poc case analysis

8/7/2019 POC case analysis

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Introduction

Gastroesophageal reflux disease(GERD), gastro-oesophageal reflux

disease(GORD), gastric reflux disease, oracid reflux disease is chronicsymptoms ormucosal damage caused by stomach acid coming up from

the stomach into the esophagus. A typical symptom is heartburn.

GERD is usually caused by changes in the barrier between the stomach and the

esophagus, including abnormal relaxation of the lower esophageal sphincter,

which normally holds the top of the stomach closed; impaired expulsion of gastric

reflux from the esophagus, or a hiatal hernia. These changes may be permanent

or temporary ("transient").

Another kind of acid reflux, which causes respiratory and laryngeal signs andsymptoms, is called laryngopharyngeal reflux (LPR) or "extraesophageal reflux

disease" (EERD). Unlike GERD, LPR is unlikely to produce heartburn, and is

sometimes called silent reflux.
http://en.wikipedia.org/wiki/Mucosahttp://en.wikipedia.org/wiki/Stomachhttp://en.wikipedia.org/wiki/Esophagushttp://en.wikipedia.org/wiki/Heartburnhttp://en.wikipedia.org/wiki/Stomachhttp://en.wikipedia.org/wiki/Lower_esophageal_sphincterhttp://en.wikipedia.org/wiki/Hiatal_herniahttp://en.wikipedia.org/wiki/Respiratoryhttp://en.wikipedia.org/wiki/Larynxhttp://en.wikipedia.org/wiki/Laryngopharyngeal_refluxhttp://en.wikipedia.org/wiki/Mucosahttp://en.wikipedia.org/wiki/Stomachhttp://en.wikipedia.org/wiki/Esophagushttp://en.wikipedia.org/wiki/Heartburnhttp://en.wikipedia.org/wiki/Stomachhttp://en.wikipedia.org/wiki/Lower_esophageal_sphincterhttp://en.wikipedia.org/wiki/Hiatal_herniahttp://en.wikipedia.org/wiki/Respiratoryhttp://en.wikipedia.org/wiki/Larynxhttp://en.wikipedia.org/wiki/Laryngopharyngeal_reflux


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Objectives


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Clients Profile

A. Socio-Demographic Date

Patient X is a 50 years old female who lives with his family atBignay, Valenzuela. She has 5 children and she is a housewife.

B. Health Pattern Assessment

[] Past Medical HistoryAccording to the patient, she felt the symptoms of GERD last

December 26 of last year, vomiting, dizziness, heartburns and fever. Thepatient is admitted to Jose Reyes Medical because of the symptoms shefelt. And again this January 23, she was brought to Jose Reyes because

of the same symptoms.

[] History of the Present Illness

The patient brought to the Emergency Room of Valenzuela MedicalCenter because of the symptoms of vomiting, dizziness, heartburns andfever.

C. Family Medical History

The patient has history of hypertension in the paternal side of thefamily.

D. Social History

The patient is a housewife; she was given by her children for herfinancial needs.


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Pathology- Physiology


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Drug Study

GENERICNAME: Hydralazine HCL

Brandname: Apresoline

Drug classification: Vasodilator drug

MECHANISM INDICATIONS CONTRA-INDICATIONS

ADVERSEEFFECTS

NURSINGresponsibilities

>increases guanosinemonophosphate levels,decreasing theaction ofthe secondmessengerIP3,limiting calciumrelease fromthe sarcoplasmic reticulumofsmooth muscle.This results inan vesselrelaxation. Itdilatesarterioles morethan veins.

>inc. cardiacoutput>Inc. Pulse rate>increase plasmarenin concentration

>not forpatients withhigh BP>with openwounds>with sclerosis

>Diarrhea>Compensatorytachycardia>Headache>Poundingheartbeat>Nauseaandvomiting

>usecautiously inelderlypatients>monitorbloodpressure>watch forover-used ofthe drug
http://en.wikipedia.org/wiki/Guanosine_monophosphatehttp://en.wikipedia.org/wiki/Guanosine_monophosphatehttp://en.wikipedia.org/wiki/Guanosine_monophosphatehttp://en.wikipedia.org/wiki/Guanosine_monophosphatehttp://en.wikipedia.org/wiki/Second_messengerhttp://en.wikipedia.org/wiki/Second_messengerhttp://en.wikipedia.org/wiki/Inositol_triphosphatehttp://en.wikipedia.org/wiki/Inositol_triphosphatehttp://en.wikipedia.org/w/index.php?title=Calcium_release&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Calcium_release&action=edit&redlink=1http://en.wikipedia.org/wiki/Sarcoplasmic_reticulumhttp://en.wikipedia.org/wiki/Sarcoplasmic_reticulumhttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Reninhttp://en.wikipedia.org/wiki/Guanosine_monophosphatehttp://en.wikipedia.org/wiki/Guanosine_monophosphatehttp://en.wikipedia.org/wiki/Guanosine_monophosphatehttp://en.wikipedia.org/wiki/Second_messengerhttp://en.wikipedia.org/wiki/Second_messengerhttp://en.wikipedia.org/wiki/Inositol_triphosphatehttp://en.wikipedia.org/w/index.php?title=Calcium_release&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Calcium_release&action=edit&redlink=1http://en.wikipedia.org/wiki/Sarcoplasmic_reticulumhttp://en.wikipedia.org/wiki/Sarcoplasmic_reticulumhttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Renin


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GENERICNAME: Dipenhydramine HCL

Brandname: Benadryl

Drug classification: anti-histamine

MECHANISM INDICATIONS CONTRA-INDICATIONS

ADVERSEEFFECTS

NURSINGresponsibilities

> blocks the

effects of the

naturally

occurring

chemical

histamine in

the body.

>relievesallergies,wateryeyes,sneezing,itching,rashes,motionsickness>use foremergencycases

>dont give whenpatient is take aMOAI>with glaucoma>stomach ulcer>enlargedprostate>hyperthyroidism>asthma

>sleepiness>fatigue>dry mouth>difficulty inurinating

>stop takingalchoholicdrinks>Watch fordizziness asadverse effect


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Surgical Intervention

A. incision and drainage- Evacuation of development of pus in the affected area

B. anterior decompression spinal fusion- This is a major surgery which utilizes a skin incision over the front

of the body to approach the spine

Indication

Degenerative conditions causing compression of spinal cord or spinalnerves, e.g. intervertebral disc prolapse, posterior vertebral body

osteophytes Instability of the spine

Spine fracture

Spinal tumour

Spinal infection (usually tuberculous or bacterial)

Spinal deformity

Miscellaneous conditions causing spinal cord or spinal nerve damage

The Procedure

The skin incision is usually on one side in the front of the body

Surgery is performed depending on individual patient A piece of bone will be harvested from the ilium, fibula or a rib to fill the

defect at the spinal column (in special conditions synthetic material orallograft may be used)

Internal fixation devices such as plates and screws may be used ifnecessary

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