance Pattern

No data was mentioned by Mrs. S, but her husband said the patient was irritable
before admission and refuses to see a doctor.

11. Values and Beliefs Pattern

According to Mrs. S, she follows Seventh Day Adventist, she goes to church and
reads the Bible with her friends. She verbalized “I am waiting for the second coming
of Jesus eagerly. I pray for my son, my grandchildren, and my husband every day”.

36
 CEPHALOCAUDAL ASSSESSMENT

General Appearance:

During the initial contact the patient was wearing t-shirt and pants, her hair is tidy and
she was wearing her eyeglasses. the patient appears weak and in pain. she was conscious,
responsive, oriented and could answer the question correctly. No signs of confusion were
noted.

Head

a. Hair, Cranial bones/skull, fontanels, sutures, others.

- Mixed gray and black hair completely distributed in head, with minimal dandruff, no lesions,
no scars, no wounds noted. No offensive smell noted.
b. Eyes
- Wears eyeglasses +2.0 (since 22 years old) revealed PERRLA, corneal blinking reflexes
present in both eyes, sclerae appeared pinkish, minimal peri-orbital edema noted on both
sides, complained of “blurring” but managed to correctly identify letters in the magazine
when shown to her. Recent visual acuity revealed OD-20/100, OS-20/60, OU-20/70.
c. Nose
- The nasal passageways were patent, septum was in place, upon illumination, the sinuses
revealed faint red color, able to identify the scent of kalamansi when introduced.
d. Ears
- Ears had intact ear canal with minimal cerumen noted, no discharges noted. No unusual
odor noted. During the whisper test, patient was able to repeat all 5 words correctly as
what the nurse said.
e. Mouth and Throat
- Mouth was clean, with complete upper and lower dentures (since 5 years). Lips
appeared chappy, tongue had minimal cracks. No odor noted from the mouth, uvula
was intact, tonsils not inflamed. On NPO due to nausea. speech was clear.

37
Neck

a. Trachea

Neck was aligned, no complaints of discomfort claimed when palpated.

b. Thyroid Gland

Thyroid gland was hardly palpable

c. Great vessels

- No bruit or abnormal sounds was identified, large vessels were intact and not swollen, carotid
pulse rate was 104 b/min.

Anterior Thorax

- Anterior thorax showed no evidence of lesions, both breasts showed no signs of mass or
discharges, during auscultation, the breath sounds were clear and the RR is 22 br/min.

Posterior Thorax

- The posterior thorax showed no evidence of scars or wounds, percussion sounds showed no
abnormal results, no lesions nor masses palpated, during auscultation, the breath sounds were
clear and the RR is 23 br/min.

Abdomen

- Abdomen was minimally hard on palpation, no scars and lesions noted, bowel sounds were
heard once every minute in all 4 quadrants, percussion sounds were dull at the epigastric
region and at hypochondriac regions; no masses palpated but showed facial grimace during
palpation on epigastric region, claimed of tenderness. Patient refused further palpation of
abdomen.

38
Perineal and Rectal Areas

The patient refuse to assess in her genital area but claimed that she is having difficulty in
urinating but feels no itchiness or discomfort in her genitals. Based on the data presented
she had a history of Gonorrhea around 10 years’ back and was treated by a private
physician with penicillin injection.

Neurologic Assessment

 Cranial Nerves revealed:

 I – Can identify the scent of kalamansi.

 II - Blurred vision, but can manage to identify the words correctly.

 III – Can move eyes up and down and vice versa.

 IV - Patient can perform eye-rolling

 V - When touched, a sensation was felt on the face.

 VI - The eyes can move from one side to another.

 VII – no signs of drooping observed.

 VIII – no hearing difficulty were noted.

 IX – Difficulty swallowing,

 X – PR – 102 b/min, Carotid PR – 104 b/min, RR – 24 br/min

 XI - Able to flexed and extend neck

 XII - Speech was clear, difficulty swallowing

Extremities

- Extremities showed muscle strength 2+ scores in both upper and 2+ scores in both lower
areas for resistance.
- Can raise arms and legs but very slowly and can identify dull and sharp stimulations in all
4 limbs.

39
 LABORATORY RESULT

Table 1. Shows diagnostic exam upon admission in the medical units revealed:

COMPLETE RESULT UNITS NORMAL RANGE INTERPRETATION

BLOOD COUNT
Hb 12 mg/dL 12- 16 mg/dL Within the normal range

Hct 41 % 36- 48% Within the normal range

WBC 11,000 mm3 4, 500- 11, 000 mm3 Within the normal range

Platelets 360,000 uL 150,000- 450,000 uL Within the normal range

Table 2. Shows the FBS result.

FASTING BLOOD RESULT UNITS NORMAL RANGE INTERPRETATION

SUGAR
FBS 130 mg/dL 60-110 mg/dL Above the normal
FBS indicate increase
blood sugar. Elevated
levels are associated
with diabetes and insulin
resistance, in which the
body cannot properly
handle sugar.

Table 3. Shows BASIC METABOLIC PANEL Test result.

40
 BASIC RESULT UNITS NORMAL INTERPRETATION
METABOLIC RANGE
PANEL
K 3.9 mEq/L 3.5-5.0 mEq/L Within the normal range

Na 142 mEq/L 135- 145 mEq/L Within the normal range

Ca 10 mg/dL 9- 11 mg/dL Within the normal range

BUN 23 mg/dL 10- 20 mg/dL High BUN level means that your kidneys

aren't working well. But elevated BUN can
also be due to: dehydration, resulting from
not drinking enough fluids or for other
reasons such as urinary tract obstruction and
taking certain medications, such as some
antibiotics.

Table 4. shows the Liver Function Test (LFT) result

Liver Function RESULT UNITS NORMAL RANGE INTERPRETATION

Test (LFT)
ALT 52 U/L 5-35 U/L When your liver is damaged or inflamed, it can release
ALT into your bloodstream. This causes your ALT levels
to rise. A high ALT level can indicate a liver problem,
which is why doctors often use an ALT test when
diagnosing liver conditions. Several things can cause
high ALT levels, including: over-the-counter pain
medications.
AST 43 U/L 10-40 U/L High AST level is a sign of liver damage, but it can also
mean you have damage to another organ that makes it, like
your heart or kidneys.

41
 ALP 121 U/L 40-120 U/L Elevated ALP levels are generally a sign of a liver
condition. An obstruction of the liver or damage to it will
cause ALP levels to rise. Abnormal ALP levels usually
indicate one of the following conditions such as overuse
of medications that harmful to the liver.
Albumin 5.9 g/dL 4.0- 5.5 g/dL High serum albumin levels could mean that you’re
dehydrated or eat a diet rich in protein. However, a serum
albumin test usually isn’t necessary to
diagnose dehydration.
Total Protein 8.4 g/dL 7.0- 7.5 g/dL
Elevated total protein is found in people who are
dehydrated, the real problem is that the blood plasma is
actually more concentrated.Certain proteins in the blood
may be elevated as your body fights an infection or some
other inflammation. 
Bilirubin 1.1 mg/dL 0.1- 1.2 mg/dL Within the normal range

GGT 57 U/L 10-40 U/L Results show higher than normal levels of GGT, it may
be a sign of liver damage. The damage may be due to one
of the following conditions: diabetes, congestive heart
failure and side effect of a drug. Certain medicines can
cause liver damage in some people. Usually, the higher
the level of GGT, the greater the level of damage to the
liver.

Table 5.Shows the ECG result

42
ECG RESULT NORMAL RANGE INTERPRETATION
Shows minimal shortened RR shortened RR interval 0.12-0.20 seconds Sinus tachycardia
interval with no apparent
abnormalities.

Table 6. Shows the ABG result.

ARTERIAL BLOOD RESULT UNITS NORMAL INTERPRETATION

GAS RANGE
pH 7.32 7.35- 7.45 The blood pH drops below 7.35 indicate acidosis and
becomes too acidic.When your lungs aren't able to move
enough carbon dioxide out of your body quickly enough,
blood pH is lowered. This is called respiratory acidosis.
PaCO2 39 mmHg 35- 45 mmHg Within the normal range

PaO2 92 mmHg 80-100 mmHg Within the normal range

HCO3 20 mEq/L 22- 26 mEq/L A low level of bicarbonate in your blood may cause a
condition called metabolic acidosis, or too much acid in
the body. A wide range of conditions, including diarrhea,
kidney disease, and liver failure, can cause metabolic
acidosis.

Table 7. Shows the Random Blood sugar (RBS) test result.

Random blood sugar (RBS) RESULT UNITS NORMAL RANGE

43
142 mg/dL 80-120 mg/dL The result indicates increase sugar level in the
blood. Hyperglycemia is a hallmark sign of
diabetes.

Table 8. Shows the URINALYSIS result.

NORMAL INTERPRETATION
COLOR Amber Urochrome Amber-colored urine can indicate patient is getting dehydrated.
TRANSPARENC Turbid Clear and If  urine looks cloudy instead of its usual clear, yellowish color, it could be due
Y transparent to infections, kidney stones, or other changes in the health.
4.8 (7.35- 7.45) If the urine sample has a lower-than-normal pH, this could indicate an
environment conducive to kidney stones. Other conditions that prefer an
PH/REACTION
acidic environment are: acidosis. Diabetic ketoacidosis, which occurs when
ketones build up in the body.
CELLS/HPF
5 <2 A higher than normal number of RBCs in the urine may be due to: bladder,
RBC kidney, or urinary tract cancer, kidney and other urinary tract problems, such
as infection, or stones and kidney injury.
11mm3
0- 5 mm3 If doctor tests the urine and finds too many leukocytes, it could be a sign of
infection. Leukocytes are white blood cells that help your body fight germs.
Moderate Leukocyte When you have more of these than usual in your urine, it's often a sign of a
esterase w/ WBC problem somewhere in your urinary tract.Some of the most common reasons
for leukocytes in urine, and other symptoms you might see with them, include:
Urinary Tract Infection (UTI).

Table 9. Shows the COMPLETE BLOOD COUNT result At present (Day 3 since admission).

COMPLETE BLOOD RESULT UNITS NORMAL RANGE INTERPRETATION

COUNT

44
 Hb 12 mg/dL 12- 16 mg/dL Within the normal range

Hct 42 % 36- 48% Within the normal range

WBC 9, 800 mm3 4, 500- 11, 000 mm3 Within the normal range

Platelets 340, 000 uL 150,000- 450,000 uL Within the normal range

TABLE 10. Shows the fasting blood sugar test result

RESULT UNITS NORMAL RANGE INTERPRETATION

FBS 152 mg/dL 60-100 mg/dL The fasting blood sugar level is elevated
and above the normal range. A high level of
fasting blood sugar indicates that the body has
been unable to lower the levels of sugar in the
blood.

Table 11. Shows the BASIC METABOLIC PANEL test result At present (Day 3 since admission).

BASIC METABOLIC RESULT UNITS NORMAL RANGE INTERPRETATION

PANEL
K 3.9 mEq/L 3.5- 5.0 mEq/L Within the normal range

Na 145 mEq/L 135- 145 mEq/L Within the normal range

45
 Ca 10.2 mg/dL 9- 11 mg/dL Within the normal range

BUN 20 mg/dL 10- 20 mg/dL Within the normal range

Serum Creatinine 1.62 mg/dL 0.7- 1.4 mg/dL Elevated creatinine levels usually
indicate that the kidneys are not working as
they should and other factors can
temporarily raise creatinine levels above
normal these include dehydration and
consuming large amounts of protein.

Table 12. Shows the Liver Function Test (LFT) At present (Day 3 since admission).
Liver Function Test RESULT UNITS NORMAL RANGE INTERPRETATION
(LFT)
ALT 51 U/L 5- 35 U/L An elevated level of ALT indicates that the enzyme
leaks out into the bloodstream when liver cells are
damaged as a result of infection.
AST 45 U/L 10-40 U/L High amount of AST in the blood indicate health
problem and can be associated with liver injury.
AST levels increase when there's damage to the
tissues and cells where the enzyme is found.
ALP 119 U/L 40-120 U/L Within the normal range

Albumin 5.6 g/dL 4.0-5.5 g/dL Compared to the prior result, the albumin level are
slight decreasing but still above normal. Higher than
normal levels of albumin may indicate dehydration
and other certain drugs.
Total Protein 8.1 g/dL 7.0-7.5 g/dL The total protein level is somewhat lower than the
previous result. A high total protein level could
indicate dehydration or an increase in the
gammaglobulin (antibody) fraction, as found in

46
 chronic inflammatory diseases and infections.
Bilirubin 1.2 mg/dL 0.1- 1.2 mg/dL Within the normal range

GGT 56 U/L 10- 40 U/L From the previous result the GGT level decreased
but still in above normal. High levels of GGT in the
blood could indicate that the enzyme is leaking out
of the liver cells and into the blood, suggesting
damage to the liver or bile ducts.

TABLE 13. Shows the ABG result At present (Day 3 since admission).

ARTERIAL BLOOD RESULT UNITS NORMAL RANGE INTERPRETATION

GAS
pH 7.35 7.35- 7.45 Within the normal range

PaCO2 44 mmHg 35- 45 mmHg Within the normal range

PaO2 94 mmHg 80- 100 mmHg Within the normal range

HCO3 22 mEq/L 22-26 mEq/L Within the normal range

Table 14. Shows the URINE Culture AND Sensitivity TEST

TEST RESULT INTERPRETATION

Ciprofloxacin is an antibiotic agent in the fluoroquinolone class
used to treat bacterial infections such as urinary tract infections.
(＋) E. coli Sensitive to ciproflaxin
Ciprofloxacin is the most potent against gram-negative bacilli
bacteria such as E.coli.

Table 15. URINALYSIS result At present (Day 3 since admission).

47
 NORMAL INTERPRETATION
COLOR Amber Urochrome The color of urine is the same as the prior results that indicate severe
dehydration becoming the urine color is amber. Dehydration, which can
concentrate your urine and make it much deeper in color, can also make
your urine appear orange.

TRANSPARENC Minimally Clear and The transparency of the urine is slightly change compared to the
Y turbid transparent previous result. Minimally turbid urine may occur occasionally due to mild
dehydration; when it occurs in the absence of symptoms and goes away
rapidly, it is usually of little consequence. Urine causing it to persistently
appear cloudy or foamy due to infections anywhere in the urinary tract.

PH/REACTION 5.7 (7.35- 7.45) PH urine level is acidic and a bit elevated compared to the first result
and one of the major factors affecting urine pH is the person’s diet it also
might indicate a medical condition.
CELLS/HPF

RBC 4 <2 When compared to the prior result of RBC in the urine it decreased from
5 to 4. A normal result is <2 red blood cells per high power field
(RBC/HPF) or less when the sample is examined. A higher than normal
number of RBCs in the urine may be due to urinary tract problems, such as
infection, or stones.

Leukocyte esterase 9.5 mm3 0-5 mm3 The WBC is resulted in significantly decreased compared to the previous
w/ WBC result and elevated levels of leukocytes in the bloodstream may indicate an
infection. This is because WBCs are part of the immune system, and they
help fight off disease and infection.

48
 DRUG STUDY

Table 16: Ciprofloxacin Drug study

DRUG NAME MECHANISM INDICATION CONTRAINDICATION ADVERSE NURSING
OF ACTION EFFECTS RESPONSIBILITIES

Generic name:  Inhibits  Treat  Hypersensitivity to CNS: agitation, Follow the 12 rights of drug
bacterial urinary drug or other headache, administration
Ciprofloxacin
DNA infections fluoroquinolones. restlessness, Patient monitoring
Brand name: Cipro synthesis caused by  Comcomitant confusion,
I.V by bacteria administration of EENT:—blurred  Assess creatinine level
inhibiting such as tizanidine. vision before giving first dose.
DOSAGE: 200 mg DNA E.coli. GI: nausea,  Monitor drug blood level
gyrase in vomiting, , closely.
Frequency: constipation,  Watch for signs and
susceptible
q 12hours for 3 days abdominal pain or symptoms of serious
gram-
discomfort, adverse reactions,
ROUTE: I.V negative dyspepsia,
and gram- including GI problems,
dysphagia,
positive and hypersensitivity
Classification: flatulence,
organisms. reactions.
fluoroquinolones GU: albuminuria,
 Given twice a day
candiduria, renal
calculi exactly at 6 am and 6 pm;
Metabolic: Make sure the patient
hyperglycemia drink plenty of water or
Other: injection-site other fluids everyday
reaction, altered while taking
taste. Ciprofloxacine.
 Instruct patient not take
or eat a lot of caffeine
products such as coffee,
tea, energy drinks, cola
or chocolate within 6

49
 hours before or 2 hours
after she take
ciprofloxacin.
 Instruct patient to avoid
taking at antacids and
vitamin or mineral
supplements within 6
hours before or 2 hours
after she take
ciprofloxacin.may
decrease the absorption
of Ciprofloxacin which
makes it less effective
when taken at the same
time.
 Inform patient that
Ciprofloxacin can cause
side effects that may
impair his thinking or
reactions.
 Instruct client to report
any adverse reaction to
the physician or nurse.
Patient teaching

 Instruct patient to take

drug with or without food
at the same time each
day.
 Advise patient to drink 8
oz of water every hour
while awake to ensure

50
 adequate hydration.
 Instruct patient to notify
prescriber at first sign of
headache, blurring of
vision; unusual
tiredness; persistent
vomiting.
 As appropriate, review
all other significant and
life-threatening adverse
reactions and
interactions, especially
those related to the drugs,
tests, foods, and herbs
mentioned above.

Table 18: Esomeprazole Sodium Drug study

DRUG NAME MECHANISM OF INDICATION CONTRAINDICATIO ADVERSE NURSING
ACTION N REACTION/ RESPONSIBILITIES

51
 SIDE EFFECTS
GENERIC NAME: By acting Treatment Contraindicated in Abdominal 1. Observe 12 rights
Esomeprazole specifically on the symptom patients with known cramps in administering
Sodium proton pump, of Duodenal Ulcer hypersensitivity to any Dry mouth medication.
esomeprazole blocks components of the Nausea and 2. Monitor
BRAND NAME: the final step in acid formulation or Vomiting improvement in
Nexium production, thus substituted Flank pain GI symptoms to
reducing gastric benzimidazoles. help determine if
DOSAGE: acidity. This effect is drug is
2O mg to incorporate dose-related up to a successful.
in 50 mL 0.9% NaCl daily dose of 20 to 3. Advice patient to
40 mg and leads to avoid foods that
FREQUENCY: inhibition of gastric may cause an
30 mins acid secretion. increase in GI
irritations (coffee,
ROUTE: THERAPEUTIC spicy and acidic
IV Infusion ACTION: foods).
Inhibits gastric acid 4. Instruct patient to
CLASSIFICATION secretion. report/ prolonged
PHARMACOLOGI side effects.
C CLASS:
Proton Pump
Inhibitors

THEREPEUTIC
CLASS:
Anti-Ulcer Agent

Table 19: Cimetidine Drug study

DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION ADVERSE NURSING

52
 ACTION REACTION/ RESPONSIBILITIES
SIDE EFFECTS
GENERIC NAME: Competitively Active Duodenal Hypersensitivity to Agitation 1. Follow the 12 rights
Cimetidine inhibits histamine ulcer (short-term cimetidine or other H2 Nausea and in administering
action at histamine therapy) receptor antagonists. Vomiting medication.
BRAND NAME: 2-receptor sites of Fever 2. Monitor pulse of
Tagamet gastric parietal Abdominal patient during first
cells, thereby cramps few days of drug
DOSAGE: inhibiting gastric regimen.
300 mg/500 ml acid secretion. 3. Monitor personal
comfort.
FREQUENCY: THERAPEUTIC 4. Inform patient short-
25 mg/h continuous ACTION: term therapy of
IV infusion Relieves ulcer pain active duodenal
and discomfort. ulcer does not
ROUTE: prevent ulcer
IV Infusion recurrence when
drug is discontinued.
CLASSIFICATION 5. Advise patient not to
PHARMACOLOGI take over-the-
C CLASS: counter cimetidine
Histamine 2-receptor for more than 2
antagonist. weeks continuously,
except with
THEREPEUTIC prescriber’s advice
CLASS: and supervision.
Antiulcer drug 6. Teach patient not to
take with aspirin,
ibuprofen, or other
anti-inflammatory
medicines unless
directed to do so by
your health care

53
professional.

54
 NURSING THEORY

In Kolcaba’s Theory of Comfort, nursing is described as the process of assessing

the comfort needs of the patient, designing and implementing appropriate nursing care
plans, and evaluating the patient’s comfort subsequent to the executed care plans. This
theory was applied to prioritize the problem and needs of the patient. Thus, leading to the
student nurses’ priorities which include “Acute pain related to biological injury agent as
evidenced by epigastric pain, worsening with food intake, nausea and vomiting, and flank
pain”, “Hyperthermia related to illness (UTI) as evidenced by temperature of 38.3 °C”,
“Imbalanced nutrition less than body requirement as evidenced by loss of appetite”.

As the theory indicated, when comfort needs are met, patients are strengthened.
Therefore, addressing such problem will improve patient’s participation to the treatment
and increases level of functioning and well-being. If a patient is comfortable, he or she
will eventually feel emotionally and mentally better. With that, management will be
easier and patient’s recovery from the disease will be faster.

Figure 11 : Conceptual Framework of Kolkaba’s Comfort Theory

55
 Based on the assessment data, major nursing diagnosis may include the
following:

 Chronic pain related to biological injury agent as evidenced by epigastric pain,

worsening with food intake, nausea and vomiting, and flank pain

 Hyperthermia related to illness (UTI) as evidenced by temperature of 38.3 °C

 Imbalanced nutrition: less than body requirements as evidenced by loss of appetite

 Sleep deprivation related to ineffective time management

 Discomfort related to acute pain as manifested by verbalization of pain

 Impaired urinary elimination related to inflammatory process

 Constipation related to insufficient fluid intake

 Deficient fluid volume related to episodes of nausea and vomiting as evidenced by

chappy lips and minimal cracks of the tongue

 Anxiety related to perceived threat of death

 Sedentary lifestyle related to insufficient knowledge of health benefits associated with

physical exercise

 Ineffective coping related to sudden change in health status

 Ineffective health management related to insufficient knowledge of therapeutic

regimen

 Deficient knowledge related to information misinterpretation

56
 COMPREHENSIVE NURSING CARE PLAN

Table 20. Nursing Care Plan No. 1

Assessment Nursing Diagnosis Planning (with Implementation Evaluation

Rationale)
Subjective Cues: Chronic pain related to After 12 hour of After 12 hours of
As patient verbalized biological injury agent nursing intervention nursing interventions
“Ta duele miyo bariga as evidenced by patient will be able to goal was partially met.
y pecho akabar kome. epigastric pain, report pain is relieved/ Patient was able to
Duele tambien miyo worsening with food controlled verbalize “hinde mas
costao” intake, nausea and - Monitored Vital gayot bien duele egual
vomiting, and flank - Monitor Vital Signs Signs del primero”.
“I’m experiencing pain pain. Rationale: To obtain
on my stomach and basic indicators of the Vital Signs showed:
chest. I’m also patient health status BP:140/90
experiencing flank RR: 19 br/min
pain.” - Acknowledge - Acknowledged
PR: 99 bpm
reports of pain reports of pain
Objective Cues: immediately
Rationale: An
BP: 140/100 immediate response to
PR: 102 bpm reports of pain may
RR: 22 br/min decrease anxiety in the
patient.
- Facial grimacing
was evident during
palpation on the
epigastric region
- Patient claimed
tenderness

57
 -Administered
- Administer medication as
medications as prescribed.
prescribed:
Ciprofloxacin
200mg,
Esomeprazole
sodium 20mg to
incorporate in 50ml
0.9% Nacl

Rationale:
Ciprofloxacin treat
urinary infections and
Esomeprazole sodium
treats symptom of
duodenal ulcer
- Minimized
- visitation hours of
- Get rid of the nurse
additional stressors - Advised significant
or sources of others to limit their
discomfort visitation of the
whenever possible patient to provide
more rest and
Rationale: Patients may relaxation
experience an
exaggeration in pain or
a decreased ability to
tolerate painful stimuli

58
if environmental,
intrapersonal factors
are further stressing the
patient.

- Provided rest
- Provide rest periods periods to promote
to promote relief, relief, sleep and
sleep, and relaxation.
relaxation
Rationale: Pain may
result in fatigue which
may result in
exaggerated pain. A
peaceful and quiet
environment may
facilitate rest.

References:
nurseslabs.com
NANDTH 15TH edition

59
Table 21. Nursing Care Plan No. 2
ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS
Hyperthermia related The goal of Care: After Goal Met!
Objective Cues: to illness as evidence 12 hours of nursing After 12 hours of
Temp: 38.3 C by temperature of intervention patient will nursing intervention
RR: 22 br/min 38.3 C be able to maintain core patient was able to
PR: 102 bpm temperature within the maintain core
Weakness normal range as temperature within
Lab Results: Urinalysis evidence by vital signs normal range as
-Moderate leukocyte within normal limits. evidence by:
esterase with WBC 11 1. Administer 1. Administered Vital signs:
mm3 medication as indicated antibiotics; Temp: 37.6 C
-turbid urine R- To treat the Ciprofloxacin 200 RR: 19 br/min
-amber color urine underlying cause mg IV q 12 hours PR: 99 bpm
- 5 RBC hpf as prescribed by
the doctor.

2. Provided tepid
2. Promote surface sponge bath and
cooling by means of promoted a well-
cool environment ventilated area to
and/or fans, cool, tepid patient by turning
sponge baths or on the electric fan
immersion, or local ice and regulating the
pack. intensity to avoid
R- To promote heat loss chills.
- Advised and
educate SO to do
tepid sponge bath
when patient is
hot. (Luke warm
water only and

60
 make sure that
armpits and groins
were included in
TSB).

3. Provided rest and

comfort.
3. Maintain bed rest.
R- To reduce metabolic
demand and oxygen 4. Advised to take 8
consumption or more than
glasses of water
4. Encourage ample per day
fluid intake.
R- If the patient is
dehydrated or 5. Infused NaCl
diaphoretic, fluid loss alternate with
contributes to fever. D5% LR for a
total of 2,500 ml
5. Administer per day on IV, as
replacement fluid and ordered
electrolytes
R- To support 6. . Helped patient
circulating volume and identify
tissue perfusion importance and
benefits of
6. Discuss the drinking right
importance of adequate amount of water.
fluid intake.
R- To prevent 7. Strictly monitored
dehydration patients input and
output.

61
7. Monitor and record
all sources of fluid loss
such as urine, vomiting
and diarrhea, wounds,
fistulas, and insensible
losses.
R- Can potentiate fluid 8. Monitored
and electrolyte losses. patient’s vital
signs and signs
and symptoms of a
8. Review worsening fever
signs/symptoms of such as
hyperthermia dehydration,
R- This indicates a need hallucination,
for prompt intervention delirium, and
seizures.

Reference: Nurse's
Pocket Guide
(Diagnoses, Prioritized
Intervention, and
Rationales) by Marilyn
E. Doenges, Mary
Frances Moorhouse,
and Alice C. Murr (12th
and 15th edition)
Nurseslabs.com

62
 Table 22. Nursing Care Plan No. 3

Assessment Nursing Diagnosis Planning Implementation Evaluation

(with Rationale)
Subjective Cue: Imbalanced After 8 hours of nursing Goal partially met.
As patient verbalized, Nutrition:Less than interventions, patient will Patient was able to take
“Nuay tambien yo gana body requirements as be able to regain her 45% of breakfast on a
kome ” evidenced by loss of appetite to eat. low protein soft diet
(“I don’t have an appetite appetite - Administer IVF NaCl - Administered IVF
to eat.”) alternate wih D5%LR NaCl alternate with
2,500 mL/day as ordered D5%LR 2,500 mL/day
Objective Cues: Rationale: as ordered
- Body weight lower than For maintenance of fluid
the ideal body and electrolytes
weight(58.5kg)
- BMI: 19.3 - Educate the patient and - Explained the
- Difficulty of swallowing significant other importance of proper
- Patient was observed to regarding the importance nutrition and foods that
be weak of eating healthy foods needs to avoid like
and it’s benefits to her greasy foods, eggs,
body dairy products, meats
Rationale: Education
provides ample
information that the
patient may not be aware
of, hence leading to the
kind of eating habits and
diet she is following
- Modified the
- Promote a pleasant environment by keeping
environment it clean and well
Rationale: A pleasing ventilated and
atmosphere helps in encouraged the patient’s
decreasing stress and is family to add
more favorable to eating ornamental plants in the

63
 room

- Assisted the patient in

- Promote proper Semi-Fowler’s position
positioning
Rationale: Elevating the
head of the bed 30-45
degree angle will aid in
swallowing and reduces
risk for aspiration when
eating
- Promoted good oral
-Promote good oral hygiene and ensured
hygiene and dentition that the patient’s
Rationale: Oral hygiene dentures are clean
has a positive effect on
appetite and on the taste
of food.
- Provided low protein
- Encourage small, soft diet such as ice
frequent feeding chips, plain crackers,
Rationale: Eating small, apples, bread and small
frequent meals lessens the sips of water
feeling of fullness and the
stimulus to vomit
- Advised patient to
- Discourage to take avoid drinking coffee
caffeinated or carbonated and soft drinks
beverages
Rationale: These
beverages will decrease
hunger and lead to early
satiety

References:

64
nurseslabs.com
NANDA 12th edition

65
Table 23: Health Teaching Plan for the Patient and her husband

HEALTH TEACHING PLAN

PURPOSE: To provide patient and significant other the knowledge, skills and positive attitude with the effective coping technique in
pain.
LEARNING NEED: Information about pain management technique
GOAL: The patient-significant others will be able to verbalize understanding in pain management techniques, including rationale
and benefits for pain management.
LEARNING LEARNING CONTENT/ Method of TIME RESOURCES Method of
OBJECTIVES CONTENT OUTLINE INSTRUCTION ALLOTTED NEEDED EVALUATION
After 40 minutes - When the - Materials: - Question and
of student nurse- patient is paper, pen, Answer
patient awake Nurse
interaction, the
patient and
husband will be  What is PAIN?
able to: DEFINITION: Pain is an  Can you briefly
unpleasant sensory and  5 minutes  pamphlet explain in your
1. Define PAIN emotional experience usually  Verbal/ oral (visible own word the
in own words produced by something that discussion text and definition of
correctly injures, or threatens to injure (lecture) images) pain?
the body.

 20
2. Demonstrate  PAIN MANAGEMENT  Demonstration minutes  Human  Observation
beginning TECHNIQUE and return resources:  Ask the patient
skills of A. GUIDED IMAGERY demonstration time and and her husband
specific PAIN - Suggest the patient family (patient with the effort of if the activity that
Management picture beside her table, husband.) the nurse was suggested
techniques as encourage by thinking in and can be carried

66
tolerated by picture to eliminate patient’s out conveniently
patient with negative thoughts, this husband by both of them.
the help of will help to relieve pain
her husband. because it involves
diversion of the patient’s
attention on something
other than her current
disease condition.
B. DEEP BREATING
EXERCISES
- Breathing deeply will
help release endorphins
which make the mind and
body experience good
sensation. It also eases
pain which is currently
condition of the patient.
C. MUSIC THERAPY
- Playing the patient
favourite music or theme
song of their marriage can
reduce the patient’s pain
because it involves
stimulation of positive
thoughts and feeling
- Identify the patient’s
favourite tracks, use the
patient phone to play
suggest music with
minimal volume every  10
morning. minutes
D. DIVERSIONAL
ACTIVITIES/  Active

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 DISTRACTION Participation
3. Identify other - Distraction helps relieve Verbal
pain pain because it involves discussion &
management diversion of the patient’s Demonstration
technique to attention on something
enforce after other than her current
the patient disease condition.
has already Other divertional activities/  5 minutes
recovered. distraction to relieve pain
such as:
- Sleep and Rest period  Summarize
- Support such as pillows common
to the painful area. concerns
- Frequent positioning
changes
4. State any - Proper body alignment
concerns and correct body  Interview, Open
about the mechanics discussion
disease - Watching TV during
condition. leisure time

 Activities that can be

done inside the house:
a. Schedule leisure time
every weekend with her
family to strengthen the
bonding with family
member.
b. Instruct patient to perform
exercises (Range of
Motion Exercises)

68
 c. water the plants
d. Cooks healthy foods with
her husband. (Must not
include consumption of
sweet, salty, gas forming
food, caffeinated
beverages, spicy and fatty
foods.)

 Exploitation of feelings
REFERENCES:
Hinkle J.L., & Cheever K. (2014). The 13th edition of Brunner& Suddarth’s Textbook of Medical- Surgical Nursing. Lippincott, Williams & Wilkins,
Philadelphia Pa.
Jeanne Segal, Ph.D., et al. (May 2020) Pain management Technique. Retrieved from https://www.helpguide.org/articles/pain/pain-symptoms-
signs-and-causes.htm
Regents of the university of Michigan. (n.d.). Managing Pain. Retrieved From https://en.m.wikipedia.org/wiki/pain_management

69
 CONCLUSIONS
•With peptic ulcer it is an open sore that occurs in the upper digestive tract and with proficient
treatment and effective Helicobacter pylori destruction result in clinical enhancement and
remedy as well as in curing of ulcers.
•While Duodenal ulcers occur when there is a disruption to the surface of the mucosa of the
duodenum signs and symptoms includes pain upon eating in the abdomen, feeling full and
bloated, nausea and vomiting and losing weight.
•A urinary tract infection is an infection in any part of the urinary system by a bacteria called
escerichia coli (E. coli). UTI’s is one of a few frequent clinical bacterial diseases in women.
•Hypertension is high blood pressure that is above normal. Tissues and organs need the
oxygenated blood that your circulatory system carries throughout the body. Therefore a blood
pressure ranges from 140-159 mmHg systolic and 90-99 mmHg diastolic is considered as a
hypertension stage 1.
•Early detection of signs and symptoms accompanied with the aid of using proper assessment
and correct prognosis is direct remedy to be vital to enhance outcomes and management.
•The theory of comfort by Katharine Kolcaba have been utilized as basis for prioritization of
identified problems because when an individual is comfortable he/she will feel safe and cared
for resulting to be more participative during the lengthy of nursing interventions that leads to
enhance health seeking behaviours to gradually recover and have better health outcomes.
•Sedentary lifestyle including foods that are high in salt and caffeine without controlling
appropriately can precipitate to the development of duodenal ulcer and hypertension.
•Past and present medical history and risk factors can lead to the current condition. However, not
all are linked with one another. Non-modifiable risk factors such as age and sex can be a cause of
the development of hypertension.

70
• Self-medication such as taking and using of over-the-counter drugs should not be encouraged.
It is not a safe practice in general and can post a potential risks that includes wrong self-analysis,
delays in looking for medical assistance when needed, dangerous drugs collaborations, mistaken
measurements, inaccurate decision of treatment and a hazard of reliance and misuse of the drugs.
•Prescribed medications such as ciprofloxacin, esomeprazole sodium, cimetidine and IVF help
improve the condition of the patient with Oxygen therapy to aid in comfort. 
•Solid support system that includes persistent family association in choice making has been
related as essential in care for the patient accompanied with right nursing interventions will
increase the improvement of the condition.

71
 RECOMMENDATIONS
Based on this study the following recommendations are made:

1. With UTI, DUODENAL ULCER and HYPERTENSION or any disease will require a
comprehensive health team approach that is well collaborated and coordinated with each
team member’s participation for the management and treatment of the condition.
2. Appropriate assessment of signs and symptoms is imperative key to know what risk and
complications may lies ahead and give the right interventions for proper diagnosis. 
3. Patient and their significant others should be empowered through health education in
order to increase understanding about health management and its benefits. Involving
family member in care of patients will equipped them with knowledge about the disease
process, intervention and treatment.
4. Individualized care plans is the key element in quality of nursing care. it custom fitted
nursing interventions with interesting focus of each problems. Patient centred care is one
fundamental reason for supporting individualized care.

72
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APPENDICES

77
Exhibits

78
79
80
81