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 DW 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 clients father died because of complications from a heart problem. The clients mother passed away because of old age. Patient AB stated that she doesnt 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 patients 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 mealsclassically, 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 D 5NSS 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 patients 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 ABs 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

patients 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 NIA CASELDA S. BSN IV-3 (Group 15)

GENERIC NAME Metoclopramide

DOSAGE

INDICATION

MECHANISM OF ACTION 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.

40mg TIV/Oral BID

It is commonly used to treat nausea and vomiting.

SIDE EFFECTS/ ADVERSE EFFECTS Hypernatremia

NURSING CONSIDERATIONS

- 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 No side effects drug. It is a dopamine- and/or adverse receptor blocking agent. effects noted. Its action on the dopamine-receptors in the chemo-emetic trigger zone produces an anti-emetic effect.

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

Multivitamins

1tab BID

It is a preparation intended to be a dietary supplement with vitamins,

Supplemental drug. No side effects Dietary supplement for and/or adverse the treatment and effects noted. prevention of deficiencies caused by vomiting. It acts as

and dietary coenzymes or catalysts minerals for in numerous metabolic nutritional processes. supplement. Mupirocin Ointment Apply twice a day on the anal area. It is used as a topical treatment for bacterial infections. Antibiotic. It inhibits No side effects protein synthesis of the and/or adverse bacteria by binding to effects noted. isoleucyl transfer RNAsynthetase. It is active against gram-positive and some gramnegative bacteria. - 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. - 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.

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. It is a cytoprotective agent, an oral gastrointestinal medication primarily

Proton pump inhibitor. No side effects It suppresses gastric and/or adverse acid secretion by effects noted. specific inhibition of the enzyme system hydrogen/potassium adenosine triphosphatase (H+/K+ ATPase) present on the secretory surface of the gastric parietal cell. Antiulcerant and No side effects antacid. and/or adverse It protects GI lining effects noted. against peptic acid, pepsin and bile salts by binding with positively-

Sucralfate

1g Oral q6

- 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 NIA CASELDA S. BSN IV-3 (Group 15)

4-WEEK STAFF SCHEDULING MONDAY AM WEEK 1 RN1 RN2 PM RN3 RN4 NIGHT RN5 RN6 AM RN7 RN8 TUESDAY PM RN9 RN10 NIGHT RN1 RN3 WEDNESDAY AM RN2 RN4 PM RN3 RN5 NIGHT RN6 RN7 AM RN8 RN9 THURSDAY PM RN10 RN1 NIGHT RN2 RN3 AM RN4 RN5 FRIDAY PM RN6 RN8 NIGHT RN7 RN9

WEEK 2 WEEK 3

RN1 RN5 RN1 RN2

RN2 RN6 RN3 RN4

RN3 RN7 RN5 RN6

RN4 RN8 RN7 RN8

RN5 RN9 RN9 RN10

RN6 RN10 RN1 RN3

RN1 RN6 RN2 RN4

RN2 RN7 RN3 RN5

RN3 RN8 RN6 RN7

RN4 RN9 RN8 RN9

RN5 RN10 RN10 RN1

RN6 RN2 RN2 RN3

RN7 RN1 RN4 RN5

RN8 RN5 RN6 RN8

RN9 RN3 RN7 RN9

WEEK 4

RN1 RN5

RN2 RN6

RN3 RN7

RN4 RN8

RN5 RN9

RN6 RN10

RN1 RN6

RN2 RN7

RN3 RN8

RN4 RN9

RN5 RN10

RN6 RN2

RN7 RN1

RN8 RN5

RN9 RN3

Name of Nursing Staff (Full-Time) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Herrera, Raetchel Kathrina B. RN1 Ibasco, John Emmanuel M. RN2 Lardizabal, Abishai R. RN3 Lim, Mary Nia Caselda S. RN4 Macalangcom, Nor-Aileen R. RN5 Decolin, Bheneth R. RN 6 Dimaampao, Johaina G. RN7 Domingo, Jayson John M. RN8 Gamboa, Stephanie Love C. RN9 Jammang, Rodel B. RN10

SHIFT HOURS AM = 6:00am to 2:00pm PM = 2:00pm to 10:00pm NIGHT = 10:00pm to 6:00am

AM WEEK 1 WEEK 2 WEEK 3 WEEK 4 RN8 RN10 RN10 RN4 RN8 RN10 RN10 RN4

SATURDAY PM RN1 RN4 RN1 RN8 RN1 RN4 RN1 RN8

NIGHT RN2 RN5 RN2 RN9 RN2 RN5 RN2 RN9

AM RN3 RN6 RN3 RN5 RN3 RN6 RN3 RN5

SUNDAY PM RN7 RN9 RN4 RN7 RN7 RN9 RN4 RN7

NIGHT RN8 RN1 RN6 RN10 RN8 RN10 RN6 RN10

Name of Nursing Staff (Full-Time)

SHIFT HOURS
11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Herrera, Raetchel Kathrina B. RN1 Ibasco, John Emmanuel M. RN2 Lardizabal, Abishai R. RN3 Lim, Mary Nia Caselda S. RN4 Macalangcom, Nor-Aileen R. RN5 Decolin, Bheneth R. RN 6 Dimaampao, Johaina G. RN7 Domingo, Jayson John M. RN8 Gamboa, Stephanie Love C. RN9 Jammang, Rodel B. RN10

AM = 6:00am to 2:00pm PM = 2:00pm to 10:00pm NIGHT = 10:00pm to 6:00am

Submitted by: LIM, MARY NIA CASELDA S. BSN IV-3 (Group 15)

CUES Subjective: Suka lang siya ng suka, bawat pinakakain sa kanya nasasayang lang. as verbalized by the patients 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 2pm10pm shift An increased in blood sodium level (156.1

NURSING DIAGNOSIS Fluid volume deficit related to vomiting as evidenced by dry skin and increased metabolic rate

INFERENCE 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

GOAL 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

INTERVENTION 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

RATIONALE Prevents gastric reflux

EVALUATION 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

To monitor for signs of bleeding To provide guidelines for fluid replacement

Activity increases intraabdominal 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

Provide small, frequent meals

Identify and limit foods that create discomfort

mmol/L, 136145 mmol/L) Promote comfort measures

precipitate 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.

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.

CUES Subjective: Nahirapan nga siya lumunok at mag-nguya, suka pa ng suka ng bawat kinakain niya. as verbalized by the patients 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

NURSING DIAGNOSIS Risk for aspiration related to vomiting secondary to ulceration.

INFERENCE 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

GOAL 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

INTERVENTION Assess for airway, breathing and circulation of the client

RATIONALE 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

EVALUATION 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

Elevate head of bed (HOB) at least 30* at all times Position patient in left lateral decubitus

Make sure oraltracheal suction machine at the bed side

Administer IVF

as prescribed

amount of fluid loss and easier administration of drugs Antacids and antiemetics can help reduced GI bleeding To decrease anxiety and to obtain clients cooperation.

Administer medications as prescribed

Provide emotional support to client, explain all procedure Provide prescribed soft diet and encourage oral feedings

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