Case Study: Analyzing the Care Plan for Gastric Ulcer Patient

This case study focuses on a 65-year-old patient, diagnosed with a bleeding gastric ulcer. The case study encompasses a thorough assessment, including the patient's medical history, current symptoms (acute epigastric pain, high heart rate), and relevant laboratory findings. The nursing care plan prioritizes addressing the patient's immediate needs, such as managing the bleeding, preventing further complications, and addressing the patient's emotional state (potential depression). Key interventions include an endoscopy to determine the cause of the bleeding and guide treatment, wound management, cardiac assessment, and family involvement to combat loneliness and improve the patient's psychological well-being. The expected outcomes include the cessation of bleeding, pain relief, and an improved emotional state. The evaluation highlights the importance of endoscopy, medication, and psychosocial support in managing the patient's condition effectively.

ISBAR – Plan
of Care
Patient name: Age / Date of Birth: Gender:
George Athenos 30/06/XX Male
Situation: Admission Diagnosis
Bleeding gastric ulcer
Pethidine as allergies
Pneumococcal and influenza due as immunization
Acute epigastric pain
Background: History
Patient was diagnosed for bowl cancer
Underwent for radial surgery
gout and osteoarthritis.
Social history
Having 4 siblings, 3 brothers and 1 sister.
Worked in family fruit and vegetable business
Lives in Horizon, South Australia
Australian, Greek orthodox.
Spoken languages are English and Greek
Widowed
Assessment:
Radiology for plan abdominal x-ray
ultrasound
Blood test

Objective Data Subjective
Data
 Heart beat 120 per minute and 24 breath per minute
as respiratory
 Acute epigastric pain
 Blood pressure 100/75  Decreasing urine output
 6/10 pain score  Gastric bleeding
 Depression
Problems (Acute or potential)
Acute epigastric pain, caused by bleeding gastric ulcers.
Infection from wounds
Loneliness
Higher risk of depression
Excessive use of alcohol
Allergies
immunization
Priority of problems
Priority of this bleeding gastric ulcers which is leading epigastric pain requires endoscopy
and X-ray. In this type, the extent and reasons can be found and appropriate treatments to the
patient can be provided.

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Expected Outcome Outcome Criteria
Prevent patients against bloody vomit, stools and
anemia.
Prevented from gastric bleeding by endoscopy and pro
medications.
Prevention of patients against depression and making
him able to participate in social activities.
Improved in behavioral conditions with clinical
depression as well as anti depressants by the local gene
practitioner.

Releasing patient from epigastric pain 120 beats per minute measured which is higher than
normal and it is a sign of depression and requires effec
anti-depressants.
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Interventions Rationale
Wound management by BCC
(Basal cell carcinoma)
Gastric bleeding can lead to anemia and enlargement in
wound so, by providing this intervention, patient can be
prevented against wound and infection.
Endoscopy and abdominal
assessment
For preventing patients against any critical condition and
eliminating poor outcome from UGIB regardless of time of
endoscopy.
Complex dressing It is important and there is requirement for preventing Geor
against allergies and exposure of wound to external
environment as it can lead infection.

Cardiac assessment Heart rate is higher than normal and by proper cardiac
assessment patient can be prevented from other heart related
diseases.
Anti-depressants and family
involvement approach
Patient is suffering from depression due to loneliness so, it i
important to make patient feel valued and comfortable. By
providing family involvement approaches, feeling of
loneliness can be reduced and anti-depressants can help
patient in living a normal life.

Evaluation
From the above study it can be evaluated that endoscopy intervention plays an important role in treating patient
against Gastric bleeding as at the time of upper endoscopy or by removing polyps during colonoscopy. Antibiotics
and acid blocking medicines can also help patients in reducing a cute epigastric pain which is caused by gastric
bleeding and ulcers. It is also found and can be evaluated that family based and other approaches play an important
role in making patients feel valued and motivated and also decreasing feelings of loneliness.
Signature Date