LYCEUM OF THE PHILIPPINES UNIVERSITY BATANGAS COLLEGE OF NURSING

Peptic Ulcer
Prepared By: Magnaye Karl Ivan B. Marco, Carissa Rafa, John Nicholson Smelser, Christianne Kay C. Tatlonghari, Kevin Bryan A. Tordecilla, Ella May A. Ubasa, Inna Beatrice S. Valencia, Gladys M. BSN III-3-D

In Partial Preparation of the Requirements for the Degree of Bachelor of Science in Nursing 1st semester S.Y. 2011-2012

Introduction A peptic ulcer may be referred to as a gastric, duodenal, oresophageal ulcer, depending on its location. A person who has a peptic ulcer has peptic ulcer disease. A peptic ulcer is an exaction (hollowed-out area) that forms in the mucosal wall of the stomach, in the pylorus (the opening between the stomach and duodenum), or in the esophagus. Erosion of a circumscribed area of mucous membrane is the cause. This erosion may extend as deeply as the muscle layers or through the muscle to the peritoneum. Peptic ulcers are most likely to be in the duodenum than in the stomach. As a rule they occur alone, but they may occur in multiples. Chronic gastric ulcers tend to occur in the lesser curvature of the stomach, near the pylorus. Esophageal ulcers occur as a result of the backward flow of HCL (Hydrochloric acid) from the stomach into the esophagus (gastroesophageal reflux disease [GERD]). Peptic ulcer disease occurs with the greatest frequency in people between 40 and 60 years of age. It is relatively uncommon in women of childbearing age, but it has been observed in children and even in infants. After menopause, the incidence of peptic ulcers in women is almost equal to that in men. Peptic ulcers in the body of the stomach can occur without excessive acid secretion. In the past, stress and anxiety were throughout to be causes of ulcers, but research has documented that peptic ulcer result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water. Person-to-person transmission of the bacteria also occurs through close contact and exposure to emesis. It is not known what H. pylori infection does not cause ulcers in all people, but mostly likely the predisposition to ulcer formation depends on certain factors, such as the type of H. pylori and other as yet unknown factors (Moss & Sood, 2003). In addition, excessive secretion of HCl in the stomach may contribute to the formation of peptic ulcers, and stress may be associated with its increased secretion. The ingestion of milk and decaffeinated beverages, smoking, and alcohol also may increase HCl secretion. Stress and eating spicy foods may make peptic ulcers worse. Familial tendency also may be significant predisposing factor. People with blood type O are more susceptible to peptic ulcer than those with blood type A, B or AB, this is another genetic link. There also is an association between peptic ulcers and chronic pulmonary disease or chronic renal disease. Other predisposing factors associated with peptic ulcer include chronic use of NSAIDs, alcohol ingestion, and excessive smoking. The researchers chose Peptic Ulcer Disease (PUD) to undergo a study for they believe that this disease has been one of the common diseases experienced by many people yet having the least home management. Thus, through knowing the nature and nursing interventions in line with the said disease can subsequently boost the knowledge, skills and attitude of the students for they can be an instrument to preach out the rightful management for peptic ulcer disease.

OBJECTIVES A. GENERAL OBJECTIVES

This study aims to develop the knowledge , skills, and attitude of the students in the management and treatment of peptic ulcer through he effective utilization of the nursing process. B. SPECIFIC OBJECTIVES 1. Get an overview of what peptic ulcer is. 2. To obtain information regarding the patients profile. 3. Identify the patients history and the risk factors contributing to peptic ulcer. 4. Perform a thorough head-to-toe physical assessment and identify deviations from normal. 5. Study the laboratory and diagnostic results and interpret the clinical significance. 6. Discuss the anatomy and physiology of the affected organs. 7. Identify the predisposing factors of peptic ulcer and explain its pathophysiology. 8. Utilize the nursing care process as the base line guide to deliver appropriate health care to the patient. 9. Discuss medication prescribed knowing its action, side effects, and contraindication toward the patient.
10. Provide information about the prognosis of the patients condition.

11. Assist the clients recovery and plan the interventions needed upon the discharge of theclient.

PATIENTS PROFILE

Name: Patient EP Age: 45 years old Address: Brgy. Pila, San Pascual Batangas Date of Birth: November 9, 1965 Civil Status: Single Nationality: Filipino Religion: Born Again Date of Admission: July 24, 2011 Time of Admission: 10:02 PM Attending Physician: Dr. Bato Chief Complaint: Severe abdominal pain and vomiting Admitting Diagnosis: Peptic Ulcer Final Diagnosis: Peptic Ulcer (Gastric Ulcer)

CLINICAL APPRAISAL Patient EP, 45 years old was admitted on July 24, 2011 at Bauan General Hospital with a chief complaint of severe abdominal pain and vomiting accompanied by her mother. She appears restless with facial grimacing and a pain scale of 7 out of 10. A. Past Health History Patient EP had never acquired mumps, chicken pox during her childhood years. She hasnt completed her vaccines and doesnt even know the vaccines administered to her, she only got it from the health center during their days for free. She also doesnt have any known allergies to any drugs, foods or insect bites. She was diagnosed to have Peptic ulcer last 2006 at Bauan Doctors General Hospital and was confined at the same hospital last 2010. According to her mother, she hasnt any accidents or injuries experienced since childhood. She takes herbal medicine and other over-the-counter drugs whenever needed. She admits that whenever she has simple colds and fever, she used to take over the counter drugs like Paracetamol, Neozep and Mefenamic Acid two to three times a day.

B. Family History A family is composed of seven members. Her father died 10 years ago due to an accident. Mrs. DP, her mother was taking care of them. Patient EP is the third child. She has four siblings. They commonly experience cough, colds, fever and headache. She got married last 1996 but was separated after a few years. She is now single and lives with her mother and eldest brother. The entire members of the immediate family are in good state of health except for the client.

As per the patients family history, there were cases of Cancer and Diabetes Mellitus.

C. Personal History Patient EP, according to her mother, is very active in their religious group. She loves to sing praising songs with her co-sisters in their association and visits regularly on their sacred place. Her daily routine includes cleaning their house and reading bible. She doesnt have good sleeping pattern, having 4-5 hours of sleep. The patients diet is composed mainly of rice, vegetables, fishes and other meats and seldom eats salty foods. When she has a wish, she mostly take fasting because it is one of their beliefs. Normally, she eats 3 times a day. Smoking and drinking alcohol is a big no to her.

D. Social History Though they are quite many in the family, it is not a hindrance for them to have a harmonious relationship among each member. They are all Roman Catholic except for the client. Patient EP finished her primary and secondary education. Unfortunately, she had to stop in college due to financial constraints. Her OFW sibling sends them money and has an estimated monthly income of Php 10.000. Their house is primarily made of cement. Health center and chapel are accessible in their community.

E. Psychological History Patient EP shared that her condition as of now was the only stress that she has. She was a bit uncomfortable in the hospital and was anxious about her condition. She verbalizes that she is contented with her life right now and all she wants is peacefulness whenever she rest at her bed as this minimizes her difficulty. She has good verbal communication, answers questions relevantly although she frequently speaks and tells stories even when not asked. The physician and nurses says that she has psychotic tendencies and being separated from her

husband is one of the predisposing factors. She doesnt have good eye contact and always look at the ceiling or shuts her eyes when talking to us.

F. History of Present Illness

According to her mother, patient EP was cleaning their house when she experienced severe abdominal pain. Later in the afternoon, vomiting occurred. She was rushed to the Emergency Room of Bauan General Hospital around 9:00 in the evening last July 24, 2011 for she cannot tolerate the pain anymore. During her hospitalization there, a consistent increase in her blood pressure was observed. For further monitoring of her condition, she was then advised to be admitted around 10:02 PM.

PHYSICAL ASSESSMENT
Date performed: July 26, 2011 General Appearance: Upon seeing patient EP, she is in a sitting position. She seems irritable, showing signs of mental illness such as yelling at her co-patients and talking to herself with unknown reason. Hooked with an IVF of D5LR 1 liter at left metacarpal vein regulated at 30 gtts/minute. Body Part Method Findings Analysis

Skin

Inspection

Color: Light to deep brown

Normal

Formation of pimples

Normal

Edema: None Normal Lesions: None Normal Moisture: Present in skin folds

Palpation

Due to temperature and humidity

Temperature: Within normal range Hair Inspection Hair growth: Evenly distributed

Normal Normal

Thickness/Thinness: Thick

Normal

Texture: Silky Normal Presence of infestation: None

Normal

Amount of body hair: Variable Normal Nails Inspection Nail shape: Convex Normal

curvature

Normal Texture: Smooth Normal Epidermis: Intact Normal Nail color: highly vascular in pink Skull and Face Inspection Symmetry and size: Normocephalic Normal

Palpation

Presence of nodules: None

Normal

Facial features: Symmetry Eyes

Normal

Eyebrows

Inspection

Hair evenly distributed, symmetrical, with equal movement

Normal

Eyelids

Inspection

Skin intact, without discharge lids close symmetrically

Normal

Transparent and

Bulbar conjunctiva

Inspection

sclera

Normal

Shiny and pinkish Palpebral conjunctiva Inspection Normal

Pupils

Inspection

Black, equal size and round

Normal

Ears

Inspection

Color: Same as the facial skin

Normal

Symmetrical aligned with outer canthus of eye

Normal

Texture: Firm areas of tenderness Auricles Inspection Elasticity: Pinna recoils when folded Normal

Normal

Nose and Sinuses

External Nose

Inspection

Shape: Symmetry

Normal

Color: Uniform in color

Normal

Flaring: None

Normal

Palpation

Lesion: None

Normal

Nasal patency: air moves freely Nasal Cavities Inspection Mucosa pink, clear, no watery discharge

Normal

Normal

Nasal septum Mouth

Inspection

Intact in midline

Normal

Outer lips

Inspection

Color: Uniform pink

Normal

Texture: Soft; moist

Normal

Teeth and gums, inner lips and buccal mucosa

Inspection

Teeth: 24

Due to poor hygiene

Pink gums, no retraction of gums Tongue Inspection In central position, pink, moist with thin whitish coating

Normal

Normal

Tongue movement: moves freely

Normal

No areas of tenderness exhibited

Normal

Base of tongue, mouth, floor frenulum

Inspection

Smooth tongue base with prominent base

Normal

Hard Palate

Lighter pink, more irregular texture Inspection Normal Lighter pink

Soft Palate

Uvula

Inspection

Position: In the midline of soft palate

Normal

Inspection

Normal

Neck

Neck muscles

Inspection

Equal size, head centered

Normal

Thyroid gland

Inspection

Not visible

Normal

Trachea

Inspection

Equal on both sides Central placement in midline of neck

Normal Normal

Thorax

Inspection

Chest symmetric

Normal

antero posterior to transverse diameter

Spine vertically aligned

Normal

Posterior Thorax

Inspection

Quiet and rhythmic. Effortless respiration No lift/ heaves

Normal

Heart and central vessel

Inspection

Normal

Auscultation

S1 and S2 heard at all sites

Normal

S1 louder at apical area

Normal

S2 louder at base of heart

Normal

Abdomen

Inspection

Unblemished skin, uniform in color

Normal

Flat, no evidence of spleen and liver enlargement

Normal

Symmetric contour, no visible vascular pattern

Normal

Audible bowel sounds Auscultation Absence of arterial bruits and friction rubs Normal Normal

Percussion

Dullness or liver and spleen

Normal

Tympany over stomach Palpation

Normal

Tenderness: Present

Due to severe abdominal pain

Relaxed abdomen without tension Lower extremities Inspection Color: Uniform color

Normal Normal

Lesions/Masses: None

Normal

Equal in size on both sides of the body

Normal

No contractures, fasciculation or tremor

Normal

Edema: None Normal

Genitalia

Refused

Summary:

After a series of Physical Assessments we found out that the patient has a moisture present on her skin folds due to the temperature and humidity o the environment she is into. We have also observed that she only has 24 numbers of teeth that is due to poor hygiene. And some tenderness is present upon the palpation of the abdomen due to occurence of severe abdominal pains. LABORATORY EXAMINATION Date: July 25, 2011 HEMATOLOGY ( CBC )

Laboratory exam

Normal values

Result

Significance

WBC

5-10x 10 /L

46/L

Increased due to infection.

HgB

4.0-5.5x10g/dL

138.6g/dL

Normal

Hct

0.37-0.47%

0.42%

Normal

Neutrophil

0.45-0.65%

0.62%

Normal

Lymphocyte

0.20-0.35%

0.21%

Normal

Date: July 25, 2011 URINALYSIS

Laboratory Exam

Normal Values

Result

Significance

pH

4.5-8pH units

60 pH units

Normal

Specific Gravity

1.001-1.025

1.015

Normal

Pus cell

0-1/hpf

20-40/hpf

Normal

RBC

5-10/hpf

5/hpf

Normal

Summary: The patient has undergone some laboratory tests and we have discovered that there is an abnormal findings in her CBC which is the increase of the WBC with a result o 46/L above its normal range of -10x 10 /L due to an infection present.

Anatomy and Physiology The stomach is located in the upper part of the abdomen just beneath the diaphragm. The stomach is distensible and on a free mesentery, therefore, the size, shape, and position may vary with posture and content. An empty stomach is roughly the size of an open hand and when distended with food, can fill much of the upper abdomen and may descend into the lower abdomen or pelvis on standing. The duodenum extends from the pylorus to the ligament of Treitz in a sharp curve that almost completes a circle. It is so named because it is about equal in length to the breadth of 12 fingers, or about 25 cm. It is largely retroperitoneal and its position

is relatively fixed. The stomach and duodenum are closely related in function, and in the pathogenesis and manifestation of disease. The stomach may be divided into seven major sections. The cardia is a 12 cm segment distal to the esophagogastric junction. The fundus refers to the superior portion of the stomach that lies above an imaginary horizontal plane that passes through the esophagogastric junction. The antrum is the smaller distal one-fourth to one-third of the stomach. The narrow 12 cm channel that connects the stomach and duodenum is the pylorus. The lesser curve refers to the medial shorter border of the stomach, whereas the opposite surface is the greater curve. The angularis is along the lesser curve of the stomach where the body and antrum meet, and is accentuated during peristalsis

The duodenum extends from the pylorus to the ligament of Treitz in a circlelike curve and is divided into four portions. The superior portion is approximately 5 cm in length, beginning at the pylorus, and passes beneath the liver to the neck of the gallbladder. The first part of the superior portion (23 cm) is the duodenal bulb. The descending or second part of the duodenum takes a sharp curve and goes down along the right margin of the head of the pancreas. The common bile duct and the pancreatic duct enter the medial aspect of this portion of the duodenum at the major papilla either separately or together. The duodenum turns medially, becoming the horizontal portion, and passes across the spinal column, inclining upward for 58 cm. The ascending portion begins at the left of the spinal column, ascending left of the aorta for 23 cm, and ends at the ligament of Treitz, where the intestine angles forward and downward to become the jejunum.

Pathophysiology Non-Predisposing Factors Age: 45 years old Gender: Female Blood Type: o Increase concentration/activity of acid-pepsin Decrease resistance of mucosa Cannot secrete mucosa Decrease acid and Due to infection; aggressive Increase function a mucosal Imbalance of increase gastrin and from quality factor intrinsic factor Infection(+) defensive ofmay occur Erosiondecreasebacteria Damaged pylori Resistance to somatostatin cells; ofdamage of mucous low H. mucosal and gastroduodenal production mucosa

Predisposing Factors Emotional Stress Lifestyle

(+) mucosal ulcerations

Prognosis: Our client has a fair prognosis. Patient EP, 45 years old was admitted last July 24 2011 at Bauan General Hospital around 10:02 PM with a complain of stomach pain. She has an admitted diagnosis of Peptic Ulcer. She was advised by her doctor to decrease her anxiety level and stress. The patient had undertaken different laboratory examinations, Ultrasounds and CBC. As compared with her condition upon admission, her current state has improved. She has taken medication like Omeprazole, Ampicillin and HNBB. The patient verbalized Ok na ako iniintay ko na lang ang aking ina, her appearance becomes better. The doctor ordered a May Go Home for her but due to her financial problem the plan to go home was averted.

Discharge Planning Medication: Advised patient and significant others regarding his home medications: Omeprazole 20mg Ampule IVT OD ANST Ampicillin 500mg IVT QID HNBB Ampule IVT QID

Environment:

Encourage client to provide a peaceful and well-ventilated environment conducive for recovery and healthy living Advice client and SO to keep the surroundings clean and free from stress Encourage client and SO to have a regular rest periods during the day

Treatment: Review medication that will be take home and stress importance of following prescribed regimen.

Stress the importance of having follow-up examinations and treatment to the patient and presence of changing physical status

Health Teaching: Discuss with patient his understanding of his condition and how it affects his body Advise patient to limit physical activity and to have adequate rest and sleep Stress the importance and advantages of compliance with medication regimen and dietary restrictions. Encourage patient to have a good personal hygiene Advise the SO to give the client the whole support needed Advise patient to follow the discharge instructions given by the doctor. Remind patient and family of the importance of participating in the health promotion activities and recommend health screening

Observation: Encourage patient to have immediate consultation if the following signs and symptoms occurs which may lead to potential complications: Hemorrhage Faintness Dizziness Nausea Tachycardia Hypotension Tachypnea

Perforation Sudden, severe upper abdominal pain (persisting an increasing intensity); pain may be referred to the shoulders, especially right shoulder Remind patient and family of the importance of participating inhealth promotion activities and recommend health screening. Vomiting and collapse (fainting) Extremely tender and rigid (board like) abdomen Hypotension and tachycardia, indivating shock Penetration Back and epigastric pain not relieved by medications that were effective in the past Pyloric obstruction Nausea and vomiting Constipation Epigastric fullness Anorexia And later weight loss

Diet: Encourage patient to eat and informed him that nutritionis very important at any medication Stress to patient to eat and informed him that nutrition is very important at any medication Stress to patient the importance of adequate intake of caloric and nutrient food rich in calcium and vitamin D to increase bone density Advise patient to exclude alcohol, carbonated beverages, coffee, spicy foods and meat extracts from his diet Encourage patient to eat three regular meals per day and in a relaxed setting and to avoid overeating Advise SO to provide attractive meals and an aesthetically pleasing setting at meal time. Spiritual: Encourage the client to pray every day Encourage the client to have faith and trust God that everything will be alright

Encourage client to participate in religious activities and to have contact with spiritual advisers

ACKNOWLEDGEMENT

We should like to express our sincerest thanks to the committed and talented team involve in this case presentation to all the students of BSN III-3/D, always remember that having each other bring out the best in our section To out parents, we would like to thank them for supporting us financially, for your understanding and undying encouragement throughout the case presentation. We sincerely thank our clinical instructor for continuing dedication and leadership that serves as our guiding light during out duty, for your trust, patience and unselfish sharing of all your knowledge. We greatly appreciate your commitment and to an excellent product and vision that has influence us to be a competitive nurse in the future. Your idea stimulates through that we continue to value. Thank you for your support. Also the nursing staffs, thank you for letting us experience your daily routines, for your warmth company and for sharing knowledge about hospital procedures. We really appreciate it! It was truly an enriching experience.

Finally, to our Almighty Father we reach you out our deepest gratitude for giving us strength, knowledge and skills to accomplish our daily task.

References:
www.bmj.com www.kidshealth.org Brunner & Suddarth, Medical-Surgical Nursing 11th edition