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LEVEL 4 . NCM 106 .

ST

SEM SY 2011-2012

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Level 4 CASE PRESENTATION Semester SY 2011-12 Statement of Objective


1st

I.

A.

General Objectives This case analysis aims to increase the understanding and knowledge of student nurses on how to care for patients with Bleeding Peptic Ulcer Disease (BPUD) to consider Upper Gastric Ulcer Disease (UGIB)

B. Specific Objectives Specifically, this case analysis aims to: 1. Define its effects to the body as Bleeding Peptic Ulcer Disease (BPUD) a whole; 2. Illustrate the pathophysiology of Bleeding Peptic Ulcer Disease (BPUD) and in relation to the signs and symptoms specifically observed in the client; 3. Describe and identify the common signs and symptoms of Bleeding Peptic Ulcer Disease (BPUD); 4. Discuss the medical and surgical interventions for the management of Bleeding Peptic Ulcer Disease (BPUD) 5. Formulate appropriate nursing care plans suited for the client based on the assessment findings; 6. Identify care measures to be given to the patient and family to promote continuity of care and independence after discharge INTRODUCTION Peptic Ulcer is an excavation formed in the mucosal wall of the stomach. It is frequently referred to as gastric ulcer caused by the erosion of a circumscribed area of mucus membrane. Chronic ulcers usually occur in the lower curvature of the stomach near the pylorus. This erosion may extend as deeply as the muscle layers or through the muscle to the peritoneum. Peptic ulcers are more likely to be in the duodenum than in the stomach. As a rule they occur alone, but they may occur in multiples. Peptic ulcer disease occurs with the greatest frequency in people between the ages of 40 and 60 years. It is relatively uncommon in women of childbearing age, but it has been observed in children and even in infants. After menopause, the incidence of peptic ulcers in women is almost equal to that in men. Peptic ulcers in the body of the stomach can occur without excessive acid secretion. However, ulcers do seem to develop more commonly in people who are tense; whether this is a contributing factor to the condition is uncertain. In addition, excessive secretion of HCl in the stomach may contribute to the formation of gastric ulcers, and stress may be associated with its increased secretion. The ingestion of milk and caffeinated beverages, smoking, and alcohol also may increase HCl secretion. Familial tendency may be a significant predisposing factor. A further genetic link is noted in the finding that people with blood type O are more susceptible to peptic ulcers than are those with blood type A, B, or AB. There also is an association between duodenal ulcers and chronic pulmonary disease or chronic renal disease. Other predisposing factors associated with peptic ulcer include chronic use of NSAIDs, alcohol ingestion, and excessive smoking. Rarely, ulcers are caused by excessive amounts of the hormone gastrin, produced by tumors. This ZollingerEllison syndrome (ZES) consists of severe peptic ulcers, extreme gastric hyperacidity, and gastrin-secreting benign or malignant tumors of the pancreas. Stress ulcers, which are clinically different from peptic ulcers, are ulcerations in the

LEVEL 4 . NCM 106 . 1

ST

SEM SY 2011-2012

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mucosa that can occur in the gastroduodenal area. Stress ulcers may occur in patients who are exposed to stressful conditions. II. Clients Profile Name Age Birth date Sex Ethnic Background Civil Status Address Religion Occupation Admitting Diagnosis Final/Principal Diagnosis Date and Time Admitted : : : : : : : : : E. L. A. 68 years old January 01, 1943 Female Kankanaey Single Country Club, Baguio City, Benguet Roman Catholic None : BPUD 2 to UGIB : BPUD 2 to UGIB : June 23, 2011 at 1:30 pm

III. Chief Complaint Vomiting of coffee-like granules of blood and defecates black-tarry stool. IV. Present History of Illness The patient was apparently well until 3 days PTA, she started to feel an abdominal pain which was characterized as burning sensation starting from the epigastric region that radiates towards the esophagus rated as 7/10; 10 as the highest, she vomited coffee ground of blood approximately 875cc with the previously ingested food and started to defecate black-tarry stool associated with diaphoresis though she havent experienced fever, loss of consciousness, headache, dizziness, anorexia and body weakness. No consultation was made though she went to the RHU and requested for medicine such as Maalox 350 mg 3x a day after meals and Kremil-S (Antacid) 350mg 3x a day 5cc before meals and Paracetamol (Antiinflammatory/antipyretic) 500mg 3x a day or Ibuprofen (NSAID) 325mg for 3x ad day to decrease abdominal pain, in which the pain rated as 9/10. The condition persisted until 1 day PTA; her neighbor noticed that she was not coming out of her house anymore. Her neighbors went to her apartment to check her out and found her vomiting fresh blood and later it shifted to coffee-like granules of blood approximately 875cc cup per bout and that she was pale and looks weak. After which they informed her relatives about it, upon knowing her condition her relatives fetched her and brought her immediately to BGHMC for evaluation. On their way to the hospital, she was still vomiting persistently approximately 875cc per bout. V. Past History of Illness The patient was hospitalized due to abdominal pain for almost 2 years in which she felt a burning sensation at the epigastric region and was diagnosed with ulcer at her 40s. She complied with the medical regimen and then stopped when she felt better. VI. Family Health History The patient verbalized that they have familial disease such as hypertension and diabetes mellitus. She emphasized that her mother died of cardiovascular disease while her one of her brothers died due to alcoholism. VII. Developmental History The patient is 67 years of age and is the last child among the 7 siblings. Among the 7 children, 5 died and only two of them were alive. According to Erik Ericksons theory she is in the stage of Integrity vs. Despair wherein she views her life as fall short as an alibi she is alone in life and she only finished grade one. As mentioned, she lives alone and the source of her daily finances is from her late mothers pension and some of which are form her nieces, which in her part is a

LEVEL 4 . NCM 106 . 1

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SEM SY 2011-2012

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failure. She was not proud about her self, for she had not accomplished a single career, she felt it was all misspent, which is a contributory factor for her detachment. She was hesitant about the surgery; this is by surgically removing a part or all of the stomach called gastrectomy. The patient had verbalized that she doesnt have money and that even with concise and consequent explanation of the problem wherein she needs the surgery to treat the bleeding and yet the response was that shes already old and she doesnt need the surgery. VIII. Social and Environmental History The patient is a smoker and a chronic alcohol drinker. The client lives alone and her apartment is located along the road known to be passed by cars that makes her environment is noisy at Country Club Baguio City. The client is currently unemployed though she had this part time job which is a Kobrador of jueteng. At times when she is not doing anything, she comes out of the house and mingles with her neighbors and share cups of coffee and at times smokes with them though most of the time she spends alone inside her apartment watching television or she just sleep. IX. Lifestyle and Health Practices The patient started to smoke cigarette in her 20s, she was an active smoker and smokes approximately 1 pack per day (number of packs times years= 3 pack-year history of smoking) but then she limited the number of sticks of cigarette in her 50s. She drinks 750cc of coffee per day and four 330 mL bottles of water per day. During leisure time, she drinks approximately 1000cc of soft drinks like coke. During meals, includes chili as an appetizer. X. Health Assessment

A. General Survey The client was received awake sitting on bed on moderate high back rest, with an ongoing IVF of PNSS at 1 litter 12 x 16 hours at 21 gtts/min at 400 mL level infusing over the right arm and shifted to KVO as temporarily with ongoing BT of I u PRBC with serial number of 2007-805875, blood type of A+ with tubing number of RO821769 and expiration date of 08/12/11. B. Head to Toe Assessment 1. Head Head is round, erect and in midline. No visible lesions seen. Head is held still and upright. Head is hard without lesion. Face is symmetric with an oblongated appearance. Hair is black and evenly distributed. Wrinkles are prominent. No swelling, tenderness and masses noted. Eyes are symmetrical. Pupils are equally round and reactive to light. Both eyes move smoothly and symmetrically in each of six fields of gaze and converge on the held object as it moves toward the nose. Palpebral conjunctiva is pale. Ears are symmetrical, with upper attachment at eye corner level (lateral canthus). Earlobes are attached which are elongated with linear wrinkles. The skin is smooth with no lesions, lumps, or nodules. Color is consistent with facial color. Auricle, tragus, and mastoid process not tender. No discharges noted. The canal walls are partly pale and smooth and without nodules. Vibrations are heard equally well in both ears. No lateralization of sound on both ears. The patient doesnt complain of ear pain, difficulty in hearing or any ear complications.

2. Eyes

3. Ears

LEVEL 4 . NCM 106 . 1

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SEM SY 2011-2012

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4. Nose and Sinuses

5. Mouth

6. Neck

7. Chest

8. Cardiac

9. Breast

10.Abdomen

11.Genito-urinary

Color is same as the rest of the face; the nasal structure is smooth and symmetric; the patient reports no tenderness. She is able to sniff through the each nostril while the other is occluded. The nasal mucosa is dry and free from exudates. Frontal and maxillary sinuses are none tender to palpation. The sinuses are not tender on percussion. Nasal flaring is seen with labored respirations indicative of hypoxia. With oxygen inhalation of 3-4 liters per minute. Lips are coarse and dry without lesions or swelling. Buccal mucosa appears pale and dry. Halitosis was noted upon opening of the mouth. The uvula is freely hanged in the midline. No redness of or exudates from the uvula or the soft palate. Tonsils are symmetric with no exudates, swelling, or lesions present. The patient complains dryness of throat, due to decrease salivary production. Breaths through mouth. Neck is free from bulging masses. The thyroid cartilage, cricoid cartilage, and thyroid gland move upward symmetrically as the client swallows. Trachea is in the midline. Lymph nodes have no signs of swelling or enlargement and no tenderness. Sternum is positioned at midline and straight which is prominent. Retractions are noted with labored breathing. Respirations are labored with associated tachycardia 110. Shallow breathing and counted respiration is 53 per minute. The scalene and sternocleidomastoid muscles are used which indicates an increased inspiratory effort. No tenderness or pain is palpated over the lung area with respirations. There is no evident adventitious breath sounds heard upon auscultation. There are no evident thoracic deformities and configurations. Mouth breather. Use of accessory muscle The jugular vein is visible for about 60 degrees. 110 beats per minute which is tachycardic that indicates hypovolemic shock. Radial and apical rates are identical. The x-ray reading states that she developed sinus tachycardia in response to decrease oxygen due to hypovolemia. Color is same with the bodys skin tone. Texture is smooth with no edema. No striae noted. Areolas are dark brown and round. Breast is symmetrical with no sign of dimpling or retraction. Breasts are symmetrically, smooth, firm and sagged. No masses are palpated. Nipple becomes erect when stimulation is introduced, no discharges noted. No lumps, lesions or tenderness noted. Abdominal contour is flat. Abdomen s free from lesions or rashes. Slight pulsation of the abdomen. There is tenderness felt in the epigastric area which is characterized as burning pain with guarding. Pain is rated as 7/10 with a Pain scale 0 as the lowest and 10 as the lowest. Umbilicus and surrounding area are free of swelling, bulges, or masses. No rebound tenderness was present in the lower left quadrant. Bruits are heard over the abdomen. The patient has a history of difficulty of urinating. Her urine color is light yellow. No lesions, masses or tumor noted at the perineal area. Urine output of 110 ml per shift.

LEVEL 4 . NCM 106 . 1

ST

SEM SY 2011-2012

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12.Muskoskeletal

13.Integumentary

Jaws moves laterally and opens mouth 1-2 inches. The patients mouth opens and closes smoothly. There is no visible bony over growth, swelling, or redness; joint is non-tender. The patients ROM is well coordinated with minimal assistance. Patient is hardened to raise leg above 900 able to raise, extend, flex, abduct, and adduct arms. Elbows are symmetric without deformities, redness, or swelling. Wrists are symmetric without redness or swelling. No movement of patella noted. Patella rests firmly over femur. No pain on examination. Feet have no pain, heat swelling, or nodules noted. Skin is smooth and warm to touch. Poor skin turgor noted. Natural hair color outnumbered by white and gray hair, scalp is oily with present dandruff. Nails are dirty, pale nail beds with capillary refill of 3-5 seconds.