Group 2:

Peptic Ulcer
ZOLETA, DAYLA SHAINE MAY

DE LEON, ALEXANDRA

CAPARROS, CLEA

BALINO, IRIS JOY

Group 2: Peptic
Ulcer Disease
Zoleta, Dayla shaine may

De Leon, AlexAndra

Caparros, Clea

Balino, Iris joy

General Objective

▪ The purpose of this study is to enhance and gain knowledge, to develop

communication and nursing skills, to provide privacy and maintain
confidentiality of the patient and to apply the right attitudes of the student
nurses in rendering and giving care to the patient with Peptic Ulcer.
Specific Objective

 Understand condition Peptic Ulcer associate it with the patient through the introduction
of the case.
 To illustrate the Anatomy and Physiology of the affected organ or the part of the body.
 To discuss the pathophysiology of the disease.
 To be clinically aware of the clinical manifestation and its complication.
 To develop an effective skill on how to plan and manage proper care in patient with
peptic ulcer.
 To formulate a drug study with regards to the patient’s condition.
 To correlate the laboratory result to its normal value.
 To provide the client nursing care plan and discharge plan to assure client’s total wellness
during his hospitalization up to the time of his hospital discharge.
 To apply right attitude by respect through providing privacy and maintaining client’s
confidentiality.
Introduction

A. Background of the study

i. Incidence, rate, gender, age, ratio and proportion
According to the latest WHO data published in 2017 Peptic Ulcer Disease
Deaths in Philippines reached 6,784 or 1.10% of total deaths. The age adjusted Death
Rate is 10.36 per 100,000 of population ranks Philippines #8 in the world. Review
other causes of death by clicking the links below or choose the full health profile.
ii. Rationale for choosing the case
The group decided to choose the case of Peptic Ulcer because it was one the
cause of death in the Philippines. The group also consider the relative of the patient
because they are cooperative and gives accurate information to be used in correlating
the actual case of the patient.
Introduction

iii. Significance of the studies

The significance of this study is to enhance/gain knowledge, to develop skills
and apply the right attitudes of the student nurses in rendering and giving care to the
patient with Peptic Ulcer its importance and implication. This study will serve as
guidelines in assessing and providing proper nursing care to patient with the same
problem or disease.
Introduction
These are other significance of the study that would support the above statement:

1. Understand condition of Peptic Ulcer associate it with the patient through the
introduction of the case.
2. To know the Nursing history: the Personal data, Health history and Physical
assessment of the patient.
3. Illustrate the anatomy and physiology and pathophysiology of the affected organ or
part of the body.
4. Discuss and determine manifestation and complications.
5. Develop of an effective skill on how to manage a proper care in patient with Peptic
Ulcer.
6. Formulate a drug study with regards to the patient’s condition.
7. Correlate the lab result to its normal value.
8. To provide the client nursing care plan and discharge plan to assure for client’s total
wellness during his hospitalization up to the time of his hospital discharge.
Introduction

iv. Scope of limitation of the Study

The study would only focus on Peptic Ulcer which is indicative to the client’s health
condition and its underlying nursing care relevant for the client within the two- week duty
at Quezon Memorial Center.
Introduction

v. Conceptual and Nursing Theory

THEORETICAL FRAMEWORKS
Self-Care Deficit Nursing Theory of Dorothea Orem
Orem developed the Self-Care Deficit Theory of Nursing, which is composed of three interrelated theories: (1) the
theory of Self-Care, (2) the theory of Self-Care Deficit, and (3) the theory of Nursing System.

Theory of Self-Care

Self-care is the performance or practice of activities that individuals initiate and perform on their own behalf to
maintain life, health, and well-being.

Self-care agency is a human ability which is “the ability for engaging in self-care.”

Therapeutic self-care demand “totality of self-care actions to be performed for some

duration in order to meet self-care requisites by using various methods and related sets of operations and actions.”
Introduction

• Three Categories of Self-Care Requisites

▪ Universal self-care requisites- are associated with life processes, maintenance of the
integrity of human structure and functioning, and with general being.
▪ Developmental self-care requisites- are associated with the developmental processes;
derived from a condition or associated with an event (e.g. adjusting to a new job).
▪ Health Deviation self-care requisites- Required in conditions of illness, injury, or
disease; includes seeking medical assistance, learning to live with effects of
condition, etc.
Introduction

▪ Theory of Self-Care Deficit

Self-care deficit is the basic element of Orem’s general theory of nursing because it
delineates when nursing is needed. Nursing is required when adults are incapable of or
limited in their ability to provide continuous effective self-care.
▪ Five methods of helping
1. Acting for or doing for another
2. Guiding and directing
3. Providing physical or psychological support
4. Providing and maintaining an environment that supports personal development
5. Teaching
Introduction

Theory of Nursing System

1. Wholly Compensatory Nursing System
2. Partly Compensatory Nursing System
3. Supportive-Educative System
The wholly compensatory nursing system is selected when the patient cannot or should
not perform any self-care actions. The partly compensatory nursing system is selected
when the patient can perform some, but not all, self-care actions. The supportive-
educative nursing system is selected when the patient can and should perform all self-
care actions.
Introduction

▪ Since the diagnosis of our patient is with Peptic Ulcer we relate Dorothea Orem’s
theory because, interrelated theories: the theory of Self-Care, the theory of Self-Care
Deficit, and the theory of nursing system to prevent them in aggregating the disease
to the patient.
▪ As a nurse our goal is to give comfort, care and maintain optimal health that can aid
the patient in their fast recovery.
Introduction

vi. Related Literature of the Study

▪ Peptic Ulcer Disease
Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, first part
of the small intestine or sometimes the lower esophagus. An ulcer in the stomach is
called a gastric ulcer, while that in the first part of the intestines is a duodenal ulcer. The
most common symptoms of a duodenal ulcer are waking at night with upper abdominal
pain or upper abdominal pain that improves with eating. With a gastric ulcer the pain
may worsen with eating. The pain is often described as a burning or dull ache. Other
symptoms include belching, vomiting, weight loss, or poor appetite. About a third of
older people have no symptoms. Complications may include bleeding, perforation and
blockage of the stomach. Bleeding occurs in as many as 15% of people.
Introduction

Common causes include the bacteria Helicobacter pylori and non-steroidal anti-
inflammatory drugs (NSAIDs). Other less common causes include tobacco smoking,
stress due to serious illness, Behcet disease, Zollinger-Ellison syndrome, Crohn disease
and liver cirrhosis, among others. Older people are more sensitive to the ulcer-causing
effects of NSAIDs. The diagnosis is typically suspected due to the presenting symptoms
with confirmation by either endoscopy or barium swallow. H. pylori can be diagnosed by
testing the blood for antibodies, a urea breath test, testing the stool for signs of the
bacteria, or a biopsy of the stomach. Other conditions that produce similar symptoms
include stomach cancer, coronary heart disease, and inflammation of the stomach
lining or gallbladder inflammation.
Introduction

Diet does not play an important role in either causing or preventing ulcers.
Treatment includes stopping smoking, stopping NSAIDs, stopping alcohol and giving
medications to decrease stomach acid. The medication used to decrease acid is usually
either a proton pump inhibitor (PPI) or an H2 blocker with four weeks of treatment
initially recommended. Ulcers due to H. pylori are treated with a combination of
medications such as amoxicillin, clarithromycin and a PPI. Antibiotic resistance is
increasing and thus treatment may not always be effective. Bleeding ulcers may be
treated by endoscopy, with open surgery typically only used in cases in which it is not
successful.
Introduction

Peptic ulcers are present in around 4% of the population. New ulcers were found
in around 87.4 million people worldwide during 2015. About 10% of people develop a
peptic ulcer at some point in their life. They resulted in 267,500 deaths in 2015 down
from 327,000 deaths in 1990. The first description of a perforated peptic ulcer was in
1670 in Princess Henrietta of England. H. pylori was first identified as causing peptic
ulcers by Barry Marshall and Robin Warren in the late 20th century, a discovery for
which they received the Nobel Prize in 2005.
Introduction

Symptoms

Signs and symptoms of a peptic ulcer can include one or more of the following:

▪ Abdominal pain, classically epigastric strongly correlated to mealtimes. In case of duodenal ulcers the pain appears about three hours
after taking a meal;

▪ Bloating and abdominal fullness;

▪ Water brash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus - although this is more associated with
gastroesophageal reflux disease);

▪ Nausea and copious vomiting;

▪ Loss of appetite and weight loss;

▪ Hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from
severe/continuing vomiting.

▪ Melena (tarry, foul-smelling feces due to presence of oxidized iron from hemoglobin);

▪ Rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis, extreme, stabbing pain, and requires
immediate surgery
Introduction

Cause
H. pylori
Helicobacter pylori is one of the major causative factors of peptic ulcer disease.
It secretes urease to create an alkaline environment which is suitable for its survival. It
expresses blood group antigen adhesin (BabA) and outer inflammatory protein adhesin
(OipA) which enables it to attach to the gastric epithelium. The bacterium also
expresses virulence factors such as CagA and PicB which cause stomach mucosal
inflammation. The VacA gene encodes for vacuolating cytotoxin, but its mechanism of
causing peptic ulcers is unclear. Such stomach mucosal inflammation can be
associated with hyperchlorhydria (increased stomach acid secretion) or hypochlorhydria
(reduced stomach acid secretion).
Introduction

Inflammatory cytokines inhibit the parietal cell acid secretion. H. pylori also
secretes certain products that inhibit hydrogen potassium ATPase, activate calcitonin
gene-related peptide sensory neurons which increases somatostatin secretion to inhibit
acid production by parietal cells, and inhibit gastrin secretion. This reduction in acid
production causes gastric ulcers. On the other hand, increased acid production at the
pyloric antrum is associated with duodenal ulcers in 10 to 15% of the H. pylori infection
cases. In this case, somatostatin production is reduced and gastrin production is
increased, leading to increased histamine secretion from the enterochromaffin cells,
thus increasing acid production. An acidic environment at the antrum causes
metaplasia of the duodenal cells, causing duodenal ulcers.
Introduction

▪ Human immune response towards the bacteria also determines the emergence of
peptic ulcer disease. The human IL1B gene encodes for Interleukin 1 beta, and other
genes that encode for tumour necrosis factor (TNF) and Lymphotoxin alpha also play a
role in gastric inflammation.
NSAIDs
▪ Taking nonsteroidal anti-inflammatory drugs (NSAID) and aspirin can increase the risk
of getting peptic ulcer disease by four times when compared to non-users. The risk of
getting peptic ulcer is two times for aspirin users. Risk of bleeding increases if NSAIDs
are combined with selective serotonin reuptake
inhibitor (SSRI), corticosteroids, antimineralocorticoids,
Introduction

▪ and anticoagulants. The gastric mucosa protects itself from gastric acid with a layer of
mucus, the secretion of which is stimulated by certain prostaglandins. NSAIDs block
the function of cyclooxygenase 1 (COX-1), which is essential for the production of
these prostaglandins. Besides, NSAIDs also inhibits stomach mucosa cells
proliferation and mucosal blood flow, reducing bicarbonate and mucus secretion,
which reduces the integrity of the mucosa. Another type of NSAIDs, called COX-2
selective anti-inflammatory drugs (such as celecoxib), preferentially inhibit COX-2,
which is less essential in the gastric mucosa. This reduces the probability of getting
peptic ulcers; however, it can still delay ulcer healing for those who already have a
peptic ulcer.
Introduction

Stress
Stress due to serious health problems such as those requiring treatment in an
intensive care unit is well described as a cause of peptic ulcers, which are also known
as stress ulcers.
While chronic life stress was once believed to be the main cause of ulcers, this is
no longer the case. It is, however, still occasionally believed to play a role. This may be
due to the well documented effects of stress on gastric physiology, increasing the risk in
those with other causes such as H. pylori or NSAID use.
Introduction

Diet
Dietary factors such as spice consumption, were hypothesized to cause ulcers
until late in the 20th century, but have been shown to be of relatively minor importance.
Caffeine and coffee, also commonly thought to cause or exacerbate ulcers, appear to
have little effect. Similarly, while studies have found that alcohol consumption
increases risk when associated with H. pylori infection, it does not seem to
independently increase risk. Even when coupled with H. pylori infection, the increase is
modest in comparison to the primary risk factor.
Introduction

Other
Other causes of peptic ulcer disease includes: gastric ischaemia, drugs, metabolic
disturbances, cytomegalovirus (CMV), upper abdominal radiotherapy, Crohn's disease, and
vasculitis. Gastrinomas (Zollinger–Ellison syndrome), rare gastrin-secreting tumors, also cause
multiple and difficult-to-heal ulcers.
▪ It is still unclear if smoking does increase the risk of getting peptic ulcers.
In addition to taking NSAIDs, you may have an increased risk of peptic ulcers if you:
▪ Smoke. Smoking may increase the risk of peptic ulcers in people who are infected with H.
pylori.
▪ Drink alcohol. Alcohol can irritate and erode the mucous lining of your stomach, and it
increases the amount of stomach acid that's produced.
▪ Have untreated stress.
▪ Eat spicy foods.
Introduction

Diagnosis
Endoscopy
In order to detect an ulcer, your doctor may first take a medical history and perform a
physical exam. You then may need to undergo diagnostic tests, such as:
Laboratory tests for H. pylori. Your doctor may recommend tests to determine
whether the bacterium H. pylori is present in your body. He or she may look for H. pylori
using a blood, stool or breath test. The breath test is the most accurate. Blood tests are
generally inaccurate and should not be routinely used.
Introduction

For the breath test, you drink or eat something that contains radioactive carbon.
H. pylori breaks down the substance in your stomach. Later, you blow into a bag, which
is then sealed. If you're infected with H. pylori, your breath sample will contain the
radioactive carbon in the form of carbon dioxide.
If you are taking an antacid prior to the testing for H pylori, make sure to let your
doctor know. Depending on which test is used, you may need to discontinue the
medication for a period of time because antacids can lead to false-negative results.
Introduction

▪ Endoscopy. Your doctor may use a scope to examine your upper digestive system
(endoscopy). During endoscopy, your doctor passes a hollow tube equipped with a lens
(endoscope) down your throat and into your esophagus, stomach and small intestine.
Using the endoscope, your doctor looks for ulcers.
If your doctor detects an ulcer, small tissue samples (biopsy) may be removed for
examination in a lab. A biopsy can also identify whether H. pylori is in your stomach
lining.
Your doctor is more likely to recommend endoscopy if you are older, have signs
of bleeding, or have experienced recent weight loss or difficulty eating and swallowing.
If the endoscopy shows an ulcer in your stomach, a follow-up endoscopy should be
performed after treatment to show that it has healed, even if your symptoms improve.
Introduction

▪ Upper gastrointestinal series. Sometimes called a barium swallow, this series of X-

rays of your upper digestive system creates images of your esophagus, stomach and
small intestine. During the X-ray, you swallow a white liquid (containing barium) that
coats your digestive tract and makes an ulcer more visible.
Treatment
Treatment for peptic ulcers depends on the cause. Usually treatment will involve
killing the H. pylori bacterium, if present, eliminating or reducing use of NSAIDs, if
possible, and helping your ulcer to heal with medication.
Introduction

Medications can include:

▪ Antibiotic medications to kill H. pylori. If H. pylori is found in your digestive tract, your doctor
may recommend a combination of antibiotics to kill the bacterium. These may include
amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl), tinidazole (Tindamax),
tetracycline (Tetracycline HCL) and levofloxacin (Levaquin).
▪ The antibiotics used will be determined by where you live and current antibiotic resistance
rates. You'll likely need to take antibiotics for two weeks, as well as additional medications
to reduce stomach acid, including a proton pump inhibitor and possibly bismuth
subsalicylate (Pepto-Bismol).
Introduction

▪ Medications that block acid production and promote healing. Proton pump inhibitors
— also called PPIs — reduce stomach acid by blocking the action of the parts of cells
that produce acid. These drugs include the prescription and over-the-counter
medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex),
esomeprazole (Nexium) and pantoprazole (Protonix).
▪ Long-term use of proton pump inhibitors, particularly at high doses, may increase your
risk of hip, wrist and spine fracture. Ask your doctor whether a calcium supplement
may reduce this risk.
Introduction

▪ Medications to reduce acid production. Acid blockers — also called histamine (H-2)
blockers — reduce the amount of stomach acid released into your digestive tract,
which relieves ulcer pain and encourages healing.
Available by prescription or over-the-counter, acid blockers include the
medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet HB) and
nizatidine (Axid AR).
▪ Antacids that neutralize stomach acid. Your doctor may include an antacid in your
drug regimen. Antacids neutralize existing stomach acid and can provide rapid pain
relief. Side effects can include constipation or diarrhea, depending on the main
ingredients.
Antacids can provide symptom relief, but generally aren't used to heal your ulcer.
Introduction

▪ Medications that protect the lining of your stomach and small intestine. In some
cases, your doctor may prescribe medications called cytoprotective agents that help
protect the tissues that line your stomach and small intestine.
Options include the prescription medications sucralfate (Carafate) and
misoprostol (Cytotec).
Introduction

▪ Follow-up after initial treatment

Treatment for peptic ulcers is often successful, leading to ulcer healing. But if
your symptoms are severe or if they continue despite treatment, your doctor may
recommend endoscopy to rule out other possible causes for your symptoms.
If an ulcer is detected during endoscopy, your doctor may recommend another
endoscopy after your treatment to make sure your ulcer has healed. Ask your doctor
whether you should undergo follow-up tests after your treatment.
▪ Ulcers that Fail to Heal
Peptic ulcers that don't heal with treatment are called refractory ulcers. There
are many reasons why an ulcer may fail to heal, including:
Introduction

▪ Not taking medications according to directions

▪ The fact that some types of H. pylori are resistant to antibiotics
▪ Regular use of tobacco
▪ Regular use of pain relievers — NSAIDs and aspirin — that increase the risk of ulcers
▪ Less often, refractory ulcers may be a result of:
▪ Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome
▪ An infection other than H. pylori
▪ Stomach cancer
▪ Other diseases that may cause ulcer-like sores in the stomach and small intestine,
such as Crohn's disease
▪ Treatment for refractory ulcers generally involves eliminating factors that may interfere with
healing, along with using different antibiotics.
Introduction

▪ If you have a serious complication from an ulcer, such as acute bleeding or a

perforation, you may require surgery. However, surgery is needed far less often than
previously because of the many effective medications now available.
Clinical Summary
A. GENERAL DATA PROFILE
NAME: PATIENT RKD
ADDRESS: CANDELARIA, QUEZON
BIRTHDAY: SEPTEMBER 14, 1990
BIRTH PLACE: CANDELARIA, QUEZON
SPOUSE NAME: JAA
NATIONALITY: FILIPINO
RELIGION: ROMAN CATHOLIC
OCCUPATIONS: FISH VENDOR
DATE OF ADMISSION: MARCH 6, 2019
ADMITTING DIAGNOSIS: ANEMIA SECONDARY TO BLEEDING PEPTIC ULCER DISEASE
ADMITTING PHYSICIAN: DR. PATRICIO, JAN MORRIS MISOLAS
Clinical Summary

B. CHIEF COMPLAINT:
Prior to admission the patient experienced abdominal pain, nausea and vomiting at
Brgy, Pahingahan Candelaria, Quezon. March 5, 2019 he admitted at Nursery Road, Masin
Norte Candelaria, Quezon then he transferred at Quezon Medical Center in Lucena, City on
March 6, 2019 at around 8:22 in the morning for laboratory purposes.
C. NURSING HISTORY
a. HISTORY OF PRESENT ILLNESS:
▪ Prior to admission the patient experienced abdominal pain, nausea and vomiting on his home
at Pahingahan, Candelaria, Quezon, and semi consciously he was brought to Quezon Medical
Center Lucena City, accompanied with his relatives. The doctor in charge ordered to have a
laboratory test to find the possible cause of his present illness.
▪ Physical assessment, Chest x-ray and other laboratory test was done. He was diagnosed
anemia secondary to bleeding peptic ulcer disease.
Clinical Summary

a. Childhood Illness:
- Fever, cough, and common cold.
b. Immunization:
- Hepatitis B, BCG, MMR
c. Allergies:
- No known allergies to foods and drugs
d. Incidents:
- Motor accident
e. Hospitalization:
- First time to be hospitalized
f. Medication currently taking:
-Tranexamic Acid 500mg
g. Domestic travel:
- The usual route of travel is within Candelaria, Quezon up to Batangas City to Lucena
City
Clinical Summary

▪ D. FAMILY HISTORY:

Mr. X Mrs. Y

PATIENT LEGEND:
Clinical Summary

E. SOCIAL HISTORY
ACCORDING TO ERIK ERIKSON
STAGE AGE CENTRAL INDICATORS INDICATORS
TASK OF NEGATIVE
POSITIVE OF
RESOLUTION RESOLUTION
YOUNG 18-40 YEARS INTEMACY VS Ability to give Persistent
ADULTHOOD OLD ISOLATION and receive love, aloneness/
commitments isolation,
and mutuality emotional distance
with others, in all relationship,
collaboration in prejudices against
work and others, lack of
affiliations established
sacrificing for vocation, and
others and seeking intimacy
responsible through causal
sexual behaviors. sexual encounter.
Clinical Summary

When it comes to Erickson’s theory, intimacy vs. isolation is stage six. This stage
happens in young adulthood and may trail off by middle age. This makes sense. When
you’re at this age, you’re probably starting college or thinking about your future. You’re
no longer in a high school where you can interact with people, so you want to have
relationship that can last. You’re no longer looking for a lovey-dovey romantic
relationship, but instead, one that you can be more intimate with. When it comes to
friendships, you want people you can spend a lifetime with and not just acquaintances.
You want to build connection to help your career.
Clinical Summary

F. ENVIRONMENT/ LIVING CONDITION

▪ Patient RKD is currently living in Brgy. Pahingahan Norte, Candelaria, Quezon,
together with his family. They live in a house made of wood and cement, near an
elementary school, away from the main road near Peter Paul Medical Center. The
patient claimed that there is no difficulty in seeking healthcare. Patient RKD has no
problems with going to church and to the market, which is near to their house.
Clinical Summary

▪ G. PHYSICAL ASSESMENT
PHYSICAL ASSESMENT NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION
GENERAL APPEARANCE o clear in appearance and o weak in appearance and o Patient loss weight due to
well groomed well groomed decrease appetite
o cooperative o in distress o Approximately 52 kg
o cooperative

SKIN o with good skin turgor o with poor skin turgor o Risk for fluid and electrolyte
imbalance
HAIR o evenly distributed hair o evenly distributed hair o Poor hygiene due to his
o thick hair o thick hair condition
o with hair color
o with no dandruff
Clinical Summary

NAILS o with good capillary refill of o Capillary refill 3 o Risk for fluid and electrolyte
1-2 seconds seconds imbalance
o with pinkish nail beds o With pallor nail beds
o with clean and short o With clean and short
o nails nails at normal angle
curvature
o Surrounding tissue were
intact and no lesions noted

SKULL AND FACE o mouth uniform consistency o mouth uniform consistency o

absence of nodules and absence of nodules and
masses masses
o rounded and smooth skull o rounded and smooth skull
contour contour
o symmetrical facial movement
Clinical Summary
EYES o no eye discharges o no eye discharges o fluid and electrolyte imbalance
o with pinkish conjunctiva o with pale conjunctiva
o eyebrows hair evenly distributed/skin o eyebrows hair evenly distributed/skin
intact intact
o symmetrical facial movement o with sunken eyeballs

EARS o Auricle color same as facial skin o Auricle color same as facial skin o
o Auricle are mobile firm and not tender o Auricle are mobile firm and not tender
o Able to hear both ears o Able to hear both ears
o no edema and discharges o no edema and discharges
Clinical Summary

MOUTH o pinkish lips o pale lips

o without missing teeth o with false teeth (upper)
o with pink gums o with pink gums
o no foul odor o with slightly foul odor
o with symmetrical contour o with symmetrical contour

MUSCULOSKETAL o symmetrical o symmetrical

(UPPER AND LOWER EXTREMETIES) o no atrophy o limited range of motion o upper and
o with full range of motion lower extremities
Clinical Summary

CHEST o Symmetrical o Normal chest expansion

o With normal sound
o Normal chest expansion

ABDOMEN o No abdominal distension o With epigastric pain o Epigastric pain from

o Flat rounded abdomen sores on stomach’s
o Symmetrical contour lining
o No surgical incision
Clinical Summary

▪ H. PATTERNS OF FUNCTIONING
FUNCTIONAL HEALTH PATTERN BEFORE DURING INTERPRETATION
HOSPITALIZATION HOSPITALIZATION
Health management pattern o Not hospitalized o First time hospital The patient and the family
admission was aware about the
condition of the patient due
to the first time admission
because anemia secondary to
bleeding peptic ulcer
disease.
Clinical Summary

Nutritional / Metabolic
o Number of meals per day o 3x a day o 3x a day o May at risk for
o Appetite
o Glass of water per day electrolyte imbalance
o Height and weight o Poor appetite o with good appetite and malnutrition
o 4x a day o 1 glass a day

o 5’2 o 5’2

o 55kgs o Approximately 52kgs

Elimination
o Frequency of urination o 5-6 x a day o 3x a day o Due to decreased
o Amount of urine per day
o Frequency of bowel movement intake, output also
o 1300 per day o 800ml /day decreased.
o Everyday o Every other day
 Clinical Summary

Activity and exercise o The patient gets easily

o Walking fatigue before and during
o Exercise o Walking
o Easily fatigue confinement.
o Fatigability o Not easily fatigue
o Activities of Daily Living o Walking / cleaning the
house

Cognitive/ Perceptual
o Orientation o Oriented to time place o Oriented o The patient is oriented and
o Responsiveness and person responds appropriately.
o Responds appropriately to
verbal and physical stimuli o Responds appropriately
Clinical Summary

Roles/ Relationship o Due to his sickness the

o A good son o Became aloof to his patient became aloof may
o As a son
o As brother o Kind family be because of the financial
o Caring burden she have caused.

Values/Beliefs o Patient believes in o Same as before o Patient is religious

god and always pray. and worships god.

Self-Perception / Self o Have a high self-worth / o Have a high self-worth o Patient still has high
Concept importance / importance self-worth in spite of his
incident he still think
that life is important that
should be lived
purposely.
Clinical Summary

Coping / stress o He seek for some o Patient is always o He has good coping
advice to his family talking to his family to techniques.
and friends lessen the stress
Clinical Summary

I. Course in the Ward

Date Medical Management Nursing Interventions Rationale
03-06-17 o Admitted o assessment of the patient care, o to give the best nursing care for the
9:20am o Vital signs q4 needs based on his perception of patient and assess the patient’s
o I and O q shift the illness is essential for the condition
o NPO provision of high quality nursing
o PNSS 1L FD 500cc then regulate at 100cc/hour care
o Labs: CBC, Na, ECG, BUN, ABO typing, o regulate IVF at prescribe rate
urinalysis, Crea, K, CXR o instructed not to eat until the o to replace fluid loss
o Meds: procedure is done o to have a further check on the
o Omeprazole 40mg IV OD o secure patient consent and explain patient’s condition accurately
o Plasil 1amp iv now the procedure to the patient o to avoid vomiting during the
o Tranexamic acid 500mg IV now then q8 prn o inform the patient about the procedure
o Inform attending physician medicine and its uses o to provide accurate information for
o Refer o observe the 10R’s the drug medication
o watch for any discrepancies o for health care provider awareness
to provide safety precautions to
patient and to avoid other
complications
o refer to ROD o to prescribed another order for
patient’s treatment
Clinical Summary

3-7-19 o To secure CBC result o instruct the o to provide accurate

o For scheduling of endoscopy procedure to the information about
with CBC result patient the procedure
o Facilitate BT o secure patient o for health care
o Refer consent and explain provider awareness
the procedure to the to provide safety
patient precautions to
o monitor blood patient and to avoid
pressure and other complications
allergic reaction o to avoid shock
Clinical Summary

3-8-19 o IVFF: PNSS 1L x 8HRS x 2cycles o regulate IVF at o to replace fluid loss
o Omeprazole drip 80mg + 80cc prescribe rate o for health care provider
PNSS x 10 hours x 3 cycles o inform the patient about awareness to provide
o Still for scheduling for endoscopy the medicine and its safety precautions to
o Continue present mgmt. uses patient and to avoid
o Refer o observe the 10R’s other complications
o Revise: o secure patient consent o to provide accurate
o Tranexamic acid to 1g IV q8 RTC and explain the information for the drug
o Vitamin K 1amp IV q8 RTC procedure to the patient medication
o Insure BT o refer to ROD
o Refer to Dr. Villamayor after 3rd o to prescribed another
blood or when blood is available order for patient’s
o For endoscopy treatment
Clinical Summary

3-9-19 o Facilitate pending BT o assessment of o to give the best

12pm o Continue present the patient care, nursing care for
management needs based on the patient and
his perception of assess the
the illness is patient’s
essential for the condition
provision of
high quality
nursing care
Clinical Summary

3-10-19 o IVFTF: PNSS 1L x 12hrs x2 o regulate IVF at o to replace fluid loss

cycles prescribe rate o to avoid vomiting
o NPO past midnight o Instructed not to eat during the procedure
o For scheduling of EGD o secure patient consent o for health care provider
o For EGD tom at MMG 10:30AM and explain the awareness to provide
o Shift omeprazole drip to procedure to the patient safety precautions to
omeprazole 40mg IV BID o inform the patient about patient and to avoid
the medicine and its other complications
uses o to provide accurate
o observe the 10R’s information for the drug
medication
Clinical Summary

3-11-19 o PNSS 1L x 12hrs x 2 cycles o regulate IVF at o to replace fluid loss

o May have soft diet prescribe rate o to provide accurate
o D/C omeprazole drip o inform the patient information for the
o Start omeprazole 40mg IV about the medicine drug medication
OD and its uses
o Still for EGD o observe the 10R’s
Clinical Summary

3-12-19 o IVFTF: PNSS 1L x 12hrs x 2 o regulate IVF at o to replace fluid loss

cycles prescribe rate o to avoid vomiting
o NPO past midnight o instructed not to eat during the
o For EGD tom 9am to MMG o secure patient procedure
o For CBC STAT consent and explain o for health care
o refer the procedure to the provider awareness
patient to provide safety
o refer to ROD precautions to
o D/C tranexamic patient and to avoid
acid 1amp other complications
o to prescribed
another order for
patient’s treatment
Clinical Summary

3-13-19 o MGH tom o give patient discharge o for proper executing of

o DAT DIET plans doctor’s order upon going
o Shift IV omeprazole 40mg 1amp to o give proper instruction on home
1g PO BID x 2 weeks then 1g PO OD how the medicines will be o for the patient to be able
for 1 ½ months taken @ home to follow on how the
o Start amoxicillin 500mg/cap 2 cap o Remind the patient about medicine will be taken
BID x 16 days the importance of follow- properly
o Clarithromycin 500mg 1 cap BID for up check-ups o for the patient to be able
14 days to obliged to have the
o Mebendazole 500mg tab 1 tab PO for follow-up check-up
1 dose only
o OPD Follow up 2 weeks QMC
OPD,WEDNESDAY 10-12nn
Clinical Summary

3-14-19 o still for MGH o instructed discharge o

plan and home meds

3-15-19 o Continue present mgmt. o assessment of the o to give the best nursing
patient care, needs care for the patient and
based on his perception assess the patient’s
of the illness is condition
essential for the
provision of high
quality nursing care
Clinical Summary

3-16-19 o Refer MGH o inform the patient o to provide accurate

o Pls give tranexamic acid 1g about the medicine information for the
now and its uses drug medication
o For repeat CBC STAT o observe the 10R’s
o Refer
Clinical Summary
3-17-19 o MGH tom o give patient discharge plans o for proper executing of
o DAT DIET o give proper instruction on doctor’s order upon going
o Shift IV omeprazole 40mg 1amp to 1g PO how the medicines will be home
BID x 2 weeks then 1g PO OD for 1 ½ taken @ home o for the patient to be able to
months o Remind the patient about the follow on how the medicine
o Start amoxicillin 500mg/cap 2 cap BID x importance of follow-up will be taken properly
16 days check-ups o for the patient to be able to
o Clarithromycin 500mg 1 cap BID for 14 obliged to have the follow-up
days check-up
o Mebendazole 500mg tab 1 tab PO for 1
dose only
o OPD Follow up 2 weeks QMC
OPD,WEDNESDAY 10-12nn
Clinical Summary
J. LABORATORY/DIAGNOSTIC EXAM

HEMTOLOGY (Candelaria, Quezon3-5-19)

RESULT REFERENCE Interpretation Implication Nursing responsibility
RANGE

HEMATOCRIT .32g/L .40-54g/L Decreased Risk for anemia o Monitor lab test
level o Monitor BP
WBC COUNT 12.5X10.9^/L 5000- Increased Can be sign of o Provide positive
reinforcement when the
10,000/cum level infection client seeks out others.
m o Assess physical and mental
status
o Provide safe and conducive
environment
Clinical Summary

SEGMENTERS .75% .40-65% High With Respiratory o Monitor VS every 2 hrs.

Segmenters Tract Infection o Encourage patient to
level position in high-
Fowler’s or semi-
Fowler’s position.
o Turn patient every 2 hrs.
and prn.
o Teach client to maintain
adequate hydration by
drinking at least 8-10
glasses of fluid/day (if
not contraindicated).
o Teach and supervise
effective coughing
techniques.
o Perform Chest Physical
therapy.
Clinical Summary

PROTHROMBIN 10.1 11.0-14.0 Increased Risk for o Monitor vital

TIME seconds level bleeding signs
o Monitor signs of
bleeding
Clinical Summary

URINALYSIS (CANDELARIA, QUEZON 3-5-19)

RESULT Interpretation Implication Nursing
responsibility

Color YELLOW dehydrated Can be sign of UTI o Monitor intake

and output
o Encourages
patient to
increased fluid
intake
Transparency HAZY Can be signs of o Monitor intake
infection and output
o Encourages
patient to
increased fluid
intake
Clinical Summary

CHEMICAL
Epithelial cells FEW Can be sign of o Encouraged fluid
infection intake
o Monitor I and O
o Instructed to
report full bladder

Mucus thread MODERATE Can be signs of o Monitor signs

infection of infection
Clinical Summary

CREATININE (3-06-19)
TEST VALUES REFERENCE Interpretation Implication Nursing
RANGE responsibility

UREA UV 25.7mg/Dl 7.18 Increased level Risk for o Encouraged

infection increased fluid
intake
o Monitor
intake and
output
Clinical Summary

(3-07-19)
Component Result Normal Interpretation Implication Nursing responsibility
range
WBC 11.98x 10^9/L 4,000-10,000 Increased Level Can be sign of infection o Provide positive
or stress reinforcement when
the client seeks out
others.
o Assess physical and
mental status
o Provide safe and
conducive
environment
Neu% 71.0% 50.0 - 60.0 Increased level Can be sign of infection o Prevent infection
or stress
o •Promote oral care
o •Promote hygiene
Clinical Summary
Lym% 19.0 % 35.0 - 45.0 Decreased level Lymphocytopenia o Minimize the risk
of infection
o Observing for
signs of infection.
o Provide patient
emotional support

Mon% 7.0 % 2.0 - 4.0 Increased level Can be sign of o Prevent infection
infection or stress
o Promote oral care
o Promote hygiene
Clinical Summary
Eos% 3.0 % 2.0 - 5.0 Decreased level Sign of infection o Rest between
activities.
o Plan ahead and save
your energy for the
most important
activities.
o Avoid or stop
activities that make
you short of breath or
make your heart beat
faster.
RBC 1.99X10^12/L 4.00 - 5.50 Decreased Level o Low oxygen level o Assess vital signs,
respiratory and
cardiovascular
systems, and level of
consciousness
Clinical Summary

HGB 5.3g/dl 12.0 - 16.0 Decreased Level o Polycythemia o Medication to

decrease blood
cells.
o Therapy to reduce
itching.

HCT 16.0% 40.0 - 54.0 Decreased Level Risk for anemia o Monitor lab test
o Monitor BP

MCH 26.6 pg 27.0 - 34.0 Decreased Level Low concentration o Monitor BP

o Monitor lab results
Clinical Summary

PCT 0.162 % 0.108- - Increased level o Low risk of sepsis o Monitor client’s
0.282 temperature
o Administer
antipyretic as
ordered
o Adjust
environmental
factors as
indicated
Clinical Summary

PTT (3-08-19)
RESULT REFERENCE Interpretation Implication Nursing Responsibility
RANGE
PROTHROMBIN 10.1 11.0-14.0 seconds Decreased level o Risk for o Monitor vital signs
TIME bleeding o Monitor bleeding
Clinical Summary

(3-13-19)
Component Result Normal range Interpretation Implication Nursing responsibility
Neu% 69.0% 50.0 - 60.0 Increased Level Can be sign of infection or stress o Prevent infection

o Promote oral care

o Promote hygiene

Lym% 20.0 % 35.0 - 45.0 Decreased level Lymphocytopenia o Minimize the risk of
infection
o Observing for signs of
infection.
o Provide patient emotional support

Mon% 7.0 % 2.0 - 4.0 Increased level Can be sign of infection or stress o Prevent infection

o Promote oral care

o Promote hygiene
HCT 39.1% 40.0 - 54.0 Decreased Level Risk for anemia o Blood transfusion as order
o Monitor BP
RDW-CV 17.5 % 11.0 - 16.0 Increased Level Can be signs of anemia o Monitor family history of anemia
o Monitor BP
o Administer vitamin B12
RDW-SD 57.7 fl 35.0 - 56.0 Increased Level Can be signs of anemia o Monitor signs of anemia
o Administer iron supplement as
prescribed
Clinical Summary
HEMATOLOGY (3-16-19)
RESULTS NORMAL REMARKS Implication Nursing intervention
TEST VALUES

HEMOGLOBIN 11.8g/dL 12-16 Decreased Level o Risk for o Blood transfusion

anemia o Monitor BP

HEMATOCRIT 36.2% 40-54 Decreased Level o Risk for o Administer

anemia intravenous iron as
prescribed
o Administer
medication that
stimulate production
of RBC
MCV 79.0Fl 80-100 Decreased Level Indicated o Administer iron
microcytic or supplement
small RBC  Monitor signs of
size hyponatremia
Clinical Summary
MCH 25.6pg 27-34 Decreased Level Can be signs of anemia  Monitor BP
 Monitor lab result: CBC

Rdw-cv 18.1% 11-16 Increased Level Can be signs of anemia  Monitor family history of
anemia
 Monitor BP
 Administer vitamin B12

Neu% 75% 50-60 Increased Level Can be sign of • Prevent infection

infection or stress  •Promote oral care
 Promote hygiene

Lymp% 15% 35-45 Decreased Level Can be sign of  Provide positive reinforcement
infection when the client seeks out others.
 Assess physical and mental
status
 Provide safe and conducive
environment
Clinical Summary

Mon% 5% 2-4 Increased Level Can be sign of  Prevent infection

infection or  Promote oral care
stress  Promote hygiene

IMPRESSION (3-06-19)
•Clear lung fields
•Normal heart shadow
•Diaphragm, osseous structures and soft tissues are intact
•Normal chest study
Clinical Discussion Of The Disease

1. ANATOMY AND PHYSIOLOGY

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from
the oral cavity, where food enters the mouth, continuing through the pharynx,
esophagus, stomach and intestines to the rectum and anus, where food is expelled.
There are various accessory organs that assist the tract by secreting enzymes to help
break down food into its component nutrients. Thus the salivary glands, liver, pancreas
and gall bladder have important functions in the digestive system. Food is propelled
along the length of the GIT by peristaltic movements of the muscular walls.
Clinical Discussion Of The Disease
Clinical Discussion Of The Disease

The primary purpose of the gastrointestinal tract is to break food down into
nutrients, which can be absorbed into the body to provide energy. First food must be
ingested into the mouth to be mechanically processed and moistened. Secondly,
digestion occurs mainly in the stomach and small intestine where proteins, fats and
carbohydrates are chemically broken down into their basic building blocks. Smaller
molecules are then absorbed across the epithelium of the small intestine and
subsequently enter the circulation. The large intestine plays a key role in reabsorbing
excess water. Finally, undigested material and secreted waste products are excreted
from the body via defecation (passing of feces).
In the case of gastrointestinal disease or disorders, these functions of the
gastrointestinal tract are not achieved successfully. Patients may develop symptoms
of nausea, vomiting, diarrhea, malabsorption, constipation or obstruction.
Gastrointestinal problems are very common and most people will have experienced
some of the above symptoms several times throughout their lives.
Clinical Discussion Of The Disease

Stomach
The stomach is a J shaped expanded bag, located just left of the midline
between the oesophagus and small intestine. It is divided into four main regions and
has two borders called the greater and lesser curvatures. The first section is the cardia
which surrounds the cardial orifice where the oesophagus enters the stomach. The
fundus is the superior, dilated portion of the stomach that has contact with the left
dome of the diaphragm. The body is the largest section between the fundus and the
curved portion of the J.
This is where most gastric glands are located and where most mixing of the food
occurs. Finally the pylorus is the curved base of the stomach. Gastric contents are
expelled into the proximal duodenum via the pyloric sphincter. The inner surface of the
stomach is contracted into numerous longitudinal folds called rugae. These allow the
stomach to stretch and expand when food enters. The stomach can hold up to 1.5 liters
of material. The functions of the stomach include:
Clinical Discussion Of The Disease

1. The short-term storage of ingested food.

2. Mechanical breakdown of food by churning and mixing motions.
3. Chemical digestion of proteins by acids and enzymes.
4. Stomach acid kills bugs and germs.
5. Some absorption of substances such as alcohol.
Most of these functions are achieved by the secretion of stomach juices by gastric
glands in the body and fundus. Some cells are responsible for secreting acid and others
secrete enzymes to break down proteins.
Clinical Discussion Of The Disease

Small intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It
averages approximately 6m in length, extending from the pyloric sphincter of the
stomach to the ileo-caecal valve separating the ileum from the caecum. The small
intestine is compressed into numerous folds and occupies a large proportion of the
abdominal cavity.
The duodenum is the proximal C-shaped section that curves around the head of
the pancreas. The duodenum serves a mixing function as it combines digestive
secretions from the pancreas and liver with the contents expelled from the stomach.
The start of the jejunum is marked by a sharp bend, the duodenojejunal flexure. It is in
the jejunum where the majority of digestion and absorption occurs. The final portion,
the ileum, is the longest segment and empties into the caecum at the ileocaecal
junction.
Clinical Discussion Of The Disease
Clinical Discussion Of The Disease

The small intestine performs the majority of digestion and absorption of

nutrients. Partly digested food from the stomach is further broken down by enzymes
from the pancreas and bile salts from the liver and gallbladder. These secretions enter
the duodenum at the Ampulla of Vater. After further digestion, food constituents such
as proteins, fats, and carbohydrates are broken down to small building blocks and
absorbed into the body’s blood stream.
The lining of the small intestine is made up of numerous permanent folds called
plicae circulares. Each plica has numerous villi (folds of mucosa) and each villus is
covered by epithelium with projecting microvilli (brush border). This increases the
surface area for absorption by a factor of several hundred. The mucosa of the small
intestine contains several specialized cells. Some are responsible for absorption, whilst
others secrete digestive enzymes and mucous to protect the intestinal lining from
digestive actions.
Clinical Discussion Of The Disease

Background of Peptic Ulcer Disease

Gastric and duodenal ulcers usually cannot be differentiated based on history
alone, although some findings may be suggestive. 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, shortly after meals with gastric
ulcer and 2-3 hours afterward with duodenal ulcer.
In uncomplicated peptic ulcer disease (PUD), the clinical findings are few and
nonspecific. “Alarm features" that warrant prompt gastroenterology referral include
bleeding, anemia, early satiety, unexplained weight loss, progressive dysphagia or
odynophagia, recurrent vomiting, and family history of gastrointestinal (GI) cancer.
Patients with perforated PUD usually present with a sudden onset of severe, sharp
abdominal pain.
Clinical Discussion Of The Disease

In most patients with uncomplicated PUD, routine laboratory tests usually are
not helpful; instead, documentation of PUD depends on radiographic and endoscopic
confirmation. Testing for H pylori infection is essential in all patients with peptic ulcers.
Rapid urease tests are considered the endoscopic diagnostic test of choice. Of the
noninvasive tests, fecal antigen testing is more accurate than antibody testing and is
less expensive than urea breath tests but either is reasonable. A fasting serum gastrin
level should be obtained in certain cases to screen for Zollinger-Ellison syndrome.
Upper GI endoscopy is the preferred diagnostic test in the evaluation of patients
with suspected PUD. Endoscopy provides an opportunity to visualize the ulcer, to
determine the presence and degree of active bleeding, and to attempt hemostasis by
direct measures, if required. Perform endoscopy early in patients older than 45-50
years and in patients with associated so-called alarm features.
Clinical Discussion Of The Disease
Most patients with PUD are treated successfully with cure of H pylori infection and/or
avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs), along with the appropriate use of
antisecretory therapy. In the United States, the recommended primary therapy for H pylori
infection is proton pump inhibitor (PPI)–based triple therapy. These regimens result in a cure of
infection and ulcer healing in approximately 85-90% of cases. Ulcers can recur in the absence of
successful H pylori eradication.
In patients with NSAID-associated peptic ulcers, discontinuation of NSAIDs is
paramount, if it is clinically feasible. For patients who must continue with their NSAIDs, proton
pump inhibitor (PPI) maintenance is recommended to prevent recurrences even after
eradication of H pylori. [3, 4] Prophylactic regimens that have been shown to dramatically
reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin
analog or a PPI. Maintenance therapy with antisecretory medications (eg, H2 blockers, PPIs) for
1 year is indicated in high-risk patients.
The indications for urgent surgery include failure to achieve hemostasis endoscopically,
recurrent bleeding despite endoscopic attempts at achieving hemostasis (many advocate
surgery after 2 failed endoscopic attempts), and perforation. Patients with gastric ulcers are
also at risk of developing gastric malignancy.
Clinical Discussion Of The Disease

Anatomy
Because many surgical procedures for peptic ulcer disease (PUD) entail some type of
vagotomy, a discussion concerning the vagal innervation of the abdominal viscera is
appropriate (see image below). The left (anterior) and the right (posterior) branches of
the vagus nerve descend along either side of the distal esophagus. As they enter the
lower thoracic cavity, they can communicate with each other through several cross-
branches that comprise the esophageal plexus. However, below this plexus, the 2 vagal
trunks again become separate and distinct before the anterior trunk branches to form
the hepatic, pyloric, and anterior gastric (also termed the anterior nerve of Latarjet)
branches. The posterior trunk branches to form the posterior gastric branch (also
termed the posterior nerve of Latarjet) and the celiac branch.
Clinical Discussion Of The Disease

The parietal cell mass of the stomach is segmentally innervated by the terminal
branches from each of the anterior and posterior gastric branches. These terminal
branches are divided during highly selective vagotomy. The gallbladder is innervated
from efferent branches of the hepatic division of the anterior trunk. Consequently,
transection of the anterior vagus trunk (performed during truncal vagotomy) can result
in a dilated gallbladder with inhibited contractility and subsequent cholelithiasis. The
celiac branch of the posterior vagus innervates the entire midgut (with the exception of
the gallbladder). Thus, division of the posterior trunk during truncal vagotomy may
contribute to postoperative ileus.
Clinical Discussion Of The Disease

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.
Clinical Discussion Of The Disease

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 nonsteroidal anti-inflammatory drugs (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, bicarbonate,
mucosal blood flow, cellular restitution, and epithelial renewal.
The gram-negative spirochete H pylori was first linked to gastritis in 1983. Since
then, further study of H pylori has revealed that it is a major part of the triad, which
includes acid and pepsin that contributes to primary peptic ulcer disease. The unique
microbiologic characteristics of this organism, such as urease production, allows it to
alkalinize its microenvironment and survive for years in the hostile acidic environment
of the stomach, where it causes mucosal inflammation and, in some individuals,
worsens the severity of peptic ulcer disease.
Clinical Discussion Of The Disease

When H pylori colonizes the gastric mucosa, inflammation usually results. The causal
association between H pylori gastritis and duodenal ulceration is now well established in the
adult and pediatric literature. In patients infected with H pylori, high levels of gastrin and
pepsinogen and reduced levels of somatostatin have been measured. In infected patients,
exposure of the duodenum to acid is increased. Virulence factors produced by H pylori, including
urease, catalase, vacuolating cytotoxin, and lipopolysaccharide, are well described.
Most patients with duodenal ulcers have impaired duodenal bicarbonate secretion,
which has also proven to be caused by H pylori because its eradication reverses the defect. The
combination of increased gastric acid secretion and reduced duodenal bicarbonate secretion
lowers the pH in the duodenum, which promotes the development of gastric metaplasia (ie, the
presence of gastric epithelium in the first portion of the duodenum). H pylori infection in areas
of gastric metaplasia induces duodenitis and enhances the susceptibility to acid injury, thereby
predisposing to duodenal ulcers. Duodenal colonization by H pylori was found to be a highly
significant predictor of subsequent development of duodenal ulcers in one study that followed
181 patients with endoscopy-negative, nonulcer dyspepsia.
Clinical Discussion Of The Disease
Clinical Discussion Of The Disease
2. PATHOPHYSIOLOGY (BOOK BASED/CLIENT BASED)
Clinical Discussion Of The Disease
PATHOPHYSIOLOGY (client based)

Excessive caffeine intake

Stress
Male
H. Pylori Infection
Type “O” blood
 Clinical Discussion Of The Disease
DRUG ACTION INDICATION CONTRAINDI DOSAGE SIDE EFFECT NURSING CONSIDERATION

CATION

BRAND Gastric acid-pump inhibitor: Short-term : Contraindicated with hypersensitivity to 40mg TIV CNS :  Assess Vital Signs
Suppresses gastric acid secretion by omeprazole or its components.Use  Check for abdominal Pain,
NAME : specific inhibition of the hydrogen- treatment of active duodenal ulcer;First- cautiously with pregnancy,lactation Headache, dizziness, asthenia, emesis, Diarrhea or
potassium ATPase enzyme system line therapy in treatment of heartburn or vertigo,insomnia, constipation.
Omeprazole symptoms of gastroesophageal reflux
at the secretory surface of the  Evaluate fluid and intake
disease (GERD); apathy,anxiety,
gastric parietal cells; blocks the  Watch for elevated liver
final step of acid production paresthesias,dream abnormalities function test results
treatment of active benign gastric ulcer;
GENERIC  Tell patient to take 30-60
Dermatologic Rash, minutes before a meal,
NAME :
preferably in morning.
inflammation, urticaria,pruritus,
Losec GERD, severe erosive esophagitis, poorly  Instruct patient to swallow
responsive symptomatic GERD; alopecia, dry skin
capsules or tablets whole and
GI: no to chew or crash them.
 Caution patient to avoid
CLASSIFI Diarrhea, abdominal pain, nausea, driving and other hazardous
Long-term :
CATION : vomiting,constipation,dry activities until he know drug
Treatment of pathologic hyper secretory mouth,tongue atrophy Respiratory effects concentration and
Antisecretory drug conditions (Zollinger-Ellison syndrome, alertness
multipl eadenomas, systemic URI symptoms, cough, epistaxis
mastocytosis); Other :
FREQUENCY: Eradication of H. pylori with amoxicillin or Cancer in preclinical studies,back pain,
metronidazole and clarithromycin fever
OD
Clinical Discussion Of The Disease
DRUG ACTION INDICATION CONTRAINDI DOSAGE SIDE EFFECT NURSING
CONSIDERATION
CATION
Generic Name Stimulates motility of - Relief of symptoms of acute  Concentrations 10 mg IV TID x PRN CNS:  Observe 15 rights in
upper GI tract without and recurrent diabetic  Allergy to drug administration.
Metoclopramide Restlessness, drowsiness,
stimulating gastric, gastroparesis- Short-term metoclopramide  Assess for allergy to
fatigue, lassitude,
Trade Name billiary, or pancreatic therapy for adults with  GI hemorrhage metoclopramide.
insomnia, extra pyramidal
secretions; appears to symptomatic GERD who fail  Mechanical obstruction  Assess for other
Reglan, Maxolon reactions, parkinsonism-
sensitize tissues to action to respond to conventional or perforation contraindications.
like reactions, akathisia,
Classification: of acetylcholine; relaxes therapy- Prevention of nausea  Pheochromocytoma  Keep
dystonia, myoclonus,
pyloric sphincter, which, and vomiting associated with  Epilepsy diphenhydramine
Dopaminergic dizziness, anxiety
when combined with emetogenic cancer injection readily
blocker available in case
effects on motility, chemotherapy- Prophylaxis of
accelerates gastric postoperative nausea and extra pyramidal
emptying and intestinal vomiting when nasogastric reactions occur (50
transit; little effect on suction is undesirable- mg IM).
gallbladder or colon Facilitation of small-bowel  Have phentolamine
motility; increases lower intubation when tube does not readily available in
esophageal sphincter pass the pylorus with case of hypertensive
pressure; has sedative conventional maneuvers crisis.
properties; induces
release of prolactin
Clinical Discussion Of The Disease
DRUG ACTION INDICATION CONTRAINDI DOSAGE SIDE EFFECT NURSING
CONSIDERATION
CATION
Generic name: Promote hepatic formation Anticoagulant-induced Hypersensitivity to any 1amp Transient "flushing  Oral administration is
of coagulation, factors II, prothrombin deficiency caused component of this medication sensations" and "peculiar" the safest and
Phytonadione
VII, IX, X essential for by coumarin or indanedione sensations of taste have been requires the presence
Brand Name: normal clotting of blood, derivatives; observed, as well as rare of bile salts for
readily absorbed from GI instances of dizziness, rapid absorption
Vitamin K •Prophylaxis and therapy of  It should be given by
tract, after IM, and weak pulse, profuse
hemorrhagic disease of the very slow IV
Frequency: q8 subcutaneous sweating, brief hypotension,
newborn; injection, or where
administration dyspnea, and cyanosis.
•hypoprothrombinemia due to appropriate, with
anti-bacterial therapy continuous infusion
of NaCl0.9% or
dextrose5% into the
lower section of the
infusion set
 Must note whether
client has allergic
reaction with vitamin
K
Clinical Discussion Of The Disease
DRUG ACTION INDICATION CONTRAINDI DOSAGE SIDE EFFECT NURSING
CONSIDERATION
CATION

Brand name: Plasil it blocks dopamine prevention of hypersensitivity, possible 1amp CNS:  Assess client for
receptors and makes chemotherapy-induced obstruction or hemorrhage, abdominal pain
Generic name: drowsiness,
the GI cells more emesis, treatment of history of seizure disorders, distention, bowel
extrapyramidal reactions,
Metoclopramide sensitive to postsurgical and diabetic pheochromocytoma, sound
restlessness, anxiety,
acetylcholine, leading gastric stasis, facilitation of Parkinson’s disease  Assess client for
Classification: depression, irritability,
to increased GI activity small bowel intubations in extrapyramidal
tardive dyskinesia
Anti-emetics and rapid movement of radiographic procedures, reactions
food through the upper management of esophageal CV:  Monitor for
Frequency: now tardive dyskinesia
GI tract reflux, treatment and
arrhythmias,
prevention of postoperative
hypertension,
nausea and vomiting when
hypotension
nasogastric suctioning is
undesirable GI:
constipation, diarrhea,
dry mouth, nausea
Endo:
Gynecomastia
Clinical Discussion Of The Disease
DRUG ACTION INDICATION CONTRAINDI DOSAGE SIDE EFFECT NURSING
CONSIDERATION
CATION
Brand name: forms a reversible Anti hemorrhagic and Patients predisposed to 500mg, IV  Gastrointestinal  >Assess patient’s
Hemostan complex that displaces antifibrinolytic for effective thrombosis. Prophylaxis during disturbances history, if with active
plasminogen from fibrin hemostasis in various surgical pregnancy and before delivery.  Hypotension intravascular clotting,
Generic name:
resulting in inhibition of and clinical cases, in traumatic Form particularly after rapid predisposed to
Tranexamic acid
fibrinolysis, it also inhibits injuries, post-tooth extraction  IV administration thrombosis;
classification: the proteolytic activity of and other dental procedures.  Thrombotic hemorrhage due to
plasmin complications have disseminated
Anti hemophilic agent been reported. intravascular
 Instances of transient coagulation
Frequency:
disturbance of colour  Monitor
Q8 x RTC vision associated with anticoagulant cover
its use.  Perform eye
examination
 >Perform liver
function tests
 Perform blood tests
 Obtain prothrombin
time of the patient
 Clinical Discussion Of The Disease
DRUG ACTION INDICATION CONTRAINDI DOSAGE SIDE EFFECT NURSING CONSIDERATION

CATION
GENERIC NAME: Prevents bacterial cell wall Treatment of infection of Hypersensitivity to 500mg Vomiting  Advise the patient’s family to
synthesis during replication. respiratory tract, skin &skin penicillins,cephalosparins, or take the medication with meals
amoxicillin Nausea
Bactericidal structures,genitourinary tract, imipenem.Not used to treat for better absorption& to reduce
BRAND NAME: otitismedia, severepneumonia, Abdominal pain GI discomfort.
meningitis,septicemia, empyema,bacteremia,  Instruct the patient’s family to
Amoxil sinusitis,bacterial pericarditis,meningitis and Diarrhea take medication as prescribed
CLASSIFICATION: endocarditisprophylaxis purulent or septic arthritis during even after feeling better and not
acutestage to double dose.
 Teach the patient’s family to
Anti-infective Drug . report sore throat, bruising,
FREQUENCY: bleeding and joint pain, this may
indicate bloodyscrasias.
BID  Advise patient’s family to watch
out for perineal itching, fever,
malaise, redness, pain, swelling,
drainage, rash, diarrhea, change
in cough, sputum or furry
tongue, this may indicate super
infection.
 Advise patient’s family to report
bloody, mucoid diarrhea which
may indicate pseudomembranous
colitis
Clinical Discussion Of The Disease
DRUG ACTION INDICATION CONTRAINDI DOSAGE SIDE EFFECT NURSING
CONSIDERATION
CATION
GENERIC NAME: Inhibits proteinsynthesis Treatment of upper Contraindicated with 500mg 1cap gastrointestinal (GI) effects,  Take drug with food if
insusceptible respiratoryinfections caused by general GI effects occur.
hypersensitivity to  Take the full course of
Biaxin, Biaxin XL bacteria,causing celldeath
S. pyogenes,S. pneumonia abnormal taste therapy.
clarithromycin,
BRAND NAME: > Treatment of lower diarrhea  Do not drink grapefruit
erythromycin, or any juice while taking this
respiratoryinfections caused by
Clarithromycin nausea drug.
macrolide antibiotic.
Mycoplasmapneumoniae,S.  Shake suspension
CLASSIFICATION: vomiting
pneumoniae, H. influenzae, M. Use cautiously with before use; do not
catarrhalis elevated blood urea nitrogen refrigerate; do not
colitis, hepatic or renal cut,crush, or chew
Macrolide antibiotic (BUN)
>Treatment of skin and
impairment, tablets; swallow whole.
FREQUENCY: structureinfections caused by
 These side effects may
S. aureus,S.pyogenes pregnancy, lactation occur: Stomach
BID
cramping, discomfort,
diarrhea; fatigue,
headache (medication
may be ordered);
additional infections in
the mouth or vagina
(consult with care
provider for treatment).
 Report severe or
watery diarrhea,severe
nausea or
vomiting, rash or itching,
mouth sores, vaginal
sores
Clinical Discussion Of The Disease
DRUG ACTION INDICATION CONTRAINDI DOSAGE SIDE EFFECT NURSING
CONSIDERATION
CATION
GENERIC Mebendazole is used indicated for the Safety during pregnancy 500mg 1tab stomach/abdominal  Monitor allergic
NAME: to treat intestinal treatment of patients two (category C), lactation, pain, to mediccation
worm infections years of age and older or in children <2 y is not  Monitor side
Mebendazole vomiting,
such as pinworm, with gastrointestinal established. effects of
BRAND NAME: roundworm, and infections caused by diarrhea, medication
Vermox hookworm. Ancylostoma duodenale  Identify the
fever,
(hookworm), Ascaris patient’s allergic
CLASSIFICATI lumbricoides headache, to medication
ON: (roundworm), Enterobius and the
Dizziness, or
antiinfective vermicularis (pinworm), drowsiness. medication
Necator americanus s/he’s taking
FREQUENCY:
(hookworm), and
BID Trichuris trichiura
(whipworm).
Clinical Discussion Of The Disease
TYPE OF CLASSIFICATION CONTENT ACTION CONTRAINDICATION HOW TO APPLIED DOSAGE NURSING
SOLUTION RESPONSIBILITY
Brand name: Isotonic Intravenous Solution It contains no Normal Saline is a Used because it has little to no effect Heart failure- 1000/500ml 1. Monitor patient frequently
antimicrobial agents. sterile, nonpyrogenic on the tissues and make the person Pulmonary edema- or:
Plain NSS solution for fluid and feel hydrated preventing Renal impairment- DOSE :
-The pH is 5.0 (4.5 electrolyte hypovolemic shock or hypotension Sodium retention a. Signs of
Other name: to7.0). 41-42 infiltration/sluggish flow
0.9%Sodium Chloride replenishment
Solution -It contains 9 g/L gtts/min b. signs of
Sodium Chloride with an phlebitis/infection
osmolality of
308mOsmol/L.-It c. well time of catheter and
contains 154mEq/L need to be replaced
Sodium and Chloride. d. Condition of catheter
dressing.

2. Check the level of the IVF.

a. Correct solution,
medication and volume.

b. Check and regulate the

drop rate.

c. Change the IVF solution if

needed.

d. Do not connect flexible

plastic
Nursing Process

▪ A. LONG TERM OBJECTIVES

The study aims to relieve abdominal pain, provide adequate nutrition and prevent
complications of the client through collaborative management with physician therapist
associate with the nutritionist.
▪ B. PRIORITIZED LIST NURSING PROBLEM
Nursing Process

PROBLEM RANKING JUSTIFICATION

Fluid volume deficit related to gastro intestinal bleeding as 1 We prioritized this because gastro intestinal bleeding can
manifested by bloody vomit and stool and cool, clammy skin cause shock and bloody vomit and stool can dehydration

Fatigue related to decreased hemoglobin and diminished 2 We rank this as the second priority because it can caused
oxygen-carrying capacity of the blood as evidenced by respiratory distress because of decreased blood that carry
reported lack of energy oxygen all over the body

Risk for fluid and electrolyte imbalanced related to 3 Fluid and electrolytes are importance in our body, we rank
inadequate dietary intake this as 3rd to be priority because if it’s not treated the patients
will become dehydrated
As manifested by poor skin turgor

Risk for imbalanced nutrition: less than body requirement 4 Although this is under physiologic needs of a human we
related to inadequate dietary intake as manifested by body ranked this as the fourth priority, it should be the first thing to
weakness and loss of weight be managed because it can be fatal if left untreated

Altered comfort related to abdominal pain as evidenced by 5 We rank this as fifth priority because abdominal pain can
facial grimace and guarding behaviour with pain scale of cause discomfort to the patient and can lead to lack of
8/10 participation

Knowledge deficit related to current condition and treatment 6 Knowledge deficit is less priority among others because this
as evidenced by frequent inquiries help the patient understand about the condition
 Nursing Process
During admission on March 06, 2019

Abdominal pain
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Altered comfort related to After 8 hours of nursing  note site of pain, duration,  pain is not always Goal has partially met: the patient
abdominal pain as evidenced intervention the patient will intensity and frequency (0-10) present, but if present verbalized pain was relieved and
“masakit ang sikmura ko” as
by facial grimace and verbalize the pain will be  review factors that can alleviate should be compared with demonstrated relaxed body posture
verbalized by the patient
guarding behavior with pain relief, demonstrate relax pain previous pain. This
 Pain scale 5/10
Objective: scale of 8/10 posture  identify and limit foods that comparison may assist in
creation discomfort such as spicy diagnosis of etiology of
 Pain scale 6/10 and carbonated drinks bleeding and development
 Facial grimace  encourage frequent meals of complication
 Guarding abdomen  encourage patient to assume  helpful in stablishing
 Irritability position and comfort diagnosis and treatment
 restlessness needs
 foods has an acid
neutralizing effect and
dilutes the gastric content
 small meal prevent
distention and the release
of gastrin
 reduces abdominal
tension and promote
sense of control
Nursing Process
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for imbalanced After 6 hours of nursing  Ascertain understanding of  To determine After nursing intervention the
nutrition: less than body interventions client will individual nutritional needs informational needs of patient was able to verbalized
“ilang araw na po akong hindi
requirement related to verbalize understanding  Assess weight, measure or client. understanding about causative
nakakakain kaya pakiramdam
inadequate dietary intake of causative factors and calculate body fat and muscle  To establish baseline factors and necessary
ko hinang hina ako” as
as manifested by body necessary interventions mass and other parameters. interventions to promote
verbalized by the patient
weakness and loss of to promote optimum anthropometric  Indicates protein- optimum nutrition
Objective: weight nutrition measurements. energy malnutrition.
 Observe for absence of  To monitor
 Weak in appearance subcutaneous fat and muscle effectiveness of efforts
 weight loss from 55kg to wasting, hair loss, fissuring of and dietary plans.
approximately 52kg nail, delayed healing of
 NPO for 8 days wounds, gum bleeding or
swollen abdomen.
 Weight regular and graph
results.
Nursing Process
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for fluid and  After 8 hours of  Monitor vital signs  To obtain After doing the necessary
electrolyte nursing  Assess for the signs of baseline data nursing interventions and
”hindi pa ako umiinom”
imbalanced related to intervention the dehydration including  This will provide teachings, the client:
as verbalized by the
inadequate dietary client exhibit skin turgor, oral a data that could
patient Achieved appropriate urine
intake signs of mucosa, etc be used to
output
Objective: improvement in  Regulate IVF as evaluate the
As manifested by
hydration status prescribed rate proper Participated in health teaching
 Poor skin turgor poor skin turgor
 Review ways to  Monitor I & O intervention that
 Dry mucous Demonstrated use of relaxation
membrane improve the  Keep a quiet the client needs.
skills to reduce anxiety
client’s environment and calm  To replaced fluid
 Sunken eyeball
 Capillary refill at 3 hydration status activities loss
seconds  Ensure that the  Provide health  To reduce the
client is teachings on avoidance dryness of the
 Weight loss from
55kg to receiving right of dehydration oral mucosa
amount of   To reduce stress
approximately 52kg
 NPO for 8 days maintenance and anxiety
fluids  To promote
awareness on
related factors
 Nursing Process
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjection: Knowledge deficit related After 8 hours of nursing  Assess the client’s knowledge  Clients may have inaccurate Goal met: the patient verbalized
to current condition and interventions, the patient and misconceptions regarding peptic information about how lifestyle understanding of the disease
“may dugo po ang dumi ko, nag ulcer disease, lifestyle behaviors, and behaviors contribute to peptic ulcer
treatment as evidenced by will able to verbalize process and treatment regimen
aalala po ako, ano po kayang the treatment regimen. Explain the disease.
frequent inquiries understanding of the disease
ibig sabihin” as verbalized by pathophysiology of disease and how it  An understanding of the disease
process and treatment
the patient relates to the functioning of the body. process helps to foster the willingness
regimen
 Instruct the client in what signs and to follow the recommended treatment
symptoms to report to the health care plan and modify behaviors to prevent
Objective: provider. recurrent episodes or related
 Discuss the therapy options and the complications.
 Frequent inquiries about
rationales for using these options.  Recognizing the signs and symptoms
his condition
 Discuss the lifestyle changes required can help ensure the early initiation of
approximately 4-5 times
to prevent further complications or treatment.
every shift
episodes of peptic ulcer disease.  The correct use of antibiotics and acid
suppression medications can promote
rapid healing of an ulcer.
 The modifications of lifestyle
behaviors such as alcohol use, coffee,
and other caffeinated beverages, and
the overuse of aspirin or other
nonsteroidal anti-inflammatory drugs
is necessary to prevent recurrent ulcer
development and prevent
complications during the healing
phase.
Nursing Process

D. Discharge Plan (M.E.T.H.O.D)

▪ Medication
Advised patient to take the prescribed medication continuously at home.
Always check the expiration date of the medicine before taking.
Nursing Process
Name of Drug Dosage & Frequency Route Curative Effects Side Effects
Amoxicillin 500mg BID PO Anti-infective Drug Vomiting

Nausea

Abdominal pain

Diarrhea
Clarithromycin 5000mg BID PO Anti-biotic gastrointestinal (GI) effects, general abnormal
taste, diarrhea

nausea

vomiting

elevated blood urea nitrogen (BUN)

Mebendazole 500mg BID PO Anti-ineffective stomach/abdominal pain, vomiting,

diarrhea,

fever,

headache,

dizziness, or

drowsiness
Omeprazole 1g PO Anti-secretory drugs Headache, dizziness, asthenia, vertigo,insomnia,

apathy,anxiety,

paresthesias,dream abnormalities

Dermatologic Rash,

inflammation,
Nursing Process

▪ Environment/Exercise
Type of Activity allowed/ to be continued:
Deep Breathing Exercises
Encouraged to do physical exercise

▪ Therapy/Treatment
Comply with medications
Increase Fluid Intake
Have small meal frequently
Nursing Process

▪ Health Teaching
Encouraged patient to do hand washing before and after eating
Encouraged patient to maintain clean environment

▪ Out-Patient

Advise the patient’s family to follow-up checkup as physician’s ordered

Advise patient and family to consult with physician if signs and symptoms of disease occur

▪ Diet

Avoid carbonated drinks, alcohol, and caffeine. Caffeine is found in some coffees, teas, and sodas. It is also
found in chocolate.
Do not eat foods that upset your stomach. These include spicy or acidic foods, such as oranges.
Eat small meals more often rather than big meals less often. An empty stomach may makes the symptoms
worse.
Nursing Process