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CASE PRESENTATION ON PEPTIC ULCER

CASE PRESENTATION ON PEPTIC ULCER



SPECIFIC OBJECTIVES                          
TIME
                                   CONTENT                     
TEACHING/
LEARNING ACTIVITY
A.V.AIDS
EVALUATION












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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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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

Damage to mucosa with alcohol abuse, smoking, NSAIDs

Infection with H. Pylori


Acid pepsinogen release with chronic vagal response to increase stress.




 
 

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:
-          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
-          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;
Drug name
Dosage
Route
Frequency
Duration

-          Omprazole
-          Claruthromycin
-          Amoxicillin
20 mg
500mg
1000mg
Oral
Oral
oral
BD
BD
BD

7-14 days
-          Omprazole
-          Bismuth subsalicylate
-          Metronidazole
-          Tetracycline
20mg
2 tablets

500mg
500mg
Oral
Oral

Oral
Oral
BD
BD

TID
QID


10 days
-          Omprazole
-          Clarithromycin
-          Metronidazole 

20mg
250mg
500mg


Oral
Oral
Oral



BD
BD
BD



7-14 days








-          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.

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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.













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?









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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.



























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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