A Case Analysis on

PEPTIC ULCER

In Partial Fulfillment of the

Requirement in NCM 216 – RLE

NUTRITION & GASTRO-INTESTINAL-

METABOLISM & ENDOCRINE

NURSING ROTATION

Submitted to:

MONALIZA LEE, RN, MN

Clinical Instructor

Submitted by:

Raven Rey E. Eduarte, St. N

Aliana Nicole B. Emuy St. N

Angeline Eve P. Gallosa St. N

Ella Mae J. Freires St. N

Marry Aireen Faith P. Lucas, St. N

Trisha Shanea S. Marcon, St. N

Angel Rebb D. Ongcay, St. N

BSN 3J - Group 2 - Subgroup 2

March 05, 2022

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TABLE OF CONTENTS

I. Introduction …………………………………………………………………………….. 2

II. Goal and Objectives…………………………………………………………………….4

III. Case Scenario……………………………………………………………….………..…5

IV. Anatomy and Physiology ………………………………………………………………6

V. Pathophysiology

a. Etiology …………………………………………………………………………..7

b. Symptomatology………………………………………………………….……10

c. Disease Process……………………………………………………………….12

d. Narrative Discussion…………………………………………………………..14

VI. Management

a. Diagnostic and Laboratory Tests……………………………………………..16

b. Medical Management………………………………………………………….24

c. Surgical Management…………………………………………………………25

d. Pharmacologic Management…………………………………………………29

VII. Prognosis ………………………………………………………………………………46

VIII. Discharge Planning……………………………………………………………………47

IX. Nursing Theory.………………………………………………………………………..50

X. Review of Related Literature…………………………………………………………53

XI. References……………………………………………………………….…………….55
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I. INTRODUCTION

Consumption of a nutritious and well-balanced diet is referred to as nutrition.

Food and drink provide you with the energy and nutrients you require. According to the
World Health Organization (2018), nutrition is an essential part of one's overall health
and development. Moreover, according to Imaware (2021), gastrointestinal refers to the
stomach and intestines. Gastrointestinal disorders are problems with the digestive
system, a large and complicated system that breaks down food to absorb water and
extract nutrients, minerals, and vitamins for the body's use while also removing waste.
Furthermore, metabolism is how food is converted into energy in the body's cells.
Everything our bodies do, from moving to thinking to growing, requires this energy.
Specific proteins regulate the body's chemical reactions during metabolism, Mandal
(2021). Lastly, the endocrine produces hormones and glands that release them into the
bloodstream, allowing them to reach organs and tissues all over the body, Hirsch
(2018).

Peptic ulcers are painful sores on your stomach lining and the upper portion of
your small intestine. Stomach pain is the most common symptom of a peptic ulcer.
Peptic ulcers are divided into two types. They're gastric ulcers, which form in the
stomach lining. Those that develop in the upper small intestine (duodenum) are called
duodenal ulcers. Infection with Helicobacter pylori (H. pylori) bacteria or frequent use of
nonsteroidal anti-inflammatory drugs (NSAIDs) is the most common cause of both types
of peptic ulcers, as stated by Gregory (2020).

According to Azhari (2018), one case of peptic ulcer disease (PUD) per 1000
person-years was reported in the general population, with H. pylori infection accounting
for 90 percent of duodenal ulcers and 70-90 percent of gastric ulcers. Anand (2021)
stated that there are around 4.6 million people in the United States who have active
peptic ulcers, with 350,000 diagnosed each year. Duodenal ulcers are diagnosed four
times more frequently than gastric ulcers. In addition, Spain has the highest annual
incidence, with 141.8 per 100,000 people. According to WHO (2018) data, peptic ulcer
disease deaths in the Philippines reached 6,283, accounting for 1.03 percent of all
deaths. With an age-adjusted death rate of 9.69 per 100,000 people, the Philippines is
ranked #18 globally.

This study will enhance the understanding of student nurses in nursing

education. This case study's data can be analyzed and used as a guide in implementing
ideal nursing action and providing high-quality treatment and care to patients. It will aid
in the development of student nurses' intellect and rational thinking when providing
health teaching or health education to our patients. For nursing practice, student nurses
will 2 apply this knowledge and skills to their clinical nursing practice with the utmost
certainty and efficiency. It would serve as an instrument to improve critical thinking skills,
be more efficient and effective in their implementations, and enhance their ability to
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establish health teachings for patients with hemorrhagic stroke. Furthermore, this study
will be used in nursing research as a reference to help student nurses learn and
comprehend the disease. It will enhance the clinical experience and personal
knowledge, aids in implementing reforms to strengthen nursing care, and aid in
discovering additional tools.
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II. OBJECTIVES

General Objective

Within 4 weeks of Nutrition and Gastro-intestinal, Metabolism and Endocrine Rotation

the student nurses of BSN-3J Group 2, Subgroup 2 will be able to create a case
analysis about Peptic Ulcer and enhance their knowledge, skills, and attitude in
implementing nursing care.

Specific Objectives

To achieve the general objectives, the student nurses specifically aim to:

a. Briefly discuss nutrition & gastro-intestinal, metabolism and endocrine concept;

b. define a brief explanation of the disease condition and provide global, national,
and local statistical data of the case if available;

c. discuss the anatomical structure and its function of the affected organ;

d. trace the pathophysiology of the disease which includes the etiology and
symptomatology;

e. thoroughly present a narrative on the pathophysiologic process;

f. list down the laboratory tests or diagnostic evaluation, medical, surgical and
nursing management;

g. correctly formulate nursing care plans related to the condition;

h. clearly state the prognosis of the disease;

i. formulate a discharge;

j. review nursing theories that correlated to the case;

k. present the RRLs (Review of Related Literature) that relates to the case; and

l. cite books, references, and websites used for sources of information in APA
format.
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III. CASE SCENARIO

A 23-year-old male visited a clinic with upper abdominal pain, heartburn, nausea,
and vomiting complaints. He was in his usual state of health five days ago when he
started having epigastric pain. After a large meal, the pain was exacerbated at night. He
was fond of fried and spicy food. His father was afflicted with peptic ulcer disease. He
claims he does not smoke cigarettes, but he consumes 20–40 units of alcohol per week.
As per the patient's medical history, he has never had a disease or taken any
medications.

General examination as follows:

● Weight: 58kg
● BMI: 19.44kg/m2
● Temperature: 36.1 °C
● BP: 120/70 mmHg
● HR: 99 bpm
● PR: 97 bpm
● RR: 23 cpm

According to the provided information, the patient's laboratory tests were done.
There were no signs of bleeding, as Hb values were normal (13.5g/dl), and there was
no blood in the stools. Serological and urea breath tests confirmed H. pylori-positive
infection in the patient.
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IV. ANATOMY AND PHYSIOLOGY

The gastrointestinal (GI) is the digestive system's tract or passageway that connects
the mouth and the anus. The GI tract houses all of the digestive system's major organs
in humans and other animals, including the esophagus, stomach, and intestines. Food
is consumed through the mouth, which is then digested to extract nutrients and absorb
energy, with waste being expelled through the anus as feces. The term "gastrointestinal"
refers to the stomach and intestines.

The organ that is affected by the peptic ulcer is the stomach or duodenum. The
stomach is a part of the gastrointestinal (GI) tract and is necessary for digestion. Food is
digested in the stomach, which is shaped like a J. It produces acids and enzymes
(substances that catalyze chemical reactions) (digestive juices). Food is broken down
by a combination of enzymes and digestive juices to pass through to the small intestine.

Several layers of muscles and other tissues make up the stomach, such as the
mucosa, submucosa, muscularis externa, and serosa. The inner lining of the stomach is
what we call the mucosa. The mucosa has small ridges when the stomach is empty
(rugae). The mucosa expands, and the ridges flatten when the stomach is full.
Connective tissue, blood vessels, lymph vessels (part of the lymphatic system), and
nerve cells are all in the submucosa (covers and protects the mucosa). The primary
muscle of the stomach is the muscularis externa. To break down food, it has three
layers that contract and relax. Lastly, the layer of the membrane covering the stomach is
the serosa. The duodenum is the first part of the small intestine, which receives partially
digested food from the stomach and begins nutrient absorption. The duodenum is the
intestine's shortest segment, measuring 23 to 28 cm (9 to 11 inches) in length.
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V. PATHOPHYSIOLOGY
a. Etiology
1. Predisposing Factors

Factors Present Rationale

Age (≥ 65) X Age has its own physiological effects

on the maturing body and increases
the risk of various disorders and
morbidities. A peptic ulcer can occur
at any age. However, it causes high
morbidity and mortality in the elderly
(≥ 65) as their immune function
naturally declines as they age,
making them more vulnerable to
illness (Arsenault, 2020).

Gender (Male) ✓ According to Sayehmiri et al. (2018),

a study in Iran, men had a greater
risk of developing peptic ulcers due
to their sedentary lifestyles, such as
overconsumption of alcohol and
smoking.

Genetics ✓ A significant number of people who

suffer from peptic ulcers have close
relatives who also suffer from the
condition, raising the possibility that
genetic factors may be involved. But
also, peptic ulcers are frequently
passed down through families and
are more common in people with
type O blood (Felman, 2019).

Zollinger-Ellison syndrome
X
Zollinger-Ellison syndrome is a rare
genetic condition that causes tumors
to form in the digestive tract,
significantly raising the risk of ulcers.
Zollinger-Ellison syndrome tumors
are made up of cells that secrete a
lot of gastrin. The stomach produces
far too much acid as a result of
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increased gastrin. Peptic ulcers

develop as a result of excess acid
(Mayo Clinic, 2020)

2. Precipitating Factors

Factors Present Rationale

Helicobacter pylori (H. pylori) ✓ The Helicobacter pylori (H. pylori)

bacteria bacteria weakens the stomach and
duodenum's protective mucous
coating, allowing acid to reach the
lining beneath. It can lead to an
increase in acid and the breakdown
of the protective mucus layer and
cause inflammation (irritation) of the
digestive tract, resulting in a sore or
ulcer (Wake Gastroenterology,
2018).

X Cyclooxygenase (an enzyme),

Non-steroidal anti-inflammatory
which is involved in synthesizing
drugs (NSAIDs)
inflammatory prostaglandins, is
inhibited by NSAIDs. Prolonged use
of NSAIDs, which lower
prostaglandin levels for an
extended period of time, exposes
the gastric mucosa to damage, as it
prevents your body from producing
a chemical that protects your
stomach and small intestine from
stomach acid, and ulcers can
develop as a result (WebMD,
2021).

Smoking X According to some studies,

smoking reduces the amount of
bicarbonate produced by the
pancreas, interfering with the
duodenum's acid neutralization.
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According to other research,

chronic cigarette smoking may
cause the stomach to secrete more
acid (Gastrointestinal Society,
2020).

Alcohol ✓ Excessive consumption of alcohol

has been associated with a higher
risk of peptic ulcer development.
Alcohol can irritate and weaken
your stomach lining over time and
cause your body to produce more
gastric acid, which is also a factor
that contributes to ulcer formation
(WebMD, 2021).
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b. Symptomatology

Symptoms Present Rationale

Heartburn ✓ Heartburn is a symptom that occurs

when stomach acid rises into the
esophagus. This causes a burning
sensation behind your breastbone or
in your upper abdomen.

Burning stomach pain ✓ Acid in the digestive tract eats away

at the inner surface of the stomach
or small intestine, causing peptic
ulcers. The acid can cause a burning
feeling and a painful open sore that
may bleed.

Bloating X This indicates that your stomach is

full with gas or air, causing your
stomach to enlarge.

Nausea ✓ Nausea can be exacerbated by

ulcers, or lesions in the stomach or
small intestinal lining. An ulcer can
create a burning feeling and nausea
when you eat.

Vomiting ✓ Peptic ulcers can prevent food from

passing through the digestive tract,
thus obstruction can lead you to, feel
bloated, vomit, and lose weight.

Coffee ground vomit X Vomit that resembles coffee grounds

is known as coffee ground vomitus.
The presence of coagulated blood in
the vomit causes this. Coffee ground
vomitus can be caused by a variety
of disorders, including stomach
ulcers, cirrhosis-related esophageal
varices, and gastritis.

Change in stool color X A stomach ulcer or a small intestinal

ulcer is an open sore on the interior
of your stomach or small intestine.
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These lesions might bleed at times.

Your stool may get black as a result
of this. When blood comes into
contact with stomach acids, it turns
black and tarry (sticky).

Loss of appetite ✓ There is a complete loss of appetite,

which will almost certainly result in
weight reduction. When the lining
of your stomach is injured, scar
tissue grows, obstructing the food
pathway and perhaps causing
swelling in the small intestines.

Abnormal weight loss ✓ Due to the inflammation that

stomach ulcers cause, they can
sometimes cause a blockage in the
digestive tract. This can cause
weight loss and a reduction in
appetite by preventing food from
flowing through your stomach.
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c. Disease Process
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d. Narrative Discussion

Peptic ulcer occurs when there is an excavation or hollowed out area that forms

in the mucosal wall of the stomach or the duodenum. It’s mechanism results from an

imbalance between gastric protective and destructive factors.

The stomach and duodenum produce gastrin that is a stimulant of gastric acid

secretion. This gastric acid is responsible for digesting food, However, the risk factor

that most commonly causes peptic ulcer disease is the infection with Helicobacter pylori­

bacteria and the use of NSAIDs, there is an increase gastrin production in the stomach

or duodenum which in turn increases gastric acid production. The stomach and

duodenum has a protective layer of mucus called the mucosa, this lining protects the

stomach and duodenum from strong acid. But, in peptic ulcer, the gastric acid

production is so excessive that it damages and erodes this mucosal layer, excavating

and creating hollowed areas or perforations which are now called the ulcers. These

formation of ulcers in the stomach or ulcers makes them have a decreased resistance

to bacteria since the protective layer is damaged, bacteria like H. pylori will grow rapidly,

causing a cycle to where gastric acid production is increased and will cause more and

more damage to the mucosal layer of the stomach and duodenum.

Peptic ulcer symptoms include pain since the acid eats away the inner surface of

the stomach or duodenum, the acid also causes heartburn because the excessive acid

often rises to the esophagus. These ulcers also prevent food from passing through the

stomach or the digestive tract which leads to vomiting, nausea, bloating and loss of

weight. Changes in stool color could also be observed, this happens if the open sore or

the ulcers bleed, it will affect the color of the stool as a result.

To diagnose and confirm an occurrence of peptic ulcer, laboratory tests such as

CBC, Serology, Urea breath test, and Stool Test to detect Helicobacter pylori infection,

Biopsy is also done by removing a piece of tissue or sample to determine if there is also

a presence of the H. pylori bacteria. Endoscopy is done to examine the mucous lining of
 15

the GI tract, and because the GI tract organs are not easily seen on an x-ray test,

patients are needed to swallow barium in order for these organs to show up on the

x-ray, by doing this, the x-ray can now detect if there are ulcerations in the GI tract. A

liquid called a contrast medium is also drunk by a patient before undergoing a CT scan,

this is a good way to see any damage peptic ulcers may have caused, such as holes in

the stomach due to erosion.

There are several ways to treat peptic ulcers, starting with stress reduction,

smoking cessation, and dietary modification. These may not help peptic ulcer disease

heal any faster, but it could help a person feel better and may reduce the risk of

developing future ulcers. There are also surgical ways to manage like vagotomy,

pyloroplasty, gastrectomy, gastroduodenostomy and gastrojejunostomy. Proton pump

inhibitor, Antibiotics, Analgesics, Anti-ulcers, Acid blockers and Antacids are also used

to treat peptic ulcer.

Successful treatment and management as quickly as possible can help further

complications. With the help of other healthcare providers, recovery can be faster and

improvements to the GI tract will be assured. The patient will have a good prognosis. In

comparison, if left untreated and poorly managed, peptic ulcer would then be fatal if the

detection of the symptoms is later recognized. If the condition is left untreated, it could

lead to a faster progression or, in a worst-case scenario, death. In this case, the patient

will then have a poor prognosis

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VI. MANAGEMENT
a. Diagnostic and Laboratory Tests

Test Rationale Results and Significance Nursing Responsibilities

1. Explain test procedure.

Complete Blood A complete blood Normal:
Explain that slight
Count (CBC) count (CBC) is a Male discomfort may be felt
group of test used
when the skin is
for basic RBC 4.35-5.65
punctured to alleviate
screening Count trillion
anxiety and discomfort.
purposes. This cells/L

blood test used to 2. Encourage patient to

Hemoglo 13.2-16.6
evaluate your avoid stress if
bin grams/dL
overall health and possible. Altered
detect a wide Hematocr 38.3-48.6% physiologic status
range of it influences and
disorders, changes normal
WBC 3.4-9.6
including anemia, hematologic values.
Count billion
infection and
cells/L 3. Explain that fasting is
leukemia.
not necessary. Drink a
Platelet 135-317
lot of water before the
Count billion/L
test if not
contraindicated.
However, fatty meals
may alter some test
results as a result of
Female
lipidemia. Drinking
RBC Count 4.35-5.65 water before the test
trillion keeps blood pressure
cells/L from dropping.

Hemoglobi 13.2-16.6 4. Apply manual pressure

n grams/dL and dressings over the
puncture site on
Hematocrit 38.3-48.6%
removal of dinner to
WBC 3.4-9.6 control bleeding and
Count billion encourage blood
clotting without
 17

cells/L constricting normal

blood circulation.
Platelet 135-317
5. Monitor the puncture
Count billion/L
site for oozing or

Abnormal: hematoma formation,

Abnormal red blood cell, bruising and

hemoglobin, or hematocrit inflammation. If a

levels may indicate hematoma develops,

anemia, iron deficiency, or apply a compress. If

heart disease. the hematoma is large,

assess pulses distal to
Significance: the site. Bruising at the
This blood test may be puncture site is not
done to look for anemia, uncommon. Signs of
which may be caused by a inflammation are
bleeding ulcer. unusual and should be
reported immediately
Serologic Test This test are used Nomal: to avoid complications.
to measure Negative: No H. pylori
6. Notify physician of
antibodies to H antibodies
unusual problems with
pylori. Antibodies
Abnormal: bleeding to prevent
are proteins made
Positive: H pylori further complications.
by the body's
antibodies were found
immune system 7. Instruct not to bend
when it detects Significance: arms as this may
harmful The test may help detect cause bruising.
substances such antibodies to the bacteria,
8. Instruct to resume
as bacteria. which may indicate a
normal activities and
current or past infection
diet.
with H. pylori. This test can
also help healthcare 9. Evaluate the outcome
provider find out whether and counsel the
the peptic ulcers are patient about anemia,
caused by H. pylori. polycythemia, risk for
infection, and related
blood disorders to
monitor if there are any
reactions, and to add
knowledge to the
patient.
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1. The patient should

Urea Breath The urea breath Normal:
have no antibiotics and
Test test, also called H. <50 DPM negative for
bismuth for 1 month
pylori test, is a H.Pylori
and no proton pump
simple and safe
Abnormal: inhibitors and
test used to detect
>200 DPM positive for sucralfate for 2 weeks
Helicobacter pylori
H.Pylori before the test.
(H. pylori),
Antibiotics, PPI, and
diagnosis H. pylori Significance:
bismuth can interfere
infection, and This test help detect with the accuracy of
determine if Helicobacter pylori (H.
this test.
treatment cured pylori), a type of bacteria
the infection. H. that may infect the 2. Explain test purpose,
pylori. stomach and is a main procedure, and

cause of ulcers in both the knowledge of signs

stomach and duodenum and symptoms and risk

factors for
transmission: close
living quarters, many
persons in household,
poor household
sanitation and hygiene,
so that the patient will
have a grasp about
his/her condition, and
the reason for the
procedure.

3. Instruct the patient not

to chew the capsule
and be at rest during
breath collection. The
capsule should not be
opened or crushed in
the mouth to avoid
contamination with oral
flora, which may have
urease activity.

4. Instruct patient not to

eat or drink anything
(including water) for
 19

four hours before the

procedure. The patient
may brush his/her
teeth and rinse their
mouth, but do not
swallow water to avoid
a false negative result.

1. Explain the collection

Stool Test The most Normal:
purpose, procedure,
common stool test The stool appears brown,
and interfering factors
to detect H. pylori soft, and well-formed in
in language the patient
is called a stool consistency. The stool
understands because
antigen test that does not contain blood,
the specimen cannot
looks for foreign mucus, pus, undigested
be obtained on
proteins meat fibers, harmful
demand, it is important
(antigens) bacteria, viruses, fungi, or
to provide detailed
associated with H. parasites. No evidence of
instructions before the
pylori infection in H pylori.
test so that the
the stool.
Abnormal: specimen is collected
The stool is black, red, when the opportunity
white, yellow, or green. presents itself.
The stool is liquid or very
2. Provide proper
hard. The stool contains
containers and other
blood, mucus, pus,
collection supplies.
undigested meat fibers,
Instruct the patient to
harmful bacteria, viruses,
defecate in a
fungi, or parasites.
large-mouthed plastic

Significance: container, bag, or

Stool antigen testing may clean bedpan. Fecal

be done to help support a samples can be runny

diagnosis of H. pylori and if the specimen

infection or to find out leaks, this can present

whether treatment for an a biohazard.

H. pylori infection has been 3. Provide for and

successful. respect the patient’s
privacy. Assist if
necessary. It is the
patient's right to control
the collection, use and
 20

disclosure.

4. Instruct patient not to

place toilet paper in
the container or
bedpan because it
interferes with testing.

5. Instruct patient in
proper handwashing
after each use of the
bathroom. Use
extreme caution and
proper handling at all
times. Any stool
collected may harbor
highly infectious
pathogens.

1. Stop medications such

Biopsy A biopsy is a Normal:
as blood thinners to
procedure to Normal if it does not show
prevent the increased
remove a piece of cancer, other damage to
risk of bleeding during
tissue or a sample the lining of the stomach,
the procedure.
of cells from your or signs of organisms that
body so that it can cause infection. 2. Advise patient to NPO
be tested in a for 8 hours before the
Abnormal:
laboratory. It is a biopsy to prevent any
Abnormal results may
procedure used to nausea and to keep
show gastritis, when the
diagnose a range any food or liquid from
lining of the stomach
of conditions, getting into the lungs
becomes inflamed or
including stomach due to the anesthesia
swollen and Helicobacter
ulcers. administered during
pylori infection.
the biopsy.

3. Blood or urine samples

Significance:
Gastric biopsies in peptic
ulcer are to be taken from
various sites of the organ.
This is due to the fact that
the differential diagnosis
may be taken before
the biopsy to check for
an infection that will
make the biopsy risky.
4. Check blood pressure
and pulse rate to look
 21

between gastric ulcer and for any signs of

ulcerative carcinoma is the bleeding inside the
most important goal of body.
biopsy. The biopsy
5. Instruct the patient to
samples can be tested for
rest in bed for 12 to 24
the presence of
hours after the biopsy,
Helicobacter pylori (H.
as directed by the
pylori) – the cause of many
doctor. Staying still in
peptic ulcers.
bed helps to heal the
site where the sample
was taken and reduce
the risk of bleeding.

Diagnostic Test Rationale Results and Significance Nursing Responsibilities

Endoscopy Upper Normal: 1. Inform the patient that

gastrointestinal The esophagus, stomach, the procedure
(GI) endoscopy is and duodenum should be assesses the
the preferred smooth and of normal esophagus and upper
diagnostic test in color. There should be no gastrointestinal tract.
the evaluation of bleeding, growths, ulcers, 2. Ensure that this
patients with or inflammation. procedure is
suspected peptic performed before an
Abnormal:
ulcer disease. A upper gastrointestinal
Gastric ulcers can be found
gastrointestinal study or barium
and appear as discrete
endoscopy allows swallow.
mucosal lesions with a
the doctor to 3. Withhold food and
punched-out smooth ulcer
examine the fluids for 6 to 8 hours
base, which often is filled
mucous lining of before the procedure.
with whitish fibrinoid
the upper 4. Inform the patient that
exudate.
gastrointestinal dentures will be
tract. Significance: removed before the
Endoscopy provides an test
opportunity to visualize the 5. Inform the patient that
ulcer, to determine the he or she will not be
presence and degree of able to speak during
active bleeding, and to the procedure and is
somewhat
 22

attempt hemostasis by uncomfortable but

direct measures, if requires only 20 to 30
required. minutes to complete.
6. A local anesthetic will
be used in your throat
and you will be given a
sedative during the
procedure.
7. Do not allow the
patient to eat or drink
until gag reflex returns;
then allow the patient
to eat lightly for 12 to
24 hours..

Barium Swallow A barium swallow, Normal: 1. Obtain history of the

or upper GI Normal esophageal, patient’s complaints or
series, is an x-ray stomach, and small symptoms, including a
test used to intestine; no ulcerations, list of known allergies,
examine the inflammation,ruptures or especially allergies or
upper digestive foreign bodies. sensitivities to latex,
tract. Because iodine, contrast
Abnormal:
these organs are medium, and dyes.
Acute and chronic gastric
normally not 2. Instruct the patient to
duodenal ulcers.
visible on x-rays, fast and restrict fluids
you need to Significance: for 8 hours prior to the
swallow barium, a This will help check for procedure.Instruct
liquid that does ulcers and it is often more patient to remove
show up on useful in identifying jewelry or other
x-rays. The complications of ulcers. metallic objects.
barium swallow is 3. Instruct patient to
also used to cooperate fully and to
diagnose peptic follow directions.
ulcer. A barium Instruct the patient to
swallow and remain still throughout
upper GI series the procedure
can be used in because movement
patients who are produces unreliable
not a candidate or results.
refuse EGD. 4. Instruct the patient to
resume usual diet,
 23

fluids, medications, or
activity, as directed by
the health care
practitioner.

Computerized A CT (computed Normal: 1. Obtain an informed

Tomography tomography) Normal size, shape of consent properly
(CT) scan scan, also called abdominal organs. signed.
a CAT scan, is a 2. The patient should fast
Abnormal:
type of and restrict fluids for 8
High-density gastric
specialized X-ray. hours prior to the
contents, focal wall
The scan can procedure.
thickening, and luminal
show 3. Instruct the patient to
outpouching
cross-sectional resume the usual diet
images of a Significance: and activities unless
specific area of This is a good way to see otherwise ordered
the body. any damage peptic ulcers 4. Encourage the patient
may have caused, such as to increase fluid intake
holes in the stomach due (if a contrast is given)
to erosion. to avoid renal
complications and to
promote excretion of
the dye.
 24

b. Medical Management

Management Rationale

Stress reduction and rest
Stress reduction may not help peptic ulcer
disease heal any faster, but it could help a
person feel better and may reduce the risk of
developing future ulcers. Reducing
environmental stress requires physical and
psychological modifications on the patient’s
part as well as the aid and cooperation of
family members and significant others.

Smoking cessation Studies have shown that smoking decreases

the secretion of bicarbonate from the
pancreas into the duodenum, resulting in
increased acidity of the duodenum. Also
smoking delays healing of gastric ulcer and
may influence duodenal ulceration.

Dietary modification Physicians often recommend lifestyle and

dietary changes for persons with ulcers in
addition to medications until complete healing
occurs. High fiber diet decreases the risk of
developing ulcer disease and vitamin A may
have a protective effect against the
development of ulcer disease. Avoiding
extremes of the temperature of food and
beverages and overstimulation from
consumption of meat extracts, alcohol, coffee,
and other caffeinated beverages, and diets
rich in cream and milk should be implemented.
 25

c. Surgical Management

Procedure Rationale

Vagotomy - Is a surgery where part of your vagus nerve

is removed. Division of the vagus nerve
removes the cephalic stimulus to oxyntonic
cells; acid secretions reduce by 60%.
Vagotomies are traditionally done to treat
peptic ulcers by reducing the amount of acid
your stomach produces

- At the gastroesophageal junction, a section

1) Truncal Vagotomy
of the vagus nerve is ripped away. This is
the area that connects the tube that runs
from your mouth to your stomach, known as
the esophagus. The lack of nerve supply in
your stomach after this operation can
prevent gastric acid from being released and
impair food transit through your intestines. A
draining procedure may be required by your
doctor.

2) Selective Vagotomy - This procedure is more exact than truncal

vagotomy, as the name implies. The vagus
nerve link to the gallbladder and intestine is
left in place, and only the section of the
nerve that leads to the stomach is removed.
The procedure was intended to have less
adverse effects than truncal vagotomy,
however further research revealed that it
was ineffective.

3) Highly Selective Vagotomy

- The most exact option is parietal cell
vagotomy, which is also known as parietal
 26

cell vagotomy. Only the segment of the

vagus nerve that connects to the parietal
cells in the stomach wall that release gastric
acid is removed.
- The rest of the nerve is left in place, allowing
it to continue to activate the valve that links
your stomach and intestine. There is no
need for a draining treatment.
- Open surgery, in which doctors open a big
portion of your belly, or laparoscopic surgery
are also options for very selective vagotomy.
Laparoscopic procedures are less invasive
and include the insertion of a tube with a
camera through tiny cuts.

Pyloroplasty - Used to treat complications in persons who

have peptic ulcers or other stomach
diseases that cause the stomach opening to
become blocked.
- Is a surgery that widens your pylorus. It
helps to control the movement of partially
digested food and digestive juices into your
small intestine.

1) Heineke-Mikulicz
- To make your pylorus wider, an incision is
pyloroplasty
made lengthwise. This is the most common
pyloroplasty procedure.

- Your doctor will make a new link between

2) Jaboulay pyloroplasty
your stomach and small intestine
(duodenum) without cutting into your pylorus
during this treatment.
 27

- This also connects your stomach directly to

your duodenum but with the incision to your
3) Finney pyloroplasty
pylorus. ‌This procedure is rarely done today.

Gastrectomy - The surgical removal of all or part of the

stomach and is done when there is a
massive hemorrhage from stress ulceration

1) Partial Gastrectomy
- During a partial gastrectomy, your surgeon
will remove the lower portion of your
stomach.
- Your surgeon will shut off your duodenum
during this procedure. The first area of your
small intestine to receive partially digested
food from your stomach is your duodenum.
The remainder of your stomach will then be
linked to your intestine.

2) Complete Gastrectomy
- This treatment, also known as total
gastrectomy, removes the entire stomach.
Your esophagus will be connected directly to
the small intestine by your surgeon. The
esophagus normally connects your throat to
your stomach.

3) Sleeve Gastrectomy - A sleeve gastrectomy can remove up to

three-quarters of your stomach. The side of
your stomach will be trimmed to form a tube
 28

shape by your surgeon. This results in a

stomach that is smaller and longer.

- A surgical operation in which a new link is

Gastroduodenostomy
formed between the stomach and the
duodenum, the first portion of the human
small intestine. This is the tiniest part, yet it
is where chemical digestion—a crucial stage
in the digestive and metabolic
processes—takes place. This procedure
restores normal gastrointestinal physiology
and preserves the duodenal passage.

- This procedure involves the creation of a

Gastrojejunostomy
connection between the stomach and the
jejunum, another section of the small
intestine. This is frequently done to empty
the stomach contents or to establish a
bypass for the gastric contents.
 29

d. Pharmacological Management

Generic Name Omeprazole

Brand Name Prilosec, Prilosec OTC, Losec, Risek

Drug Pharmacologic: Proton pump inhibitor

classification
Therapeutic: Antiulcer agent

Mechanism of Omeprazole reduces gastric acid secretion through a unique

action mechanism of action. Omeprazole belongs to a new class of
antisecretory compounds, the substituted benzimidazoles that do
not exhibit anticholinergic or histamine antagonistic properties. It
inhibits secretion of gastric acid by irreversibly blocking the
enzyme system of hydrogen/potassium adenosine triphosphate
(H+/K+ ATPase), the proton pump of the gastric parietal cell. This
effect is dose-related and leads to inhibition of both basal and
stimulated acid secretion irrespective of the stimulus.

Dosage Helicobacter pylori (H. pylori) eradication.

Adults
 30

20 or 40 mg PO twice daily in combination with clarithromycin

and either amoxicillin or metronidazole for 14 days. FDA-labeling
suggests an additional 18 days of omeprazole 20 mg PO once
daily in patients with ulcers.

Duodenal ulcer
Adults and Adolescents 17 years and older

20 mg PO once daily for 4 to 8 weeks. Most patients heal within

4 weeks; some patients may require 8 weeks of therapy

Indication Omeprazole is indicated for the short-term treatment of peptic

ulcer disease in adults, and patients with duodenal ulcer disease
and H. pylori infection. Omeprazole is also indicated for gastric
ulcers in adults, gastroesophageal reflux disease, for healing
erosive esophagitis and Zollinger-Ellison syndrome.

Contraindication Hypersensitivity to any of the components of Risek or to

substituted benzimidazoles.

● Cold symptoms such as stuffy nose, sneezing, sore throat

Side effects
(especially in children);
● Fever (especially in children);
● Stomach pain, gas;
● Nausea, vomiting, diarrhea; or
● Headache

Adverse effects ● CNS: dizziness, drowsiness, fatigue, headache,

weakness
● CV: chest pain
● GI: abdominal pain, acid regurgitation, constipation,
flatulence
● Derm: itching rash
 31

Drug interaction ● Atazanavir, rilpivirine, and nelfinavir. Omeprazole may

greatly decrease the effects of these drugs and could
make them less effective over time. You shouldn’t take
these drugs with omeprazole.
● Clopidogrel. Omeprazole may reduce the effects of
clopidogrel, causing your blood to clot. You shouldn’t take
this drug with omeprazole.
● Voriconazole. This drug may increase the levels of
omeprazole in your body. If you’re taking high doses of
omeprazole, your doctor may adjust your omeprazole
dose
 32

Nursing ● Assess for possible contraindications and cautions such

Responsibilities as history of allergy to a proton pump inhibitor to reduce
the risk of hypersensitivity reaction
● Perform a physical examination to establish baseline data
before beginning therapy and to determine the
effectiveness of the therapy
● Administer drug 30-60 minutes before meals, capsules
should be swallowed whole; do not crush or chew to
ensure the therapeutic effectiveness of the drug.
● If using this drug to treat H pylori, Instruct patient to take
medication as directed even if feeling better for full course
of therapy
● Assess dizziness that might affect gait, balance, and other
functional activities. Report balance problems and
functional limitations to the physician, and caution the
patient and family/caregivers to guard against falls and
trauma. Omeprazole may cause occasional drowsiness or
dizziness
● Instruct patient to return for follow-up if symptoms are
unresolved after 4 to 8 weeks of therapy because serious
underlying conditions could be causing the symptoms.
● Advise patient to avoid foods that may cause an increase
in GI irritation such as spicy foods as these can make
your symptoms worse.
● Monitor patient for anemia because drug can interfere
with absorption of vitamin B12.
● Monitor patients elimination pattern because drug may
cause diarrhea.
● Instruct patient to report bothersome or prolonged side
effects, including headache, skin rash, nausea, diarrhea,
and stomach pain to immediately manage these side
effects and prevent further complications.
 33

Generic Name Amoxicillin

Brand Name Apo-Amoxi, Moxatag, Novamoxin

Drug Classification Pharmacologic Class: Penicillin

Therapeutic Class: Antibiotic

Mechanism of Amoxicillin works by binding proteins and inhibiting certain

action processes in bacterial cells. This causes the cell walls to break
down and destroys the bacteria, a process called bactericidal
killing.

Dosage H. Pylori Infection

● PO: ADULTS, ELDERLY: 1 g twice a day in combination

with at least 1 other antibiotic and an acid-suppressing
agent (proton pump inhibitor or H2 antagonist).

Indication Amoxicillin alone is indicated to treat susceptible bacterial

infections of the ear, nose, throat, genitourinary tract, skin, skin
structure, and lower respiratory tract. Amoxicillin is given with
clavulanic acid to treat acute bacterial sinusitis, community
acquired pneumonia, lower respiratory tract infections, acute
bacterial otitis media, skin and skin structure infections, and
urinary tract infections. Amoxicillin is given with omeprazole in
the treatment of H. pylori.

Contraindication ● Hypersensitivity to any penicillin.

● History of allergies (esp. cephalosporins), infectious
mononucleosis, renal impairment, asthma.

Side effects Frequent: GI disturbances (mild diarrhea, nausea, vomiting),

headache, oral/vaginal candidiasis.
 34

Occasional: Generalized rash, urticaria.

Adverse effects Antibiotic-associated colitis, other super-infections (abdominal

cramps, severe watery diarrhea, fever) may result from altered
bacterial balance of GI tract. Severe hypersensitivity reactions,
including anaphylaxis, acute interstitial nephritis, occur rarely.

Drug interaction DRUG: Allopurinol may increase incidence of rash. Probenecid

may increase concentration, toxicity risk. May decrease the
effect of oral contraceptives.

HERBAL: None significant.

FOOD: None known.

Nursing ● Evaluate the patient’s history of allergies, especially

Responsibilities penicillins, cephalosporins, renal impairment to prevent
complications and provide other treatment for the
allergy.
● Assess muscle aches and joint pain (arthralgia) that
may be caused by serum sickness. Notify physician if
these symptoms seem to be drug related rather than
caused by musculoskeletal injury, or if muscle and joint
pain are accompanied by allergic-like reactions (fever,
rashes, etc. to immediately manage as these are side
effects caused by the drug.
● Monitor signs of blood dyscrasias such as eosinophilia
(fatigue, weakness, myalgia) and leukopenia (fever,
sore throat, signs of infection). Report these signs to the
physician. Blood dyscrasias, although rare, can be fatal.
● Monitor for S&S of an urticarial rash (usually occurring
within a few days after start of drug). These S&S may
suggest hypersensitivity reactions.
● Closely monitor diarrhea to rule out
pseudomembranous colitis.
● Always wash hands thoroughly and disinfect equipment
(whirlpools, electrotherapeutic devices, treatment
tables, and so forth. Use universal precautions or
isolation procedures as indicated for specific patients to
help prevent the spread of infection
 35

● Instruct patient to notify physician immediately of signs

of superinfection, including black, furry overgrowth on
tongue, vaginal itching or discharge, and loose or
foul-smelling stools to prevent further complications.
● Instruct patient to take drug around the clock, do not
miss a dose, and continue therapy until all medication is
taken, unless otherwise directed by a physician. Timing
is critical when it comes to antibiotics. That's because a
certain amount of the antibiotic needs to be inside the
body for a certain length of time in order to get rid of the
bacteria.
● Watch out for seizures. Epileptic seizures are neurotoxic
manifestations caused by some antibiotics including
amoxicillin.
● Monitor vital signs, especially temperature to check for
any signs of infection.
 36

Generic Name Lansoprazole

Brand Name Prevacid, Prevacid Solu Tab, and Prevacid 24HR

Drug Classification Pharmacologic Class: Proton Pump Inhibitors

Therapeutic Class: Gastrointestinal Agent; Antisecretory

Mechanism of Lansoprazole inhibits gastric acid secretion by irreversibly

action blocking the hydrogen-potassium adenosine triphosphate
enzyme system (H+, K+-ATPase) or "proton pump" in gastric
parietal cells.

Dosage Duodenal Ulcer

● PO: ADULTS, ELDERLY: 15 mg/day, before morning

meal for up to 4 wks. Maintenance: 15 mg/day.

Gastric Ulcer

● PO: ADULTS: 30 mg/day for up to 8 wks.

NSAID Gastric Ulcer

● PO: ADULTS, ELDERLY: (Healing): 30 mg/day for up to

8 wks. (Prevention): 15 mg/day for up to 12 wks.

H. Pylori Infection

● PO: ADULTS, ELDERLY: (triple drug therapy including

amoxicillin, clarithromycin) 30 mg q12h for 10–14 days.
 37

Indication Short-term treatment (4 weeks and less) of healing,

symptomatic relief of active duodenal ulcer; short-term
treatment (8 weeks and less) for healing, symptomatic relief of
erosive esophagitis. Long-term treatment of pathologic
hypersecretory conditions, including Zollinger-Ellison
syndrome. Short-term treatment (8 weeks and less) of active
benign gastric ulcer, H. pylori–associated duodenal ulcer,
maintenance treatment for healed duodenal ulcer. Treatment of
gastroesophageal reflux disease (GERD), NSAID-associated
gastric ulcer. Relief of frequent heartburn (2 or more
days/week). Short-term treatment of erosive esophagitis.
Stress ulcer prophylaxis in critically ill.

Contraindication Hypersensitivity to lansoprazole or other proton pump inhibitors

Side effects Occasional: Diarrhea, abdominal pain, rash, pruritus, altered

appetite.

Rare: Nausea, headache.

Adverse effects Bilirubinemia, eosinophilia, hyperlipidemia occur rarely.

Drug interaction DRUG: May decrease concentration of atazanavir. May

interfere with absorption of ampicillin, digoxin, iron salts,
ketoconazole. Sucralfate may delay absorption. May increase
the effects of warfarin. May decrease the effect of clopidogrel.

HERBAL: St. John’s wort may decrease concentration/effects.

FOOD: Food may decrease absorption.

Nursing ● Assess for epigastric/abdominal pain, evidence of GI

Responsibilities bleeding, ecchymosis to rule out if there is really a
problem and avoid medication administration errors.
● Monitor improvements in GI symptoms (gastritis,
heartburn, and so forth) to help determine if drug
therapy is successful.
● Assess dizziness that might affect gait, balance, and
other functional activities. Report balance problems and
functional limitations to the physician, and caution the
 38

patient and family/caregivers to guard against falls and

trauma.
● Monitor for therapeutic effectiveness of concurrently
used drugs that require an acid medium for absorption
(e.g., digoxin, ampicillin, ketoconazole).
● Inspect the skin for lesions, rash, pruritus, and dryness
to identify possible adverse effects.
● Administer drug before meals to ensure the therapeutic
effectiveness of the drug.
● Offer support and encouragement to help the patient
cope with the disease and the drug regimen.
● Monitor CBC, kidney & liver function tests, and serum
gastric levels periodically to provide baseline data and
monitor the effectiveness of drug.
● Monitor the patient’s nutritional status; use of small
frequent meals may be helpful if GI upset is a problem to
know if the patient’s appetite is being altered.
● Instruct patient to report bothersome or prolonged side
effects, including headache, skin rash, or GI effects
(nausea, diarrhea, abdominal pain) to immediately
manage these side effects and prevent further
complications.
 39

Generic name Famotidine

Brand name Pepcid, Pepcid AC

Classification Pharmacologic class: Histamine-2 blocker

Therapeutic class: Antiulcer agent

Mechanism of action In normal digestion, parietal cells in the gastric epithelium

secrete hydrogen (H+ ) ions, which combine with chloride
ions (Cl − ) to form hydrochloric acid (HCl), as shown below
left. However, HCl can inflame, ulcerate, and perforate gastric
and intestinal mucosa normally protected by mucus.
Famotidine, an H2 -receptor antagonist, reduces HCl
formation by preventing histamine from binding with H2
receptors on the surface of parietal cells, as shown below
right. By doing so, the drug helps prevent peptic ulcers from
forming and helps heal existing ones.

Dosage TABLETS

Adults and children weighing 40 kg (88 lb) or greater. 40 mg

once daily at bedtime or 20 mg twice daily up to 8 wk.

Indication Short-term treatment of active duodenal ulcer. Prevention,

maintenance of duodenal ulcer recurrence. Treatment of
active benign gastric ulcer, pathologic GI hypersecretory
conditions.

Contraindication Hypersensitivity to famotidine, other H2-receptor antagonists,

or their components
 40

Side effects Occasional (5%): Headache. Rare (2% or less): Confusion,

constipation, diarrhea, dizziness.

● EENT: Dry mouth, laryngeal edema, taste alteration,

Adverse effects
tinnitus
● GI: Abdominal pain, anorexia, cholestatic jaundice,
constipation, diarrhea, elevated liver enzymes,
hepatitis, jaundice, nausea, vomiting
● Other: Anaphylaxis, angioedema, hyperuricemia

Drug interaction Drugs dependent on gastric pH for absorption: Reduced

absorption of these drugs

Tizanidine: Possibly substantial increase in blood tizanidine

levels with increased risk of adverse reactions

Nursing ● If using one dose a day, administer drugs at bedtime.It

Responsibilities appears to be a successful and well-tolerated
technique for preventing postprandial heartburn and
the sleep disturbances that accompany it.
● Decrease doses with renal failure.
● Know that adult patients who have a suboptimal
response or an early symptomatic relapse after
completing famotidine therapy, should be evaluated for
gastric malignancy.
● Instruct pt to increase fluid and fiber intake to prevent
constipation
● Monitor daily pattern of bowel activity, stool
consistency.
● Assess for abdominal pain and occult blood
● Monitor for headache.
● Assess for confusion in elderly.
● Consider interrupting treatment in pts who develop
thrombocytopenia.
● Report persistent symptoms of heartburn, acid
indigestion, sour stomach.
 41

Generic name Carafate

Brand name Sucralfate

Classification Pharmacologic class: GI protectant

Therapeutic class: Antiulcer

Mechanism of action May react with hydrochloric acid in the stomach to form a
complex that buffers acid. The complex adheres
electrostatically to proteins on the ulcer’s surface and
creates a protective barrier at the ulcer site. Sucralfate also
inhibits back- diffusion of hydrogen ions and absorbs bile
acids and pepsin, actions that promote healing of an
existing duodenal ulcer and prevent recurrent ulcer
formation.

Dosage Active Duodenal Ulcers

PO: ADULTS, ELDERLY: 1 g 4 times/day (before meals and

at bedtime) for up to 8 wks.

Maintenance Therapy of Duodenal Ulcers

PO: ADULTS, ELDERLY: 1 g twice daily.

Indication To prevent the recurrence of duodenal ulcers.

Contraindication Hypersensitivity to sucralfate. Cautions: Chronic kidney

disease (due to accumulation of aluminum). Pts with active
GI bleeding, phosphate deficiency.
 42

Side effects Frequent (2%): Constipation.

Occasional (less than 2%): Dry mouth, backache, diarrhea,

dizziness, drowsiness, nausea, indigestion, rash, urticaria,
pruritus, abdominal discomfort.

● CNS: Dizziness, drowsiness, headache, insomnia,

Adverse effects
light-headedness, vertigo
● EENT: Dry mouth
● ENDO: Hyperglycemia
● GI: Constipation, diarrhea, indigestion, nausea,
vomiting
● OTHER: Anaphylaxis, angioedema

Drug interaction Cimetidine, ciprofloxacin, digoxin, fluoroquinolone

antibiotics, ketoconazole, l-thyroxine, phenytoin, quinidine,
tetracycline, theophylline: Decreased bioavailability of these
drugs.

Nursing ● Monitor daily pattern of bowel activity, stool

Responsibilities consistency.
● Use sucralfate cautiously in patients with chronic
renal failure because of increased risk of aluminum
toxicity.
● Administer drug to patient when he has an empty
stomach.
● Administer antacids between doses of sucralfate, not
within 30 min before or after sucralfate doses.
● Measure and record regular weight to monitor
mobilization of edema fluid.
● Monitor diabetic patient’s blood glucose level closely
because sucralfate may cause hyperglycemia
significant enough to require an adjustment of
antidiabetic drug therapy prescribed.
● Assess dizziness and drowsiness that might affect
gait, balance, and other functional activities
● Report balance problems and functional limitations to
the physician and caution the patient and
family/caregivers to guard against falls and trauma.
● Advise patients to foods that may cause an increase
in GI irritation such as spicy and acidic foods.
 43

● Instruct patients to report troublesome side effects

such as severe or prolonged skin reactions (rash,
itching) or GI problems (nausea, diarrhea,
constipation, gastric pain, indigestion, dry mouth).
 44

Generic name Acetaminophen

Brand name Tylenol

Classification Pharmacologic class: Nonsalicylate, para-aminophenol

derivative Therapeutic class: Antipyretic, nonopioid
analgesic

Mechanism of action Inhibits the enzyme cyclooxygenase, blocking prostaglandin

production and interfering with pain impulse generation in
the peripheral nervous system. Acetaminophen also acts
directly on the temperature-regulating center in the
hypothalamus by inhibiting synthesis of prostaglandin E2 .

Dosage Regular strength (325 MG): Caplets, Capsules, Chewable

tablets, Elixir, Gelcaps, Liquid Solution, Sprinkles,
Suspensions, Tablets:

Adults and children 12 yr and over. 640 or 650 mg every 4

to 6 hr, as needed.Maximum: 3,250 mg (5 doses) in 24 hr.

Indication To relieve mild to moderate pain

Contraindication Hypersensitivity to acetaminophen or its components,

severe hepatic impairment, severe active liver disease

Side effects ● Nausea

● Stomach pain
● Loss of appetite
● Itching
● Rash
● Headache
● Dark urine
● Clay-colored stools,
 45

● Jaundice (yellowing of skin or eyes).

ENDO: Hypoglycemic coma

Adverse effects
GI: Abdominal pain, constipation, diarrhea, hepatotoxicity,
jaundice, nausea, vomiting

Drug interaction DRUG: Alcohol (chronic use), hepatotoxic medications (e.g.,

phenytoin), hepatic enzyme inducers (e.g., phenytoin,
rifAMPin) may increase risk of hepatotoxicity with prolonged
high dose or single toxic dose. May increase risk of bleeding
with warfarin with chronic, high-dose use. HERBAL: St.
John’s wort may decrease blood levels. FOOD: Food may
decrease the rate of absorption. LAB VALUES: May
increase serum ALT, AST, bilirubin; prothrombin levels (may
indicate hepatotoxicity).

Nursing ● Take acetaminophen exactly as directed on the

Responsibilities prescription or package label. Do not take more
acetaminophen or take it more often than directed,
even if you still have fever or pain.
● Caution patients not to exceed recommended dosage
or take other drugs containing acetaminophen at the
same time because of risk of liver damage.
● Assess pain and other variables (range of motion,
muscle strength) to document whether this drug is
successful in helping manage the patient's pain and
decreasing impairments
● Use acetaminophen cautiously in patients with
hepatic impairment or active hepatic disease,
alcoholism, chronic malnutrition, severe hypovolemia,
or severe renal impairment.
● Know that before and during long-term therapy
including parenteral therapy, liver function test
results, including AST, ALT, bilirubin, and creatinine
levels, as ordered must be monitored because
acetaminophen may cause hepatotoxicity. Ensure
that the daily dose of acetaminophen from all sources
does not exceed maximum daily limits.
● Monitor renal function in patients on long-term
therapy. Keep in mind that blood or albumin in urine
may indicate nephritis; decreased urine output may
 46

indicate renal failure; and dark brown urine may

indicate presence of the metabolite phenacetin.
● Discontinue drugs if hypersensitivity reactions occur.
● Monitor for S&S of: hepatotoxicity, even with
moderate acetaminophen doses, especially in
individuals with poor nutrition or who have ingested
alcohol over prolonged periods; poisoning, usually
from accidental ingestion or suicide attempts;
potential abuse from psychological dependence
(withdrawal has been associated with restless and
excited responses).
● Teach patients to recognize signs of hepatotoxicity,
such as bleeding, easy bruising, and malaise, which
commonly occurs with chronic overdose.
● Acetaminophen is intended for temporary use only -
should not be given for more than 4 - 5 days without
physician reassessment.
 47

VII. PROGNOSIS

After the underlying cause of peptic ulcer disease (PUD) is successfully treated, the
prognosis is favorable. Patients with peptic ulcers need to take medications to lessen the
amount of acid in their stomach. It requires antibiotics if the patient develops H. pylori
infection it can help the ulcer heal faster and prevent a recurrence. Continued use of aspirin,
ibuprofen, or naproxen may increase the likelihood of your ulcer returning. Maintaining
excellent cleanliness and avoiding alcohol, smoking, and NSAIDs can help prevent ulcer
recurrence. Recurrence is unfortunately widespread, with rates reaching 60% in most
datasets. Gastric perforation caused by NSAIDs occurs at a rate of 0.3 percent per patient
each year. Even the symptoms go away for a while. An ulcer, if left untreated, can lead to
life-threatening complications. Even after treatment, certain ulcers may reappear,
necessitating further treatment.

In conclusion, if left untreated or is poorly managed, it will most likely progress into
complications and eventually would lead to death. Ulcers spread as the stressful situation
persists; the lesions are reversed as the patient recovers. This is a typical pattern of stress
ulceration. Shock precedes the ulceration, resulting in reduced gastric mucosal blood flow
and reflux of duodenal contents into the stomach. Furthermore, huge amounts of pepsin are
secreted. Ischemia, acid, and pepsin all combine to create an excellent environment for
ulceration. A small percentage of people who bleed from an acute ulcer have never had any
digestive problems before, but they develop symptoms afterward. Moreover if there here
obstruction which can prevent food from passing through the digestive tract, leading you to
feel bloated, vomit, and lose weight due to swelling from inflammation or scarring and can
be a result of Internal bleeding it can take the form of slow blood loss, which can lead to
anemia, or catastrophic blood loss, which may necessitate hospitalization. But if peptic
ulcers are adequately managed and discovered early, treatment of this condition would
result in a good prognosis.
 48

VII. DISCHARGE PLANNING

Method Health Teachings Rationale

Medication 1.) Take your medications Chronic illness

on a daily basis, as management, acute issue
prescribed by your doctor. treatment, and long-term
health and well-being are
all top priorities.

2.) Educate the patient and

Patients gain from
his family about the
education because it
importance of each drug,
allows them to make better
as well as any possible
decisions.
side effects or unfavorable
consequences.

Exercise 1.) Instruct the patient to It has the ability to diminish

have moderate physical gastric secretions and
activity. improve immunological
function, the latter of which
may minimize the risk of
Helicobacter pylori
infection. It can also aid in
the expulsion gas that
causes pain and the
progression of digestion.

Treatment 1.) Encourage the patient To establish a personalized

to consult a dietitian or food plan for patients with
nutritionist. peptic ulcer disease.

Hygiene 1.) Wash hands regularly To aid in bacterial

and properly with soap and prevention and control.
water.
 49

2.)Take shower and To help prevent irritation,

change clothes everyday.
inflammation, and sores
caused by dead skin cell
accumulation by washing
the skin. Microorganisms
can be present on dirty
clothing, which can lead to
skin infection.

Outpatient Referral 1.) Encourage the patient A doctor can help you
to follow up with the manage any chronic
primary health care conditions you may have
provider. and make specialized
recommendations to
improve your health.

2.) Encourage the patient

To instill trust in clients and
and family to ask questions
offer them with sufficient
if further information is
information.
needed.

Diet 1.) Encourage the patient An empty stomach may

to eat little meals more aggravate the symptoms.
frequently instead of large
meals less frequently.

These alterations may

2.)Instruct the patient not
even lead to an increase in
to increase the
stomach acid.
consumption of milk and
dairy products.

3.) Instruct the patient to This may cause

avoid foods and drinks discomfort.
such as alcohol, coffee,
caffeinated soda, fatty
foods, chocolate, and spicy
 50

foods.

4.) Encourage the patient Gastric acid secretion can

to avoid eating within 3 occur during the night as a
hours before bedtime. result of bedtime snacking.

5.) Instruct the patient not Acid reflux, gastritis, and

to skip meals. stomach acid are common
side effects of fasting for
long periods of time.
Excessive digestive fluids
can damage the lining of
the intestine and cause
ulcers.
 51

VIII. NURSING THEORY

IMOGENE KING

“GOAL ATTAINMENT THEORY”

"Nursing is a process of action, reaction, and interaction whereby nurse and

client communicate information about their perspective in the nursing environment,"
according to the Theory of Goal Attainment. The model's title implies that it is centered
on achieving certain life objectives. It outlines how the nurse and the patient work
together to communicate information, create objectives, and take steps to reach those
goals. Roles, stress, space, and time are all aspects that influence the achievement of
objectives. The nurse's purpose, on the other hand, is to assist patients in maintaining
their health so that they can perform their jobs. She established various concepts to
assist nurses comprehend their job, including the patient, who she described as a social
person with three basic needs: the need for health information, the need for
preventative treatment, and the need for care when the patient is unable to help himself
or herself.

Imogene King’s goal attainment theory relates to peptic ulcer disease since the
nurse's role is to comprehend information, plan, administer, and evaluate nursing care
throughout the nursing process. This can help to improve the situation of the patient,
and to prevent complications of the disease, in order for the patient to be able to
function properly. The nurse should make it a goal to be an instrument in helping
patients recover their health. And in order to do so, it's critical to work with the patient to
create health objectives and then take efforts to attain them.
 52

DOROTHY JOHNSON

“BEHAVIORAL SYSTEM MODEL”

In Dorothy Johnson's theory, nursing is defined as "an external regulatory force

that acts to maintain the organization and integration of the patient's behaviors at an
optimal level under those conditions in which the behavior poses a threat to the patient's
physical or social health, or in which illness is discovered." It also states that "each
individual has structured, deliberate, repeating methods of acting that create a
behavioral system peculiar to that individual." Each subsystem has four structural
qualities, according to Johnson: a goal based on (1) a universal drive, (2) a set, (3) a
choice, and (4) action (behavior). Each of these four components contributes to the
visible activity of a person.

The Behavioral System Model may be utilized to assist the client maintain a
healthy lifestyle and attain optimum health. Maintaining a healthy lifestyle can aid in the
treatment of the condition and the prevention of consequences. This approach can also
assist in the elimination of harmful behaviors by providing a universal motivation to
select a goal, choosing healthy methods to avoid more complications, and taking action
to attain all of these goals. It encourages efficient and effective patient behavior in order
to avoid illness, and it highlights the need for research-based knowledge of nursing
care's influence on patients. In order to preserve a behavioral system equilibrium and
steady state, he or she must make more or less automatic modifications and
adaptations to natural variables that impact him or her.
 53

NOLA PENDER

“HEALTH PROMOTION MODEL”

According to the Health Promotion Model, each person's unique characteristics

and experiences impact their subsequent behaviors. The set of behaviorally specific
knowledge and impact variables has a lot of motivating power. These factors can be
altered through nursing interventions. The Health Promotion Model's targeted
behavioral goal and endpoint is health-promoting behavior. Health-promoting behaviors
should promote health, functional capability, and quality of life at all stages of
development. The ultimate behavioral demand is influenced by conflicting demands and
preferences, which might jeopardize planned health-promoting activities. The Health
Promotion Model was designed as a "complementary counterpart to health-protection
approaches," and it has evolved to encompass health-promoting practices that may be
applied to people of all ages. Its purpose is to help nurses learn about and understand
the key drivers of health behaviors so that they may employ behavioral counseling to
promote well-being and healthy lifestyles.

To increase one's well-being and realize one's health potential, Health Promotion
Theory may be used in this scenario. It's a different perspective on health. Promoting
wellness and healthy lifestyles is crucial for minimizing inequities in illness burden
among the poor and other disadvantaged groups. Nurses must assume an active
leadership role and adopt a health advocacy approach to promote health in order to
enhance the health status of their patients. To promote health in areas such as diet,
exercise, and positive thinking, all of which are choices and factors in living a healthy
lifestyle, as well as to eliminate the self-destructive nature of poor decisions and replace
them with healthier alternatives.
 54

IX. REVIEW OF RELATED LITERATURE

Peptic Ulcer Disease is Associated with Increased Risk of Chronic Urticaria

Independent of Helicobacter pylori Infection: A Population‑Based Cohort Study

According to some research, patients with chronic urticaria have an increased

risk of developing peptic ulcer disease (PUD). It is uncertain whether PUD is a risk
factor for chronic urticaria. This study aimed to use the Taiwan National Health
Insurance Research Database to determine the incidence of chronic urticaria and risk
variables in patients with PUD. Incidences of chronic urticaria were significantly more
significant in the PUD+HP and PUD HP groups than in the non-PUD group. The risk
difference became significant two years after individuals with PUD underwent HP
infection testing, and it remained so until the end of the study. Patients with PUD who
were female or aged 40–64 years had a significant increase in risk. In terms of risk,
there was no difference between the PUD+HP and PUD HP groups. In conclusion,
Independent of HP infection, peptic ulcer disease is associated with an increased
chronic urticaria risk. Patients with PUD who were female or aged 40–64 years are
more likely to have chronic urticaria.

Exploiting Drug Delivery Systems for Oral Route in the Peptic Ulcer Disease Treatment

Peptic ulcer disease (PUD) is a common condition induced by acid and pepsin,
causing lesions in the mucosa of the duodenum and stomach. The pathogenesis of
PUD is a many-sided scenario, which involves an imbalance between protective factors,
such as prostaglandins, blood flow, and cell renewal, and aggressive ones, like alcohol
abuse, smoking, Helicobacter pylori colonization, and the use of non-steroidal
anti-inflammatory drugs. The treatment of PUD still needs to be explored and improved
since its prevalence and incidence rise every year. According to the scientific reports
presented in this review, oral drug-delivery systems can enhance the action of the drugs
used in the treatment of PUD, improving their effectiveness and safety through a
prolonged and directed drug release to the gastric or intestinal environment. Such
systems can also be used as a strategy to decrease the undesirable effects of
commercially available drugs (especially when we think about NSAIDs). Through their
unique properties, the drug-delivery systems allow the use of conventional medicines
more efficiently, overcoming their limitations and improving the healing of PUDs.

Primary versus Delayed Primary Skin Closure in Operated Patients due to Perforated
Peptic Ulcer Disease: A Randomized Controlled Clinical Trial

Perforated peptic ulcer (PPU) is a life-threatening consequence of peptic ulcer

disease. This condition is characterized by a dirty abdomen, which increases the risk of
infection after surgery. In dirty abdominal wounds, delayed primary skin closure is
occasionally preferred over primary closure to reduce the risk of surgical site infection.
The skin is sutured immediately after surgery in primary skin closure. Meanwhile, in
 55

delayed primary skin closure, the incision is left open for 2–5 days before being sutured.
The delayed primary and primary closure groups did not significantly differ in
postsurgical wound infection occurring on the 3rd, 7th, 14th, and 30th days after
surgery, mortality rate, and duration of hospitalization. Due to the risk of postoperative
surgical site infection, delayed primary closure is not advised over primary closure in
patients who have had PPU surgery.
 56

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