Peptic Ulcer nursing assessments

nursing diagnosis for peptic ulcers

Acute pain related to the effect of gastric acid secretion on damaged tissue Anxiety related to an acute illness Imbalanced nutrition: less than body requirements related to changes in diet

hemorrhage

Gastritis and hemorrhage from peptic ulcer are the two most common causes of upper GI tract bleeding (which may also occur with esophageal varices, as discussed in Chapter 49). Hemorrhage in patients with peptic ulcers is associated with a 10% mortality rate (Wong & Sung, 2013). Bleeding peptic ulcers account for 36% of all upper GI bleeds and it may be manifested by hematemesis or melena (Anand, 2015; Wong & Sung, 2013). The vomited blood can be bright red, or it can have a dark coffee grounds appearance from the oxidation of hemoglobin to methemoglobin. When the hemorrhage is large (2000 to 3000 mL), most of the blood is vomited.

potential compications of peptic ulcers

Hemorrhage Perforation Penetration Gastric outlet obstruction

NA for gastric outlet obstruction

NG tube to decompress the stomach. Confirmation that obstruction is the cause of the discomfort is accomplished by assessing the amount of fluid aspirated from the NG tube. A residual of more than 400 mL suggests obstruction. Usually, an upper GI study or endoscopy is performed to confirm gastric outlet obstruction. Decompression of the stomach and management of extracellular fluid volume and electrolyte balances may improve the patient's condition and avert the need for surgical intervention. Balloon dilation of the pylorus via endoscopy may be beneficial.

gastric outlet obstruction

Peptic ulcer disease is the leading benign (noncancerous) cause of gastric outlet obstruction (Castellanos & Podolsky, 2014). Gastric outlet obstruction occurs when the area distal to the pyloric sphincter becomes scarred and stenosed from spasm or edema or from scar tissue that forms when an ulcer alternately heals and breaks down. The patient may have nausea and vomiting, constipation, epigastric fullness, anorexia, and, later, weight loss.

Billroth II (gastrojejunostomy)

Removal of lower portion (antrum) of stomach with anastomosis to jejunum. Dotted lines show portion removed (antrectomy). A duodenal stump remains and is oversewn.

Antrectomy Billroth I (gastroduodenostomy)

Removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. May be performed in conjunction with a truncal vagotomy.

evaluation of patient with peptic ulcers

Reports freedom from pain between meals and at night Reports feeling less anxiety Maintains weight Demonstrates knowledge of self-care activities Avoids irritating foods and beverages (alcohol) and medications (NSAIDs) Takes medications as prescribed No evidence of complications (e.g., hemorrhage, perforation or penetration, gastric outlet obstruction)

vagotomy

Severing of the vagus nerve. Decreases gastric acid by diminishing cholinergic stimulation to the parietal cells, making them less responsive to gastrin. May be performed via an open surgical approach or laparoscopy. May be performed to reduce gastric acid secretion. A drainage type of procedure (see pyloroplasty) is usually performed to assist with gastric emptying (because there is total denervation of the stomach).

truncal vagotomy

Severs the right and left vagus nerves as they enter the stomach at the distal part of the esophagus; most commonly used to decrease acid secretions.

selective vagotomy

Severs vagal innervation to the stomach but maintains innervation to the rest of the abdominal organs.

SXS of perforation

Sudden, severe upper abdominal pain (persisting and increasing in intensity); pain may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm Vomiting Collapse (fainting) Extremely tender and rigid (boardlike) abdomen Hypotension and tachycardia, indicating shock

assessment

The nurse asks the patient to describe the pain, its pattern and whether or not it occurs predictably (e.g., after meals, during the night), and strategies used to relieve it (e.g., food, antacids). If the patient reports a recent history of vomiting, the nurse determines how often emesis has occurred and notes important characteristics of the vomitus: Is it bright red, does it resemble coffee grounds, or is there undigested food from previous meals? Has the patient noted any bloody or tarry stools? The nurse also asks the patient to list their usual food intake for a 72-hour period. Lifestyle and other habits are a concern as well. For example, do they smoke cigarettes? If yes, how many? Does the patient ingest alcohol? If yes, how much and how often? Are NSAIDs used? Is there a family history of ulcer disease? The nurse assesses the patient's vital signs and reports tachycardia and hypotension, which may indicate anemia from GI bleeding. The stool is tested for occult blood, and a physical examination, including palpation of the abdomen for localized tenderness, is performed.

penetration is

erosion of the ulcer through the gastric serosa into adjacent structures such as the pancreas, biliary tract, or gastrohepatic omentum (membranous fold of the peritoneum)

SXS of penetration are

include back and epigastric pain not relieved by medications that were effective in the past. Like perforation, penetration usually requires surgical intervention.

nursing interventions include

relieving pain, reducing anxiety, maintaining optimal nutritional status, monitoring and managing complications (hemorrhage, perforation and penetration, gastric outlet obstruction

perforation is

the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. It is an abdominal emergency and requires immediate surgery. Perforation of a peptic ulcer is associated with a 10% to 25% mortality rate, making it the most lethal of all complications

surgeries for peptic ulcer include

vatotomy, truncal vagotomy, selective vagotomy, gastroduodenostomy, gastrojejunostomy

The nurse must monitor what in hemmorage

vital signs frequently and evaluate the patient for tachycardia, hypotension, and tachypnea. Other nursing interventions include monitoring the hemoglobin and hematocrit, testing the stool for gross or occult blood, and recording hourly urinary output to detect anuria or oliguria (absence of or decreased urine production).