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Duodenal Ulcer Nursing Case Studies with Pathophysiology and NCP

Sunday, 10 August 2014

A duodenal ulcer is a circumscribed lesion in the mucosal membranes of the proximal part of the small intestines. It follows a chronic course characterized by remission and exacerbation, commonly requiring surgery.

Pathophysiology
With a duodenal ulcer, Helicobacter pylori releases a toxin that promotes mucosal inflammation and ulceration. Ulceration stems from the inhibition of prostaglandin synthesis, increased gastric acid and pepsin secretion, reduced gastric mucosal blood flow, or decreased cryoprotective mucus production.

Complications
■ GI hemorrhage
Abdominal or intestinal infarction
■ Ulcer penetration into attached structures
■ Duodenal obstruction



Assessment (only potential abnormalities listed)

Nursing history by Functional health pattern


Health perception and management
Duodenal ulcer

■ Steady, gnawing, burning, aching, or hungerlike discomfort high in the right epigastrium; pain occurs 2 to 4 hours after meals, usually doesn't radiate, and is relieved by food or antacids

■ Increased risk if male, ages 40 to 60, with type O blood, a cigarette smoker, or with chronic emotional stress

■ Ingestion of drugs (such as aspirin-containing compounds, corticosteroids, phenylbutazone, or indomethacin [Indocin])

■ Family history of ulcers

Nutrition and metabolism

■ History of excessive alcohol consumption
■ Nausea
■ Vomiting (even in the absence of obstruction)

Elimination
■ Feeling of fullness
■ Gaseous indigestion
■ Constipation

Activity and exercise
■ Fatigue
■ Exacerbation of pain following unusual physical exertion
■ Orthostatic hypotension, if actively bleeding

Sleep and rest

■ Sleep disturbances due to pain, commonly occurring between 12 a.m. and 3 a.m.

Coping and stress management
■ Recent or current stressful life events
■ Denial during pain‑free periods

Physical Examination
Mental status and behavior
■ Tense posture
■ Facial grimacing

Integumentary
(if hypovolemia is present)
■ Pallor
■ Cool, clammy skin
■ Poor skin turgor

Cardiovascular
(if hypovolemia is present)
■ Hypotension
■ Tachycardia

Gastrointestinal
■ Localized tenderness over ulcer site

Neurologic
(if hypovolemia is present)
■ Dizziness
■ Restlessness
■ Irritability

Diagnostic studies
■ Hemoglobin level and hematocrit are decreased if bleeding is occurring.

■ Serum pepsinogen I level and fasting gastrin level are elevated and provide evidence for gastrinoma or antral G cell hyperfunction.

■ Endoscopy reveals the ulcer's location and allows for biopsy and cytology.

■ Abdominal X-ray reveals free air due to perforation.

■ Screening test for H. pylori may be positive.

■ Single‑or double‑contrast radiography locates the ulcer.

Nursing care plan
Nursing diagnosis
Nursing priorities

Risk for deficient fluid volume related to vomiting, diarrhea, or GI hemorrhage
     Prevent or promptly identify and treat hemorrhage.
     Monitor fluid balance.

Chronic pain related to increased hydrochloric acid secretion; increased spasm, intragastric pressure, and motility of the upper GI tract; and inflammation of the esophagus, stomach, and duodenum
     Relieve pain.


Imbalanced nutrition: Less than body requirements related to nausea and vomiting, dysphagia, and mouth soreness
     Reestablish nutritional balance.



Other potential nursing diagnoses: Ineffective individual coping related to recurrent GI distress Acute pain related to tissue inflammation, injury, or infection Deficient knowledge related to lack of information about disease process and treatment plan




Risk for deficient fluid volume related to vomiting, diarrhea, or GI hemorrhage

Expected outcome
The patient will maintain stable vital signs and will demonstrate signs of adequate hydration (moist mucous membranes, good skin turgor, and adequate urine output).

Suggested NOC Outcomes
Electrolyte & acid-base balance; Fluid balance; Hydration
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Monitor and record the patient's vital signs every 15 minutes, if bleeding or every 4 hours, if stable.
Monitoring vital signs allows for rapid assessment of change, and prevention and treatment of complications.
Independent
Withhold oral foods and fluids until vomiting has subsided. Administer I.V. fluids and blood transfusions, as ordered. Monitor CBC and serum electrolyte levels, as ordered, and report abnormalities.
Allowing the patient to eat and drink may cause more vomiting and lead to metabolic alkalosis, hypokalemia, or hyponatremia. Restoring intravascular volume reduces the effects of fluid loss.

Collaborative
Administer antiemetics, antidiarrheals, and anticholinergics, as ordered. Note the effects of medications and observe for adverse reactions.

Antiemetics prevent activation of the vomiting center in the brain stem. Antidiarrheals help decrease fluid loss from diarrhea.
Anticholinergics decrease gastric acid secretion and GI tone and motility and effectively control nausea and vomiting in acute gastritis. Lack of effectiveness can indicate the need to reevaluate the pharmacologic regimen.
Independent
Assess the patient's skin for signs of dehydration—poor skin turgor, dry skin and mucous membranes, and pallor. Also assess for thirst, especially in the elderly or debilitated patient.
Poor skin turgor, dry skin and mucous membranes, and increased thirst can indicate hypovolemia resulting from decreased extracellular fluid volume.
Independent
Monitor and record intake and output every 8 hours. Include all vomitus, diarrhea, tube drainage, and blood loss in output, and all blood products and I.V. fluids in input. Record hourly urine output in the unstable patient. Record daily weights.
Accurate monitoring of intake and output alerts caregivers to imbalances that can cause hypovolemic shock. Weight loss can reflect hypovolemia.

Independent
Assess and record the patient's level of consciousness (LOC), muscle strength, and coordination at least every 8 hours. Report changes promptly.

Confusion, dizziness, weakness, or stupor can indicate hypovolemia and electrolyte imbalance. A decreased LOC reflects cerebral hypoxemia caused by decreased circulating blood volume.
Independent
Observe for and report signs of GI hemorrhage. Describe any hematemesis, melena, or other signs of intestinal bleeding, including amount, consistency, and color. Test all stools and vomitus with a guaiac reagent strip (Hemoccult).
Hematemesis of frank red blood indicates active bleeding, whereas coffee‑ground vomitus indicates old bleeding. Checking GI output for occult blood can provide for the early detection of bleeding.

Collaborative
Institute nasogastric (NG) intubation if ordered.

NG intubation reveals the presence or absence of blood in the stomach, helps to assess the rate of bleeding, and empties and decompresses the stomach.

[Additional individualized interventions]


Suggested NIC Interventions
Bleeding precautions; Fluid/electrolyte management; Fluid monitoring; Hypovolemia management; Intravenous (IV) therapy

Chronic pain related to increased hydrochloric acid secretion; increased spasm, intragastric pressure, and motility of the upper GI tract; and inflammation of the esophagus, stomach, and duodenum

expected outcome
The patient will rate pain as less than 3 on a 0 to 10 pain rating scale and will identify factors that may reduce episodes of pain.

Suggested NOC Outcomes
Comfort level; Pain: Adverse psychological response; Pain control; Pain: Disruptive effects; Pain level
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Assess and document the patient's pain characteristics, including onset, location, duration, and severity; radiation to back, neck, or shoulder; and its relationship to activity, position changes, eating patterns, bowel movements, and the ingestion of spicy foods, coffee, alcohol, hot or cold liquids, or certain medications. Notify the physician of any findings. Assess and document pain-relief measures.
Accurate assessment is important in determining the cause of the patient's pain and formulating a medical diagnosis.

Independent
Instruct the patient and his family about pain‑prevention measures. If pain causes the patient to awaken at night or if the pain is worse on awakening, instruct the patient to sleep with the head of the bed elevated and to avoid eating for 3 hours before bedtime. Advise the patient to avoid bending, lifting heavy objects, wearing constrictive clothing, and straining for a bowel movement. Assess the patient's diet and habits to identify known causes of pain, such as spicy foods, alcohol, caffeinated products, aspirin, and smoking.

Eating stimulates gastric acid secretion. The patient with esophagitis should avoid eating for 3 hours before bedtime and should elevate the head of the bed to prevent gastric reflux during sleep. Bending, lifting, wearing constrictive clothing, and straining decrease esophageal pressure and increase intra‑abdominal pressure. Spicy foods, alcohol, caffeinated products, and aspirin irritate the gastric lining, increasing discomfort, and should be avoided. Cigarette smoking stimulates increased gastric secretion, which can contribute to further inflammation.
Collaborative
Administer medications and evaluate their effect. Observe the patient for adverse effects.

Lack of medication effectiveness can indicate improper administration, inadequate dosage, the need to change medications, or new or complicating factors.
Independent
Provide rest periods and a quiet environment, minimizing visitors and telephone calls.
GI symptoms are usually reduced by rest and a quiet environment.

Independent
Teach the patient the role of diet in controlling GI symptoms. Help him identify specific foods that may increase discomfort.

Dietary restrictions other than the avoidance of excessive alcohol and caffeine aren't currently recommended. Identifying personal food intolerances aids diet planning.
Independent
Encourage adequate caloric intake from the basic food groups at regular intervals. Encourage frequent small meals. Recommend the avoidance of heavy eating late at night.
Food acts as an antacid, neutralizing stomach acid 30 to 60 minutes after ingestion.

Independent
Teach the patient about lifestyle changes to reduce physical and emotional stress. Help the patient identify specific personal stressors and recognize the relationship between increased stress and ulcer pain. As appropriate, present information on relaxation techniques, exercise, priority setting, time management and personal organization, building and nurturing relationships, the importance of "play" time, and assertiveness techniques.
Stressful life situations, such as occupational, financial, or family problems, are reported more commonly in patients with duodenal ulcers that require longer than 6 weeks to heal. Identifying cause‑and‑effect relationships helps the patient make necessary lifestyle changes.

Independent
Encourage the patient who smokes to quit.

Research indicates that patients who smoke have impaired ulcer healing and a higher mortality when compared with nonsmokers.
Independent
Teach the patient the signs and symptoms that indicate ulcer recurrence and bleeding, including pain, hematemesis, dark or tarry stools, pallor, increasing weakness, dizziness, or faintness.
Early identification of ulcer recurrence and bleeding can permit intervention before bleeding becomes severe.


[Additional individualized interventions]


Suggested NIC Interventions
Analgesic administration; Medication management; Pain management; Patient-controlled analgesia (PCA) assistance

Imbalanced nutrition: Less than body requirements related to nausea and vomiting, dysphagia, and mouth soreness

Expected outcome
The patient will verbalize relief of nausea and vomiting and will discuss nutritional needs with the dietitian.
Suggested NOC Outcomes
Nutritional status; Nutritional status: Food & fluid intake; Nutritional status: Nutrient intake; Weight control
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Assess the patient's ability to retain oral food and fluids, noting nausea, vomiting, or regurgitation; dysphagia for solids or liquids; and complaints of mouth pain or soreness. Record all observations.
Careful assessment of the patient's symptoms aids differential diagnosis.

Collaborative
Monitor the patient's intake and output. Withhold oral foods and fluids until vomiting subsides. Administer I.V. fluids, as ordered.

Food and fluids may cause further vomiting, requiring I.V. fluids to maintain hydration. Monitoring intake and output allows for assessment of fluid balance and identification of fluid deficit or excess.
Collaborative
Teach the patient with esophageal strictures who can't eat solids about dietary changes to assist eating. Refer the patient to a dietitian for further assistance with dietary needs. Document all teaching.

Dietary instruction aims to establish a balanced diet and ultimately return the patient's weight to normal. Thorough teaching can prevent subsequent problems and complications. Careful documentation of teaching provides a record for other caregivers so that reinforcement and review can be provided, as appropriate.

[Additional individualized interventions]


Suggested NIC Interventions
Diet staging; Fluid monitoring; Nutrition management; Nutritional monitoring; Weight gain assistance

Teaching checklist
■ Disease process
■ Treatment plan
■ Risk factor reduction
■ Medications
■ Dietary modifications
■ Stress reduction strategies
■ Activity restrictions
■ Follow-up care
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