PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)

Intramuros, Manila

College of Nursing

A Case Analysis on

Peptic Ulcer Disease with Partial Gastric Obstruction

In Partial Fulfillment for the Requirement in Related Learning Experience

Medicine Ward

Gat Andres Bonifacio Memorial Medical Center

Submitted by:

BSN IV-3 (Group 15)

Submitted to:

MR. TIRSO O. GONZALES, RN

Date Submitted:

February 21, 2012

I. INTRODUCTION

This case features Patient AB, a 72 years old female, Roman Catholic, who lives in 169 B

Yonger St. Balut, Tondo. She currently resides with her five children and their respective

families. She is brought by her son in Gat Andres Bonifacio Memorial Medical Center

Emergency Room (GABMMC – ER) on January 23, 2012. The patient complains of

dehydration, lightheadedness, weakness, and heart palpitations caused by vomiting and nausea

for one week prior to admission. She experienced diaphoresis, hematemesis, and tachycardia

upon admission. Her vital signs were taken as follows: Blood pressure = 100/70 mmHg, Pulse =

109 bpm, Temp = 37.3 °C, Respiratory rate = 19 cpm. An IVF of 500 ml D₅W incorporated with

2 vials of dopamine was immediately administered to the patient. Her physician ordered the

following laboratory and diagnostic tests: complete blood count, fasting blood sugar, chest x-ray,

BUN and creatinine, blood uric acid, Troponin T, ECG, urinalysis, HDL, LDL, and blood

chemistry. Her blood sugar result was 75 mg/dl. She was admitted in the Medical Ward at the

same day with an admitting diagnosis of t/c Acute Coronary Syndrome but her clinical diagnosis

is Peptic Ulcer Diagnosis with Partial Gastric Obstruction.

II. BODY

One year prior to admission, Patient AB had a history of forgetting to eat her meal and drink

water occasionally which leads to constant abdominal pain and an evident continuous weight

loss of the patient. One week prior to admission, the patient experiences abdominal pain in the

epigastric area, vomiting, nausea. She ignored the symptoms and did the usual activities of

daily living. Two hours prior to admission, the patient continues to complain of severe abdominal

pain in the epigastric area with the pain scale of 7 out of 10, 10 as the highest, hematemesis,

diaphoresis, nausea, weakness, heart palpitations, and lightheadedness. Her blood sugar was

75 mg/dl upon admission on January 23, 2012. She was admitted with a t/c Acute Coronary

Syndrome. On February 7, 2012, a physical examination was done by the resident doctor on

duty which revealed the clinical diagnosis of Peptic Ulcer Disease with Partial Gastric

Obstruction.

According to Patient AB, her immunization was not complete all through childhood years.

She has no known food or non-food protein allergies. The patient had been previously admitted

in Gat Andres Bonifacio Medical Memorial Center (GABMMC) for 2 weeks on June 2007 with a

diagnosis also of Community-Acquired Pneumonia. The client cannot recall the drugs given to

her except for Salbutamol. She had mumps, chickenpox, and measles and was given proper

medical attention. The client’s father died because of complications from a heart problem. The

client’s mother passed away because of old age. Patient AB stated that she doesn’t smoke and

drink alcohol. The patient mentioned that she is living together with her five children with a

mixed type of house. According to the patient’s son, she often forgets to eat her meals from time

to time which lead to her peptic ulcer disease.

Peptic ulcer disease can be differentiated as either gastric or duodenal ulcers. Epigastric

pain is the most common symptom of both gastric and duodenal ulcers. It is characterized by a

gnawing or burning sensation and occurs after meals—classically, before meals with gastric

ulcer and 2-3 hours afterwards with duodenal ulcer. Peptic ulcers are defects in the gastric or

duodenal mucosa that extend through the muscularis mucosa. The epithelial cells of the

stomach and duodenum secrete mucus in response to irritation of the epithelial lining and as a

result of cholinergic stimulation. The superficial portion of the gastric and duodenal mucosa

exists in the form of a gel layer, which is impermeable to acid and pepsin. Other gastric and

duodenal cells secrete bicarbonate, which aids in buffering acid that lies near the mucosa.

Prostaglandins of the E type (PGE) have an important protective role, because PGE increases

the production of both bicarbonate and the mucous layer. In the event of acid and pepsin

entering the epithelial cells, additional mechanisms are in place to reduce injury. Within the

epithelial cells, ion pumps in the basolateral cell membrane help to regulate intracellular pH by

removing excess hydrogen ions. Through the process of restitution, healthy cells migrate to the

site of injury. Mucosal blood flow removes acid that diffuses through the injured mucosa and

provides bicarbonate to the surface epithelial cells. Under normal conditions, a physiologic

balance exists between gastric acid secretion and gastroduodenal mucosal defense. Mucosal

injury and, thus, peptic ulcer occur when the balance between the aggressive factors and the

defensive mechanisms is disrupted. Aggressive factors, such as NSAIDs, H pylori infection,

alcohol, bile salts, acid, and pepsin, can alter the mucosal defense by allowing back diffusion of

hydrogen ions and subsequent epithelial cell injury. The defensive mechanisms include tight

intercellular junctions, mucus, mucosal blood flow, cellular restitution, and epithelial renewal.

H. pylori are known microorganisms that contribute to peptic ulcer disease. It evades attack

by the host immune system and causes chronic, indolent inflammation by several

mechanisms. H. pylori can damage the mucosal defense system by reducing the thickness of

the mucus gel layer, diminishing mucosal blood flow, and interacting with the gastric epithelium

throughout all stages of the infection. H. pylori infection can also increase gastric acid secretion;

by producing various antigens, virulence factors, and soluble mediators, H. pylori induces

inflammation, which increases parietal-cell mass and, therefore, the capacity to secrete acid. It

has been found to independently and significantly increase the risk of gastric and duodenal

mucosal damage and ulceration. It acts synergistically through pathways of inflammation in the

development of ulcers and in ulcer bleeding.

Partial gastric obstruction is a medical condition where there is a part of the pylorus which is

obstructed, where the outlet of the stomach is located. It is usually caused by peptic ulcer

disease. Individuals with gastric obstruction will often have recurrent vomiting of food that has

accumulated in the stomach, but which cannot pass into the small intestine due to the

obstruction. The stomach often dilates to accommodate food intake and secretions. Projectile

vomiting may sometimes occur, along with constipation, loss of weight, and epigastric pain.

It is believed to be a result of oedema or the presence of an excessive amount of fluid in or

around serous cavities of the body and scarring of peptic ulcer, followed by healing and fibrosis,

which leads to obstruction of the gastroduodenal junction. It is usually an ulcer in the first part of

the duodenum.

On physical examination last February 21, 2012, the patient experienced abdominal pain

with a pain scale of 6 out of 10, 10 as the highest, with episodes of vomiting. A light brownish

colored vomitus was observed. Upon palpation, a scaphoid abdomen with negative succession

splash is noted. A succussion splash describes the sound obtained by shaking an individual

who has free fluid and air or gas in a hollow organ or body cavity. It is usually elicited to confirm

intestinal or pyloric obstruction due to pyloric stenosis or gastric carcinoma. Patient AB has no

urine output on February 21, 2012, 2pm – 10pm shift. The urine seen in the urine bag during the

PM shift was yellow orange colored. Her foley catheter was clamped for bladder training and the

patient also had no oral intake of any fluids with exception with her IV infusion of D5NSS one

liter on her right metacarpal vein. NGT drainage was cloudy yellow, no coffee colored and blood

seen. Vital signs were taken and recorded at the same date: Blood pressure = 110/70 mmHg,

Pulse = 102 bpm, Temp = 36.7 °C, Respiratory rate = 17 cpm.

Patient AB went under ultrasound of the whole abdomen and blood chemistry on February

7, 2012. It is usually used to visualize muscles, tendons, and many internal organs, to capture

their size, structure and any pathological lesions with real time tomographic images. The

diagnostic result was possible cholelithiasis with normal size of liver, an under filled bladder, and

a non-dilated biliary tree. An under filled bladder indicates that the patient is in foley catheter at

that time which may contribute to under filling of urine to the bladder. The blood chemistry is a

routine bloodwork that is often a part of a diagnostic workup, with the blood being analyzed to

check for specific elements which could contribute clues to the diagnosis. There is an increased

in blood sodium level (156.1 mmol/L, 136-145 mmol/L) because of dehydration where If the

amount of water ingested consistently falls below the amount of water lost, the serum sodium

level will begin to rise, leading to hypernatremia. Increased in segmenters (0.76, 0.60-0.70) is

also noted due to the inflammatory process involving peptic ulcer disease. Other laboratory

tests done were complete blood count which is for is used as a broad screening test to check for

such disorders as anemia, infection, and many other diseases. Fasting blood sugar was will

measure blood glucose after the patient has not eaten for at least 8 hours while the chest x-ray

is a painless, noninvasive test that helps see the structures inside your chest, such as your

heart, lungs, and blood vessels. The BUN test will be used along with the creatinine test to

monitor kidney failure whereas the blood uric acid reflects adequacy of the patient’s renal tissue

perfusion thereby glomerular filtration of metabolites. Cholesterol testing of HDL and LDL will be

done to track how well the prescribed diet and drugs are succeeding in lowering cholesterol to

desired levels. Troponin T test is primarily ordered to help diagnose a heart attack and to

distinguish chest pain that may be due to other causes.

Patient AB’s medications are Omeprazole (40mg TIV/Oral BID), Sucralfate (1g Oral q6),

Motilium (10mg/tab TID), Multivitamins (1tab BID), Mupirocin Ointment (apply 2x a day),

Metoclopramide (STAT, 1amp). Omeprazole is a proton pump inhibitor that is useful in treating

both gastroduodenal ulcer disease and to prevent or treat gastric erosions caused by

ulcerogenic drugs. Sucralfate is a cytoprotective agent, an oral gastrointestinal medication

primarily indicated for the treatment of active ulcers. Motilium is an antidopaminergic drug for

generally to suppress nausea and vomiting, as a prokinetic agent. Multivitamins is a preparation

intended to be a dietary supplement with vitamins, and dietary minerals for nutritional

supplement. Mupirocin ointment is used as a topical treatment for bacterial skin infections.

Metoclopramide is an antiemetic and gastroprokinetic agent. It is commonly used to treat

nausea and vomiting.

IV fluids are IV fluids are used to correct electrolyte imbalances, to deliver medication and to

replace fluid loss. An IV catheter is inserted on her right metacarpal vein letting an IV solution of

D5NSS, 1L to infuse at 12 hours as ordered. D5NSS is a hypertonic solution draws fluids from

the ICF causing cells to shrink and ECF to expand. This is given to patients in treating

dehydration. Electrocardiogram (ECG) was used to diagnose if the patient has other conditions

including heart problems. However, the interpretations of the physician were not included in the

patient’s chart. The patient was subjected to soft diet and oral feeding is encouraged. A soft diet

contains foods that are soft and easy for the patient to chew or swallow. These foods may be

chopped, ground, mashed, pureed, and moist. This is indicated for Patient AB who has problem

chewing and swallowing as well as to avoid aspiration and gastric reflux.

III. CONCLUSION

A peptic ulcer is a sore in the inner lining of the stomach or in the duodenum. Ulcers develop

when the intestine or stomach's protective layer is broken down. When this happens, digestive

juices can damage the intestine or stomach tissue. Peptic ulcers are no longer a condition that

most people have to live with their entire lives. Treatment cures most ulcers and symptoms go

away quickly. Urea breath test and a stool antigen test can determine whether an H.

pylori infection is present or not. The availability of medicines that reduce the amount of acid

produced by the stomach used to treat all forms of peptic ulcer disease. These include H2

blockers, proton pump inhibitors (PPIs), and antacids. Because the medicines now used to treat

peptic ulcer disease work so well, surgery is rarely used to treat peptic ulcer disease. Surgery

generally is reserved for people who have a life-threatening complication of an ulcer, commonly

obstruction. In some cases, even these complications can be treated without surgery. If

indicated in cases of failed medical therapy and recurrent obstruction occurs, the surgery

usually performed is an Antrectomy which is the partial removal of the stomach, Vagotomy

which is severing of the vagus nerve and Billroth I which involves anastomosing the duodenum

to the distal stomach or gastrojejunostomy. This helps reduce acid in the stomach which is

responsible for the peptic ulcer.

When this disease is left untreated, many ulcers eventually heal but ulcers often recur if the

cause of the ulcer is not eliminated or treated. If treatment for the ulcer does not work, the

resident doctor will most likely endorse the patient to a gastroenterologist. The

gastroenterologist will do an endoscopy to look at the ulcer and to take a biopsy for possible

serious complication may occur.

PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)

Intramuros, Manila

College of Nursing

GAT ANDRES BONIFACIO MEMORIAL MEDICAL CENTER

Medical Ward

Mission

To provide total quality health care guaranteed satisfaction through quality patient care with the

use of advanced technology and modern facilities, manned by qualified, competent and

dedicated human resources.

Vision

It aims to attain the best patient care and to have the most competent staff to deliver the best

quality health care needed thereby ensuring continued commitment for a healthy tomorrow.

Submitted by:

LIM, MARY NIÑA CASELDA S.

BSN IV-3 (Group 15)

GENERIC NAME

DOSAGE INDICATION MECHANISM OF ACTION

SIDE EFFECTS/ ADVERSE EFFECTS

NURSING CONSIDERATIONS

Metoclopramide 40mg TIV/Oral BID

It is commonly used to treat nausea and vomiting.

Antiemetic and gastroprokinetic agent. It enhances the motility of the upper GI tract and increases gastric emptying without affecting gastric, biliary or pancreatic secretions. It increases lower esophageal sphincter tone.

Hypernatremia - Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or tremors.- Monitor for possible hypernatremia and hypokalemia.

Motilium 10mg/tab TID

It generally to suppress nausea and vomiting.

Antidopaminergic drug. It is a dopamine-receptor blocking agent. Its action on the dopamine-receptors in the chemo-emetic trigger zone produces an anti-emetic effect.

No side effects and/or adverse effects noted.

- If there is an overdose, specific anticholinergic agents, antiparkinsonian medications, or antihistamines with anticholinergic properties may be useful in controlling the extrapyramidal reactions associated with domperidone toxicity.- Gastric lavage as well as the administration of activated charcoal may be useful in facilitating the elimination of motilium.

Multivitamins 1tab BID It is a preparation intended to be a dietary supplement with vitamins,

Supplemental drug. Dietary supplement for the treatment and prevention of deficiencies caused by vomiting. It acts as

No side effects and/or adverse effects noted.

- Instruct patient to take the vitamin with meals or water.

and dietary minerals for nutritional supplement.

coenzymes or catalysts in numerous metabolic processes.

Mupirocin Ointment

Apply twice a day on the anal area.

It is used as a topical treatment for bacterial infections.

Antibiotic. It inhibits protein synthesis of the bacteria by binding to isoleucyl transfer RNA-synthetase. It is active against gram-positive and some gram-negative bacteria.

No side effects and/or adverse effects noted.

- Instruct patient on the correct application of mupirocin. Advise patient to apply medication exactly as directed for the full course of therapy. If a dose is missed, apply as soon as possible unless almost time for next dose. - Avoid contact with eyes.- Assess lesions before and daily during therapy.

Omeprazole 40mg TIV/Oral BID

It is a proton pump inhibitor that is useful in treating both gastroduodenal ulcer disease and to prevent or treat gastric erosions caused by ulcerogenic drugs.

Proton pump inhibitor. It suppresses gastric acid secretion by specific inhibition of the enzyme system hydrogen/potassium adenosine triphosphatase (H+/K+ ATPase) present on the secretory surface of the gastric parietal cell.

No side effects and/or adverse effects noted.

- Monitor for S&S of adverse CNS effects (vertigo, agitation, depression) especially in severely ill patients.- Report any changes in urinary elimination such as pain or discomfort associated with urination to physician.- Report severe diarrhea. Drug may need to be discontinued.

Sucralfate 1g Oral q6 It is a cytoprotective agent, an oral gastrointestinal medication primarily

Antiulcerant and antacid.It protects GI lining against peptic acid, pepsin and bile salts by binding with positively-

No side effects and/or adverse effects noted.

- Administer drug on an empty stomach, 1 hour before meals, or 2 hours after meals and at bedtime.- Monitor for side-effects like constipation and GI upset.

indicated for the treatment of active ulcers.

charged proteins in exudates forming a viscous paste-like adhesive substance thus forming a protective coating.

- Encourage intake of high-fiber foods and increased fluid intake.- Administer antacids between doses of sucralfate, not within 30 minutes of sucralfate dose.

Submitted by:

LIM, MARY NIÑA CASELDA S.

BSN IV-3 (Group 15)

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

AM PM NIGHT AM PM NIGHT AM PM NIGHT AM PM NIGHT AM PM NIGHT

WEEK 1

RN1RN2

RN3RN4

RN5RN6

RN7RN8

RN9RN10

RN1RN3

RN2RN4

RN3RN5

RN6RN7

RN8RN9

RN10RN1

RN2RN3

RN4RN5

RN6RN8

RN7RN9

WEEK 2

RN1RN5

RN2RN6

RN3RN7

RN4RN8

RN5RN9

RN6RN10

RN1RN6

RN2RN7

RN3RN8

RN4RN9

RN5RN10

RN6RN2

RN7RN1

RN8RN5

RN9RN3

WEEK 3

RN1RN2

RN3RN4

RN5RN6

RN7RN8

RN9RN10

RN1RN3

RN2RN4

RN3RN5

RN6RN7

RN8RN9

RN10RN1

RN2RN3

RN4RN5

RN6RN8

RN7RN9

WEEK 4

RN1RN5

RN2RN6

RN3RN7

RN4RN8

RN5RN9

RN6RN10

RN1RN6

RN2RN7

RN3RN8

RN4RN9

RN5RN10

RN6RN2

RN7RN1

RN8RN5

RN9RN3

4-WEEK STAFF SCHEDULING

Name of Nursing Staff (Full-Time)

1. Herrera, Raetchel Kathrina B. – RN12. Ibasco, John Emmanuel M. – RN23. Lardizabal, Abishai R. – RN34. Lim, Mary Niña Caselda S. – RN45. Macalangcom, Nor-Aileen R. – RN56. Decolin, Bheneth R. – RN 67. Dimaampao, Johaina G. – RN78. Domingo, Jayson John M. – RN89. Gamboa, Stephanie Love C. – RN910. Jammang, Rodel B. – RN10

SHIFT HOURS

AM = 6:00am to 2:00pm

PM = 2:00pm to 10:00pm

NIGHT = 10:00pm to 6:00am

Name of Nursing Staff (Full-Time)

11. Herrera, Raetchel Kathrina B. – RN112. Ibasco, John Emmanuel M. – RN213. Lardizabal, Abishai R. – RN314. Lim, Mary Niña Caselda S. – RN415. Macalangcom, Nor-Aileen R. – RN516. Decolin, Bheneth R. – RN 617. Dimaampao, Johaina G. – RN718. Domingo, Jayson John M. – RN819. Gamboa, Stephanie Love C. – RN920. Jammang, Rodel B. – RN10

Submitted by:

LIM, MARY NIÑA CASELDA S.

BSN IV-3 (Group 15)

CUES NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

SHIFT HOURS

AM = 6:00am to 2:00pm

PM = 2:00pm to 10:00pm

NIGHT = 10:00pm to 6:00am

SATURDAY SUNDAYAM PM NIGHT AM PM NIGHT

WEEK 1

RN8RN10

RN1RN4

RN2RN5

RN3RN6

RN7RN9

RN8RN1

WEEK 2

RN10RN4

RN1RN8

RN2RN9

RN3RN5

RN4RN7

RN6RN10

WEEK 3

RN8RN10

RN1RN4

RN2RN5

RN3RN6

RN7RN9

RN8RN10

WEEK 4

RN10RN4

RN1RN8

RN2RN9

RN3RN5

RN4RN7

RN6RN10

DIAGNOSISSubjective:“Suka lang siya ng suka, bawat pinakakain sa kanya nasasayang lang.” as verbalized by the patient’s son

Objective:Pulse = 102 bpm

Profuse vomiting with light brownish colored vomitus

(+) Generalized body weakness

(+) Dry Skin and more than 2 seconds skin turgor

No urine output within 2pm-10pm shift

An increased in blood sodium level (156.1 mmol/L, 136-

Fluid volume deficit related to

vomiting as evidenced by dry skin and increased

metabolic rate

Decreased intravascular,

interstitial, and/or intracellular fluid.

This refers to dehydration with

changes in sodium.

(Release of cytokines,

hypopolysaccharide, heat-shock protein

enzymes) and (Hydrogen ions and

pepsins)

Inflammatory Cascade Initiated

(Cytokines, neutrophiles,

lymphocytes, etc)

Mucosal damage and ulceration

Mild irritation of the stomach lining

Vomiting

Fluid volume deficit

Within 8 hours of nursing intervention, the client will be able to have:

Vital signs within normal range.

Moist and good skin turgor

Decrease in vomiting

Urge to drink fluids and eat soft diet foods

Elevate head of bed at least 30 degrees

Assess GI status

Monitor intake and output and correlate with weight changes, measure fluid loss via emesis and etc.

Schedule activities to provide undisturbed rest periods

Provide small, frequent meals

Identify and limit foods that create discomfort

Prevents gastric reflux

To monitor for signs of bleeding

To provide guidelines for fluid replacement

Activity increases intra-abdominal pressure and can predispose to further bleeding

To prevent distention and the release of gastric

Some foods cause distress like spicy foods and decaffeinated coffee can precipitate

GOAL WAS MET. Within 8 hours of nursing intervention, the client was able to have:

Vital signs within normal range.

Moist and good skin turgor

Decrease in vomiting

Urge to drink fluids and eat soft diet foods

145 mmol/L)

Promote comfort measures

Encouraged increase in fluid intake

Provided skin and mouth care, massaged skin, and applied emollients as necessary

Turned patient q2h and provided support for body prominences.

dyspepsia.

To enhance ability to participate in activities

To relieve thirst and aids in body fluid replacement

Regular skin and mouth care relieves dryness and discomfort. Light massage promotes circulation. Use of emollients and mild soaps promotes good hygiene and comfort without excessive drying of the skin.

Patients with fluid volume deficit are more at risk for skin breakdown.

CUES NURSING DIAGNOSIS

INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

Subjective:“Nahirapan nga siya lumunok at mag-nguya, suka pa ng suka ng bawat kinakain niya.” as verbalized by the patient’s son.

Objective:Profuse vomiting with light brownish colored vomitus

Dysphagia

(+) coughing when swallowing soft food diets

Absence of urgency to drink and swallow foods or clear liquids

Risk for aspiration related to vomiting

secondary to ulceration.

Decreased intravascular,

interstitial, and/or intracellular fluid.

This refers to dehydration with

changes in sodium.

(Release of cytokines,

hypopolysaccharide, heat-shock protein

enzymes) and (Hydrogen ions and

pepsins)

Inflammatory Cascade Initiated

(Cytokines, neutrophiles,

lymphocytes, etc)

Mucosal damage and ulceration

Mild irritation of the stomach lining

Vomiting

Risk for aspiration

After 8 hrs of nursing intervention the patient will be able reduce risk for aspiration as evidenced by:

Improved swallowing

(-) coughing when swallowing soft food diets

Increased urgency to drink and eat foods

Assess for airway, breathing and circulation of the client

Elevate head of bed (HOB) at least 30* at all times

Position patient in left lateral decubitus

Make sure oral-tracheal suction machine at the bed side

Administer IVF as prescribed

Protection of the airway with intubation may be needed to avoid respiratory compromise from aspiration of blood

Elevating the HOB can improve airway and reduce risk for aspiration.

Left lateral decubitus position will help prevent aspiration of GI contents when feeding

To provide initial intervention when the client experienced aspiration.

To replace amount of fluid loss and easier

GOAL WAS MET. After 8 hrs of nursing intervention the patient was able reduce risk for aspiration as evidenced by:

Improved swallowing

(-) coughing when swallowing soft food diets

Increased urgency to drink and eat foods

Administer medications as prescribed

Provide emotional support to client, explain all procedure

Provide prescribed soft diet and encourage oral feedings

administration of drugs

Antacids and antiemetics can help reduced GI bleeding

To decrease anxiety and to obtain client’s cooperation.

Avoid irritating foods, coffee, milk, bland diet. When therapy does not produce healing, surgery is required.