Case Presentation On Peptic Ulcer 1d4n2y
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PEPTIC PEPTIC ULCER ULCER DISEASE DISEASE
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 itted: Jan.5,2010 BP:100/120 mmHg Time itted:9:34 Pm Temp. : 37.1 C Impression/Diagnosis: HVD/UTI/Acid PR: 84 Bpm Peptic Disease RR: 24 m • 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 itted: Jan.5,2010 Chief Complaints: Palpitation 3 Months PTA Med: Metropolol Previously itted last Nov. Secondary to palpitation/Dx HVD Impression/Diagnosis: HVD/UTI/ Acid Peptic Disease Physician: 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 Clinical Normal Patterns of Inspection Functioning (prior to observation on ission) First Day of duty
Patterns of functioning: Respiration •Tachypnea *Normal Personal Hygiene: •Daily Bath •Brushing of teeth *Dry Skin 3x a day * Dry scalp
On-going Appraisal observation 2nd day of duty
*Normal
Other sources, lab. Exam Results
Nursing History Normal Patterns of Functioning (prior to ission)
Communication & Special senses: •No difficulties in speaking, hearing, seeing and understanding •Slightly read & write English Coping with Stress: *Rest *Family Circulation: *tachycardia *Take medication
Clinical Inspection On-going Appraisal Other sources, lab. observation on observation 2nd day ofExam Results First Day of duty duty
*Weak Voice
*Irritable
*Normal PR *Normal BP
*Irritable, tense
Nursing History Clinical Inspection Normal Patterns of observation on First Functioning (prior to Day of duty ission)
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
On-going Appraisal observation 2nd day of duty
Other sources, lab. Exam Results
*poor appetite *D5 NSS 1L @20 gtts/mins Results U/A Color-light yellow Transparency- clear Specificity- 1.005 pH 6.5 Albumin-negative Sugar- negative PUS 1-2 RB 1-2 WBC- 10.12 Hgb. -116 Hct. -0.35 Neutrophil- 0.73 Lymphocyte- 0.25 Eosinophils- 0.02
•DAT
Nursing History Clinical Inspection Normal Patterns of observation on First Functioning (prior to Day of duty ission)
Exercise: •Hiking & stretching within 30 mins. Twice a week •Right Handed Pain/Discomfort: * Epigastric pain *Take medication Regulatory Mechanism *Dizzy
•Acute Pain
•Temp- 37.1C •Dry skin
On-going Appraisal Other sources, lab. observation 2nd day ofExam Results duty
Nursing History Clinical Inspection Normal Patterns of observation on First Functioning (prior to Day of duty ission)
On-going Appraisal Other sources, lab. observation 2nd day ofExam Results duty
Elimination: Void?- 3-5x a day Bowel Movement? Once a day
* Void- 2x
* Void- 2x
Results U/A Color-light yellow Transparency- clear Specificity- 1.005 pH 6.5 Albumin-negative Sugar- negative PUS 1-2 RB 1-2 WBC- 10.12 Hgb. -116 Hct. -0.35 Neutrophil- 0.73 Lymphocyte- 0.25 Eosinophils- 0.02
Nursing History Clinical Inspection Normal Patterns of observation on First Functioning (prior to Day of duty ission)
On-going Appraisal Other sources, lab. observation 2nd day ofExam Results duty
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
Nursing History Clinical Inspection Normal Patterns of observation on First Functioning (prior to Day of duty ission)
Recreational/ Diversion: •Done for fun? Playing cards •Past time while ill? Sleep Health 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?
On-going Appraisal Other sources, lab. observation 2nd day ofExam Results duty
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 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
Mucosal ulcerations
Severe ulcerations: Signs and symptoms: •Epigastric pain •Hematemesis •pale •pyrosis
DIAGNOSTIC TEST
Barium Meal X-ray Gastroscopy Endoscopy Upper Gastrointestinal (GI) series Blood H. Pylori Test Breath H. Pylori Test Helicobacter pylori Stool Antigen (HpSA) Test Stomach biopsy Tissue 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.pylori Smoking reduction and rest Dietary modification Surgical 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 byed and the stomach is end-to-end anastomosed to the jejunum FOLLOW UP CHECK UP
NURSING MANAGEMENT
Monitor I & O Monitor the pt. hgb, hct, & electrolytes level istered 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
ister meds. Properly & to teach pt. do set duration of each medication Stress relief Exercises Lifestyle 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
Ferosemide
Diuretices, loop
Contraindication Adverse Effect Nsg. Dose, route, Consideration frequency
Edema from heartContraindicated Therapeutic Give diuretics10 mg slow failure, hepaticinpatients dose commonlyin morning toIVTT syndrome; mild-to-hypertensive tocauses ensure that moderate HPN;these drugs & inmetabolic &major diuresis adjunct treatment inpt. with anuria,electrolyte occurs before acute pulmonaryhepatic coma ordisturbance, bedtime. edema orsevere particularly Take safety hypertensive crisis. electrolyte potassium measures for depletion. depletion. Itall ambulatory also may causept. until hyperglycemia, response to hyperurecemia, diuretics in hypochloremic known alkalosis & hypomagnesemi a.
Drug Name
Classification Indication
Captopril
Angiotensiv econverting enzyme inhibitors
Contraindication
Adverse Effect
Nsg. Consideration
Dose, route, frequency
Hypertension, Contraindicated inAngioedema ofIf pt. has impaired25 mg, heart failure,pt. hypersensitivethe face &renal function, give1tab now LVD, MI, andto these drugs limits, drugs,a reduced dosage diabetic cough, If pt. becomes nephropathy dysgeusia, pregnant, stop ACE fatigue, inhibitors headache, Give captopril 1 hyperkatemia, hour before meals hypotension, proteinuria, rash & tachucardia
Drug Name
Classification
Metoprolol
Antianginale
Indication
Contraindication Adverse Effect Nsg. Consideration
Dose, route, frequency
Moderate toBeta BlockersBeta blockersDon’t give a beta50 mg, 1 tab now anginaare may causeblocker or calcium (Beta Blockers) serve channel blocker to (beta blockers)contraindicated bradycardia, relieve acute angina classic, effort-in pt.cough, diarrhea,Warn pt. not to induced angina, hypersensitive disturbing stop drug abruptly without prescriber’s Prinzmetal to them and indreams, approval angina, pt. withdizziness, Withhold the dose recurrent cardiogenic dyspnea, & notify angina, acuteshock, sinusfatigue, fever,prescriber’s if pt. angina, unstablebradycardia, heart failure,heart rate is slower than 60 bpm or angina heat blockhypotension, systolic BP is slower greater thanlethargy, than 90 mmHg first degree ornausea, Tell Pt. to report bronchial peripheral pervious/ persistent asthma edema, &adverse reaction wheezing.
Drug Name
Classification
Cimetidine
Histamine receptor antagonist
Indication
Contraindicatio Adverse Effect Nsg. n Consideration
Dose, route, frequency
2-Acute duodenalContra H2-receptor Adjust dosage400 mg, 1 tab PC or gastric ulcer,indicated in pt.antagonists for pt. with Zollinger-Ellison hypersensitive rarely caenal disease. syndrome, to these drugs adverse Don’t exceed gastro reactions. recommended esophageal Cardiac infusion rates reflux arrhythmias, when giving IV; dizziness, doing so fatigue, increases risk of gynecomastia, adverse CV headache, mild &effects. transient Caution pt. to diarrhea &avoid smoking thrombocytosemi during therapy a are possible
Drug Name
Classification
Indication
Contraindication Adverse Effect
Nsg. Consideration
Dose, route, frequency
Losartan
Anti hypertensives
Essential &Contraindicated Commonly Give drug with50 mg, 1 tab OD secondary HPN in pt.causes fod at bedtime,every 8 am hypersensitive toorthostatic as indicated these drugs & inchanges in HR,When mixing & those withheadache, giving parenteral hypotension hypotension, drugs, Follow nausea &manufacturer’s vomiting guidelines To prevent dizziness, light headedness or fainting advice changes in position.
Drug Name
Classification
Indication
Contraindication
Adverse Effect Nsg. Consideration
Dose, route, frequency
Aspirin
Anti Platelet,For arthritis,Contraindicated inHearing loss,Give aspirin100 mg 1 tab antipyretic mild pain orpt. hypersensitivetinnitus, with food milk,OD P.C. fever, to drug & thosedyspepsia, GIantacid or large prevention ofwith bleedingbleeding, GIglass of water thrombosis, disorder such asdistress, to reduce GI reduction of MIhemophilia, vonnausea, occultreactions. risk in Pt. withWillebrand diseasebleeding, If pt. has previous MI& telangiectasia, orvomiting, trouble orun stableNSAIDinducedtransient renalswallowing, angina, Kawasakisensitivity insufficiency, crush aspirin, syndrome; reactions thrombo combine with prophylaxis for cytopenia, soft food or attack, bruising, rash,dissolve it in rheumatic uticaria, liquid. Don’t fever, peri angioedema crush entericceuditis afet Reye syndrome coated aspirin. acute MI, & Give PR after a stent bowel movement implantation or at night to maximize absorption Stop aspirin 5-7 days before elective surgery
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 area •Weak •Restless •Unable to response well •Loss of appetite •Pain scale: 6
Acute/ chronic pain related to lesions secondary to increased gastric secretions
After 8 hours of Independent: 1. Hydrochloric Goal met as evidence nsg. & medical mgt. 1. Explain the relationship acid(HCL) presumably by PT; pt. will: between hydro chronic acid is an important 1.verbalized relief of a. verbalize relief of secretion and onset of pain variable in the pain pain 2. Explain the risks of appearance of peptic 2.able to sleep b. able to sleep well nonsteroidal antiulcer dse, because of inflammatory drugs this relationship, (NSAIDs) control of HCL (e.g. Motrin, Aleve, Relafen) secretion is 3. Help the pt. to identify considered an irritating substances( E.g. essential aim of Fried food, spicy foods, treatment. coffee) 2. NSAIDs cause 4. Encourage the pt. to avoid superficial irritation smoking and alcohol use. of the gastric mucosa 5. Encourage the pt. to and inhibit the reduce intake of caffeine- production of containing and alcoholic prostaglandins that beverages, if indicated protect gastric 6. Teach Pt. the importance mucosa of continuing treatment even 3. Avoidance of in the absence of pain. irritating substances Dependent: can help to prevent 1. ister drug therapy asthe pain response. prescribed 4. Smoking decreases a. antacids pancreatic secretion b. histamine of bicarbonate; this c. h2 blocker increase duodenal d. anticholinergics acidity. Tobacco delays the healing of gastric duodenal ulcer and increases their frequency 5. Gastric acid secretion may be stimulated by caffeine
Cues & Evidence
Nsg. Diagnosis
Objective
Intervention
S= “wala akong ganang kumain” as verbalized by the pt. O= facial Grimace Restlessness Anorexia: pt. not able to consume foods serve V/S: T=37.5 C PR=65 BPM RR=14 M BP=110/80 mmHg
Nutrition Imbalace After 8 hours of nsg. & Independent: medical mgt. pt. will: 1. Monitor V/S as less than body a. Will be able to weight related to consume served food ordered. 2. Instruct pt. to loss of appetite
Rationale
Evaluation
1. As baseline data Patient will be able in cases of to consume served alterations from food. the normal. increase the intake 2. Water is of water considered as a 3. Identify and limit good antacid. foods that create 3. Food has acid discomfort 4. Encourage small, neutralizing effects & dilutes. frequent meals. 5. Provide prescribed4. Small meals diet. prevent distention Dependent: & the release of ister drug gastrin. therapy: 5. To avoid gastric a.Antacid irritation b.Histamine-2 Antagonist
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.
Prepared by: Limpango, Joan Nudalo, Raiza Paradero, Desiree Pison, Wilsan Puno, Rebekah Ann Tan, Cristali Tinamisan, Johnny Santillan, Juliet Sumile, Daisy Mae Sawit, Johnderick Resma, Rosalie Rudie, Aldin Urian, Pedro
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 itted: Jan.5,2010 BP:100/120 mmHg Time itted:9:34 Pm Temp. : 37.1 C Impression/Diagnosis: HVD/UTI/Acid PR: 84 Bpm Peptic Disease RR: 24 m • 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 itted: Jan.5,2010 Chief Complaints: Palpitation 3 Months PTA Med: Metropolol Previously itted last Nov. Secondary to palpitation/Dx HVD Impression/Diagnosis: HVD/UTI/ Acid Peptic Disease Physician: 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 Clinical Normal Patterns of Inspection Functioning (prior to observation on ission) First Day of duty
Patterns of functioning: Respiration •Tachypnea *Normal Personal Hygiene: •Daily Bath •Brushing of teeth *Dry Skin 3x a day * Dry scalp
On-going Appraisal observation 2nd day of duty
*Normal
Other sources, lab. Exam Results
Nursing History Normal Patterns of Functioning (prior to ission)
Communication & Special senses: •No difficulties in speaking, hearing, seeing and understanding •Slightly read & write English Coping with Stress: *Rest *Family Circulation: *tachycardia *Take medication
Clinical Inspection On-going Appraisal Other sources, lab. observation on observation 2nd day ofExam Results First Day of duty duty
*Weak Voice
*Irritable
*Normal PR *Normal BP
*Irritable, tense
Nursing History Clinical Inspection Normal Patterns of observation on First Functioning (prior to Day of duty ission)
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
On-going Appraisal observation 2nd day of duty
Other sources, lab. Exam Results
*poor appetite *D5 NSS 1L @20 gtts/mins Results U/A Color-light yellow Transparency- clear Specificity- 1.005 pH 6.5 Albumin-negative Sugar- negative PUS 1-2 RB 1-2 WBC- 10.12 Hgb. -116 Hct. -0.35 Neutrophil- 0.73 Lymphocyte- 0.25 Eosinophils- 0.02
•DAT
Nursing History Clinical Inspection Normal Patterns of observation on First Functioning (prior to Day of duty ission)
Exercise: •Hiking & stretching within 30 mins. Twice a week •Right Handed Pain/Discomfort: * Epigastric pain *Take medication Regulatory Mechanism *Dizzy
•Acute Pain
•Temp- 37.1C •Dry skin
On-going Appraisal Other sources, lab. observation 2nd day ofExam Results duty
Nursing History Clinical Inspection Normal Patterns of observation on First Functioning (prior to Day of duty ission)
On-going Appraisal Other sources, lab. observation 2nd day ofExam Results duty
Elimination: Void?- 3-5x a day Bowel Movement? Once a day
* Void- 2x
* Void- 2x
Results U/A Color-light yellow Transparency- clear Specificity- 1.005 pH 6.5 Albumin-negative Sugar- negative PUS 1-2 RB 1-2 WBC- 10.12 Hgb. -116 Hct. -0.35 Neutrophil- 0.73 Lymphocyte- 0.25 Eosinophils- 0.02
Nursing History Clinical Inspection Normal Patterns of observation on First Functioning (prior to Day of duty ission)
On-going Appraisal Other sources, lab. observation 2nd day ofExam Results duty
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
Nursing History Clinical Inspection Normal Patterns of observation on First Functioning (prior to Day of duty ission)
Recreational/ Diversion: •Done for fun? Playing cards •Past time while ill? Sleep Health 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?
On-going Appraisal Other sources, lab. observation 2nd day ofExam Results duty
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 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.
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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
Mucosal ulcerations
Severe ulcerations: Signs and symptoms: •Epigastric pain •Hematemesis •pale •pyrosis
DIAGNOSTIC TEST
Barium Meal X-ray Gastroscopy Endoscopy Upper Gastrointestinal (GI) series Blood H. Pylori Test Breath H. Pylori Test Helicobacter pylori Stool Antigen (HpSA) Test Stomach biopsy Tissue 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.pylori Smoking reduction and rest Dietary modification Surgical 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 byed and the stomach is end-to-end anastomosed to the jejunum FOLLOW UP CHECK UP
NURSING MANAGEMENT
Monitor I & O Monitor the pt. hgb, hct, & electrolytes level istered 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
ister meds. Properly & to teach pt. do set duration of each medication Stress relief Exercises Lifestyle 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
Ferosemide
Diuretices, loop
Contraindication Adverse Effect Nsg. Dose, route, Consideration frequency
Edema from heartContraindicated Therapeutic Give diuretics10 mg slow failure, hepaticinpatients dose commonlyin morning toIVTT syndrome; mild-to-hypertensive tocauses ensure that moderate HPN;these drugs & inmetabolic &major diuresis adjunct treatment inpt. with anuria,electrolyte occurs before acute pulmonaryhepatic coma ordisturbance, bedtime. edema orsevere particularly Take safety hypertensive crisis. electrolyte potassium measures for depletion. depletion. Itall ambulatory also may causept. until hyperglycemia, response to hyperurecemia, diuretics in hypochloremic known alkalosis & hypomagnesemi a.
Drug Name
Classification Indication
Captopril
Angiotensiv econverting enzyme inhibitors
Contraindication
Adverse Effect
Nsg. Consideration
Dose, route, frequency
Hypertension, Contraindicated inAngioedema ofIf pt. has impaired25 mg, heart failure,pt. hypersensitivethe face &renal function, give1tab now LVD, MI, andto these drugs limits, drugs,a reduced dosage diabetic cough, If pt. becomes nephropathy dysgeusia, pregnant, stop ACE fatigue, inhibitors headache, Give captopril 1 hyperkatemia, hour before meals hypotension, proteinuria, rash & tachucardia
Drug Name
Classification
Metoprolol
Antianginale
Indication
Contraindication Adverse Effect Nsg. Consideration
Dose, route, frequency
Moderate toBeta BlockersBeta blockersDon’t give a beta50 mg, 1 tab now anginaare may causeblocker or calcium (Beta Blockers) serve channel blocker to (beta blockers)contraindicated bradycardia, relieve acute angina classic, effort-in pt.cough, diarrhea,Warn pt. not to induced angina, hypersensitive disturbing stop drug abruptly without prescriber’s Prinzmetal to them and indreams, approval angina, pt. withdizziness, Withhold the dose recurrent cardiogenic dyspnea, & notify angina, acuteshock, sinusfatigue, fever,prescriber’s if pt. angina, unstablebradycardia, heart failure,heart rate is slower than 60 bpm or angina heat blockhypotension, systolic BP is slower greater thanlethargy, than 90 mmHg first degree ornausea, Tell Pt. to report bronchial peripheral pervious/ persistent asthma edema, &adverse reaction wheezing.
Drug Name
Classification
Cimetidine
Histamine receptor antagonist
Indication
Contraindicatio Adverse Effect Nsg. n Consideration
Dose, route, frequency
2-Acute duodenalContra H2-receptor Adjust dosage400 mg, 1 tab PC or gastric ulcer,indicated in pt.antagonists for pt. with Zollinger-Ellison hypersensitive rarely caenal disease. syndrome, to these drugs adverse Don’t exceed gastro reactions. recommended esophageal Cardiac infusion rates reflux arrhythmias, when giving IV; dizziness, doing so fatigue, increases risk of gynecomastia, adverse CV headache, mild &effects. transient Caution pt. to diarrhea &avoid smoking thrombocytosemi during therapy a are possible
Drug Name
Classification
Indication
Contraindication Adverse Effect
Nsg. Consideration
Dose, route, frequency
Losartan
Anti hypertensives
Essential &Contraindicated Commonly Give drug with50 mg, 1 tab OD secondary HPN in pt.causes fod at bedtime,every 8 am hypersensitive toorthostatic as indicated these drugs & inchanges in HR,When mixing & those withheadache, giving parenteral hypotension hypotension, drugs, Follow nausea &manufacturer’s vomiting guidelines To prevent dizziness, light headedness or fainting advice changes in position.
Drug Name
Classification
Indication
Contraindication
Adverse Effect Nsg. Consideration
Dose, route, frequency
Aspirin
Anti Platelet,For arthritis,Contraindicated inHearing loss,Give aspirin100 mg 1 tab antipyretic mild pain orpt. hypersensitivetinnitus, with food milk,OD P.C. fever, to drug & thosedyspepsia, GIantacid or large prevention ofwith bleedingbleeding, GIglass of water thrombosis, disorder such asdistress, to reduce GI reduction of MIhemophilia, vonnausea, occultreactions. risk in Pt. withWillebrand diseasebleeding, If pt. has previous MI& telangiectasia, orvomiting, trouble orun stableNSAIDinducedtransient renalswallowing, angina, Kawasakisensitivity insufficiency, crush aspirin, syndrome; reactions thrombo combine with prophylaxis for cytopenia, soft food or attack, bruising, rash,dissolve it in rheumatic uticaria, liquid. Don’t fever, peri angioedema crush entericceuditis afet Reye syndrome coated aspirin. acute MI, & Give PR after a stent bowel movement implantation or at night to maximize absorption Stop aspirin 5-7 days before elective surgery
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 area •Weak •Restless •Unable to response well •Loss of appetite •Pain scale: 6
Acute/ chronic pain related to lesions secondary to increased gastric secretions
After 8 hours of Independent: 1. Hydrochloric Goal met as evidence nsg. & medical mgt. 1. Explain the relationship acid(HCL) presumably by PT; pt. will: between hydro chronic acid is an important 1.verbalized relief of a. verbalize relief of secretion and onset of pain variable in the pain pain 2. Explain the risks of appearance of peptic 2.able to sleep b. able to sleep well nonsteroidal antiulcer dse, because of inflammatory drugs this relationship, (NSAIDs) control of HCL (e.g. Motrin, Aleve, Relafen) secretion is 3. Help the pt. to identify considered an irritating substances( E.g. essential aim of Fried food, spicy foods, treatment. coffee) 2. NSAIDs cause 4. Encourage the pt. to avoid superficial irritation smoking and alcohol use. of the gastric mucosa 5. Encourage the pt. to and inhibit the reduce intake of caffeine- production of containing and alcoholic prostaglandins that beverages, if indicated protect gastric 6. Teach Pt. the importance mucosa of continuing treatment even 3. Avoidance of in the absence of pain. irritating substances Dependent: can help to prevent 1. ister drug therapy asthe pain response. prescribed 4. Smoking decreases a. antacids pancreatic secretion b. histamine of bicarbonate; this c. h2 blocker increase duodenal d. anticholinergics acidity. Tobacco delays the healing of gastric duodenal ulcer and increases their frequency 5. Gastric acid secretion may be stimulated by caffeine
Cues & Evidence
Nsg. Diagnosis
Objective
Intervention
S= “wala akong ganang kumain” as verbalized by the pt. O= facial Grimace Restlessness Anorexia: pt. not able to consume foods serve V/S: T=37.5 C PR=65 BPM RR=14 M BP=110/80 mmHg
Nutrition Imbalace After 8 hours of nsg. & Independent: medical mgt. pt. will: 1. Monitor V/S as less than body a. Will be able to weight related to consume served food ordered. 2. Instruct pt. to loss of appetite
Rationale
Evaluation
1. As baseline data Patient will be able in cases of to consume served alterations from food. the normal. increase the intake 2. Water is of water considered as a 3. Identify and limit good antacid. foods that create 3. Food has acid discomfort 4. Encourage small, neutralizing effects & dilutes. frequent meals. 5. Provide prescribed4. Small meals diet. prevent distention Dependent: & the release of ister drug gastrin. therapy: 5. To avoid gastric a.Antacid irritation b.Histamine-2 Antagonist
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.
Prepared by: Limpango, Joan Nudalo, Raiza Paradero, Desiree Pison, Wilsan Puno, Rebekah Ann Tan, Cristali Tinamisan, Johnny Santillan, Juliet Sumile, Daisy Mae Sawit, Johnderick Resma, Rosalie Rudie, Aldin Urian, Pedro
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