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.
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