case presentation on peptic ulcer

PEPTIC ULCERPEPTIC ULCERDISEASEDISEASE

PEPTIC ULCERPEPTIC ULCERDISEASEDISEASE

Introduction

Peptic Ulcer

• Ulcers average between one-quarter and one-half inch in diameter. They develop when digestive juices produced in the stomach, intestines, and digestive glands damage the lining of the stomach or duodenum.

The two important digestive juices are hydrochloric acid and the enzyme pepsin. Both substances are critical in the breakdown and digestion of starch, fat, and proteins in food. They play different roles in ulcer:

• Hydrochloric Acid. A common misbelieve is that excess hydrochloric acid, which is secreted in the stomach, is solely responsible for producing ulcers.

• H. pylori- the bacteria that has been the cause of most peptic ulcers.

• Pepsin. Is an enzyme that breaks down proteins in food. Since the stomach and duodenum are also composed of protein, however, they too are susceptible to the actions of pepsin.

• Bicarbonate, which the mucous layer secretes, neutralizes the digestive acids. Hormone like substances called prostaglandins help keep the blood vessels in the stomach dilated, ensuring good blood flow and protecting against injury.

(Prostaglandins are also believed to stimulate bicarbonate and mucus production.

Patient Profile

• Patient’s Name: Criselda Llorente Siangco Sex: Female• Age: 43 y.o.• Status: Married• Address: Pigcarangan, Tubod, Lanao Del Norte• Religion: Roman Catholic • Occupation: housewife• Citizenship: Filipino• Chief Complaints: Palpitation 3months PTA V/S:• Date Admitted: Jan.5,2010 BP:100/120 mmHg• Time Admitted:9:34 Pm Temp. : 37.1 C• Impression/Diagnosis: HVD/UTI/Acid PR: 84 Bpm Peptic Disease RR: 24 Cpm• Physician: Dra. Marjueta Opamen • Room: Critical Ward

NURSING ASSESSMENT

General Information:Patient’s Name: Criselda L. Siangco Sex: F Age: 43 y.o.Religion: Roman Catholic Occupation: Housewife

Address: Pigcarangan, Tubod, LDN Status: Married Date Admitted: Jan.5,2010Chief Complaints: Palpitation 3 Months PTA Med: Metropolol Previously admitted last Nov. Secondary to palpitation/Dx HVDImpression/Diagnosis: HVD/UTI/ Acid Peptic DiseasePhysician: Dra. Marjueta Opamen

Present Illness

• Palpitation 3 mos. PTA• Jan.5,2010 @ 9:30 PM

Reaction to & Expectations about Hospitalization

• HPN/ Ulcer• It can be treated

through hospitalization

• It can affect their daily living

• Yes, it can change my ability to function as a mother and a wife

• Sad and irritable• Lonely and sad

Previous Illness

• HVD• Over fatigue• They give their care

Reactions about Treatment & Diagnostic Procedures

• It can relieve the pain and cure my illness

• Is it really make me feeling well?

• Afraid

Nursing History Normal Patterns of Functioning (prior to admission)

Clinical Inspection observation on First Day of duty

On-going Appraisal observation 2nd day of duty

Other sources, lab. Exam Results

Patterns of functioning:Respiration•TachypneaPersonal Hygiene:•Daily Bath•Brushing of teeth 3x a day

*Normal

*Dry Skin* Dry scalp

*Normal





Communication & Special senses:•No difficulties in speaking, hearing, seeing and understanding•Slightly read & write EnglishCoping with Stress:*Rest*FamilyCirculation:*tachycardia*Take medication

*Weak Voice

*Irritable

*Normal PR*Normal BP

*Irritable, tense





Food & Fluid Intake:•Meals? 3x a day•Snack? Seldom•Content? Rice & vegetables•1 cup of coffee every morning•Like all kinds of food

*56 kg*5’4*pale skin

*poor appetite*D5 NSS 1L @20 gtts/minsResults U/AColor-light yellowTransparency- clearSpecificity- 1.005 pH 6.5Albumin-negativeSugar- negativePUS 1-2RB 1-2WBC- 10.12Hgb. -116Hct. -0.35Neutrophil- 0.73Lymphocyte- 0.25Eosinophils- 0.02

•DAT





Exercise:•Hiking & stretching within 30 mins. Twice a week•Right HandedPain/Discomfort:* Epigastric pain*Take medicationRegulatory Mechanism*Dizzy

•Acute Pain

•Temp- 37.1C•Dry skin





Elimination:Void?- 3-5x a dayBowel Movement? Once a day

* Void- 2x * Void- 2x Results U/AColor-light yellowTransparency- clearSpecificity- 1.005 pH 6.5Albumin-negativeSugar- negativePUS 1-2RB 1-2WBC- 10.12Hgb. -116Hct. -0.35Neutrophil- 0.73Lymphocyte- 0.25Eosinophils- 0.02





Rest and sleep:•Sleep 8 hours a day•Retiring? 10PM•Arising? 5PM•No difficulty in sleeping•Staying sleep with husband•Interferes sleep with noise•2 Pillows

•8 hours•Nature of sleep? Normal





Recreational/ Diversion:•Done for fun? Playing cards•Past time while ill? SleepHealth Supervision:•Take Medicine as prescribed•Illness send to bed? Fever, HPN, epigastric pain•Reason for consulting Doctor? To relieve pain & to Know my health status•Do when angry? Went to quite place

ANATOMY & PHYSIOLOGY

Digestive System Digestive system is the series of tube-like organ that converts our

meals into chemical compound that can be absorbed by the body’s cells. It also separates out unneeded materials and flushed them out of the body. In all there’s about 30-foot-long(9-meter-long) tube that begins with the mouth, where food enters the body, and ends with the anus, where solid wastes are expelled. Along the way, food is broken down, sorted, and reprocessed before being circulated around the body to nourish and replace cells and supply energy to our muscles.

Mouth & Throat The digestive process begins here, where food is grind into pieces and

prepared for delivery to the stomach. It then enters the pharynx, or throat a muscular funnel that pushes that chewed food into the esophagus while simultaneously blocking off the trachea( Wind pipe).

• Salivary Glands- Three pairs of salivary glands secrete saliva, a mixture of water, enzymes and gluey protein called Mucin, into the mouth to moisten the food. Enzymes in the saliva interact with food and begin the process of chemical digestion.

• Teeth- Bony structures that tear, chop, and grind food for swallowing. Sharp incisors and pointed canines in the front of the mouth are designed to tear into tough foods, while flattened premolars and molars in the back grind grains and plant matter.

• Tongue- This muscular organ maneuvers food around during chewing and mixes it with saliva to form a wet lump called a BOLUS. The top and sides of the tongue are covered with little projection called papillae, many of which contains taste buds.

• Esophagus- The esophagus is 10-inch-long(25-cm-long) muscular tube that connects the pharynx to the stomach . When food enters the esophagus, a wave of muscular contractions called PERISTALSIS push and pull the food to the stomach. Mucus secretion keep the lump of food, or bolus sliding a mere four to eight seconds.

• Upper Esopahageal Sphincter- This valve, found just below the intersection of the throat and esophagus, is a ring of muscles that relaxes to let food enter the esophagus.

• Stomach- this muscular, expandable J-shaped pouch is responsible for holding and digesting food, as well as removing it’s nutrients. When food enters the stomach, its muscular walls contact and churn the food with powerful gastric acids that kill bacteria and break down proteins. The result is a creamy substance called CHYME which the stomach stores until it is ready for release into the small intestine.

• Liver- weighing in at 3 pounds(1.3Kg), this wedge-shaped organ is the body’s largest gland. The liver is an accessory organ for the digestive system. Among its many roles is detoxification of the blood. It also creates bile, which is used to break down fats.

• Gall Bladder- this plum-size, green, muscular sac hangs from the liver. The gall bladder collects, stores, and concentrate bile from the liver.

• Pancreas- This long organ, positioned behind the stomach, produces insulin and enzymes that aid digestion. Pancreatic enzymes help digest food in the small intestine, while insulin helps regulate the amount of sugar in the blood.

• Intestines- The small intestine measures 20 feet(6meters) in length and 1 inch(2.5cm) in diameter. Thousands of folds and millions of finger-like projection called VILL increase the surface are of the small intestine ,which absorb 90% of nutrients and water the body will receive from digested food.

• Duodenum- This is the first portion of the small intestine, where secretion from the liver and pancreas are received and most of the chemical digestion takes place.

• Jejunum- This is the long, coiled middle portion of the small intestine that stretches from the duodenum to the ileum.

• Ileum- this is the final portion of the small intestine, where remaining nutrients are absorbed and utilized.

• The Large Intestine absorb the last bits of nutrients and water from indigestible foods, compacts the remaining matter, and eliminates it as feces.

• Ascending Colon- the large intestine surrounds the small intestine like an inverted Y. The first portion of the large intestine, the ascending colon, is stimulated vertically on the right side of the body. The ascending colon extracts remaining moisture from food before its excretion.

• Transverse Colon- Connecting the ascending and descending colons, this part of the large intestine is situated horizontally above the small intestine.

• Descending Colon- Found on the left side of the body, the descending, or left colon, stores stool the will be emptied into the rectum

• Rectum- Only 5 inches(12cm) long, the rectum sits just above the anal canal. Feces are stored here briefly prior to defecation.

• Anus- This ring of muscles is the external opening of the rectum, through which fecal matter is expelled. Peristaltic waves in the colon and contraction of the abdominal muscles trigger defecation.

PATHOPHYSIOLOGY

Damage to mucosa with alcohol abuse, smoking, use

of NSAID’s

Infection with Helicobacter Pylori

Damaged mucousal

Erosion of mucous membrane

Low function of mucosal cells; low quality of

mucous

Erosive gastritis

Severe ulcerations:Signs and symptoms:•Epigastric pain•Hematemesis•pale•pyrosis

Mucosal ulcerations

DIAGNOSTIC TEST

Barium Meal X-rayGastroscopyEndoscopyUpper Gastrointestinal (GI) seriesBlood H. Pylori TestBreath H. Pylori TestHelicobacter pylori Stool Antigen

(HpSA) TestStomach biopsyTissue H. Pylori Test

MEDICAL MANAGEMENT

ANTIBIOTICS -metrodinazole , amoxicillin ,

clarithromycin -to eradicate h.pylori -surgical intervention

PROTON PUMP INHIBITORS -clansoprazole , omeprazole

• Proton pump inhibitors (or "PPI"s) are a group of drugs whose main action is pronounced and long-lasting reduction of gastric acid production.

Bismuth salts -suppress or eradicate h.pyloriSmoking reduction and restDietary modificationSurgical procedure -vagotomy -Billroth I and Billroth II

Vagotomy

-A vagotomy is a surgical procedure that is performed only in humans. It is resection (removal of, or at least severing) of part of the vagus nerve.

Antrectomy (billroth I) - is the resection, or surgical

removal, of a part of the stomach known as the antrum. The antrum is the lower third of the stomach that lies between the body of the stomach and the pyloric canal, which empties into the first part of the small intestine.

Gastrojejunostomy (Billroth II)

-GI surgery A procedure in which the duodenum is excised or bypassed and the stomach is end-to-end anastomosed to the jejunum

FOLLOW UP CHECK UP

NURSING MANAGEMENT

Monitor I & OMonitor the pt. hgb, hct, &

electrolytes levelAdministered prescribed IV fluids

& blood replacement if acute bleeding is present

Cessation of Smoking Encourage bed rest Provide small frequent meals Watch for diarrhea caused by antacids & other

meds. Advice pt. to avoid extremely hot & cold

foods, to chew thoroughly & to eat in a leisurely fashion

Administer meds. Properly & to teach pt. do set duration of each medication

Stress reliefExercisesLifestyle changes

Instead of meat change it to Fruits & vegetables that are rich in fiber diet

Moderate amount in drinking of milk (2-3 cups a day)

Minimize drinking of coffee & carbonated beverages

No to spices & peppers Minimize use of garlic in foods Encourage olive oil in cooking of foods.

Drug Study

Drug Name Classification

Indication Contraindication

Adverse Effect

Nsg. Consideration

Dose, route, frequency

Ferosemide Diuretices, loop

Edema from heart failure, hepatic syndrome; mild-to-moderate HPN; adjunct treatment in acute pulmonary edema or hypertensive crisis.

Contraindicated inpatients hypertensive to these drugs & in pt. with anuria, hepatic coma or severe electrolyte depletion.

Therapeutic dose commonly causes metabolic & electrolyte disturbance, particularly potassium depletion. It also may cause hyperglycemia, hyperurecemia, hypochloremic alkalosis & hypomagnesemia.

Give diuretics in morning to ensure that major diuresis occurs before bedtime.Take safety measures for all ambulatory pt. until response to diuretics in known

10 mg slow IVTT

Drug Name Classification

Indication Contraindication Adverse Effect Nsg. Consideration


Captopril Angiotensive- converting enzyme inhibitors

Hypertension, heart failure, LVD, MI, and diabetic nephropathy

Contraindicated in pt. hypersensitive to these drugs

Angioedema of the face & limits, drugs, cough, dysgeusia, fatigue, headache, hyperkatemia, hypotension, proteinuria, rash & tachucardia

If pt. has impaired renal function, give a reduced dosageIf pt. becomes pregnant, stop ACE inhibitorsGive captopril 1 hour before meals

25 mg, 1tab now

Drug Name Classification Indication Contraindication

Adverse Effect

Nsg. Consideration


Metoprolol Antianginale(Beta Blockers)

Moderate to serve angina (beta blockers) classic, effort-induced angina,Prinzmetal angina, recurrent angina, acute angina, unstable angina

Beta Blockers are contraindicated in pt. hypersensitive to them and in pt. with cardiogenic shock, sinus bradycardia, heat block greater than first degree or bronchial asthma

Beta blockers may cause bradycardia, cough, diarrhea, disturbing dreams, dizziness, dyspnea, fatigue, fever, heart failure, hypotension, lethargy, nausea, peripheral edema, & wheezing.

Don’t give a beta blocker or calcium channel blocker to relieve acute anginaWarn pt. not to stop drug abruptly without prescriber’s approvalWithhold the dose & notify prescriber’s if pt. heart rate is slower than 60 bpm or systolic BP is slower than 90 mmHgTell Pt. to report pervious/ persistent adverse reaction

50 mg, 1 tab now


Adverse Effect

Nsg. Consideration


Cimetidine Histamine 2- receptor antagonist

Acute duodenal or gastric ulcer, Zollinger-Ellison syndrome, gastro esophageal reflux

Contra indicated in pt. hypersensitive to these drugs

H2-receptor antagonists rarely cause adverse reactions. Cardiac arrhythmias, dizziness, fatigue, gynecomastia, headache, mild & transient diarrhea & thrombocytosemia are possible

Adjust dosage for pt. with renal disease.Don’t exceed recommended infusion rates when giving IV; doing so increases risk of adverse CV effects.Caution pt. to avoid smoking during therapy

400 mg, 1 tab PC


Adverse Effect

Nsg. Consideration


Losartan Anti hypertensives

Essential & secondary HPN

Contraindicated in pt. hypersensitive to these drugs & in those with hypotension

Commonly causes orthostatic changes in HR, headache, hypotension, nausea & vomiting

Give drug with fod at bedtime, as indicatedWhen mixing & giving parenteral drugs, Follow manufacturer’s guidelinesTo prevent dizziness, light headedness or fainting advice changes in position.

50 mg, 1 tab OD every 8 am


Adverse Effect

Nsg. Consideration


Aspirin Anti Platelet, antipyretic

For arthritis, mild pain or fever, prevention of thrombosis, reduction of MI risk in Pt. with previous MI orun stable angina, Kawasaki syndrome; prophylaxis for attack, rheumatic fever, peri ceuditis afet acute MI, & stent implantation

Contraindicated in pt. hypersensitive to drug & those with bleeding disorder such as hemophilia, von Willebrand disease & telangiectasia, or NSAID- induced sensitivity reactions

Hearing loss, tinnitus, dyspepsia, GI bleeding, GI distress, nausea, occult bleeding, vomiting, transient renal insufficiency, thrombo cytopenia, bruising, rash, uticaria, angioedema Reye syndrome

Give aspirin with food milk, antacid or large glass of water to reduce GI reactions.If pt. has trouble swallowing, crush aspirin, combine with soft food or dissolve it in liquid. Don’t crush enteric- coated aspirin.Give PR after a bowel movement or at night to maximize absorptionStop aspirin 5-7 days before elective surgery

100 mg 1 tab OD P.C.

Nursing Care Plan

Cues & Evidence: Nsg. Diagnosis Objective Intervention Rationale Evaluation

S= “ Sakit akong Kutokuto” as verbalized by the pt.O= Seen lying on bed with grimaced face and pressing her epigastric areaWeakRestlessUnable to response wellLoss of appetitePain scale: 6

Acute/ chronic pain related to lesions secondary to increased gastric secretions

After 8 hours of nsg. & medical mgt. pt. will:a. verbalize relief of painb. able to sleep well

Independent:1. Explain the relationship between hydro chronic acid secretion and onset of pain2. Explain the risks of nonsteroidal anti- inflammatory drugs (NSAIDs)(e.g. Motrin, Aleve, Relafen)3. Help the pt. to identify irritating substances( E.g. Fried food, spicy foods, coffee)4. Encourage the pt. to avoid smoking and alcohol use.5. Encourage the pt. to reduce intake of caffeine- containing and alcoholic beverages, if indicated6. Teach Pt. the importance of continuing treatment even in the absence of pain.Dependent:1. administer drug therapy as prescribeda. antacidsb. histaminec. h2 blockerd. anticholinergics

1. Hydrochloric acid(HCL) presumably is an important variable in the appearance of peptic ulcer dse, because of this relationship, control of HCL secretion is considered an essential aim of treatment.2. NSAIDs cause superficial irritation of the gastric mucosa and inhibit the production of prostaglandins that protect gastric mucosa3. Avoidance of irritating substances can help to prevent the pain response.4. Smoking decreases pancreatic secretion of bicarbonate; this increase duodenal acidity. Tobacco delays the healing of gastric duodenal ulcer and increases their frequency5. Gastric acid secretion may be stimulated by caffeine ingestion. Alcohol can cause gastritis6. Dietary restrictions and medications must be continued for the prescribed duration. Pain may be relieved long before healing is complete.

Goal met as evidence by PT;1.verbalized relief of pain2.able to sleep

Cues & Evidence Nsg. Diagnosis Objective Intervention Rationale Evaluation

S= “wala akong ganang kumain” as verbalized by the pt.O= facial GrimaceRestlessnessAnorexia: pt. not able to consume foods serveV/S:T=37.5 CPR=65 BPMRR=14 CPMBP=110/80 mmHg

Nutrition Imbalace less than body weight related to loss of appetite

After 8 hours of nsg. & medical mgt. pt. will:a. Will be able to consume served food

Independent:1. Monitor V/S as ordered.2. Instruct pt. to increase the intake of water3. Identify and limit foods that create discomfort4. Encourage small, frequent meals.5. Provide prescribed diet.Dependent:Administer drug therapy:a.Antacidb.Histamine-2 Antagonist

1. As baseline data in cases of alterations from the normal.2. Water is considered as a good antacid.3. Food has acid neutralizing effects & dilutes.4. Small meals prevent distention & the release of gastrin.5. To avoid gastric irritation

Patient will be able to consume served food.

Prognosis

• When the underlying cause for peptic ulcer disease is successfully treated, the prognosis (expected outcome) for patients with the condition is excellent.To help prevent peptic ulcers, avoid the following:

• Alcohol• Common sources of Helicobacter pylori bacteria (e.g.,

contaminated food and water, floodwater, raw sewage)• Long-term use of nonsteroidal anti-inflammatory drugs

(NSAIDs) • Smoking• Good hygiene can help reduce the risk for peptic ulcer

disease caused by Helicobacter pylori infection. Washing the hands thoroughly with warm soapy water after using the restroom and before eating and avoiding sharing eating utensils and drinking glasses also can reduce the spread of bacteria that can cause PUD.

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case presentation on peptic ulcer

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