University of Perpetual Help System

Isabela Campus

CASE STUDY
On

Peptic Ulcer Disease

(PUD)

Presented by:

AGCAOILI, JOCELYN G.
Presented to:

MR. RAYMUND, RN.MAN.

Clinical Instructor

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INTRODUCTION

Peptic Ulcer

 a lesion in the mucosa of the lower esophagus, stomach, pylorus, or

duodenum.
 also known as ulcus pepticum, PUD or peptic ulcer disease, is an ulcer
(defined as mucosal erosions equal to or greater than 0.5 cm) of an area
of the gastrointestinal tract that is usually acidic and thus extremely painful
 Causative factors include mucosal infection by the bacterium Helicobacter
pylori (mechanism unclear).
 Use of non-steroidal anti-inflammatory drugs (NSAIDs), especially aspirin.
 Genetic factors such as cigarette smoking, stress, and lower socio-
economic status may play a role.
 Complications include GI hemorrhage, perforation, and gastric outlet
obstruction.

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DEMOGRAPHIC DATA

A. Patient’s Profile
Patient’s name : Mr. AA
Age : 34 years old
Sex : Male
Address : Alicaocao, Cauayan City
Civil Status : Married
Occupation : Delivery Boy
Religion : Roman Catholic
Date of Admission : January 31, 2010
Diagnosis : Peptic Ulcer Disease (PUD)
Attending Physician: Dr. Bartolome

PATIENT’S HISTORY

Patient has been having on and off epigastric pain for about a year which was

not associated with food intake. Patient took esomeprazole (Nexium) as needed for pain

which afforded relief.

One and a half month prior to admission, patient had recurrence of epigastric

pain, 6-7/10 in severity, relieved by esomeprazole. He experienced loss of appetite,

diarrhea and a feeling of fullness in upper abdomen after eating.

He then sought consult with a private medical doctor and was advised gastroscopy.

IV.PAST HEALTH HISTORY

On his early childhood, he had chickenpox and measles. When he had a fever,

her mother wiped her whole body to relieve the heat. He sometimes had headache and

diarrhea but he will just take a medicine for it. At the age of ten, he had felt pain at his

epigastric area and his parents brought him to the hospital for a checkup. He had a

diagnosis of an acute gastritis. He remembers that, he felt so tired at that time. He

received a complete immunization. He does not have any allergies to foods or drugs. In

the year 1979, he was hospitalized due to malaria at Luna Medical Center. At the age of

40, he was diagnosed as hypertensive.

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History of Present Illness

Mr. AA was admitted due to on and off epigastric pain at Chong Hua

Hospital. Patient was seen lying awake on bed, conscious, coherent, not in respiratory

distress and appropriately responds to questions when asked.

Vital Signs taken during the first contact with the patient:

Blood Pressure : 140/100 mmHg

Heart Rate : 66 beats per minute

Respiratory Rate : 15 cycles per minute

Temperature : 36.2 0C

On January 31, 2010 at around 9:47am, he was rushed to Cauayan District

Hospital due to onset of pain on his epigastric area and right lower quadrant. Patient

has been having on and off epigastric pain for about a year. which was not associated

with food intake. Patient took esomeprazole (Nexium) as needed for pain which

afforded relief.

One and a half month prior to admission, patient had recurrence of epigastric

pain, 6-7/10 in severity, relieved by esomeprazole. He experienced loss of appetite,

diarrhea and a feeling of fullness in upper abdomen after eating.

He then sought consult with a private medical doctor and was advised gastroscopy.

According to the patient, when she was 14 years old, they started to notice the
deformity of Mr. X on his lower extremity particularly on his legs, but the parents did not
seek for medical help instead they ask for a help at Philippine Charity Sweepstake
Office (PCSO) and they was given a crutches which Mr. X was not able to utilized
because of his resistance.
Mr. X was completely immunized at Nueva Ecija according to his mother.
On April, 2008 he was brought to a private clinic at Marikina City for check up
and referred to Marikina Orthopedic Specialty & National Kidney & Transplant Institution
for initial diagnostic work up which was not completed due to financial constraints, was
then initially diagnosed as metabolic bone disease, He was referred to Philippine
Orthopedic Center as an outpatient, series of diagnostic test was done like urinalysis,
ionized Ca#, general x-ray. Some doctors diagnosed it as Rickets.
On January 6, 2010, at around 4:35 o’clock in the morning but due to heavy pile
of patient, he was attended at around 9:27 am. Mr. X was rushed to Philippine
Orthopedic Center (POC) at around 4:35am due to swelling and tenderness both on

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lower extremities sustained from a fall one day prior to admission, he was received via
stretcher accompanied by his relatives at his room of choice attended by both Dr. Chan
and Dr. Sanidad. According to the SO, he was sitting on a chair when he suddenly
stand and bent, he was then out of balance causing him to fall on his hips, after series
of examinations and diagnostic procedures Mr. X was diagnosed as Pathologic
Fracture, medial 3rd bilateral femur problem secondary to metabolic bone disease,
probably Parathyroid tumor.

2) Past Medical History

The patient has no previous confinement. He had no allergy to foods & drugs.
His childhood illnesses were fever, cough, colds, measles & chicken pox. No
experienced of vehicular accident.

3) Family Medical History

According to the mother, they had history of mongolism, her brother (the uncle of
Mr. X) is a mongoloid, and on the part of the father of Mr. X, they had history of
Diabetes Mellitus. More often, immediate family of Mr. X is experiencing only from
fever, cough and colds.

4) Personal and Social History

The patient no longer attends school since his admission to the hospital but the
willingness to go back to school still his priority despite of deformity. Mr. X can still write
and read well.

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VII. PHYSICAL ASSESSMENT

Areas to be assess:

General Survey: Patients is lying on bed with IV infusion on right hand.

Vital signs: T - 37.2
RR - 35
PR - 82
BP - 130/80

Method ActualFinding Analysis

HEAD

A. Hairs
●Thickness/thinness -Inspection -thick and short -Normal
-Palpation -hair

●Presence of -Inspection -no lice Normal

intestation

●Color Inspection Black Normal

B. Scalp and cranium

●Skull's size /shape Palpation Rounded /symmetrical Normal
and symmetry
●Presence of Palpation Smooth,uniform,no Normal
nodules/mass nodules or masses
depression

C. Facial Features

●Symmetry of Inspection Hair evenly distributed, Normal

structures and skin intact,
distribution of hair symmetrically align,
equal movement.
●Symmetry of facial Inspection symmetrical, facial Normal
movement movements

D. Eyes and vision

●eyebrows Inspection Hair evenly distributed, Normal

skin intact,
symmetrically align,
equal movement.

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 ●Eyelashes Inspection Curved and outward, Normal
black color, no
discharge bilateral
blinking.

●Palpebral Inspection Pinkish in color, no Normal

conjunction lesions.

● Lacrimal gland Palpation No tenderness Normal

●Sclera Inspection white Normal

●Pupils Inspection -Black in color, equal in Normal

size, round smooth
border.

●Visual fields Inspection -pupil constrict when Nomal

looking at far objects,
courage when near
object is moved toward
nose.
E. Ears and earings:

●Auricle Inspection -Client can see Normal

object in the periphery

●Gross hearing Acuity test Symmetrical,auricle, Normal

aligned with outer
canthus of the eye
F. Nose and synusis

●Nose Inspection able to hear ticking in Normal

both ears

●Facial sinuses Palpation Symmetric, no Normal

discharge,uniform color,
no lesion.
G. Mouth

●Lips Palpation Not tender Normal

●Teeth -Inspection/ Not tender Normal

palpation

●Tongue -Inspection -uniform light brown in -Normal

color

H. Neck:

●Lymph nodes -Inspection -no inflammation - Normal

●Thyroid glands -Palpation - no inflammation, no - Normal

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 masses

I. Thorax

●Posterior thorax -Inspection -pinkish in color, no -Normal

lesions

●Anterior thorax -Inspection -not palpable -Normal

-not visible in inspection -Normal

J. Abdomen: - Auscultation -Flabby, with hypoactive -due to (+)

bowel sound on right epigastric pain
lower quadrant

K. Skin: -Palpation -no masses were noted -Normal

-Inspection/ -no tenderness Normal

Palpation
-Inspection -quiet, effortless Normal

●Skin turgor -Inspection -Unblemished skin, -Normal

uniform in color
L. Nails:

●Capillary refill -Inspection -1-2 seconds return to -Normal

pink color

●Toe bed -finger nail -Palpation -1-2 seconds return to -Normal

bed pink color

M. Upper extremities:
●Muscle -Inspection -equal in size -Normal

●Grip strength -Inspection -equal in strength on -Normal

each side

●ROM -Inspection - equal in strength -Normal

N. Lower Extremities:

●Muscle -Inspection - negative for edema -Normal

●ROM -Inspection - Equal strength - Normal

●Nails - Inspection - Clean & short - Normal

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 LABORATORY EXAMINATION
HEMATOLOGY SECTION

COMPONENT RESULT FINDINGS INTERPRETATION

Hemoglobin 11.6 -Normal

Hematocrit 47 -Normal

WBC 11.6 -Increased -Bacterial infection

Granulocate 73 -Normal

Lymphocytemonoyte 27 -Decreased -Viral infection

Eosinophils - -

Platelet count - -

URINALYSIS

PHYSICAL CHARACTERISTIC
Color: Yellow Characteristics: Clear
Reaction: 8.0 Specific gravity: 1.010
Albumin: trace CBC/hpf : 15-20
Sugar : negative ErthCell : +
Crystal : A PO4 = +
Bacteria : mucus thread = ++++

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10
PATHOPHYSIOLOGY ( Peptic Ulcer Disease)

Modifiable factor:
 Single bad parathyroid gland
grow large develops into
tumors
idiopathic

Parathyroid gland tumor or

adenoma

Losses control of its

hormone regulatory system

Starts to make PTH all

the time more than body
needs

Excessive PTH circulating in the

blood

Triggers the release of

calcium out of the bones into
circulation

Increases blood level of

calcium circulating in the
blood

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 Signs and symptoms of
increase calcium in the
blood

bones brain muscle Intestinal function

Little calcium left Sleepy/drowsy Loss of energy Becomes efficient

in absorbing
calcium found in
Tired all the time diet
osteopenia osteoporosis
Calcium level goes
up
Larger bone
Less bone Bone
mass soften and

Knee deformity Barrel

Wrist
deformity/ joint
shortening
Bilateral fracture of medial 3rd of

Immobilization (foam

Self care
Impaired
Slow

constipation

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 DISCUSSION ON THE PATHOPHYSIOLOGY OF ACID PEPTIC DISEASE

The stomach's lining has a protective layer of cells that produce mucus. The

mucus prevents the stomach from being injured by stomach acids and digestive juices.

When this protective layer is damaged, it cannot secrete enough mucus to act as a

barrier against HCl, thus an ulcer may occur. Peptic ulcers occur mainly in the

gastroduodenal mucosa because this tissue cannot withstand the digestive action of

gastric acid (HCl) and pepsin. Normally, when the mucosa is damaged, the defensive

forces will respond.

Stomach ulcers may develop from: the presence of bacteria called Helicobacter

pylori (H. pylori), the most common cause of stomach ulcers; decreased resistance of

the lining of the stomach to stomach acid and increased production of stomach acid.

Stomach ulcers are more likely to occur in people who: regularly take

nonsteroidal anti-inflammatory drugs (NSAIDS), such as aspirin, ibuprofen, and

naproxen; smoke cigarettes and intake of excessive alcohol. In addition, substances

that increase the production of stomach acids, such as caffeine, may increase the risk

of ulcers and are known to worsen the pain.

Usually, the ulceration is preceded by shock; this leads to decreased gastric

mucosal blood flow and to reflux of duodenal contents into the stomach. In addition,

large quantities of pepsin are released. The combination of ischemia, acid, and pepsin

creates an ideal climate for ulceration.

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 ACUTE PAIN R/T CHEMICAL BURN OF GASTRIC MUCOSA

NURSING PLANNING NURSING RATIONALE EVALUATION

ASSESSMENT DIAGNOSIS INTERVENTION
SUBJECTIVE: Acute pain r/t ● After 8 hours of Independent ● Goal met, patient has
Chemical burn of nursing intervention the  Note reports of pain,  Pain is not always verbalized relief of pain.
“Sumasakit ang gastric mucosa patient will including location, present, but if present
sikmura ko verbalize relief of pain. duration, intensity (0– should be compared with >Demonstrated relaxed body posture
pgkatapos kumain” 10 scale) patient’s previous pain and be able to sleep/rest
(I’ve been experiencing >Demonstrate relaxed symptoms. This appropriately.
abdominal pain body posture and be able comparison may assist in
immediately after
to sleep/rest diagnosis of etiology of
eating) as
appropriately. bleeding and
verbalized by the
development of
patient
complications.

 Review factors that
aggravate or alleviate
 Helpful in establishing
diagnosis and treatment
OBJECTIVE: pain.
needs.
 Abdominal  Identify and limit foods  Food has an acid
guarding that create discomfort neutralizing effect and
such as spicy or
dilutes the gastric
 Restlessness carbonated drink.
contents.

 facial grimacing  Encourage small,

frequent meals  Small meals prevent
distension and the
 pain scale of 6 release of gastrin
out of 10
 Encourage patient to
 Reduces abdominal
assume position of
 V/S taken as tension and promotes
comfort.
follows COLLABORATIVE sense of control.

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  Provide and
T: 37.5˚C implement prescribed
P: 65 dietary modifications.
R: 14  Patient may receive
BP: 110/ 80 nothing by mouth (NPO)
initially. When oral intake
Administer medications as is allowed, food choices
indicated depend on the diagnosis

 Analgesics, e.g.,
morphine sulfate
 May be narcotic of
choice to relieve
acute/severe pain and
reduce peristaltic activity.
Note: Meperidine
(Demerol) has been
associated with
increased incidence of
 Antacids nausea/vomiting

 Decreases gastric acidity

by absorption or by
chemical neutralization.
Evaluate choice of
antacid in regard to total
health picture, e.g.,
 Anticholinergics, e.g., sodium restriction
belladonna, atropine
 May be given at
bedtime to decrease
gastric motility, suppress
acid production, delay
gastric emptying, and
alleviate nocturnal pain
associated with gastric
ulcer.

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 CONSTIPATION R/T INACTIVITY AND DECREASED INTESTINAL MOTILITY

ASSESSMENT NURSING PLANING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Subjective: Constipation ● After 30 min the ●Auscultate bowel ●Bedrest, use of After 4 hours of nursing
related to patient will be able to sounds . Monitor analgesic and changes in intervention the patient
“Ilang araw na inactivity and know the causes of elimination habits. dietary habits can slow shall be able to establish
akong hindi decreased constipation. peristalsis and produce and regain normal patterns
dumudumi “as intestinal constipation. Bowel of bowel functioning.
verbalized by the motility and sound are decrease in .
patient. physical constipation.
movement. ●Provide privacy - Comfort of stool passage
and place bedside ●Initiate and enhance
Objective: commode like defecation and fracture - stool soft and formed
> facial grimace fracture pan or bed pan limits flexion of hips
pan and lessen pressure on - passage of stool with out
>abdominal lumbar region/ lower aids.
distention extremities.
●Encourage
>hard formed stool increased fluid ●Keep the body well
dark brown intake up to hydrated and improve
2,000ml/day with in stool consistency.
>straining with cardiac tolerance.
defecation
●Increase amount
of roughage/fiber ●Adding bulk to stool
in the diet,limit gas helps promote
forming foods ,like constipation. Gas forming
fruits- papaya, foods may cause
pineapple,pomelo. abdominal distention.

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●Assist in perianal
skin condition ●preventing skin irritation.
frequently, noting
changes or
beginning
breakdown.

Independent :

●Administer
dulcolax ●To facilitates defecation
suppository as
doctor's order

Collaborative:

●Consult with ●Fiber acts as stimulant

dietitian to provide to defecation.
well balance diet
high in fiber and
bulk.

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 IMPAIRED PHYSICAL MOBILITY R/T FALL TRAUMA SECONDARY TO FRACTURE

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

S: Impaired physical  After 2 hrs  Assess degree of  To determine  After 2-3 days of
“Hindi ako makatayo at mobility r/t fall of nursing muscle strength client activity level nursing
makalakad” as trauma secondary intervention and tolerance to and serve as a interventions the
verbalized by the to fracture. the patient activities baseline data. patient shall be able
patient. will be able  Determine  To identify what to maintain or regain
to maintain activities that can activities will be mobility at the
or regain be perform by the facilitated by the highest possible
O: mobility at client unaided and nurse or s.o. level.
 Bilateral fracture the highest activities that  Early mobility
of M3rd femur possible needs assistance.  Increase muscle
 limb on foam level.  Place in supine  To promote strength function.
traction position independent
 Immobilization of periodically if attitude and sense
limb possible when of well being
 Limited ROM traction is used to
 Decrease limb stabilize lower limb
muscle strength fractures.
 Difficulty turning  Assist with  Increases blood
 Pain upon encourage self flow to muscle and
movement. care activities bone to improve
(bathing,toileting) muscle tone and
maintain joint
mobility.
 Advice/ educate  Isometricts
high in protein, contract muscles
carbohydrates, w/o bending joints
vitamins. or moving limbs

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 and help maintain
muscle strength
and mobility.

 Reposition  Reduces risk of

periodically and flexion contracture
encourage deep of hip
breathing,
coughing
exercises.  Improves muscle
 Consult with strength and
physical/ circulation,
occupational enhances client
therapist or control in situation
rehabilitation  Nutrients are
specialist. required for rapid
healing
 Prevents /reduces
incidence of skin
and respiratory
complications.
 Usefull in creating
aggressive
individualized
activity/ exercise
program. Client
may require long
term assistance
with movement ,
strengthening and
with bearing
exercises.

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 Name of drug Action Indication Contraindication Side/Adverse Nursing
effects consideration
Generic name: Bacteriostatic effect Serious infections for Contraindicated with CNS: headache, mild 1. Culture infection
Pentamycetin against susceptible which no other allergy to depression, mental before beginning
bacteria; prevents cell antibiotic is effective chloramphenicol confusion therapy.
Brand Name: replication
Chloramphenicol Use cautiously with GI: nausea, vomiting, 2. Do not give this
Acute infections renal failure, hepatic diarrhea drug IM because it is
Dr. Order: caused by Salmonella failure, pregnancy, ineffective.
1g. slow IV q 60 typhi lactation
OTHER: fever, 3. Monitor hematologic
Classification: urticaria data carefully,
Antibiotic; Anti- especially with long-
infective term therapy by any
route of administration.

4. Reduce dosage in
patients with renal of
hepatic disease.

5. Change to another
antibiotic as soon as
possible.

6. Report sore throat,

tiredness, unusual
bleeding or bruising,
pain in the extremities
and etc.

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 Name of drug Action Indication Contraindication Side/adverse Nursing
effects consideration
Generic name: Completely inhibits •Duodenal and gastric Contraindicated in • Vertigo, malaise, Assess patient for
Ranitidine action of histamine on ulcers patients hypersensitive headache, blurred abdominal pain. Note
the H2 at receptor •Maintenance therapy to drug and those with vision, jaundice, presence of blood in
Brand Name: sites of parietal cells, for gastric and porphyria burning and itching at emesis, stool, or
Zantol decreasing gastric acid duodenal ulcer  •Use cautiously injection site gastric aspirate
secretions •GERD in patients with •Ranitidine may be
Dr. Order: •Erosive esophagitis hepatic dysfunction. added to total
25mg/ml 1amp IV •Heartburn Adjust dose in parenteral nutrition
patients with solution
Classification: impaired renal •Instruct patient on
H2 receptor function proper use of OTC
antagonist preparation as
indicated.
•Remind patient to
take once daily
prescription drug at
bedtime for best
results

•Instruct patient to take

without regard to
meals because
absorption isn’t
affected by food

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 Name of drug Action Indication Contraindication Side/Adverse Nursing
effects consideration
Generic name: Inhibits sodium and - acute pulmonary  Anuria  To prevent
Zoltax chloride reabsorption edema: edema Vertigo, dizziness,
 hepatic coma & nocturia, give
at the proximal and hypertension headache, aresthesia, preparation in the
precoma
Brand Name: distal tubules and the orthostatic morning and early in
 severe
Cefuroxime ascending loop of hypotension, the afternoon
hypokalemia &/or
Henle thrombophlebitis,
hyponatremia  Watch for signs
Dr. Order: abdominal pain,
 hypovolemia w/ of hpokalemia
500mg. 1 tab BID hypokalemia,
or w/o hypotension  do not confuse
anemia
 Hypersensitivity with Torsemide or
Classification: muscle spasm
to furosemide or Lasix with Lonox
2nd generation sulfonamides  advise patient
cephalosporin Body as a Whole:
Thrombophlebitis (IV to take drug with food
site); pain, burning, to prevent GI upset
cellulitis (IM site);
superinfections, Inform patient of
positive Coombs' test. possible need for
GI: Diarrhea, nausea, potassium or
antibiotic-associated magnesium
colitis. Skin: Rash, supplements
pruritus, urticaria.
Urogenital: Increased
serum creatinine and
BUN, decreased
creatinine clearance.

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