PEPTIC ULCER

DISEASE

Introduction

Peptic Ulcer
Ulcers average between one-quarter and one-half inch in
diameter. They develop when digestive juices produced in
the stomach, intestines, and digestive glands damage the
lining of the stomach or duodenum.
The two important digestive juices are hydrochloric acid and
the enzyme pepsin. Both substances are critical in the
breakdown and digestion of starch, fat, and proteins in
food. They play different roles in ulcer:
Hydrochloric Acid. A common misbelieve is that excess
hydrochloric acid, which is secreted in the stomach, is
solely responsible for producing ulcers.

 H. pylori- the bacteria that has been the cause of most peptic
ulcers.
Pepsin. Is an enzyme that breaks down proteins in food. Since
the stomach and duodenum are also composed of protein,
however, they too are susceptible to the actions of pepsin.
Bicarbonate, which the mucous layer secretes, neutralizes the
digestive acids. Hormone like substances called prostaglandins
help keep the blood vessels in the stomach dilated, ensuring
good blood flow and protecting against injury.

(Prostaglandins are also believed to stimulate bicarbonate and

mucus production.

Patient Profile

Patients Name: Criselda Llorente Siangco

Sex: Female
Age: 43 y.o.
Status: Married
Address: Pigcarangan, Tubod, Lanao Del Norte
Religion: Roman Catholic
Occupation: housewife
Citizenship: Filipino
Chief Complaints: Palpitation 3months PTA
V/S:
Date Admitted: Jan.5,2010
BP:100/120 mmHg
Time Admitted:9:34 Pm
Temp. : 37.1 C
Impression/Diagnosis: HVD/UTI/Acid
PR: 84 Bpm
Peptic Disease
RR: 24 Cpm
Physician: Dra. Marjueta Opamen
Room: Critical Ward

NURSING ASSESSMENT

General Information:
Patients Name: Criselda L. Siangco
Sex: F
Age: 43 y.o.
Religion: Roman Catholic
Occupation: Housewife
Address: Pigcarangan, Tubod, LDN
Status: Married
Date Admitted: Jan.5,2010
Chief Complaints: Palpitation 3 Months
PTA
Med: Metropolol Previously admitted
last Nov. Secondary to palpitation/Dx
HVD
Impression/Diagnosis: HVD/UTI/ Acid
Peptic Disease
Physician: Dra. Marjueta Opamen

Present Illness
Palpitation 3 mos. PTA
Jan.5,2010 @ 9:30 PM

Reaction to & Expectations

about Hospitalization

HPN/ Ulcer
It can be treated
through hospitalization
It can affect their daily
living
Yes, it can change my
ability to function as a
mother and a wife
Sad and irritable
Lonely and sad

Previous Illness
HVD
Over fatigue
They give their care

Reactions about Treatment &

Diagnostic Procedures

It can relieve the pain

and cure my illness
Is it really make me
feeling well?
Afraid

Nursing History
Normal Patterns
of Functioning
(prior to
admission)

Patterns of
functioning:
Respiration
Tachypnea
Personal
Hygiene:
Daily Bath
Brushing of
teeth 3x a day

Clinical
Inspection
observation on
First Day of
duty

On-going Appraisal
observation 2nd day of
duty

*Normal

*Normal

*Dry Skin
* Dry scalp

Other sources, lab.

Exam Results

Nursing History Normal

Patterns of Functioning
(prior to admission)

Communication &
Special senses:
No difficulties in
speaking, hearing,
seeing and
understanding
Slightly read & write
English
Coping with Stress:
*Rest
*Family
Circulation:
*tachycardia
*Take medication

Clinical
Inspection
observation on
First Day of
duty

On-going Appraisal
observation 2nd day
of duty

*Weak Voice

*Irritable

*Normal PR
*Normal BP

*Irritable, tense

Other sources, lab.

Exam Results

Nursing History
Normal Patterns of
Functioning (prior
to admission)

Food & Fluid

Intake:
Meals? 3x a day
Snack? Seldom
Content? Rice &
vegetables
1 cup of coffee
every morning
Like all kinds of
food

Clinical Inspection
observation on
First Day of duty

On-going
Appraisal
observation 2nd
day of duty

Other sources, lab.

Exam Results

*56 kg
*54
*pale skin

*poor appetite
*D5 NSS 1L @20
gtts/mins
Results U/A
Color-light yellow
Transparencyclear
Specificity- 1.005
pH 6.5
Albumin-negative
Sugar- negative
PUS 1-2
RB 1-2
WBC- 10.12
Hgb. -116
Hct. -0.35
Neutrophil- 0.73
Lymphocyte- 0.25
Eosinophils- 0.02

DAT

Nursing History
Normal Patterns of
Functioning (prior
to admission)

Clinical Inspection
observation on First
Day of duty

Exercise:
Hiking &
stretching within
30 mins. Twice a
week
Right Handed
Pain/Discomfort:
* Epigastric pain
*Take medication
Regulatory
Mechanism
*Dizzy

Acute Pain

Temp- 37.1C
Dry skin

On-going Appraisal
observation 2nd day
of duty

Other sources, lab.

Exam Results

Nursing History
Normal Patterns of
Functioning (prior
to admission)

Clinical Inspection
observation on First
Day of duty

On-going Appraisal
observation 2nd day
of duty

Other sources, lab.

Exam Results

* Void- 2x

* Void- 2x

Results U/A
Color-light yellow
Transparencyclear
Specificity- 1.005
pH 6.5
Albumin-negative
Sugar- negative
PUS 1-2
RB 1-2
WBC- 10.12
Hgb. -116
Hct. -0.35
Neutrophil- 0.73
Lymphocyte- 0.25
Eosinophils- 0.02

Elimination:
Void?- 3-5x a day
Bowel Movement?
Once a day

Nursing History
Normal Patterns of
Functioning (prior
to admission)

Clinical Inspection
observation on First
Day of duty

On-going Appraisal
observation 2nd day
of duty

Rest and sleep:

Sleep 8 hours a
day
Retiring? 10PM
Arising? 5PM
No difficulty in
sleeping
Staying sleep
with husband
Interferes sleep
with noise
2 Pillows

8 hours
Nature of sleep?
Normal

Other sources, lab.

Exam Results

Nursing History
Normal Patterns of
Functioning (prior
to admission)

Recreational/
Diversion:
Done for fun?
Playing cards
Past time while
ill? Sleep
Health
Supervision:
Take Medicine as
prescribed
Illness send to
bed? Fever, HPN,
epigastric pain
Reason for
consulting
Doctor? To
relieve pain & to
Know my health

Clinical Inspection
observation on First
Day of duty

On-going Appraisal
observation 2nd day
of duty

Other sources, lab.

Exam Results

ANATOMY & PHYSIOLOGY

Digestive System
Digestive system is the series of tube-like organ that converts our meals
into chemical compound that can be absorbed by the bodys cells. It also
separates out unneeded materials and flushed them out of the body. In all
theres about 30-foot-long(9-meter-long) tube that begins with the mouth,
where food enters the body, and ends with the anus, where solid wastes
are expelled. Along the way, food is broken down, sorted, and reprocessed
before being circulated around the body to nourish and replace cells and
supply energy to our muscles.
Mouth & Throat
The digestive process begins here, where food is grind into pieces and
prepared for delivery to the stomach. It then enters the pharynx, or
throat a muscular funnel that pushes that chewed food into the esophagus
while simultaneously blocking off the trachea( Wind pipe).

Salivary Glands- Three pairs of salivary glands secrete saliva, a mixture of

water, enzymes and gluey protein called Mucin, into the mouth to moisten
the food. Enzymes in the saliva interact with food and begin the process of
chemical digestion.
Teeth- Bony structures that tear, chop, and grind food for swallowing.
Sharp incisors and pointed canines in the front of the mouth are designed
to tear into tough foods, while flattened premolars and molars in the back
grind grains and plant matter.
Tongue- This muscular organ maneuvers food around during chewing and
mixes it with saliva to form a wet lump called a BOLUS. The top and sides
of the tongue are covered with little projection called papillae, many of
which contains taste buds.
Esophagus- The esophagus is 10-inch-long(25-cm-long) muscular tube that
connects the pharynx to the stomach . When food enters the esophagus, a
wave of muscular contractions called PERISTALSIS push and pull the food
to the stomach. Mucus secretion keep the lump of food, or bolus sliding a
mere four to eight seconds.
Upper Esopahageal Sphincter- This valve, found just below the
intersection of the throat and esophagus, is a ring of muscles that relaxes
to let food enter the esophagus.

Stomach- this muscular, expandable J-shaped pouch is responsible for

holding and digesting food, as well as removing its nutrients. When food
enters the stomach, its muscular walls contact and churn the food with
powerful gastric acids that kill bacteria and break down proteins. The
result is a creamy substance called CHYME which the stomach stores until
it is ready for release into the small intestine.
Liver- weighing in at 3 pounds(1.3Kg), this wedge-shaped organ is the bodys
largest gland. The liver is an accessory organ for the digestive system.
Among its many roles is detoxification of the blood. It also creates bile,
which is used to break down fats.
Gall Bladder- this plum-size, green, muscular sac hangs from the liver. The
gall bladder collects, stores, and concentrate bile from the liver.
Pancreas- This long organ, positioned behind the stomach, produces insulin
and enzymes that aid digestion. Pancreatic enzymes help digest food in the
small intestine, while insulin helps regulate the amount of sugar in the
blood.
Intestines- The small intestine measures 20 feet(6meters) in length and 1
inch(2.5cm) in diameter. Thousands of folds and millions of finger-like
projection called VILL increase the surface are of the small intestine
,which absorb 90% of nutrients and water the body will receive from
digested food.

Duodenum- This is the first portion of the small intestine, where secretion
from the liver and pancreas are received and most of the chemical digestion
takes place.

Jejunum- This is the long, coiled middle portion of the small intestine that
stretches from the duodenum to the ileum.

Ileum- this is the final portion of the small intestine, where remaining
nutrients are absorbed and utilized.

The Large Intestine absorb the last bits of nutrients and water from
indigestible foods, compacts the remaining matter, and eliminates it as feces.

Ascending Colon- the large intestine surrounds the small intestine like an
inverted Y. The first portion of the large intestine, the ascending colon, is
stimulated vertically on the right side of the body. The ascending colon
extracts remaining moisture from food before its excretion.

Transverse Colon- Connecting the ascending and descending colons, this part
of the large intestine is situated horizontally above the small intestine.

Descending Colon- Found on the left side of the body, the descending,
or left colon, stores stool the will be emptied into the rectum

Rectum- Only 5 inches(12cm) long, the rectum sits just above the anal
canal. Feces are stored here briefly prior to defecation.

Anus- This ring of muscles is the external opening of the rectum,

through which fecal matter is expelled. Peristaltic waves in the colon
and contraction of the abdominal muscles trigger defecation.

PATHOPHYSIOLOGY

Damage to mucosa with

alcohol abuse, smoking, use
of NSAIDs

Infection with Helicobacter

Pylori

Damaged mucousal

Erosion of mucous
membrane

Low function of mucosal

cells; low quality of
mucous

Erosive gastritis

Mucosal ulcerations

Severe ulcerations:
Signs and symptoms:
Epigastric pain
Hematemesis
pale
pyrosis

DIAGNOSTIC TEST

 Barium Meal X-ray

Gastroscopy
Endoscopy
Upper Gastrointestinal (GI) series
Blood H. Pylori Test
Breath H. Pylori Test
Helicobacter pylori Stool Antigen (HpSA)
Test
Stomach biopsy
Tissue H. Pylori Test

MEDICAL MANAGEMENT

 ANTIBIOTICS
-metrodinazole , amoxicillin ,
clarithromycin
-to eradicate h.pylori
-surgical intervention
PROTON PUMP INHIBITORS
-clansoprazole , omeprazole

 Proton pump inhibitors (or "PPI"s) are a

group of drugs whose main action is
pronounced and long-lasting reduction of
gastric acid production.

Bismuth salts

-suppress or eradicate h.pylori

Smoking reduction and rest
Dietary modification
Surgical procedure

-vagotomy
-Billroth I and Billroth II

Vagotomy
-A vagotomy is a surgical
procedure that is performed only
in humans. It is resection
(removal of, or at least severing)
of part of the vagus nerve.

 Antrectomy (billroth I)
- is the resection, or surgical removal,
of a part of the stomach known as the
antrum. The antrum is the lower third
of the stomach that lies between the
body of the stomach and the pyloric
canal, which empties into the first
part of the small intestine.

 Gastrojejunostomy (Billroth II)

-GI surgery A procedure in which
the duodenum is excised or bypassed
and the stomach is end-to-end
anastomosed to the jejunum
FOLLOW UP CHECK UP

NURSING MANAGEMENT

 Monitor I & O
Monitor the pt. hgb, hct, &
electrolytes level
Administered prescribed IV fluids &
blood replacement if acute bleeding
is present

 Cessation of Smoking
Encourage bed rest
Provide small frequent meals
Watch for diarrhea caused by antacids & other
meds.
Advice pt. to avoid extremely hot & cold foods, to
chew thoroughly & to eat in a leisurely fashion

Administer meds. Properly & to teach

pt. do set duration of each
medication
Stress relief
Exercises
Lifestyle changes

 Instead of meat change it to Fruits & vegetables

that are rich in fiber diet
Moderate amount in drinking of milk (2-3 cups a
day)
Minimize drinking of coffee & carbonated
beverages
No to spices & peppers
Minimize use of garlic in foods
Encourage olive oil in cooking of foods.

Drug Study

Drug Name

Classificati
on

Indication

Contraindicati
on

Adverse
Effect

Nsg.
Considerati
on

Dose, route,
frequency

Ferosemide

Diuretices,
loop

Edema from heart

failure,
hepatic
syndrome; mild-tomoderate
HPN;
adjunct treatment
in acute pulmonary
edema
or
hypertensive crisis.

Contraindicat
ed inpatients
hypertensive
to
these
drugs & in pt.
with
anuria,
hepatic coma
or
severe
electrolyte
depletion.

Therapeutic
dose
commonly
causes
metabolic &
electrolyte
disturbance,
particularly
potassium
depletion. It
also
may
cause
hyperglycemi
a,
hyperurecem
ia,
hypochloremi
c alkalosis &
hypomagnese
mia.

Give
diuretics in
morning to
ensure that
major
diuresis
occurs
before
bedtime.
Take safety
measures
for
all
ambulatory
pt.
until
response to
diuretics in
known

10 mg slow
IVTT

Drug Name

Classificati
on

Indication

Contraindication

Adverse Effect

Nsg. Consideration

Dose,
route,
frequency

Captopril

Angiotens
iveconvertin
g enzyme
inhibitors

Hypertensio
n,
heart
failure, LVD,
MI,
and
diabetic
nephropathy

Contraindicated
in
pt.
hypersensitive
to these drugs

Angioedema
of the face &
limits, drugs,
cough,
dysgeusia,
fatigue,
headache,
hyperkatemia
, hypotension,
proteinuria,
rash
&
tachucardia

If
pt.
has
impaired
renal
function, give a
reduced dosage
If pt. becomes
pregnant,
stop
ACE inhibitors
Give captopril 1
hour
before
meals

25 mg,
1tab now

Drug Name

Classification

Indication

Contraindicati
on

Adverse
Effect

Nsg.
Consideration

Dose, route,
frequency

Metoprolol

Antianginale
(Beta

Moderate to
serve angina
(beta
blockers)
classic,
effortinduced
angina,
Prinzmetal
angina,
recurrent
angina, acute
angina,
unstable
angina

Beta Blockers
are
contraindicat
ed
in
pt.
hypersensitiv
e to them and
in pt. with
cardiogenic
shock, sinus
bradycardia,
heat
block
greater than
first degree
or bronchial
asthma

Beta blockers
may
cause
bradycardia,
cough,
diarrhea,
disturbing
dreams,
dizziness,
dyspnea,
fatigue,
fever, heart
failure,
hypotension,
lethargy,
nausea,
peripheral
edema,
&
wheezing.

Dont give a beta

blocker
or
calcium channel
blocker
to
relieve
acute
angina
Warn pt. not to
stop
drug
abruptly without
prescribers
approval
Withhold
the
dose & notify
prescribers
if
pt. heart rate is
slower than 60
bpm or systolic
BP is slower than
90 mmHg
Tell Pt. to report
pervious/
persistent
adverse reaction

50 mg, 1 tab
now

Blockers)

Drug Name

Classification

Indication

Contraindica
tion

Adverse
Effect

Nsg.
Consideration

Dose, route,
frequency

Cimetidine

Histamine 2receptor
antagonist

Acute
duodenal
or
gastric ulcer,
ZollingerEllison
syndrome,
gastro
esophageal
reflux

Contra
indicated in
pt.
hypersensiti
ve to these
drugs

H2-receptor
antagonists
rarely
cause
adverse
reactions.
Cardiac
arrhythmias,
dizziness,
fatigue,
gynecomastia,
headache, mild
&
transient
diarrhea
&
thrombocytose
mia
are
possible

Adjust
dosage for pt.
with
renal
disease.
Dont exceed
recommended
infusion rates
when
giving
IV; doing so
increases risk
of adverse CV
effects.
Caution pt. to
avoid smoking
during
therapy

400 mg, 1 tab

PC

Drug Name

Classification

Indication

Losartan

Anti
hypertensives

Essential
secondary
HPN

&

Contraindicatio
n

Adverse
Effect

Nsg.
Consideration

Dose, route,
frequency

Contraindicate
d
in
pt.
hypersensitive
to these drugs
& in those with
hypotension

Commonly
causes
orthostatic
changes
in
HR,
headache,
hypotension,
nausea
&
vomiting

Give
drug
with fod at
bedtime,
as
indicated
When mixing
&
giving
parenteral
drugs, Follow
manufacturer
s guidelines
To
prevent
dizziness,
light
headedness
or
fainting
advice
changes
in
position.

50 mg, 1 tab
OD every 8
am

Drug Name

Classification

Indication

Contraindication

Adverse
Effect

Nsg.
Consideration

Dose, route,
frequency

Aspirin

Anti Platelet,
antipyretic

For arthritis,
mild pain or
fever,
prevention of
thrombosis,
reduction of
MI risk in Pt.
with previous
MI
orun
stable angina,
Kawasaki
syndrome;
prophylaxis
for
attack,
rheumatic
fever,
peri
ceuditis afet
acute MI, &
stent
implantation

Contraindicated
in
pt.
hypersensitive
to drug & those
with
bleeding
disorder such as
hemophilia, von
Willebrand
disease
&
telangiectasia,
or
NSAIDinduced
sensitivity
reactions

Hearing loss,
tinnitus,
dyspepsia, GI
bleeding, GI
distress,
nausea,
occult
bleeding,
vomiting,
transient
renal
insufficiency,
thrombo
cytopenia,
bruising,
rash,
uticaria,
angioedema
Reye
syndrome

Give aspirin
with
food
milk, antacid
or large glass
of water to
reduce
GI
reactions.
If pt. has
trouble
swallowing,
crush aspirin,
combine with
soft food or
dissolve it in
liquid. Dont
crush
entericcoated
aspirin.
Give PR after
a
bowel
movement or
at night to
maximize
absorption
Stop aspirin

100 mg 1 tab
OD P.C.

Nursing Care Plan

Cues & Evidence:

Nsg. Diagnosis

Objective

Intervention

Rationale

Evaluation

S= Sakit akong
Kutokuto as
verbalized by the
pt.
O= Seen lying on
bed with grimaced
face and pressing
her epigastric area
Weak
Restless
Unable to
response well
Loss of appetite
Pain scale: 6

Acute/ chronic
pain related to
lesions
secondary to
increased
gastric
secretions

After 8 hours of
nsg. & medical
mgt. pt. will:
a. verbalize relief
of pain
b. able to sleep
well

Independent:
1. Explain the relationship
between hydro chronic
acid secretion and onset
of pain
2. Explain the risks of
nonsteroidal antiinflammatory drugs
(NSAIDs)
(e.g. Motrin, Aleve,
Relafen)
3. Help the pt. to identify
irritating substances( E.g.
Fried food, spicy foods,
coffee)
4. Encourage the pt. to
avoid smoking and alcohol
use.
5. Encourage the pt. to
reduce intake of
caffeine- containing and
alcoholic beverages, if
indicated
6. Teach Pt. the
importance of continuing
treatment even in the
absence of pain.
Dependent:
1. administer drug
therapy as prescribed
a. antacids
b. histamine
c. h2 blocker
d. anticholinergics

1. Hydrochloric
acid(HCL)
presumably is an
important variable
in the appearance
of peptic ulcer dse,
because of this
relationship,
control of HCL
secretion is
considered an
essential aim of
treatment.
2. NSAIDs cause
superficial
irritation of the
gastric mucosa and
inhibit the
production of
prostaglandins that
protect gastric
mucosa
3. Avoidance of
irritating
substances can help
to prevent the pain
response.
4. Smoking
decreases
pancreatic
secretion of
bicarbonate; this
increase duodenal
acidity. Tobacco
delays the healing

Goal met as
evidence by PT;
1.verbalized relief
of pain
2.able to sleep

Cues & Evidence

Nsg. Diagnosis

Objective

Intervention

Rationale

Evaluation

S= wala akong
ganang kumain
as verbalized by
the pt.
O= facial
Grimace
Restlessness
Anorexia: pt. not
able to consume
foods serve
V/S:
T=37.5 C
PR=65 BPM
RR=14 CPM
BP=110/80
mmHg

Nutrition
Imbalace less
than body
weight related
to loss of
appetite

After 8 hours of
nsg. & medical mgt.
pt. will:
a. Will be able to
consume served
food

Independent:
1. Monitor V/S as
ordered.
2. Instruct pt. to
increase the
intake of water
3. Identify and
limit foods that
create discomfort
4. Encourage
small, frequent
meals.
5. Provide
prescribed diet.
Dependent:
Administer drug
therapy:
a.Antacid
b.Histamine-2
Antagonist

1. As baseline
data in cases of
alterations from
the normal.
2. Water is
considered as a
good antacid.
3. Food has acid
neutralizing
effects &
dilutes.
4. Small meals
prevent
distention & the
release of
gastrin.
5. To avoid
gastric irritation

Patient will be
able to consume
served food.

Prognosis

When the underlying cause for peptic ulcer disease is successfully

treated, the prognosis (expected outcome) for patients with the
condition is excellent.To help prevent peptic ulcers, avoid the
following:
Alcohol
Common sources of Helicobacter pylori bacteria (e.g.,
contaminated food and water, floodwater, raw sewage)
Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs)
Smoking
Good hygiene can help reduce the risk for peptic ulcer disease
caused by Helicobacter pylori infection. Washing the hands
thoroughly with warm soapy water after using the restroom and
before eating and avoiding sharing eating utensils and drinking
glasses also can reduce the spread of bacteria that can cause PUD.

Prepared by:
Limpango, Joan
Nudalo, Raiza
Paradero, Desiree
Pison, Wilsan
Puno, Rebekah Ann
Tan, Cristali
Tinamisan, Johnny
Santillan, Juliet
Sumile, Daisy Mae
Sawit, Johnderick
Resma, Rosalie
Rudie, Aldin
Urian, Pedro