CASE STUDY

1. BIOGRAPHICAL DATA
2. Patient Name: Nazish

3. Age: 25 years

4. Gender: Female

5. Ward: Medical Ward

6. Hospital: General Hospital, Lahore

7. Diagnosis: Gastritis

8. Date of Admission: 12-06-2025

9. Religion: Islam

10. Marital Status: Single

Health Perception and Health Management Pattern

 Perception of Health: Patient perceives herself as generally healthy but reports frequent
stomach pain and bloating.
 Management: No regular medication; takes over-the-counter painkillers occasionally for
headaches or stomach ache. No known allergies.
 Past History: Had similar complaints 6 months ago but did not seek medical attention.

Nutritional-Metabolic Pattern

 Appetite: Poor appetite for the past 3 days.

 Diet: Irregular eating habits, often consumes spicy and junk food.
 Fluid Intake: Approximately 4-5 glasses of water per day.
 Weight: 48 kg; reported recent weight loss of 2 kg over the last month.
 Nutritional Issues: Reports nausea, bloating, and a burning sensation in the stomach

Elimination Pattern

 Bowel Habits: Constipation for the past 2 days.

 Urinary Pattern: Normal frequency and colour; no burning or pain.

Activity-Exercise Pattern

 Physical Activity: Limited; mostly sedentary lifestyle.

 Mobility: Independent, no assistance needed.
  Fatigue: Complains of mild weakness and fatigue.

Sleep-Rest Pattern

 Sleep Duration: Sleeps 5-6 hours per night.

 Sleep Quality: Poor due to abdominal discomfort and pain at night.
 Napping: Sometimes naps in the afternoon.

Cognitive-Perceptual Pattern

 Orientation: Alert and oriented to time, place, and person.

 Pain: Epigastric pain, burning in nature, 6/10 on pain scale.
 Learning Needs: Interested in learning about the causes and management of gastritis.

Self-Perception and Self-Concept Pattern

 Self-Image: Feels frustrated and concerned about her health and appearance due to weight
loss.
 Emotional Status: Mild anxiety about diagnosis but optimistic about recovery.

Role-Relationship Pattern

 Family Role: Eldest daughter; supports her family emotionally.

 Relationships: Good relationship with family; has emotional support from mother and
sister.

Sexuality-Reproductive Pattern

 Menstrual Cycle: Regular, no current complaints.

 Sexual History: Not applicable (unmarried).

Coping-Stress Tolerance Pattern

 Coping Mechanism: Talks to family and listens to music.

 Stressors: Upcoming exams and family responsibilities.
 Psychological Support: Receives adequate support from family

Value-Belief Pattern

 Religious Beliefs: Practices Islam, prays regularly.

 Belief about Illness: Believes health and sickness are a test from Allah. Accepts illness as
temporary.
Physical Examination of Patient
General Appearance

 Consciousness: Fully conscious, alert, and oriented to time, place, and person.
 Build: Thin, moderately nourished
 Posture: Comfortable but prefers lying in semi-Fowler’s position
 Expression: Appears anxious and mildly distressed due to abdominal pain

Vital Signs

Parameter Finding Normal Range

Temperature 98.6°F (37°C) 97.8–99.1°F

Pulse 88 bpm, regular 60–100 bpm

Respiratory Rate 18 breaths/min 12–20 breaths/min

Blood Pressure 110/70 mmHg 100–120 / 60–80 mmHg

Oxygen Saturation (SpO₂) 98% on room air ≥ 95%

Systemic Examination

1. Gastrointestinal System

 Inspection: Flat abdomen, no visible masses or distension

 Palpation: Tenderness in epigastric region, no rigidity or guarding
 Percussion: Tympanic sound in upper abdomen
 Auscultation: Normal bowel sounds present
 Other symptoms: Nausea, early satiety, no vomiting at present

2. Cardiovascular System

 Heart sounds: S1 and S2 normal, no murmurs

 Peripheral pulses: Present and equal in all extremities
 Capillary refill: < 3 seconds

3. Respiratory System

 Breath sounds: Clear and bilateral

 No wheezing or crackles
 Chest movement: Equal on both sides
4. Nervous System

 Cranial nerves: Intact

 Motor function: Normal power in all limbs
 Reflexes: Normal deep tendon reflexes
 Gait: Normal

5. Integumentary System

 Skin: Warm, dry, no rash or lesions

 Turgor: Slightly decreased (suggests mild dehydration)
 Nails: Normal, no cyanosis or clubbing
 Eyes: No jaundice or pallor visible in sclera

Laboratory Investigations
Test Name Normal Range Patient Findings Purpose

WBC:
4,000–11,000/mm³ WBC: 9,500/mm³
CBC (Complete Blood To check for infection or
Hb: 12–16 g/dL Hb: 11.2 g/dL (↓)
Count) anaemia. Slight anaemia noted.
Platelets: 150,000– Platelets: 280,000/mm³
450,000/mm³

ALT: 7–56 U/L ALT: 34 U/L

LFT (Liver Function To rule out liver involvement.
AST: 10–40 U/L AST: 28 U/L
Tests) Normal.
ALP: 44–147 IU/L ALP: 110 IU/L

Na⁺: 135–145 mEq/L Na⁺: 138

Normal. To monitor
Serum Electrolytes K⁺: 3.5–5.0 mEq/L K⁺: 4.0
fluid/electrolyte balance.
Cl⁻: 96–106 mEq/L Cl⁻: 102

To rule out gastrointestinal

Stool Occult Blood Test Negative Negative
bleeding.

Urea Breath Test or

Confirms presence of
Stool Antigen Test for Negative Positive for H. pylori
Helicobacter pylori infection.
H. pylori

Upper GI Endoscopy Mild gastric mucosal Confirms gastritis and assesses

Normal mucosa
(performed) erythema, no ulcer severity.

Prescribed Medication with Mechanism of Action

 Drug Name Dose Route Frequency Purpose / Action

Once daily (before Proton pump inhibitor to reduce gastric

Omeprazole 20 mg Oral
breakfast) acid secretion.

TID (three times a day) for

Metronidazole 400 mg Oral Antibiotic to eradicate H. pylori infection.
7 days

BID (twice a day) for 7 Second antibiotic in H. pylori triple

Clarithromycin 500 mg Oral
days therapy.

Prokinetic; reduces nausea and promotes

Domperidone 10 mg Oral TID before meals
gastric emptying.

IV Normal Saline 500 ml IV 1000ml i/v od To maintain hydration.

Paracetamol 500 mg Oral as needed For pain and mild fever if present.

Pathophysiology

Irritating factors (e.g., H. pylori, NSAIDs, alcohol, spicy food, stress)

↓
Disruption of gastric mucosal barrier
↓
Exposure of stomach lining to gastric acid and pepsin
↓
Inflammation of gastric mucosa (gastritis)
↓
Mucosal edema, hyperemia (increased blood flow), and infiltration of WBCs
↓
Possible erosion or ulceration of mucosa
↓
Gastric symptoms (pain, nausea, vomiting, early satiety, bloating)
↓
If persistent → Chronic gastritis
↓
Mucosal atrophy and increased risk of gastric ulcers or cancer

Nursing Care Plan – Gastritis (Patient: Nazish, 25 years old)

 Goals /
Nursing Nursing
Assessment Expected Rationale Evaluation
Diagnosis Interventions
Outcomes
- Assess pain level Pain assessment
Patient reports using 0–10 scale monitors treatment
Short term goal: Patient
epigastric pain every 4 hours. response.
Acute pain Pain will reduce reported pain
(6/10), nausea, - Administer Medications reduce
related to to 2/10 within 4- reduced to
and bloating. omeprazole/antacids acid secretion.
inflammation 5 hours. 2/10 within 2
- Tenderness on as prescribed. - Positioning reduces
of gastric Long term goal days.
abdominal - Encourage semi- gastric pressure.
mucosa Patient will Appears more
palpation. Fowler’s position. - Dietary changes
verbalize relief. comfortable.
- Poor appetite. - Educate patient to prevent worsening of
avoid spicy foods. symptoms.
- Monitor dietary
intake and weight
- Weight: 48 kg - Tracks nutritional
Imbalanced - Patient will eat daily. Patient
(↓2 kg over 1 improvement.
nutrition: less at least 75% of - Provide small, tolerating soft
month). - Small portions
than body meals within 3 frequent, non- diet; intake
- Low oral reduce nausea.
requirements days. irritating meals. improved to
intake. - Prevents irritation
related to poor - Maintain stable - Avoid spicy, acidic 70–80%.
- Reports early of gastric lining.
appetite and weight during foods. Weight
satiety and - Controls nausea,
nausea hospital stay. - Administer stabilized.
nausea. improves appetite.
antiemetics if
needed.
- Encourage rest
- Patient reports
- Patient will periods and - Promotes rest and
difficulty Patient slept
Disturbed sleep 6–7 hours relaxation relaxation.
sleeping due to 6 hours
sleep pattern per night within techniques. - Environmental
pain. uninterrupted
related to 3 days. - Dim lights and control improves
- Sleeps 4–5 by day 3.
abdominal - Verbalize reduce noise at night. sleep.
hours per night. Reports better
discomfort improved sleep - Give medications - Medication helps
- Appears tired rest.
quality. before bedtime as reduce discomfort.
during the day.
prescribed.
- Patient
- Patient will - Listen actively and - Builds trust and
expresses
verbalize provide reassurance. understanding. Patient less
concern about Anxiety
reduced anxiety - Explain disease and - Knowledge reduces anxious, asks
diagnosis. related to
within 48 hours. treatment clearly. uncertainty. questions
- Appears hospitalization
- Participate in - Involve her in daily - Participation with interest.
anxious. and health
care and care decisions. increases control. Cooperating
- Asks frequent condition
decision- - Allow family - Family support with care.
questions about
making. communication. reduces isolation.
her condition.

Reflective Log:
1. Description
During my clinical rotation, I cared for a 25-year-old female patient named Nazish who was
admitted with acute gastritis. She presented with symptoms such as abdominal pain, nausea, poor
appetite, and fatigue. As a student nurse, I was assigned to monitor her vital signs, administer
medications (like omeprazole), and provide dietary education and emotional support. I also
participated in making her nursing care plan under supervision.

2. Feelings

Initially, I felt anxious and unsure, especially when talking about dietary management and
emotional support. I was concerned that I might not explain things effectively. However, I also felt
motivated to help her feel better. When I saw her pain reducing and her engagement improving
with care, I felt relieved and satisfied with the progress.

3. Evaluation

The experience had both positive and challenging aspects. On the positive side, I communicated
well with the patient, followed the care plan, and noticed improvements in her condition. On the
downside, I initially hesitated to educate the patient due to fear of saying something incorrect.
However, I took feedback from my supervisor and improved gradually.

4. Analysis

This case helped me understand that gastritis not only requires medical treatment but also
lifestyle and emotional support. The patient's anxiety was affecting her sleep and eating habits,
which further worsened her symptoms. My role in emotional support and education played a
significant part in her recovery. I realized how effective communication and empathy help in
holistic nursing care.

5. Conclusion

From this experience, I learned the importance of patient education, dietary guidance, and
emotional support in managing gastritis. I also realized that it's okay to feel unsure initially, but
seeking guidance and reflecting on practice helps me grow professionally. I gained confidence in
applying the nursing process and interacting with patients.

6. Action Plan

In future, I will:

 Enhance my knowledge of GI disorders and medications.

 Practice communication and patient education skills more effectively.
 Use active listening and empathy to build rapport.
 Seek feedback regularly to improve clinical confidence.