"PEPTIC ULCER DISEASE"







INTRODUCTION:

Peptic Ulcer Disease also known as “ulcus pepticum”, is an ulcer (defined as mucosal erosions equal to or greater than 0.5 cm) of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. Peptic Ulcer Disease is a common disorder that affects millions of individuals in the United States each year. Peptic Ulcer Disease has a major impact on our health care system by accounting for roughly 10% of medical costs for digestive diseases. In the last two decades, major advances have been made in the understanding of the pathophysiology of PUD, particularly regarding the role of Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs). This has led to important changes in diagnostic and treatment strategies, with the potential for improving the clinical outcome and for decreasing health care costs.

An ulcer is an open sore in the lining of the stomach or intestine, much like mouth or skin ulcers. Peptic ulcers are eventually caused by acid and pepsin, a digestive stomach enzyme. These ulcers can occur in the stomach, where they are called gastric ulcers. Or they can occur in the first portion of the intestine. These are called duodenal ulcers. "Peptic Ulcer" is the term used to describe either or both of these two types of ulcers.

In the end, it is acid that causes the injury to the stomach or bowel lining. However, a revolutionary and startling recent discovery is that most peptic ulcers result from a stomach infection caused by the bacteria, Helicobacter pylori.


Predisposing Factors
  • gram- negative bacteria( H. Pylori) acquired through ingestion of food and water
  • person to person transmission of the bacteria(close contact and exposure to emesis)
  • excessive secretion of HCL in the stomach
  • chronic use of NSAIDs, alcohol ingestion and excessive smoking



Surgical Management
  • vagotomy
  • pyloroplasty(transecting nerves that stimulate acid secretion and opening of the pylorus)
  • antrectomy(removal of pyloric antrum-portion of the stomach with anastomosis),surgical connection to either the doudenum (gastroduodenostomy Billroth 1), or jejunum (gastrojejunostomy or Billroth 11)




PATIENT HISTORY:

Biographic Data;

Name: Ms.Venus Danielies,28 y/o female,
Chief Complaint; “recurrent epigastric pain”

History of Present Illness; Few hrs PTA, she had nausea & vomiting. Persistence prompted consult.
VS taken: BP-120/70; Temp-36.7C; PR-84bpm; RR-16/min.
Bowel Movement: thrice/shift; UO:40cc/hour

Medical Diagnosis: Peptic Ulcer Disease
Past Medical History: Significant Childhood Illnesses: >none

Adult Illnesses/ Hospitalization: >none
Current Health Status:
Medications:
  • Incorporate Gentamycin Sulfate 40mg to present IVF STAT
Stock dose: 40mg/ampule
  • Domperidone 20mg tab p.o.TID
Stock: 10mg tab
  • Esomeprazole 30rng/ml per IV push h.s.
Stock: 40mg/3ml

Diet/ Sleep/ Exercise: >none
Psychosocial History: none
Family History; none




ANATOMY AND PHYSIOLOGY OF GASTROINTESTINAL SYSTEM

digestive_system_functions.jpg



PATHOPHYSIOLOGY


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GORDON'S FUNCTIONAL HEALTH PATTERN


ELIMINATION PATTERN

>The client defecates not more than 3 times per shift, and micturates 40cc per hour.

*it is the only one that is significant


MEDICATION:
Medication
Frequency
1st Day
2nd Day
Gentamycin Sulfate
40 mg to present IVF
STAT











Domperidone
20 mg tab p.o.
TID











Esomeprazole
30mg/ml per IV push
h.s.













DRUG COMPUTATION:
DRUG 1
DRUG 2
DRUG 3
desired x dilution
stock dose

40 mg x 1ml
4o mg = 1ml or 1 ampule
desired x dilution
stock dose

20mg
10mg = 2 tab.
desired
stock

30 mg x 3ml
40 mg
= 2.25 ml



IV FLOW SHEET
DATE
SHIFT
BOTTLE #
SOLUTION
Gtts/min
AMT. INFUSED
AMT. ENDORSED

7:00-3:00
1
D5NM
62-63 gtts/min.
94 cc
406cc
3:00-11:00





11:00-7:00






7:00-3:00





3:00-11:00





11:00-7:00








IV COMPUTATION

- gtts/min
vol. of IVF x 60 gtts/cc
no. of hrs x 60 min

500cc x 15 gtts/cc
8 hrs x 60 min

= 15.625 gtts/min

- amount infused
500 cc
8 hrs
= 62. 5 cc / hr

62.5 cc/ hr x 1 1/2 hr
= 94 cc

- amount endorsed
500cc - 94 cc
= 406 cc



INTAKE AND OUTPUT MONITORING
INPUT SUMMARY




Date
Time
IVF
ORAL
BLOOD
IV MEDS
MISC
TOTAL

7:00-3:00
94 cc


3.25 cc

97.25 cc

3:00-11:00







11:00-7:00







7:00-3:00







3:00-11:00







11:00-7:00







OUTPUT SUMMARY
DATE
TIME
NGT
BLOOD
URINE
VOMITUS/STOOL
MISC
TOTAL

7:00-3:00


60 cc
3x per shift

60cc

3:00-11:00







11:00-7:00







7:00-3:00







3:00-11:00







11:00-7:00









PAG-AARAL NG GAMOT
Generikong Pangalan:

Domperidone
20 miligramo tabletas p.o. TID

Brand pangalan:
Motilium

Indikasyon:

Para sa pamamahala ng pagduduwal at pagsusuka.
Klasipikasyon:


Antidopaminergic na gamot
Aksyon:


Ang Domperidone ay isang dopamine receptor blocking agent. Ang aksyon nito sa dopamine-receptors ay ang chemo-pampasuka zone trigger gumagawa ng isang anti-pampasuka epekto..
Kontradiksyon:


Ang gamot na ito ay kontraindikado sa mga pasyente na lubhang sensitibo sa domperidone.

Sa mga pasyente na may isang prolacting-releasing pitiyuwitari tumor (prolactinoma)

· Dapat hindi gagamitin tuwing pagpapasigla na ukol sa sikmura at ito ay dapat na iwasan dahil maaaring maging mapanganib. Halimbawa sa gastrointestinal pagsuka ng dugo.
Negatibong Reaksyon:


sensitibong reaksiyon,pangangati,
pagtaas ng produksyon ng gatas,pagsakit ng ulo, pagkahilo, pagkatuyo ng bibig,nerbyos,o pagiging iritable, nahihirapan matulog, tiyan at pagkamanhid ng binti.
Konsiderasyon
ng nars:

Ang mga babae na umiinom ng domperidone ay tumataas ang suplay ng gatas.

Generikong pangalan:

Gentamycin Sulfate
40 mg to present IVF STAT

Brand pangalan:
Cidomycin

Indication:
Serious infection of gastrointestinal tract (GIT).
Klasipikasyon:


Anti-infective aminoglycoside antibiotic
Aksiyon:


Inhibits protina synthesis sa pamamagitan ng umiiral na direkta sa 30s ribosomal subunic; bactericidal.
Kontradiksyon:


Ang gamot na ito
ay kontraindikado sa pasyente na lubhang sensitibo sa gamot at sa ibang aminoglycosides.
Negatibong reaksiyon:

CNS:
Lagnat,pagsakit ng ulo, pagkahilo at panananmlay

CV:
Pagbaba ng presyon ng dugo


ENT:
paglabo ng mata at paghugong sa tenga.

GI:
pagsuka at pagduduwal.

GU:
Nephrotoxicity, posibleng pagtaas sa ihi at tae ng cast.

Hematologic: anemia, leucopenia, thrombocytopenia.

Musculoskeletal: muscle twitching.

Skin:
Tagulabay, pruritus.
Konsiderasyon ng Nars:


Kumuha ng ispesimen para sa kultura at sensitivity test bago ang pagbibigay sa unang dosis.


Suriin ang pandinig ng mga pasyente bago at sa panahon ng terapyutika.

timbangin ang pasyente.
at imonitor ang tungkulin ng bato.

Generikong Pangalan:

Esomeprazole Magnesium
30 mg/mL per IV push h.s.

Brand pangalan:
Nexium


Indikasyon:

Upang gamutin ang gastroesophageal kati sakit (GERD)

Upang matanggal ang Helicobacter pylori.
Klasipikasyon:


Proton pump inhibitor

Gastrointestinal tract na gamot.
Aksiyon:


Proton pump inhibitor binabawasan nito ang asido sa sikmura, pagtatago at bumababa ukol sa kaasiman ng sikmura.
Kontradiksyon:


Mga pasyenteng tumatanggap ng tuloy-tuloy na NSAID therapy ay mas may mataas na panganib para sa gastrointestinal ulser.

Gamiting maingat sa mga pasyente na may hepatic kakapusan at sa mga buntis o nagpapasusong kababaihan.

.
Negatibong Reaksiyon:

CNS:
Pagsakit ng ulo


GI:
Tuyo ang bibig, pagtatae, sakit sa tiyan, pagduduwal, utot, pagsusuka, at paninigas ng dumi.
Konsiderasyon ng Nars:

Magbigay ng gamot na hindi bababa sa 1 oras bago kumain.

Antacids maaaring magamit habang ang pagkuha ng gamot.

imonitor ang pasyente para sa singaw sa balat, sundalo sintomas at atay function test.

mahabang terapyutika sa omeprazole ay maaaring maging sanhi ng atrophic kabag.



NURSING CARE PLAN
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective:
“ Sumasakit ang sikmura ko pagkatapos ko kumaen” sabi ng pasyente.


Objective:
-Pain scale of 6/10

BP: 120/70
Temp: 36.7
PR: 84
RR: 16
Acute Pain r/t Chemical burn of gastric mucosa.
Matapos ang 8 oras ng nursing interbensyon ang pasyente ay verbalize lunas sa sakit.
- Tandaan ang mga ulat ng mga sakit, kabilang ang lokasyon, tagal, intensity. (0-10 scale)


-Repasuhin ang mga kadahilanan na magpagalit o alleviate sakit.


- Kilalanin at limitasyon ng mga pagkain na lumikha ng paghihirap tulad ng maanghang at carbonated inumin.

- Hikayatin ang mga maliliit na madalas kumain.


- Hikayatin ang pasyente na magpalagay sa posisyon na maginhawa.
- Sakit ay hindi palaging kasalukuyan ay dapat na ihambing sa nakaraang pasyente sintomas ng sakit. Paghahambing na ito ay maaaring makatulong sa diyagnosis ng pinagmulan ng dumudugo at pagunlad ng komplikasyon.

- Nakakatulong sa pagpapatatag ng mga pangangailangan diyagnosis at pag gamot.

- An pagkain ay may isang acid neutralizing epekto at dilutes ang mga nilalaman sa sikmura.


- Maliliit na pagkain maiwasan ang hilab at ang release ng gastrin.

- Binabawasan ng tiyan ang hilab at nagtataguyod ng kahulugan ng control.
Layunin natutugunan, ang pasyente ay may verbalized lunas sa sakit.



DISCHARGE PLAN

  • Medication
- Ranitidine (Zantac)

- Omeprazole (Prilosec, Zegerid)

- Aluminum and magnesium hydroxide (Mylanta, Maalox)

- Amoxicillin (Amoxil, Trimox)

- Clarithromycin (Biaxin)

- Sucralfate (Carafate)

  • Exercise
- Some evidence suggests that exercise may help reduce the risk for ulcers in some people.

  • Treatments
- If H. pylori bacteria is present, the treatment goal may be to eradicate the bacterium. No single antibiotic can do the job, so multiple antibiotics are necessary — usually two antibiotics combined with an acid reducer such as a proton pump inhibitor and sometimes a bismuth compound.

- If the peptic ulcer is due to use of nonsteroidal anti-inflammatory drugs (NSAIDs), they should be discontinued because they slow or prevent healing. NSAIDs are available both by prescription and over-the-counter. Nonprescription NSAIDs include aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve). Doctors may recommend NSAIDs with a lower risk for causing ulcers, such as COX-2 inhibitors.

- Patients who must continue using NSAIDs may take a prostaglandin analog to protect the stomach from damage caused by frequent use of aspirin or NSAIDs, or a proton pump inhibitor (which also reduces the amount of acid produced by the stomach).

- Quitting smoking, limiting consumption of caffeine and alcohol and reducing stress can speed healing and prevent ulcers from recurring. -

- Ulcers that do not respond to treatment may have complications or be cancerous. If an ulcer eats through the wall of the stomach or intestine into the abdominal cavity or if it continues to bleed, surgery to cut the nerve to the stomach or remove part of the stomach may be required.

  • Health Teachings
- Don't start smoking.If you smoke, quit. Smokers are much more likely to develop ulcers than nonsmokers. For ways to quit smoking, see the topic quitting smoking.

- Avoid taking certain medicines.Avoid taking aspirin,ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs)for longer than a few days at a time. If you are taking aspirin regularly for heartproblems, ask your doctor about taking another medicine to help protect yourstomach andintestines from ulcers.

- Drink alcoholicbeverages only in moderation. Limit alcohol to 2 drinks a day for men and 1 drink a day for women. Never drink alcohol on an empty.

  • Out Patient
- Any odd signs must be immediately reported to the physician.

  • Diet
- Eat 5 to 6 small meals a day instead of 3 larger meals. It is important that you avoid overeating. Frequent, smaller meals will be more comfortable and easier on the stomach than two or three large meals a day.

- Eat a diet rich in fiber, especially from fruits and vegetables.

- Rest and relax a few minutes before and after each meal, as well as remaining relaxed during meals.

- Eat slowly and chew you food well

- Avoid eating within 3 hours before bedtime
- Eat foods that are low fat
- Avoid foods that are fried
- Avoid foods that are spicy
- Cut down on the following foods:
· Coffee
· Decaffeinated coffee
· Tea
· Cola drinks
· Carbonated beverages
· Citrus fruits
· Tomato-based products
· Chocolate
- Avoid drinking alcohol