This is the similar case given to you during discussion. The case of Mrs. Carmen. CASE SCENARIO: Mrs. Carmen is a 70 year old female, widow with 3 children (oldest 38; youngest 30). She was diagnosed...

This is the similar case given to you during discussion. The case of Mrs. Carmen.

CASE SCENARIO:

Mrs. Carmen  is a  70 year old female,  widow with 3 children (oldest 38; youngest 30). She was diagnosed to have Gastric Ulcer, Upper gastrointestinal bleeding (UGIB) . She is newly admitted at the medical ward (Rm 2, Bed #1).

• Conscious, coherent, lying sideways on bed while holding her abdomen. Pale-looking. Usually frowns when she tries to speak, When asked about her abdominal pain scale, she says “Now, its 9, yesterday it was just around 7.”


• Vital signs are as follows: BP-130/90; PR-93; RR- 22; Temp 38.0


• Present medical history reveals that she has been taking NSAIDs as she was complaining of knee pains. The client stated, “My doctor used to give me NSAIDs to relieve pain. Since it is an OTC drug, I kept on buying it and take it whenever I feel pain. I did not know I should have taken it with meals.” She was brought to the hospital after vomiting blood and passing out.


• Past medical history (+) HPN since 2007 (+) DM since 2003 Taking Losartan and Metformin as maintenance drugs


• Family history (+) DM, HPN, Cancer


• Laboratory and diagnostic work-ups were as follows:

CBC – lower than normal (Hgb ; Hct  )

Blood typing  = O+, Esophagogastroduodenoscopy +duodenal ulceration

BUN, Creatinine, Prothrombin Time (prolonged-high), Partial Thromboplastin time (prolonged –high), CT scan – UGIB

She is a Christian and prefers to hear someone read the bible in the morning as she wakes up. She has some difficulty in hearing from the left ear, she wears glasses when reading. She loves watching TV, her usual companion is her youngest daughter where she lives together with 3 grandchildren whom she adores.

WHAT TO DO:

1. Make a list po 5 identified problems then prioritze

2. Make an NCP of the 1st priority problem. (Follow the 7-column format below)

Patient’s Name                                               Age                  Sex                              Room/Bed #

Medical Diagnosis                                                                   Date                            Shift

Prepared by                                                                            Supervisor/CI