PUD

Question 1

PUD

Answer 1

• A peptic ulcer is an erosion of the mucosal lining of the stomach, esophagus, or duodenum
  
  • Most common in duodenum
  • Mucous membranes can become eroded to the point that the epithelium is exposed to gastric acid and pepsin, which can precipitate bleeding and perforation
    
    • Perforation that extends thru all the layers of the stomach or duodenum can cause peritonitis
  • If a person has a peptic ulcer, they have PUD
• Most peptic ulcers are caused by gram negative Helicobacter pylori
  
  • Contact w/ the bacteria from food, water, body fluids like saliva

Question 2

stress ulcers

Answer 2

• Stress ulcers can also occur from acute period of stressful events like burns, shock, severe sepsis, multiple organ trauma
  
  • These are different than peptic ulcers and can be present in a ventilated client in the ICU
  • Curling’s ulcer: in clients w/ burns
  • Cushing’s ulcer: in clients w/ head/brain trauma
  • Bleeding is primary manifestation of stress ulcer
  • Clients experiencing trauma often receive PPI prophylaxis to prevent development of stress ulcer

Question 3

PUD: health promotion and dz prevention

Answer 3

• Drink alcohol in moderation
• Stop smoking and using tobacco
• Use stress mgmt techniques
• Avoid NSAIDs as indicated
• Limit caffeine containing beverages
• Consume a balanced diet
• Engage in exercise

Question 4

PUD: risk factors

Answer 4

• H. pylori infection
• NSAID and corticosteroid use
• Severe stress
• Familial tendency
• Hypersecretory state
• Gastric secreting benign or malignant tumors of the pancreas
• Type O blood
• Excess alcohol consumption
• Chronic pulmonary or kidney dz
• Zollinger Ellison syndrome: combo of peptic ulcers, hypersecretion of gastric acid, and gastric secreting tumors
• Pernicious anemia

Question 5

PUD: expected findings

Answer 5

• Dyspepsia: heartburn, bloating, n/v
  
  • Can be perceived as uncomfortable fullness or hunger
• Dull, gnawing pain or burning sensation at the midepigastrium or back
• Physical Assessment:
  
  • Pain or epigastric tenderness or abdominal distention
  • Blood emesis: hematemesis or stools (melena)
  • Weight loss

Question 6

gastric ulcer VS. duodenal ulcer

Answer 6

• gastric ulcer:
  
  • pain most commonly 30-60 min after meal
  • less often pain at night
  • pain exacerbated by ingestion of food
  • malnourishment
  • hematemesis
• duodenal ulcers:
  
  • pain occurs 1.5-3 hrs after a meal
  • awakening w/ pain at night
  • pain relieved by ingestion of food/antacid
  • well-nourished
  • melena

Question 7

PUD: lab tests

Answer 7

• H. pylori testing: gastric samples collected via endoscopy to check for H. pylori
• Urea breath testing: client exhales into a collection container (baseline), drinks carbon enriched urea solution, and is asked to exhale into the collection container
  
  • The client should be NPO prior to test
  • If H. pylori is present, the solution will breakdown and CO2 will be released
  • Serologic testing documents presence of H. pylori based on antibody assays
• Stool sample test: for presence of H. pylori antigen
• H&H: unexpected findings secondary to bleeding
• Stool sample: for occult blood

Question 8

PUD: EGD

Answer 8

• provides a definitive diagnosis of peptic ulcers and can be repeated to evaluate tx effectiveness
  
  • Gastric samples obtained to test for H. pylori
• Nursing Actions:
  
  • Monitor V/S until sedation wears off
  • Keep client NPO until return of gag reflex
  • Monitor for manifestations of perforation: pain, bleeding, fever
• Client Edu: NPO 6-8 hours prior to exam

Question 9

PUD: nursing care

Answer 9

• Client should avoid foods that cause distress: coffee, tea, carbonated beverages
• Monitor for orthostatic changes in V/S and tachycardia, as these signs of suggestive of GI bleed or perforation
• Administer saline lavage via NG tube
• Administer medication as prescribed
• Decrease environmental stress
• Encourage rest periods
• Encourage smoking cessation and avoiding alcohol consumption
• Monitor lab results (H&H, coagulation studies)

Question 10

PUD: medication classes

Answer 10

• abx
• H2 receptor antagonists
• PPIs
• antacids
• mucosal protectant

Question 11

PUD: abx

Answer 11

• metronidazole, amoxicillin, clarithromycin, tetracycline
• Eliminate H. pylori infection
• Nursing Considerations:
  
  • Combo of 2-3 abx is administered
• Client edu:
  
  • Complete full course of abx

Question 12

PUD: H2 receptor antagonists

Answer 12

• ranitidine, famotidine, cimetidine, nizatidine
• Suppress the secretion of gastric acid by selectively blocking H2 receptors in parietal cells lining the stomach
• Used in conjunction w/ abx to tx ulcers caused by H. pylori
• Used to prevent stress ulcers in clients who are NPO after major surgery, have large burns, are septic, have inc intracranial pressure
• Nursing Considerations:
  
  • Ranitidine and famotidine: can be given IV in acute situations
  • Ranitidine can be taken w/ or w/o food
  • Tx of PUD is usually started as an oral dose BID until ulcer is healed followed by a maintenance dose taken once daily at bedtime
• Client edu:
  
  • Instruct client to notify provider of obvious or occult GI bleeding
  • Complete prescribed regimen even if S/S subside

Question 13

PUD: PPIs

Answer 13

• pantoprazole, omeprazole, lansoprazole, esomeprazole
• Suppress gastric acid secretion by irreversibly inhibiting the enzyme that produces gastric acid and inhibits basal and stimulated acid production
• Nursing Considerations:
  
  • Insignificant ADRs w/ short term tx
  • Long term use can inc risk of frx, pneumonia, acid rebound, and possibility of c. diff
  • Rabeprazole and pantoprazole are enteric coated and should not be crushed
• Client edu:
  
  • Instruct client not to crush, chew, or break sustained release capsules
  • Take omeprazole and lansoprazole once daily prior to eating main meal of the day
  • Take rabeprazole after eating breakfast
  • Encourage client to avoid alcohol and irritating NSAIDs
  • Complete regimen even if S/S subside

Question 14

PUD: antacids

Answer 14

• Aluminum hydroxide and magnesium hydroxide: neutralize acid in the gut
  
  • Medication provides symptomatic relief by does not accelerate healing
• Antacids can be given 7x a day, 1-2 hours after meals and at bedtime to neutralize gastric acid which occurs with food ingestion
• Nursing Considerations:
  
  • Give 1-2 hours apart from other meds to avoid reducing absorption of other meds
  • Monitor kidney function for clients prescribed aluminum hydroxide and magnesium hydroxide
• Client edu:
  
  • Encourage compliance by reinforcing the intended effect of the antacid (relief of pain, promote healing of ulcer)
  • Teach clients to take all meds at least 1-2 hours before or after taking an antacid
  • Avoid use of flavored antacids which delay emptying of the stomach

Question 15

PUD: mucosal protectants

Answer 15

• Sucralfate coats the ulcer and protects it from the actions of pepsin and acid
• Bismuth subsalicylate prevents H. pylori from binding to the mucosal wall
• Nursing Considerations:
  
  • Administer on empty stomach 1 hour before meals and at bedtime
  • Oral suspension is easier for the older adult clients to ingest b/c tablet form is large and difficult to swallow
  • Monitor for adverse effect of constipation
• Client Edu:
  
  • If taking bismuth subsalicylate, avoid aspirin to avoid salicylate overdose
  • Clients taking bismuth subsalicylate can have black stools which are temporary and harmless

Question 16

PUD: EGD

Answer 16

• Areas of bleeding can be treated w/ epinephrine or laser coagulation
• Nursing Actions:
  
  • Preprocedure: initiate 2 large bore IV catheters
  • Postprocedure: monitor V/S
  • Keep client NPO until V/S return

Question 17

PUD: gastrectomy

Answer 17

• all or part of stomach removed w/ laparoscopic or open approach
  
  • Antrectomy: antrum portion (lower portion of stomach) is removed
  • Gastrojejunostomy: lower portion of stomach is excised, the remaining stomach is anastomosed to jejunum, and remaining duodenum is surgically closed

Question 18

PUD: vagotomy

Answer 18

• vagus N is cut to dec gastric acid production in the stomach
  
  • Often done laparoscopically to reduce postop complications

Question 19

PUD: pyloroplasty

Answer 19

• opening b/w stomach and small intestine is enlarged to increase the rate of gastric emptying
• Nursing Actions:
  
  • Monitor incision for evidence of infection
  • Place client in semi-fowler’s to facilitate lung expansion
  • Monitor NG tube drainage
  • Scant blood can be seen in first 12-24 hours
  • Notify provider before repositioning or irrigating NG tube
  • Monitor bowel sounds
  • Advance diet as tolerated to avoid diarrhea and abdominal distention
  • Administer analgesics, stool softeners
• Client edu:
  
  • Teach client to take vitamin and mineral supplements due to decreased absorption after gastrectomy, including vitamin B12, D, calcium, iron, folate
  • Tell client to consume small, frequent meals while avoiding large quantities of carbs

Question 20

PUD: nutrition

Answer 20

diet should restrict acid producing foods: milk products, caffeine, decaf coffee, spicy foods, NSAIDs

Question 21

PUD: list the possible complications

Answer 21

• perforation/hemorrhage
• pernicious anemia
• dumping syndrome
• pyloric obstruction

Question 22

PUD: perforation/hemorrhage complication

Answer 22

• When peptic ulcers perforate or bleed, it is an emergency
  
  • Perforation presents as:
    
    • Severe epigastric pain spreading across abdomen
      
      • Pain can radiate into shoulders, especially right shoulder due to irritation of the phrenic nerve
    • Abdomen can become tender and rigid
    • Hyperactive to diminished bowel sounds
    • Rebound tenderness
    • Shock, hypoTN, tachycardia
  • GI bleeding in the form of hematemesis or melena can cause:
    
    • Manifestations of shock: hypoTN, tachycardia, dizziness, confusion
    • Decreased Hgb
• Nursing Actions:
  
  • Perform frequent assessments of pain and V/S to detect subtle changes that can indicate perforation of bleeding
  • Provide O2 or ventilation as needed
  • Start 2 large bore IV lines for replacement of blood and fluids
  • Report findings, prepare for endoscopic or surgical intervention, replace fluid and blood losses to maintain BP, insert NG tube, provide saline lavages

Question 23

PUD: pernicious anemia

Answer 23

• Occurs due to deficiency of the intrinsic factor normally secreted by the gastric mucosa
• Manifestations: pallor, glossitis, fatigue, paresthesias
• Client edu:
  
  • Lifelong monthly vitamin B12 injections

Question 24

PUD: dumping syndrome complication–manifestations

Answer 24

• Can occur following gastrectomy surgery
  
  • It is a group of manifestations that occur following eating
  • A shift of fluid to the abdomen is triggered by rapid gastric emptying or high carb ingestion
  • Rapid release of metabolic peptides following ingestion of a food bolus causes dumping syndrome
• Client reports:
  
  • Full sensation
  • Weakness
  • Diaphoresis
  • Palpitations
  • Dizziness
  • Diarrhea
  • Vasomotor symptoms that can occur 10-90 min following a meal: pallor, perspiration, palpitations, HA, feeling of warmth, dizziness, drowsiness
  • Late symptoms: related to the rapid release of blood glucose followed by an inc in insulin production resulting in hypoglycemia

Question 25

PUD: dumping syndrome complication--nursing actions

Answer 25

* Monitor for vasomotor manifestations * assist/instruct the client to lie down when vasomotor manifestations occur * Administer meds: * Octreotide subQ can be prescribed if manifestations are severe and not effectively controlled w/ dietary measures * It blocks gastric and pancreatic hormones which can lead to dumping syndrome * Malnutrition and fluid electrolyte imbalances can occur due to altered absorption * Monitor I&O, lab values, weight

Question 26

early and late vasomotor manifestations of dumping syndrome

Answer 26

* early manigestations: * onset: w/in 30 min after eating * cause: rapid emptying * symptoms: n/v, sweating, dizziness, tachycardia, palpitations * late manifestations: * onset: 1.5-3 hrs after earing * cause: excessive insulin release * symptoms: dizziness & sweating, tachycardia & palpitations, shakiness & feelings of anxiety, confusion

Question 27

PUD: dumping syndrome complication--client edu

Answer 27

* Lying down after a meal to slow the movement of food w/in the intestines * Limit amount of fluid ingested at 1 time * Eliminate liquids w/ meals, for 1 hour prior to, and following a meal * Consume high protein, high fat, low fiber, and low to moderate carb diet * Avoid milk and sugars (sweets, fruit juice, milk shakes, honey, syrup, jelly) * consume small, frequent meals

Question 28

PUD: pyloric obstruction complication

Answer 28

* Occurs due to scarring, edema, or spasm of the area distal to the pyloric sphincter and prevents emptying of the stomach * Manifestations: * Feelings of fullness * Distention * Nausea after eating * Emesis consisting of undigested food * Nursing actions: * Insert an NG tube for gastric decompression * Monitor fluid and electrolyte status