CASE PRESENTATION ON PEPTIC ULCER
SPECIFIC OBJECTIVES
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TIME
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CONTENT
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TEACHING/
LEARNING
ACTIVITY
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A.V.AIDS
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EVALUATION
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
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define peptic
ulcer.
explain the incidence of peptic ulcer.
list down
the types of peptic ulcer.
discuss the
etiology of peptic ulcer.
explain the pathophysiology of peptic ulcer.
enlist clinical maifestations of
Peptic ulcer
enumerate diagnostic findings for peptic ulcer.
explain the
medical management for peptic ulcer.
describe the
surgical management for peptic ulcer.
discuss
nursing management of peptic ulcer.
list out the
complications of peptic ulcer.
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1 min
5min
1min
10
min
5min
3 min
8 min
5min
5 min
8 min
5 min
10 min
5 min
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PEPTIC
ULCER
INTRODUCTION:
Peptic ulcer
disease is a condition characterized by erosion of the gastric mucosa
resulting from the digestive action of Hcl acid and aspirin. It involves a
break in the continuity of the esophageal, gastric, or duodenal mucosa, due
to the ulceration is called as a peptic ulcer.peptic ulcer disease occurs in
approximately 10% of the population. Men are more likely to have both gastric
and duodenal ulcers.
DEFINITION:
Peptic ulcer disease is a condition
characterized by erosion of GI mucosa resulting from the digestive action of
Hcl acid and aspirin.
LEWIS.
Peptic ulcer
is erosion of the mucosal wall of the stomach or the first part of the small
intestine, is called as the peptic ulcer.
Ansari and kaur (2011)
Peptic ulcer
disease involves a break in the continuity of the esophageal, gastric, or
duodenal mucosa, due to the ulceration is called as a peptic ulcer.
Joyce M Black (2004)
Peptic ulcer
disease refers to ulcerations in the mucosa of the lower oesophagus, stomach,
or duodenum.
- Lippin cott (2006)
INCIDENCE:
Peptic ulcer disease occurs in
approximately 10% of population.
-
Gastric ulcers are more likely to occur during the
5th and 6th decades of life.
-
Duodenal ulcers more commonly occur during the 4th
and 5th decades for men.
-
For women the occurrence is about 10 years later
in life.
-
Men are more likely to have both gastric and
duodenal ulcers.
-
Duodenal ulcers have a higher incidence than
gastric ulcers.
TYPES OF PEPTIC ULCER
Peptic ulcer
a)Duodenal ulcers
b) Gastric ulcers
c)Stress induced and drug induced
ulcers.
1.
Duodenal
ulcers:
Duodenal ulcers usually occurs with in 1.5cm of the pylorus and are
usually characterized by high gastric acid secretion.
-
Some are associated with normal gastric secretion that
associated with rapid emptying of the stomach.
-
It is located in the right hypochondriac region
.The pain usually occurs 2 to 4 hours
after meals,
-
Protein rich meals
-
Alcohol consumption
-
Calcium
-
Vagal stimulation
Clients
with duodenal ulcers have more rapid gastric emptying.
2.
Gastric ulcers;
Gastric ulcers which tend to heal with in a few weeks, form with in 1
inch of the pylorus of the stomach in an area where gastritis is common.
Gastric ulcers are probably caused by a break in the mucosal barrier.
The pain is associated with gastric ulcers is located high in the epigastrium occurs about 1 to 2
hours after meals .
3.
Stress induced
and drug induced ulcers:
Besides peptic ulcers, acute gastric erosion, frequently called
stress-ulcers or stress erosive gastritis, can occur after an acute medical
crisis.
-
Severe trauma
-
Severe burns
-
Head injury
-
Ingestion of a drug (ex; aspirin, NSAIDs)
-
Shock
-
Sepsis
ETIOLOGY:
The cause of peptic ulcer is not known,
but it is believed that there are 3 factors that greatly influence its
development.
-
A source of irritation such as an increase of
hydrochloric acid (Hcl) with a decrease of Alkaline mucus secreted by the
surface cells.
-
A breakdown of the local tissue resistance and
defence mechanisms
-
Influence of heredity, hormones, and personality.
-
Corticotrophins and adrenocorticosteroids, the
salcylates and Phenylbutazene are known to contribute to the development of
peptic ulcer.
-
Infection with H. Pylori.
RISK FACTORS:-
-
Smoking
-
Chewing tobacco
-
Steroids
-
Aspirin
-
NSAIDs
-
Caffeine
-
Alcohol
-
Stress
Certain
medical conditions include
-
Chron’s disease.
-
Zollingert- Ellison syndrome.
-
Hepatic and biliary disease may also play role.
PATHOPHYSIOLOGY
Damaged mucosal barrier
Imbalance
of aggressive and defensive factor.
Damaged mucosa is unable to secrete
enough mucus to act as a barrier
against hydrochloric acid.
Low function of mucosal cells; low
quality of mucus.
Infection
gives increased Gastrin
.
Mucosal ulcerarations, possible
bleeding and scarring.
A damaged mucosa could not secrete
anough mucus act as a barrier aginst gastria acid.
Severe ulcerations
Peptic ulcers occur more often in the
duodenum.
CLINICAL MANIFESTATIONS;
Ø Pain
It is common for the person with gastric or duodenal ulcers to have no
pain or other symptoms.
When pain occurs with ‘’duodenal ulcer’’ it is described as’’
burning’’ or ‘’crampinlike’’.located in the epigastric region beneath the
Xiphoid process.
The pain associated with gastric ulcers is located high in the
epigastrium and occurs spontaneously about 1 to 2 hours after meals. The pain
is like ‘’burning’’ or ‘’gaseous’’.
Some persons do not experienced any
pain until the presence of the ulcer is demonstrated through a serious
complication such as Hemorrhage or Perforation.
-
Nausea and vomiting – due to gastric irritation.
-
Weight loss – decreased intake of food and fluids.
-
Dysphagia – due to the infection.
-
Anorexia
-
Bleeding
Bleeding occurs in chronic stage.
-
Anemia- cause of bleeding
-
Dizziness – weekness of the body
DIAGNOSTIC FINDINGS:
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History collection and physical examination
-
Lab investigations like CBP, CUE.
-
Upper GI endoscopy with possible tissue biopsy and
cytology
-
Upper I radiographic examination (Barium Study)
-
Serial stol specimens to detect occult blood.
-
Gastric secretory studies- elevated in Zollinger-
Ellison syndrome.
-
Serology to test for H.Pylory antibodies
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C- urea breath test to detect H.Pylory.
-
A complete blood count with decreased hematocrit
and hemoglobin values may indicate bleeding.
-
Esophagogastroduodenoscopy- with biopsy.
MANAGEMENT:
MEDICAL
MANAGEMENT
The primary objective of intervention for
peptic ulcer is to provide stomach rest.
Approaches;
-
Neutralizing or buffering hydrochloric acid
-
Inhibiting acid secretions.
-
Decrease the activity of pepsin and hydrochloric
acid.
-
Eradicating HPylori from Gastro I ntestinal Tract.
Medications;
-
Physical and emotional rest
-
Dietary management
-
Stress management or reduction.
Vaccine:
HELIVAX – Is
being tested to prevent infection with H.Pylory and could be added to the
list of routine immunization in children in the future.
-
The client experiences a decreased in pain with
eventual elimination of all ulcer pain and related manifestations.
-
Eliminate use of NSAIDs or other causative drugs.
-
Eliminate cigarette smoking (impairs healing).
-
Well- balanced diet with meals at regular
intervals.
-
Avoid dietary irritants.
SURGICAL MANAGEMENT:
1.
Surgical interventions may be indicated for
hemorrhage, obstruction, perforation, acid reduction. Surgery may also may be
indicated with ulcer disease of long duration or severity or difficulty with
medical regimen compliance.
2.
Gastroduodenostomy:(Billiroth
– I)
a.
Partial gastrectomy with removal of antrum and
pylorus of the stomach.
b.
The gastric stump is anastomosed with the
duodenum.
3.
Gastrojejunostomy
(Billiroth-II):
a.
Partial gastrectomy with removal of antrum and
pylorus of stomach.
b.
The gastric stump is anastomosed with the jejunum.
4.
Antrectomy:
a.
Gastric resection includes a small cuff of
duodenum, the pylorus, and the antrum ( lower half of the stoach).
b.
The duodenal stump is closed, and the jejunum is
anastomosed to the stomach.
5.
Total gastrectomy:
a.
Also called as esophagojejunostomy.
b.
Removal of the stomach with attachment of the
esophagus to the jejunum or duodenum.
6.
Pyloroplasty:
A longitudinal incision is made in the pylorus, and it is closed
transversely to permit the muscle to relax and to establish an enlarged
outlet.
7.
Vagotomy:
The surgical division of the vagus nerve to eliminate the impulses
that stimulate Hcl secretion.
NURSING MANAGEMENT:
ü Determine
location, character, radiation of pain, factors aggravating or relieving
pain, how long it lasts, when it occurs should assess.
ü Asses about
the eating patterns, regulating and types of food taking, eating
circumstances.
ü Should assess
about medications ( especially Aspirin, anti- inflammatory drugs, or
steroids)
ü Assess or
collect the history of illness including previous GI bleeding.
ü Perform physical
assessment with documentation of positive abdominal findings.
ü Obtain the
psychosocial history.
ü Check vital
signs including lying, standing and sitting blood pressures and pulses to
determine if orthostasis is present due to bleeding.
NURSING DIAGNOSIS:
1.
Fluid volume deficit related to hemorrhage as
manifested by dryness of the skin.
2.
Acute pain related to epigastric distress
secondary to perforation as manifested by facial expression.
3.
Imbalanced nutrition less than body requirement
related to less intake of food as manifested by weight loss.
4.
Risk for infection related to surgical management
as manifested by increased body temperature.
5.
Risk for injury related to bleeding.
6.
Anxiety related to disease process as manifested
by facial expression.
7.
Knowledge deficit related to treatment regimen as
manifested by repeatedly asking questions.
COMPLICATIONS:
1.
Hemorrhage
2.
Perforation
3.
Obstruction
1.
Hemorrhage:
ü
Assess
bleeding
Presence of occult blood in the stool (melena)
manifested by vomitus containing bright red blood(hematemasis).
Usual
manifestation of GI bleeding is either vomiting of coffee ground like
material or passing of tarry stools.
ü
Prevent shock:
Treat hypovolemic shock, prevent
dehydration and electrolyte imbalance and stop bleed.
ü
Replace fluids:
Administer the IV fluids and if possible to take
more oral fluids. Replace the blood volume. Maintain the I/O chart.
ü
Administer vasopressors:
We can control bleeding by the vasopressors.
ü
Maintain rest:
The
client must have minimal activity for several days after bleeding has
subsided. Rest will decrease the blood pressure and GI activity.
ü
Maintain high gastric Ph:
During
the first few days of hemorrhageing gastric p H should maintained between 5-5
and 7.0. by this we can administer the H2 –receptor antagonists IV for 4 days
as prescribed.
Give
antacids 1 hour before or 2 hours after the H2 receptor antagonists, so that
antacids do not interfere with absorption of drugs.
ü
Stop bleeding surgically:
If bleeding continues beyond 48 hours, recurs or
associated with perforation or obstruction, surgery may be indicated.
2.
Perforation:
Perforation is usually a surgical
emergency.
ü
Assess pain:
Perforation occurs most frequently with duodenal ulcers. The clients
experiences sudden, sharp, severe pain beginning in the midepigastrium.
ü
Raplace fluids:
If
perforation occurs, the clients needs immediate replacement of fluids,
electrolytes and blood as well as administration of the antibiotics.
ü
Current perforation surgically:
When surgery is necessary, the
surgeon evacuates the escaped gastric contents, cleans the peritoneal cavity
by flushing it out with normal saline or an antibiotic or both and closes the
perforation by patching it with omentum.
3.Obstruction:
Long- standing ulcer desease causes
scarring because of repeated ulcerations and healng. Scarring at the pylorus
frequently causes pyloric obstruction.
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Discussion
Teacher:explains by using o.h.p.
Student:listens
and observes, takes notes.
Teacher:explains
by using chart.
Student:observes
and takes notes.
.
Teacher :explains .
Student:listens ,observes.
Teacher: explains by using flash cards
Students:listen
,observers and take notes.
Teacher:explains by using PPT
Student:listens,observes
and takes notes.
Teacher:
explains by
using Model
Student:observes
and notes down.
Teacher:
explains by
using flash cards
Student:observes
and notes down.
Teacher
:explains by using P.P.T
Student:observes
and notes down.
Teacher:explains by using ppt.
Student:listens
and observes, takes notes.
Teacher:explains
Student:listens
and observes, takes notes.
Teacher:explains by using Chart
Student:listens
and observes, takes notes.
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O.H.P
PAMPHLET
Lecture cum
discussion
FLASH CARDS.
P.P.T
MODEL
P.P.T
P.P.T
LEAFLET
CHART
|
.
What do you
mean by peptic ulcer?
What are the
types of peptic ulcer?
.
What are the
etiological factors of peptic ulcer?
How does
pathophysiology takes place in peptic ulcer?
What are the
clinical manifestations of peptic ulcer?
How will you
diagnose peptic ulcer?
What are the
drugs used to treat peptic ulcer?
What are the
surgical procedures used to treat peptic ulcer?
What is the nursing
management for the peptic ulcer?
What are the
complications of peptic ulcer.
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SUMMARY.:
Till
now we discussed regarding definition, etiology, pathophysiology, clinical
manifestations, diagnostic findings, medical and surgical management, nursing
management and complications of peptic ulcer.
CONCLUSION:
By the end of the class
students will be able to attain knowledge regarding peptic ulcer disease
condition and its management, develops positive attitude and improves skills in
providing nursing care to the clients with peptic ulcer.
BIBLIOGRAPHY
ü Davidson’s’’TEXT
BOOK OF PRINCIPLES AND PRACTICE OF MEDICINE’’ 20th Edition (2006); Published
by Elsevier Publishers; page no;884-887
ü Joyce .M.Black’TEXT BOOK OF MEDICAL
SURGICAL NURSING’ 7th Edition; Volume-1 (2007), Published by
Elsevier; Page No-747-749
ü Brunner and Suddarth’s ‘’TEXT BOOK OF
MEDICAL SURGICAL NURSING’’11TH Edition(2006), Volume-1;
Published By Wolters Kluwer; Page No-1804-1806
ü BT.Basavanthappa’’TEXT
BOOK OF MEDICAL SURGICAL NURSING ’’ 2nd Edition (2009);
Published by Jaypee Brothers; Page No.472-476
ü Shffar’s’’TEXT BOOK OF MEDICAL SURGICAL
NURSING’’7TH Edition(2004); Published by B.I.Publications; Page
Np-.786-789
OBJECTIVES
GENERAL
OBJECTIVE:
At the end of the
class students will be able to attain
indepth knowledge regarding peptic ulcer condition and its management, develops
positive attitude and improves skills in providing nursing care to the clients
with peptic ulcer.
SPECIFIC
OBJECTIVES:
By the end of the class
students will be able to:
v define
peptic ulcer
v list down the types of peptic ulcer.
v discuss
the etiology of peptic ulcer.
v explain
the pathophysiology of peptic ulcer.
v enlist
clinical manifestations of Peptic ulcer
v enumerate
diagnostic findings for peptic ulcer.
v explain
the medical management for peptic ulcer.
v describe
the surgical management for peptic ulcer.
v discuss
nursing management of peptic ulcer.
v list
out the complications of peptic ulcer.
SIGNATURE OF
THE
SIGNATURE OF THE
INTERNAL EXAMINER
EXTERNAL EXAMINER
STUDENT PROFILE
NAME OF THE STUDENT :
M.Sc (N) I YEAR
SUBJECT :
MEDICAL SURGICAL NURSING
TOPIC : PEPTIC ULCER
GROUP : B.Sc (N ) II Yr STUDENTS
DATE :
29/11/2014
DURATION : minutes
VENUE : COLLEGE OF NURSING
METHOD OF TEACHING : LECTURE CUM DISCUSSION,
AV
AIDS : CHART, OHP, PAMPHLET,
LEAFLET, MODEL AND
POWER
POINT PRESENTATION
EVALUATION:
Marks- 15
Time-30min
1.
Define the peptic ulcer? 1M
2.
List down the types of peptic ulcer? 2M
3. Discuss
the etiology of peptic ulcer? 2M
4. Explain
the pathophysiology of peptic ulcer? 2M
5. Enlist
clinical manifestations of peptic ulcer? 2M
6.
Describe the surgical management for
peptic ulcer? 3M
7.
Discuss nursing management of peptic
ulcer? 2M
ASSIGNMENT:
Write assignment on Nursing
Management on Peptic Ulcer?
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