CHAPTER TWO: HEALTH PROBLEMS AND NURSING DIAGNOSIS

By | July 14, 2021

CHAPTER TWO

ANALYSIS OF DATA

The analysis is the second step in the nursing process. This is the systematic organization of data that has been given by the client and family to help the nurse identify problems and come out with nursing interventions. This analysis includes a comparison of data with standards. The factors contributing to the problems are considered and specific nursing diagnoses are chosen for the patient and family care plan.

 

COMPARISON OF DATA WITH STANDARDS

Under this, information gathered on patients is compared with those in the literature review. These include diagnostic investigation, causes, clinical features, treatment, and complications.

TABLE 3:CLINICAL FEATURES

CLINICAL FEATURES IN TEXTBOOKS CLINICAL FEATURES EXHIBITED BY CLIENT
1.      Epigastric pain. 1. There was epigastric pain.
2.      Haematemesis. 2. Client did not exhibit haematemesis.
3.      Loss of appetite. 3. Client had loss of appetite.
4.      Loss of weight. 4. Client experienced weight loss.
5.      Melaena. 5. Client did not pass melaena stools.
7.      Heart burns. 7. Client experienced heartburns.
8.      Nausea and vomiting. 8. Client experienced nausea and vomiting.
9.      Weakness. 9. Client experienced weakness.
10.  Insomnia. 10. Client had insomnia.

MEDICAL TREATMENT GIVEN TO CLIENT

  1. Capsule Omeprazole 20miligram bd x 14 days.
  2. Tablet Clarithromycin 500milligram bd x 14 days
  3. Capsule Amoxicillin 500gram tid x 14 days
  4. Tablet paracetamol 1gram tds x 7days.
  5. Tablet Metoclopramide 10milligram daily x 5 days
  6. IV Dextrose Normal Saline 4liters over 48 hours
  7. IV Ringers Lactate 1litre over 12 hours

CHAPTER TWO: HEALTH PROBLEMS AND NURSING DIAGNOSIS

COMPLICATIONS

This is any disease or disorder that occurs during the course of the condition or because of another disease. With reference to the literature review, the complications of the condition are: perforation, intractable ulcer, haemorrhage, shock, peritonitis, pyloric obstruction and severe anaemia.

PATIENT/FAMILY STRENGTHS

  1. Patient was able to express and describe the intensity of pain.
  2. She was willing to comply with treatment regimen of her condition to speed up recovery process
  3. Patient had the ability to communicate effectively with the medical and nursing staff and expressed her fears and anxiety.
  4. Family was able to provide patient with basic needs like food, clothing, non-insured drugs and visited her on daily basis.
  5. Patient was willing to perform mild exercises.
  6. Patient was willing to lie down in bed.
  7. Patient was also in the right state of mind which really facilitated her education on the condition.

HEALTH PROBLEMS

From the data collected on the patient and clinical manifestation presented by the patient the following health problems were identified.

  1. Patient experienced pain in the epigastric region of the abdomen.
  2. Patient was vomiting.
  3. Patient and family were anxious of hospitalization.
  4. Patient had no appetite for food.
  5. Patient had constipation.
  6. Patient could not sleep.
  7. Patient had no knowledge on condition.

NURSING DIAGNOSIS

  1. Pain (epigastric) related to erosion of the lining of the gastro intestinal tract(GIT).
  2. Risk for electrolyte imbalance related vomiting.
  3. Anxiety related to unknown outcome of hospitalization.
  4. Risk for impaired nutrition (less than body requirement) related to anorexia.
  5. Impaired elimination pattern(constipation) related to reduced fibre intake.
  6. Sleeping pattern disturbances related to change of environment.
  7. Knowledge deficit related to inadequate information on the causes of Peptic Ulcer Disease and its management.

 

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