A Case Analysis on

PEPTIC ULCER DISEASE

In Partial Fulfillment of the

Requirements in NCM 216 - RLE
METABOLISM NURSING ROTATION

Submitted to:
CATHYA JANE P. MORALES, RN
Clinical Instructor

Submitted by:
Aguilar, Marcia Atthea S.
Austria, Dionne May
Emellano, Casey C.
Fernando, Nicole Alexis M.
Funticha, Ruark E.
Ignacio, Sharmela M.
Rubio, Ima Leigh Althea D.
BSN 3I – Group 3 ­– Subgroup 1

February 5, 2022
 TABLE OF CONTENTS
I. Introduction
II. Goals and Objectives
III. Pathophysiology
A. Etiology
B. Symptomatology
C. Schematic Tracing
D. Narrative
IV. Management
A. Diagnostic Test
B. Laboratory Test
V. Drug Study
VI. Medical Management
VII. Surgical Management
VIII. Nursing Management
IX. Prognosis
X. Discharge Plan
XI. Nursing Theory
XII. Review of Related Literature
XIII. Reference
Introduction - Emellano
Metabolism rotation will make use of nursing interventions and nursing skills for
prevention. The student nurses are expected to make nursing care plans and other
nursing requirements to handle the patient concerning gastric ulcer. In this rotation, we
will be able to obtain knowledge and nursing skills in handling.

Peptic ulcer disease is caused by a bacterial infection that eats away at the
digestive system's protective coating. When open sores, or ulcers, develop in the
stomach or the first section of the small intestine, it is known as peptic ulcer disease.
The bacteria Helicobacter pylori (H. pylori) and long-term use of nonsteroidal
anti-inflammatory medicines (NSAIDs) and naproxen sodium are the most prevalent
causes of peptic ulcers. In this case, gastric ulcers will be discussed in which stomach
ulcers (gastric ulcers) are open sores that develop on the stomach lining. In other
words, if the ulcer is in your stomach, it is called a gastric ulcer

Moreover, In the United States, peptic ulcer disease affects approximately 4.6
million people annually, with an estimated 460,000 of the US population specifically in
gastric ulcers, with a yearly incidence of more than 5 per 1000 adults. The prevalence of
peptic ulcer disease has shifted from predominance in males to similar occurrences in
females (Anand, 2021). In the Philippines, Peptic Ulcer Disease Fatalities reached
6,283 in 2018 of all deaths, according to the latest World Health Organization data. An
age-adjusted death rate of 9.69 per 100,000 people makes the Philippines ranked
number 18 globally (World Health Organization, 2018). However, there were no specific
statistical data about gastric ulcers in the Philippines. In Davao city, In 2019, the
Department of Health-Region 11 (DOH-11) said three patients is under investigation
(PUI) for 2019 coronavirus disease (Covid-19) have died while waiting for their results
from the Research Institute for Tropical Medicine (RITM), The patient had complaints on
epigastric pain with shortness of breath and had undergone an operation at the
Southern Philippines Medical Center and died from septic shock secondary to
generalized peritonitis secondary to perforated peptic ulcer disease. However, there
were no specific statistical data about gastric ulcer in Davao city (Palicte, 2019).
 In relation to metabolism rotation, the topic given for the case analysis will
contribute information and understanding to improve the quality of nursing care. In
nursing education, it provides knowledge to deliver proper diagnosis and treatment prior
to gastric ulcer. In nursing research helps student nurses determine the effective and
best application or implementation and utilize resources to improve the standard of
care. As student nurses, we are responsible for giving appropriate care which is precise
and effective for our patients, especially having this kind of disease that requires more
attention. It is significant to learn and apply different learning and disciplines to return to
normal health. We aim to provide comfort by showing empathy to foster a collaborative
relationship with patients by explaining the situation regarding the disease, which could
also help show proper diagnosis and treatment.

Objectives - Emellano
General Objective:

At the end of the 5 weeks Metabolism Rotation, the BSN - 3I group 3, subgroup one, will
be able to gain knowledge and acquire a deep understanding, which serves as a
support to create a case analysis about gastric ulcer.

Specific Objectives:

To be able to achieve the general objectives, the student nurses aim to:

a. Create an introduction by explaining the disease and its nature;

b. formulate general and specific objectives;

c. distinguish the pathophysiology of gastric ulcer;

d. identify the possible predisposing and precipitating factors of etiology;

e. select all the accompanying signs and symptoms related to gastric ulcer;

f. describe the physical assessment and apply medical, surgical, and nursing
management of gastric ulcer;

g. distinguish the possible good and bad prognosis of gastric ulcer;

h. formulate a discharge plan pertaining to gastric ulcer;

i. select nursing theories that correlate and are appropriate to gastric ulcer;

j. give additional information or data from a review of related literature related to

gastric ulcer and;

k. provide references about gastric ulcer.

Anatomy and Physiology
The Stomach is saclike expansion in the digestive system. It is part of the
gastrointestinal (GI) tract. The purpose is to digest food and send it to the small
intestine. When the stomach receives food, it contracts and produces acids and
enzymes that break down food. (Cleveland Clinic, 2020). Below are the following parts
of the stomach:
Esophagus. It serves to pass food and liquids from the mouth down made of muscles
that contract to move food to the stomach and accomplished by periodic contractions or
peristalsis.
Cardia. It contains the cardiac sphincter, which prevents food from traveling back up
your esophagus.
Fundus. It is a rounded section next to the cardia below on the diaphragm a
dome-shaped muscle that helps to breathe.
Body or Corpus. The largest section of the stomach in the body contracts and begins
to mix food.
Antrum. This lies below on the body it holds food until the stomach is ready to send it to
the small intestine.
Pylorus. This ring of tissue controls when and how the stomach contents move to the
small intestine.

Moreover, several layers of muscle and other tissues make up in the stomach:
Mucosa. When the stomach is empty, the mucosa has small ridges. When the stomach
is full, the mucosa expands, and the ridges flatten.
Submucosa. contains connective tissue, blood vessels, lymph vessels and nerve cells
it covers and protects the mucosa.
Muscularis externa. The primary muscle of the stomach and it has three layers that
contract and relax to break down food.
Serosa. It is a layer of membrane that covers the stomach.

Pathophysiology
 Peptic ulcer disease is a condition that causes formations of excavation or the
hollowed-out area in the mucosa of the stomach. And this occur mainly in the
gastroduodenal mucosa because this tissue cannot withstand the digestive action of
gastric acid (HCl) and pepsin. Because the mucosa is injured, it is unable to produce
enough mucus to act as a barrier to normal digestive juices. Inflammation, damage, and
subsequent erosion of the mucosa occur when the mucosa is exposed to stomach acid
(HCl), pepsin, and other irritating substances (e.g., NSAIDs or H. pylori). When it comes
to acid secretion, patients with duodenal ulcers tend to secrete more acid than normal,
whilst those with stomach ulcers tend to secrete less. Even normal or lowered levels of
HCl can cause peptic ulcers if the mucosal barrier is damaged (Hinkle, & Cheever,
2018). This section will focus mainly on the gastric ulcer, discussing the risk factors,
symptoms, management and prognosis .
A. Etiology - Ignacio
I. Predisposing

Present Mechanism/Rationale

Sex ✔ According to a 2014 study of Harvard Medical

School, gastric ulcer affects women more than
men. And this is supported by Brunner and
Suddarth’s textbook of medical-surgical nursing,
where it is stated that gastric ulcer is more
prevalent in women while duodenal ulcer is more
prevalent in men (Hinkle, & Cheever, 2018).

Age ╳ Gastric ulcer can occur at any age but throughout

the decade it has been prevalent among the
population with an age bracket of 55-65. And in
some studies, this was known to be associated
with the increased risk of acquiring H. pylori with
 increased age (Hinkle, & Cheever, 2018). Also, an
individual’s pylorus relaxes as age advances, and
with this, excess bile can now seep up in the
stomach which later erodes its lining of it (Pathak,
2021).

Race ╳ Gastric ulcer has a high prevalence rate among

Black and Hispanic people which relates to the
parent-child transmission of H. pylori among these
populations. Since 80% of gastric ulcer is mostly
due to H. pylori infection there is a significant
prevalence rate among poor countries with low
sanitary facilities and personal hygiene, and where
there is an apparent oral-oral or fecal-oral
transmission (Hinkle, & Cheever, 2018).

Familial tendencies can also be one of the risk

Familial ╳
factors of developing a gastric ulcer and people
Tendency
with blood type O are specifically at risk of
developing this PUD. Having blood type O is
associated with the enhanced binding of H.pylori
to the epithelial cells (Harding, Kwong, Roberts,
Hagler, & Reinisch, 2020).

II. Precipitating

Present Mechanism/Rationale

Chronic Use ✔ Overuse or long-term usage of NSAIDs like

of NSAIDs ibuprofen and aspirin is one of the causes of
non-H.pylori gastric ulcers. NSAIDs inhibit the
 synthesis of prostaglandin and increase the
secretion of gastric acid and will then decrease
the integrity of the mucosal barrier. And this
gets even worse when taken with
anticoagulants and corticosteroids, for this can
decrease the renewal and protective effect of
the mucosal cell (Hinkle, & Cheever, 2018).

Alcohol ✔ Alcohol intake is one of the lifestyle factors that

contribute to the stimulation of gastric acid
secretion which can cause acute mucosal
lesions (Hinkle, & Cheever, 2018).

Smoking ✔ Smoking is also a lifestyle factor that can

contribute to developing acute mucosal lesions
and aside from this, smoking can also delay the
healing of those already developed stomach
ulcers (Hinkle, & Cheever, 2018).

Psychological ╳ According to the study of Hinkle and Cheever,

Distress (2018) psychological distress like stress and
depression can either contribute to the delayed
healing of the already developed ulcer or to the
actual development of the ulcer (Lee, Yu, Choi,
Jeon, Kim, Kim, Kim, Park, & Chae, 2017).

Helicobacterr ╳ Helicobacter pylori infection is one of the major

pylori risk factors for PUD, 80% of gastric ulcers and
90% of duodenal ulcers are mainly associated with
H.pylori infection. Although not all people infected
 with H. pylori develop ulcers, it seems that only
those infected with the CagA-positive strain are
the most likely to develop PUD. Moreover, the
bacteria are able to survive in an acidic
environment for a long period of time and by then
it colonizes the gastric epithelial cells within the
mucosal layers. It will, later on, produce urease,
which can metabolize urea-producing ammonium
chloride and other damaging chemicals. Urease
will then activate the immune response with both
antibody production and the release of
inflammatory cytokines. This will then lead to the
increased gastric secretion that causes tissue
damage, that leads to PUD (Hinkle, & Cheever,
2018).

B. Symptomatology - Ignacio

Signs & Symptoms Present Mechanism/Rationale

Burning Stomach ✔ Gastric ulcer is an open sore in the

pain inner lining of the stomach that is
caused by the gastric acids, and this
would be painful since there is an
erosion mucosal layer that is supposed
to protect the stomach from the gastric
acid. The patient may feel burning pain
in an empty stomach and immediately
after eating (Harding, Kwong, Roberts,
Hagler, & Reinisch, 2020). Indicators
 that are associated with pain can be the
excessive sweating, verbalization of
pain and facial expression.

Feeling of fullness, ✔ Feeling of fullness, bloating and belching

Bloating or Belching or excessive burping is due to the
inflammation caused by the H.pylori
infection in the stomach ( Robinson, 2021).

Intolerance to Fatty ╳ Since Fatty foods take a longer time to

foods digest, this could only aggravate the
discomfort that the patient is already
feeling from the gastric ulcer
(DerSarkessian, 2021).

Heartburn ✔ Another symptom of gastric ulcer is

heartburn, which is commonly
associated with indigestion that is
generally experienced by patients with
gastric ulcers, eating mainly worsens
the pain in the stomach because food
ingestion irritates the ulcer in the
stomach (Pathak, 2021).

Nausea ╳ Having a gastric ulcer might make you

feel sick to your stomach, especially if
you've gone without meals for an
extended period of time. The stomach's
inflammatory reaction, which can
produce stomach contractions, is
 triggered by ulcers in the stomach
(Prima Medicine, n.d).

Vomiting or Vomiting ✔ Vomiting is due to the strong

with streaks of Blood inflammatory reaction of the stomach
or Coffee ground that produces spasm, and vomiting with
emesis blood may indicate bleeding in the GI
tract caused by the ulcer and brown
color may indicate that gastric acid
converts the red hemoglobin into brown
hematin. This is a serious problem
indicating severe ulcer and can
contribute to different complications like
dehydration and anemia (Sullivan,
2019).

Black or tarry stool ╳ If your feces seems to be black, which is

the color of blood that has been digested,
you may have a bleeding ulcer. Ulcers that
are bleeding are a major medical problem
that needs immediate treatment (Prima
Medicine, n.d).

Trouble Breathing ╳ When stomach acid flows back up into

the esophagus, this is known as acid
reflux. The acid can irritate the airways,
causing them to enlarge. This can make
it difficult to breathe (Johnson, 2019).
 Feeling faint ✔ The majority of stomach ulcers go
unnoticed until they become more
serious, such as bleeding. Blood loss
might cause stomach discomfort and
dizziness as a result of this (Nall, 2018).

Unexplained Weight ✔ A gastric ulcer is frequently

loss exacerbated by eating, particularly spicy
meals. Due to the fact that eating
causes pain, many individuals with
gastric ulcers avoid eating and as a
result, lose weight (Johns Hopkins
Medicine, n.d.).

Appetite changes ╳ It can be difficult to do things like eating

and other daily tasks without feeling a
burning sensation in your stomach if you
have a gastric ulcer. Many people may be
uncomfortable after a meal because the
ulcer is irritated, rather than feeling better
(Harding, Kwong, Roberts, Hagler, &
Reinisch, 2020).

A bleeding ulcer might be slow and go

Anemia ✔
unnoticed, or it can trigger a
life-threatening hemorrhage. Ulcers that
bleed slowly may not generate
symptoms until the person becomes
anemic (DeBanto, 2021).
 Disease process
A. Schematic Tracing - Funticha
B. Narrative - Funticha
Peptic ulcer disease can involve the stomach or duodenum. Gastric and
duodenal ulcers usually cannot be differentiated based on history alone, although some
findings may be suggestive. Epigastric pain is the most common symptom of both
gastric and duodenal ulcers, characterized by a gnawing or burning sensation and that
occurs after meals—classically, shortly after meals with gastric ulcers and 2-3 hours
afterward with duodenal ulcers. The pathogenesis of duodenal ulcers and gastric ulcers
is multifactorial and most likely reflects a combination of pathophysiologic abnormalities
and environmental and genetic factors. Most peptic ulcers occur in the presence of acid
and pepsin when HP, NSAIDs, or other factors disrupt normal mucosal defense and
healing mechanisms. Most peptic ulcers occur in the presence of acid and pepsin when
H. Pylori infection, NSAIDs, or other factors disrupt normal mucosal defense and
healing mechanisms.
Acid is an independent factor that contributes to disruption of mucosal integrity.
Increased acid secretion has been observed in patients with Duodenal Ulcer and may
result from HP infection. Patients with Gastric Ulcer usually have normal or reduced
rates of acid secretion. Alterations in mucosal defense induced by H. Pylori or NSAIDs
are the most important cofactors in peptic ulcer formation. Mucosal defense and repair
mechanisms include mucus and bicarbonate secretion, intrinsic epithelial cell defense,
and mucosal blood flow. Maintenance of mucosal integrity and repair is mediated by
endogenous prostaglandin production.
Peptic ulcer is diagnosed through a series of x-rays or a test called endoscopy.
This test allows the physician to pass a thin, bendy tube down the throat and into the
stomach and small intestine. The tube has a camera at the end to check the lining for
ulcers. Doctors may also take a small piece of the lining to test for H. pylori. Blood,
breath, and stool sample tests also can screen for the bacteria.
After confirming that the patient is having this condition, medical, surgical, and
nursing interventions will follow. In medical management, the patient may be given
Antacids, Antibiotics, Histamine/Dopamine Receptor Antagonist,
Prostaglandin/Somatostatin Analogue, Proton Pump Inhibitor, Sucralfate. The patient
may also opt to undergo Vagotomy, Antrectomy, Pyloroplasty or Billroth I or II for the
surgical management. Lastly, various nursing interventions will be carried out to address
the health condition of the patient, such as relieving the pain of the patient and to
improve nutrition.
If treated, the prognosis of peptic ulcer is good after the underlying cause; usually
H. Pylori Infection or NSAID use is successfully treated and the appropriate use of
antisecretory therapy. If not treated Ulcers can lead to serious health problems,
including: Bleeding, Perforation (a hole through the wall of the stomach) caused by
peritonitis, Gastric outlet obstruction (from swelling or scarring) that blocks the
passageway from the stomach to the small intestine or even death if left untreated.

Management
A. Laboratory Test - Rubio

B. Diagnostic Test - Rubio

Drug Study - Austria

Generic Name PANTOPRAZOLE

Brand Name PROTIUM, PROTONIX

Classification ● Pharmacotherapeutic: BENZIMIDAZOLE

● Clinical: PROTON PUMP INHIBITOR

Mode of Action Inhibits hydrogen-potassium adenosine triphosphate enzyme

 system in gastric parietal cells. Inhibits the final step in gastric acid
production. Increases gastric mucus and bicarbonate production,
creating a protective coating on the gastric mucosa.

Ordered Dose 80mg IV q12

Indication To treat pathological hypersecretion

Contraindication Hypersensitivity to pantoprazole or other proton pump inhibitors.

Use cautiously in severe hepatic disease; atrophic gastritis with
long-term use; increased risk of osteoporosis-related hip, wrist, or
spine fractures with long-term use; concurrent use of atazanavir,
nelfinavir, or methotrexate; pregnant or breastfeeding patients;
and children.

Side Effects Diarrhea, headache, dizziness, pruritus, and rash

Adverse ● CNS: dizziness, headache

Reaction ● CV: chest pain
● EENT: rhinitis
● GI: vomiting, diarrhea, abdominal pain, dyspepsia
● Metabolic: hyperglycemia
● Musculoskeletal: hip, wrist, spine fractures (with long-term
daily use)
● Skin: rash, pruritus
● Other: injection site reaction

Drug Interaction ● DRUG: May increase the effects of warfarin. May decrease
effects of atazanavir, captopril, clopidogrel, dasatinib,
nelfinavir. HERBAL: Ginger, goldenseal may decrease the
effect.
● LAB VALUES: May increase serum creatinine, cholesterol,
uric acid, glucose, lipoprotein, ALT.
Nursing ● Advise patient to avoid hazardous activities because
Responsibilities dizziness may occur.
● Advise patient to avoid alcohol, salicylates, and ibuprofen
as this may cause further GI irritation.
● Instruct patient to report abdominal pain or diarrhea that
does not resolve; this may indicate colon infection.
● Assess neurological status, including level of orientation,
affect, and reflexes to evaluate for CNS effects of the drug.
● Monitor patient for bone fracture; proton pump inhibitors
increase the risk of osteoporosis-related fractures of the
hip, wrist, or spine.
● Monitor for diarrhea; if severe diarrhea occurs, drug may
need to be discontinued to prevent further complications.
● Monitor for hepatotoxicity; serum ALT elevation may occur
during treatment.
● Provide appropriate safety and comfort measures if CNS
effects occur to prevent patient injury.
● Assess for muscle pain, increased CPK, weakness, and
swelling of affected muscles; may indicate rhabdomyolysis,
and drug needs to be discontinued.
● Assess for electrolyte imbalances; hyponatremia or
hypomagnesemia may occur during treatment.

Generic Name METOCLOPRAMIDE

Brand Name REGLAN

Classification ● Pharmacotherapeutic: DOPAMINE RECEPTOR

ANTAGONIST
● Clinical: ANTIEMETIC, UPPER GI STIMULANT

Mode of Action Stimulates motility of upper GI tract. Blocks dopamine/serotonin

receptors in the chemoreceptor trigger zone. Enhances
acetylcholine response in upper GI tract; increases lower
esophageal sphincter tone.

Ordered Dose 10mg IV q8

Indication For gastroesophageal reflux

Contraindication Contraindications: Hypersensitivity to metoclopramide.

Concurrent use of medications is likely to produce extrapyramidal
reactions. Situations in which GI motility may be dangerous (e.g.,
GI hemorrhage, GI perforation/obstruction), history of seizure
disorder, pheochromocytoma. Cautions: Renal impairment, HF,
cirrhosis, hypertension, depression, Parkinson’s disease, elderly.

Side Effects ● Frequent: Drowsiness, restlessness, fatigue, lethargy.

● Occasional: Dizziness, anxiety, headache, insomnia,
breast tenderness, altered menstruation, constipation,
 rash, dry mouth, galactorrhea, gynecomastia.
● Rare : Hypotension, hypertension, tachycardia.

Adverse ● CNS: Sedation, fatigue, restlessness, headache,

Reaction sleeplessness, dystonia, dizziness, drowsiness, suicidal
ideation, seizures, EPS, neuroleptic malignant syndrome;
tardive dyskinesia (.3 mo, high doses)
● CV: Hypotension, supraventricular tachycardia
● GI: Dry mouth, constipation, nausea, anorexia, vomiting,
diarrhea
● GU: Decreased libido, prolactin secretion, amenorrhea,
galactorrhea
● HEMA: Neutropenia, leukopenia, agranulocytosis
● INTEG: Urticaria, rash

Drug Interaction ● DRUG: Alcohol, other CNS depressants (e.g., lorazepam,

morphine, zolpidem) may increase CNS depressant effect.
Anticholinergics (e.g., scopolamine), opioid analgesics
(e.g., morphine, hydromorphone) may decrease effects on
GI motility.
● LAB VALUES: May increase serum aldosterone, prolactin

Nursing ● Watch out for signs and symptoms of hypertension; the

Responsibilities drug may increase catecholamine levels.
● Monitor IV rate and avoid rapid IV delivery; this may cause
anxiety, restlessness, and drowsiness.
● Instruct the patient to report involuntary movements of
face, eyes, or limbs; muscle rigidity; altered consciousness;
irregular pulse or blood pressure; rapid or irregular
heartbeats; or excessive sweating; the drug may need to
be discontinued to prevent further adverse effects.
 ● Advise patient to avoid alcohol and CNS depressants
because it may increase CNS depression.
● When the drug is discontinued, explain that withdrawal
symptoms may occur such as dizziness, nervousness, and
headache; this helps alert the patient of what to expect.
● Keep diphenhydramine injection readily available; this may
need to be administered when extrapyramidal reactions
occur.
● Monitor for possible fluid retention or volume overload; this
may occur due to transient increase in plasma aldosterone
level.
● The drug should be avoided from being exposed to light;
the drug is sensitive to light and may decrease in potency.
● Avoid tasks requiring alertness, especially within 2 hours
after each dose as the drug causes drowsiness and may
lead to accidents.
● Instruct the patient to immediately report signs and
symptoms of acute dystonia such as trembling hands and
facial grimacing; the drug may need to be discontinued to
avoid further complications.

Generic Name OCTREOTIDE

Brand Name SANDOSTATIN

Classification ● Pharmacotherapeutic: SOMATOSTATIN ANALOGUE

● Clinical: ANTIDIARRHEAL

Mode of Action Suppresses secretion of serotonin, gastrin, VIP, insulin,

glucagon, secretin, pancreatic polypeptide; increasing fluid and
electrolyte absorption from GI tract.

Ordered Dose 500mcg in D50W 250cc

Indication Control of variceal bleeding

Contraindication Hypersensitivity to octreotide. Cautions: Diabetic pts with

gastroparesis, renal failure, hepatic impairment, HF, concomitant
medications altering heart rate or rhythm. Concurrent use of
medications that prolong QT interval, elderly pts.

Side Effects ● Frequent: Diarrhea, nausea, abdominal discomfort,

headache, injection site pain.
● Occasional: Vomiting, flatulence, constipation, alopecia,
facial flushing, pruritus, dizziness, fatigue, arrhythmias,
ecchymosis, blurred vision.
● Rare: Depression, diminished libido, vertigo, palpitations,
dyspnea.
Adverse ● CNS: Headache, dizziness, fatigue, weakness,
Reaction depression, anxiety, tremors, seizures, paranoia
● CV: Sinus bradycardia, conduction abnormalities,
dysrhythmias, chest pain, shortness of breath,
thrombophlebitis, ischemia, CHF, hypertension,
palpitations, QT prolongation, ST-T wave changes
● ENDO: Hypo/hyperglycemia, ketosis, hypothyroidism,
galactorrhea, diabetes insipidus
● GI: Diarrhea, nausea, abdominal pain, vomiting,
flatulence, distension, constipation, hepatitis, elevated liver
function tests, GI bleeding, pancreatitis, cholelithiasis,
ileus
● GU: UTI
● HEMA: Hematoma of inj site, bruise
● INTEG: Rash, urticaria, pain, inflammation at injection site
● MS: Joint and muscle pain

Drug Interaction ● DRUG: May decrease the effectiveness of cyclosporine.

Glucagon, growth hormone, insulin, oral antidiabetics
(e.g., glipizide, metformin) may alter glucose
concentrations.
● HERBAL: Avoid herbs that have hypoglycemic activity
(e.g., garlic, ginger, ginseng).
● LAB VALUES: May decrease serum thyroxine (T4). May
increase serum alkaline phosphatase, ALT, AST, GGT.

Nursing ● Assess for cardiac status. The drug may affect variceal
Responsibilities flow by reducing it, causing bradycardia.
● Monitor thyroid function; drug suppresses
thyroid-stimulating hormone secretion, which may cause
hypothyroidism.
 ● Change the patient's position from time to time; this is
done to minimize orthostatic hypotension.
● Monitor for hyperglycemia or hypoglycemia; the drug may
cause alterations in the balance between insulin,
glucagon, and growth hormone.
● Monitor fluid and electrolyte balance; drug stimulates fluid
and electrolyte absorption from the GI tract.
● Monitor fecal fat and serum carotene to aid in the
assessment of possible drug-induced aggravation of fat
malabsorption.
● Monitor bowel sounds, stool consistency, and abdominal
pain; the patient may show signs of gallbladder disease or
pancreatitis.
● Instruct the patient to avoid activities that require
concentration and alertness, this is to avoid untoward
incidents.
● Assess for signs and symptoms of gallbladder disease or
pancreatitis. Drug is known to inhibit hepatic bile secretion
and gallbladder emptying.
● Instruct patient to notify physician about abdominal pain;
may indicate pancreatitis.

Generic Name REBAMIPIDE

Brand Name MUCOSTA

Classification ANTIULCER

Mode of Action An amino acid derivative that works by enhancing the mucosal
defense system and scavenging free radicals in the body.

Ordered Dose 100mg PO TID AC

Indication To treat peptic ulcers, gastroduodenal ulcers, and gastric

disorders. Indicated during bleeding, erosion, redness, and
edema.

Contraindication Hypersensitivity to the drug.

Side Effects Rash, pruritus, drug-eruption-like eczema, constipation, bloating,

diarrhea, nausea, vomiting, upset stomach, heartburn, abdominal
pain, belching, taste abnormality, cold sweat, and difficulty
breathing.

Adverse Thrombocytopenia, leucopenia, hypersensitivity and

Reaction anaphylactoid reactions (e.g. hives, rash, itching, eczema),
shock, jaundice. Rarely, liver dysfunction.

Drug Interaction Drug may suppress celecoxib or diclofenac effects.

Nursing ● Administer the drug apart from any other oral medication
Responsibilities an hour before or 2 hours after; this is to ensure adequate
absorption of the other medications.
● Instruct the patient to chew tablets thoroughly and follow
with water. This is to ensure that therapeutic levels reach
the stomach to decrease acidity.
● Assess for any signs of electrolyte imbalance; early
detection would prevent complications and allow for
 prompt interventions.
● Monitor the patient for diarrhea or constipation; through
this a bowel program may be implemented before severe
effects occur.
● Monitor nutritional intake; ensuring adequate fluid and
nutritional intake promotes faster healing and GI stability.
● Advise the patient to avoid black pepper, caffeine, alcohol,
harsh spices, extremes in temperature of food; this may
aggravate the patient’s condition.
● Advise the patient to quit smoking; smoking would
decrease the medication’s effectiveness.
● Instruct the patient that the drug should be continued for
prescribed time to be effective and complete the treatment.
● Instruct the patient to report diarrhea, black tarry stools,
abdominal pain, cramping, and menstrual disorders; this is
to allow prompt interventions to be given when needed.
● Report persistent symptoms of heartburn, indigestion, and
sour stomach; the drug may be discontinued to prevent
further complications.
Generic Name Dextrose and Sodium Chloride inj

Brand name Dextrose 5% in 0.9 Sodium Chloride

Classification Glucose-Elevating Agents

Mode of Action This medication is an intravenous (IV) solution used

to supply water, calories, and electrolytes (e.g.,
sodium, chloride) to the body. It is also used as a
mixing solution (diluent) for other IV medications.

Ordered Dose 1L at 80 ml/hr at right basilic vein

Indication Is indicated as a source of water, electrolytes, and

calories.

Contraindication Solutions containing dextrose may be

contraindicated in patients with known allergies to
 corn or corn products.

Side Effects ● Abnormal heart rate

● Low blood pressure
● Fatigue
● Weakness
● Muscle cramps
● Constipation
● Fever
● Infection at the site of injection
● Blood clot or inflammation surrounding the
site of injection
● Extravasation
● Hypervolemia

Adverse Effects ● Hyperosmolarity

● Edema
● Venous thrombosis
● Tachypnea
● Fever
● Hyperosmolar syndrome
● Hypervolemia
● Phlebitis
● Diarrhea
● Polydipsia
● Pulmonary edema
● Cerebral hemorrhage
● Mental confusion, unconsciousness
● Cerebral ischemia
● Hypophosphatemia
 ● Hypomagnesemia
● Hyperglycemia
● Injection site extravasation
● Tissue necrosis

Drug Interaction Has no listed serious interactions with other drugs.

Nursing responsibilities 1. Make sure to document the patient’s health

history accurately.

Rationale: to prevent any incident of anaphylaxis

from the solution.

2. Assess the patient’s renal functioning.

Rationale: Administration of Dextrose and Sodium

Chloride, may result in sodium retention.

3. Before infusion, assess the patient’s vital signs,

edema status, lung sounds, and heart sounds.
Continue monitoring during and after the infusion.

Rationale: To obtain baseline data.

4. Look for signs of hypervolemia such as

hypertension, bounding pulse, pulmonary crackles,
dyspnea, shortness of breath, peripheral edema,
jugular venous distention, and extra heart sounds.

Rationale: These are signs of fluid overload.

5. Observe for any signs of decreased urine output,

poor skin turgor, tachycardia, weak pulse, and
hypotension.

Rationale: In order to address any manifestation of

continued hypovolemia.

6. Observe patients who are being treated for

hypovolemia.

Rationale: This is to prevent hypervolemia since

treating hypovolemia can quickly develop fluid
overload following rapid or over infusion of isotonic
IV fluids.

7. Elevate the head of the bed at 35 to 45 degrees.

Rationale: to prevent congestion

8. Elevate the patient’s leg.

Rationale: If edema is present, elevate the legs of

the patient to promote venous return.

9. Educate patients and families.

Rationale: Teach patients and families to recognize

signs and symptoms of fluid volume overload.
Instruct patients to notify their nurse if they have
trouble breathing or notice any swelling.

10. Close monitoring for patients with heart failure.

Rationale: Because isotonic fluids expand the

intravascular space, patients with hypertension and
heart failure should be carefully monitored for signs
 of fluid overload.

Generic Name Dextrose monohydrate

Brand name Dextrose 50% in water

Classification Glucose elevating agent

Mode of Action When administered intravenously this solution

restores blood glucose levels in hypoglycemia and
provides a source of carbohydrate calories.

Carbohydrates in the form of dextrose may aid in

minimizing liver glycogen depletion and exert a
protein-sparing action.

Ordered Dose 50ml/vial IV PRN

Indication Indicated in the treatment of insulin hypoglycemia
(hyperinsulinemia or insulin shock) to restore blood
glucose levels. The solution is also indicated, after
dilution, for intravenous infusion as a source of
carbohydrate calories in patients whose oral intake
is restricted or inadequate to maintain nutritional
requirements.

Contraindication Should not be used when intracranial or intraspinal

hemorrhage is present, nor in the presence of
delirium tremens if the patient is already dehydrated.
Dextrose injection without electrolytes should not be
administered simultaneously with blood through the
same infusion set because of the possibility that
pseudoagglutination of red cells may occur.

Side Effects ● Hyperglycemia, Hypokalemia

● Edema
● Hyper/hypovolemia
● Ketonuria
● Glycosuria
● Excessive urination
● Diarrhea
● Excessive thirst
● Vein irritation
● Pulmonary edema/rapid breathing
Adverse Effects Hyperosmolar syndrome, febrile response, infection
at the site of injection, venous thrombosis or
phlebitis extending from the site of injection,
extravasation, and hypervolemia.

Drug Interaction Has no listed serious interactions with other drugs.

Nursing responsibilities 1. Before infusion, assess the patient’s vital signs,

edema status, lung sounds, and heart sounds.
Continue monitoring during and after the infusion.

Rationale: To obtain baseline data.

2. Watch for signs of hypervolemia.

Rationale: Since hypertonic solutions move fluid

from the ICF to the ECF, they increase the
extracellular fluid volume and increase the risk for
hypervolemia. Look for signs of swelling in arms,
legs, face, shortness of breath, high blood pressure,
and discomfort in the body (e.g., headache,
cramping).

3. Monitor and observe the patient during

administration.

Rationale: Hypertonic solutions should be

administered only in high acuity areas with constant
nursing surveillance for potential complications.

4. Verify order.
Rationale: Prescription for hypertonic solutions
should state the specific hypertonic fluid to be
infused, the total volume to be infused, the infusion
rate, and the length of time to continue the infusion.

5. Assess health history.

Rationale: Patients with kidney or heart disease and

those who are dehydrated should not receive
hypertonic IV fluids. These solutions can affect renal
filtration mechanisms and can easily cause
hypervolemia in patients with renal or heart
problems.

6. Ensure that administration of hypertonic fluids

does not precipitate fluid volume excess or overload.

Rationale: To prevent fluid overload.

7. Do not administer peripherally.

Rationale: Hypertonic solutions can cause irritation

and damage to the blood vessel and should be
administered through a central vascular access
device inserted into a central vein.

8. Monitor blood glucose closely.

Rationale: Rapid infusion of hypertonic dextrose

solutions can cause hyperglycemia. Use caution for
patients with diabetes mellitus.

9. Watch out for signs and symptoms of the

hyperosmolar syndrome such as mental confusion
 and loss of consciousness, especially in patients
with chronic uremia and those with known
carbohydrate intolerance.

Rationale: This may be a result of too rapid

administration.

10. When introducing additives, use an aseptic

technique, mix thoroughly, and do not store.

Rationale: To prevent the introduction of bacteria in

the body.

Generic Name Potassium Chloride

Brand name Kaon-Cl, Klor-Con, Klor-Con M10, Klor-Con M20,

Micro-K

Classification Pharmacotherapeutic: Electrolyte supplements

Clinical: Potassium Replenisher

Mode of Action The potassium ion (K+) is the principal intracellular
cation of most body tissues. Potassium ions
participate in a number of essential physiological
processes, including the maintenance of intracellular
tonicity; the transmission of nerve impulses; the
contraction of cardiac, skeletal, and smooth muscle;
and the maintenance of normal renal function.

Ordered Dose 40 mEqs incorporate with combiflex @ 80ml/hr

3 cycles

Indication Potassium chloride extended-release capsules are

indicated for the treatment and prophylaxis of
hypokalemia in adults and children with or without
metabolic alkalosis, in patients for whom dietary
management with potassium-rich foods or diuretic
dose reduction is insufficient.

Contraindication Contraindicated in patients on amiloride or

triamterene.

Side Effects ● Nausea

● Vomiting flatulence
● Abdominal pain/discomfort
● Diarrhea
Adverse Effects ● Arrhythmias
● Bleeding
● Dyspepsia
● Hyperkalemia
● Rash
● Perforation
● Gastrointestinal obstruction
● Gastrointestinal ulceration
● Gastrointestinal perforation
● Hyponatremia
● Hyponatremia encephalopathy

Drug Interaction Use with triamterene or amiloride can produce

severe hyperkalemia. Concomitant use is
contraindicated

1. Assess for hypokalemia (weakness, fatigue,

Nursing responsibilities
polyuria, polydipsia).
2. Monitor serum potassium, calcium,
phosphate.
3. If GI disturbance is noted, dilute preparation
further.
4. . Be alert to decreased urinary output (may be
an indication of renal insufficiency).
5. Check the IV site closely during the infusion
for evidence of phlebitis (heat, pain, red
streaking of skin over vein, hardening of
vein).
6. Check the IV site closely during the infusion
for extravasation (swelling, pain).
 7. Be alert to evidence of hyperkalemia (skin
pallor/coldness, paresthesia, feeling of
heaviness of lower extremities).
8. Administer intravenous calcium gluconate if
the patient is at no risk or low risk of
developing digitalis toxicity.

Patient / Family Teaching

9. Report numbness, feeling of heaviness of
lower extremities, weakness, unusual fatigue.
10. Eliminate foods and medications containing
potassium and any agents with
potassium-sparing properties such as
potassium-sparing diuretics, ARBs, ACE
inhibitors, NSAIDs, certain nutritional
supplements, and many others.

Generic Name Acetaminophen, Paracetamol

Brand name Biogesic, Calpol, Dymadon, Lemsip, Panadol,

Panamax, and Tylenol

Classification Central nervous system agent; non-narcotic and

analgesic, antipyretic
Mode of Action Paracetamol exhibits analgesic action by peripheral
blockage of pain impulse generation. It produces
antipyresis by inhibiting the hypothalamic
heat-regulating center. Its weak anti-inflammatory
activity is related to inhibition of prostaglandin synthesis
in the CNS.

Ordered Dose
Paracetamol 150mg

Indication Acetaminophen injection is indicated for the

management of mild to moderate pain, the
management of moderate to severe pain with adjunctive
opioid analgesics, and the reduction of fever.

Contraindication Hypersensitivity to acetaminophen or phenacetin; use

with alcohol.

Side Effects Hives; difficulty breathing; swelling of your face, lips,

tongue, or throat, stomach pain, and loss of appetite;
dark urine, clay-colored stools; or jaundice (yellowing of
the skin or eyes).

Adverse Effects Significant: Thrombocytopenia, leucopenia,

neutropenia, pancytopenia, methaemoglobinaemia,
agranulocytosis, angioedema, pain and burning
sensation at inj site.
Gastrointestinal disorders: Nausea, vomiting,
constipation.
Nervous system disorders: Headache.
Psychiatric disorders: Insomnia.
Skin and subcutaneous tissue disorders: Erythema,
flushing, pruritus.
Potentially Fatal: Hepatotoxicity, acute renal tubular
necrosis. Rarely, hypersensitivity reactions such as
acute generalised exanthematous pustulosis (AGEP),
Stevens-Johnson syndrome (SJS), toxic epidermal
necrolysis (TEN)

Drug Interaction Decreased absorption with cholestyramine. Decreased

serum concentrations with rifampicin and some
 anticonvulsants (e.g. phenytoin, phenobarbital,
carbamazepine, primidone). Enhances the
anticoagulant effect of warfarin and other coumarins
with prolonged use. Increased absorption with
metoclopramide and domperidone. Increased serum
concentration with probenecid. May increase serum
concentration of chloramphenicol.

Nursing responsibilities
1. Report N&V. cyanosis, shortness of breath, and
abdominal pain as these are signs of toxicity.

Rationale : Paracetamol is generally a safe,

non-prescription pain reliever, but misuse and
overdose do occur. This is because so many
medications contain paracetamol that it's easy to
take too much of the drug without realizing it.

2. Report paleness, weakness, and heartbeat skips

Rationale: Long-term use of paracetamol was
linked with a small increased risk of adverse
events such as heart attacks, gastrointestinal
bleeds (bleeding inside the digestive system) and
impaired kidney function.

3. Report abdominal pain, jaundice, dark urine,

itchiness, or clay-colored stools.

Rationale: An acetaminophen overdose can

damage your liver, nausea, pain in your upper
stomach, itching, loss of appetite, dark urine,
clay-colored stools, or jaundice (yellowing of your
 skin or eyes). In rare cases, acetaminophen may
cause a severe skin reaction.

4. Educate patients about their medications.

Rationale: This will help patients determine

whether a medication is working appropriately. It
will also help patients identify undesired side
effects that may require intervention

5. Monitor for S&S of: hepatotoxicity, even with

moderate acetaminophen doses, especially in
individuals with poor nutrition.

Rationale: Early detection can decrease the

severity of hepatotoxicity if the drug is
discontinued.

6. Do not take other medications (e.g., cold

preparations) containing acetaminophen without
medical advice

Rationale: It can lead to overdose and

overdosing and chronic use can cause liver
damage and other toxic effects.

7. Do not self-medicate adults for pain more than

10 days (5 days in children) without consulting a
physician.

Rationale: Can lead to drug addiction, allergy,

habituation, worsening of ailment, incorrect
diagnosis and dosage, or even disability and
 premature death.

8. Monitor CBC, liver, and renal functions.

Rationale: Paracetamol is a widely known

over-the-counter analgesic and antipyretic which,
in acute poisoning usually causes liver damage,
and less commonly damage to the kidney, heart,
and pancreas.

9. Assess for fecal occult blood and nephritis.

Rationale: Acetaminophen is typically the safest

painkiller available for use by kidney disease
patients but should still be used under
supervision by a doctor since nephritis is a
condition in which the nephrons, the functional
units of the kidneys, become inflamed.

10. Avoid using OTC drugs with Acetaminophen.

Rationale: Medicines available without a

prescription, also called “over-the-counter,” or
“OTC” medicines but it has fewer side effects . To
prevent acetaminophen overdose, you need to
be able to read labels and recognize when their
medicines contain acetaminophen.

Generic Name Hyoscine Butylbromide

Brand name Buscopan

Classification
Pharmacotherapeutic: Anticholinergic

Clinical: Anti Nausea, antiemetic

Mode of Action Scopolamine butylbromide binds to muscarinic M3

receptors in the gastrointestinal tract. This prevents
acetylcholine from binding to and activating the
receptors which would result in contraction of the
smooth muscle. The inhibition of contraction reduces
spasms and their related pain during abdominal
cramping.

Ordered Dose 20 mg/mL Solution for Injection (I.M./I.V.)

Indication Indicated for the relief of spasm of the genito-urinary

tract or gastro- intestinal tract and for the symptomatic
relief of irritable bowel syndrome.

Contraindication Myasthenia gravis, narrow-angle glaucoma, tachycardia,

megacolon; hypersensitivity.

Side Effects Constipation, dry mouth, trouble urinating, nausea, rash,

itching, swelling of the hands or feet, trouble breathing,
increased pulse, dizziness, diarrhea, vision problems,
eye pain.

Adverse Effects
CNS: dizziness, anaphylactic reactions, anaphylactic
shock, increased ICP, disorientation, restlessness,
irritability, dizziness, drowsiness, headache, confusion,
hallucination, delirium, impaired memory
 CV: hypotension, tachycardia, palpitations, flushing

GI: Dry mouth, constipation, nausea, epigastric distress

DERM: flushing, dyshidrosis

GU: Urinary retention, urinary hesitancy

Resp: dyspnea, bronchial plugging, depressed

respiration

EENT: mydriasis, dilated pupils, blurred vision,

photophobia, increased intraocular pressure, difficulty of
swallowing.

Drug Interaction May decrease the absorption of oral medicines due to

decreased gastric motility and delayed gastric emptying.
The sedative effect of hyoscine may be enhanced by
other CNS depressants. Other drugs with anticholinergic
properties (e.g. amantadine, antihistamines) may
enhance the effects of hyoscine.

Nursing responsibilities
1. Drug compatibility should be monitored closely in
patients requiring adjunctive therapy.

Rationale: Therapeutic drug monitoring is

important as the concentrations of many drugs
are not clearly related to their effects. For
selected drugs therapeutic drug monitoring aims
to enhance drug efficacy, reduce toxicity or assist
with diagnosis.

2. Raise side rails as a precaution because some

patients become temporarily excited or
disoriented and some develop amnesia or
become drowsy.

Rationale: In some patients, especially the

elderly, hyoscine may cause the central
anticholinergic syndrome (excitement, ataxia,
hallucinations, behavioral abnormalities, and
drowsiness).
3. Reorient patient, as needed, Tolerance may
develop when therapy is prolonged.

Rationale: Tolerance develops when a person

has been regularly taking a drug and their body
begins to adapt itself to the presence of the
chemicals in the drug.

4. Assess for use of other CNS depressants, drugs

with anticholinergic action, history of narrow-angle
glaucoma.

Rationale: The central nervous system (CNS)

effects of anticholinergic agents have been
documented in various patient populations and to
varying degrees in case reports, brain-activity
surrogates, and computerized cognitive testing.

5. Monitor BP for possible hypertension.

Rationale: Hyoscine butylbromide injection can

cause adverse effects including tachycardia,
hypotension, and anaphylaxis.

6. Hyoscine may make a patient dizzy or cause

vision problems; use caution engaging in
activities requiring alertness.

Rationale: Hyoscine Injection may cause

drowsiness, dizziness or blurred vision.

7. Inform the patient to consult the doctor

immediately if he or she experiences any of the
following while using this medicine: red and
painful eye, possibly with headache, loss of
vision, or seeing halos around lights.

Rationale: These symptoms may be caused by

an increase in pressure inside the eyeball and
require urgent investigation by the doctor.
 8. Watch out for Symptoms of overdose may
include: irregular heartbeat, reddened skin,
drowsiness. Instruct the patient to immediately
alert the physician once these are noticed or
experienced.

Rationale: Overdose of this anticholinergic

medication can lead to toxicity including
disorientation, agitation, visual and auditory
hallucinations, tachycardia, arrhythmias including
QTc prolongation, visual disturbances and urinary
retention.

9. Do not administer if the client has abnormal

muscle weakness.

Rationale: Hyoscine work by relaxing muscle

thereby increasing the episodes of weakness to
the client.

10. Use cautiously if the patient has a very high fever.

Rationale: May promote further increases in the

temperature of the client.

Medical Management - Austria

The most common treatment for peptic ulcer disease is through pharmacologic
therapy. This would usually include a combination of antibiotics, proton pump inhibitors,
and bismuth salts which suppress or eradicate the infection. However, there are also
other ways to decrease the manifestation of its signs and symptoms. This could be
done through stress reduction and rest. By doing so, the body’s ability to heal itself will
not be hindered. Patients are also advised to avoid smoking or discontinue smoking if
the patient is already a smoker. Studies have shown that bicarbonate secretion from the
pancreas decreases due to smoking, thereby increasing acidity. Smoking cessation
would help prevent this. Lastly, dietary modifications may be done, such as avoiding
extreme temperatures of food and overstimulation. Certain foods and beverages such
as meat extracts, alcohol, coffee, and other caffeinated beverages, and diets rich in
cream and milk may be removed from the patient’s diet (Belleza, 2021).

MEDICAL BRIEF DESCRIPTION OF NURSING

MANAGEMENT THE PROCEDURE RESPONSIBILITIES

TOTAL PARENTERAL Parenteral nutrition is the ● Monitor signs of infection.

NUTRITION administration of nutrition Bacteria may grow in
outside the gastrointestinal high glucose and protein
tract. TPN is done solutions.
intravenously and this is the ● Use stricT aseptic
only way a patient receives technique with IV tubing,
nutrition. This is usually dressing changes, and
indicated when an TPN solution to avoid risk
inadequate gastrointestinal of developing infections.
function is present (Hamdan ● Monitor blood glucose
and Puckett, 2022). levels as they may be
affected if TPN is
discontinued, rate is
reduced or if excess
levels of insulin are
added to the solution.
● Monitor for signs of fluid
overload. Hypertonic
solutions may create
intravascular shifting of
extracellular fluid.
● Monitor for signs and
symptoms of electrolyte
imbalances.
● Monitor serum protein
 levels. Low serum protein
levels may lead to fluid
loss.
● Monitor for signs and
symptoms of excess fluid
volume.
● Administer the prescribed
rate of TPN solution via
an infusion pump.
● Place the client in a
semi-fowler’s or
high-fowler’s position.
This will promote ease in
breathing and allows
pooling of fluid in the
bases; and for gas
exchange to be more
available to lung tissue.
● When discontinuing TPN,
taper off the rate
gradually. This prevents
hypoglycemic episodes
caused by withdrawal.

BLOOD This procedure is done ● Ensure correct

TRANSFUSION through providing donated preparation of the patient
blood intravenously to a and care procedure is
patient. This allows done. This is to eliminate
replacement of blood loss errors that may cause
from surgery or injury. It is further harm to the
also indicated for patients patient.
whose bodies can’t produce ● Obtain consent before
some of the blood’s proceeding with any
components correctly invasive procedure or
(MayoClinic, 2020). therapy.
● Assess for any allergies
to prevent complications.
● Ask for history of blood
transfusion. The
physician may [rescribe
premedication to prevent
febrile non-hemolytic
reaction.
● Warm the blood products
to prevent chills.
● Determine that the
correct gauge of IV
needle is being used to
allow ease of passage of
RBCs.
● Obtain vitals signs to be
used as indicators of
potential adverse
reactions.
● Ensure a comfortable
position for the patient.
● Practice strict asepsis.
● While therapy is ongoing,
monitor for allergic,
pyrogenic, or hemolytic
 reaction. This ensures
immediate interventions
when needed.

Surgical Management - Fernando

Peptic ulcer disease used to be the most prevalent reason for gastric surgery, but
it's now a rare occurrence. There has been a significant reduction in the need for
elective surgery due to the introduction of effective antisecretory drugs (H2 blockers and
proton pump inhibitors) and the realization that management for Helicobacter pylori
infection may remove most ulcer recurrences. Bleeding, perforation and obstruction of
the gastric outlet are all consequences of peptic ulcer disease that continue to occur.
Because surgery is the mainstay of emergency therapy for these life-threatening
complications and is unresponsive to medical treatment, a thorough grasp of surgical
care is essential (Vernon, Ferzoco, & Ashley, 2021).

Procedure Rationale Nursing Responsibilities

Vagotomy A procedure to surgically remove a Preoperative

part or the whole portion of the vagus ● Secure informed
nerve that controls digestion. The aim consent.
is to reduce stomach acid. A vagotomy ● Have the patient on
is usually performed under general NPO 8 hours prior to
anesthesia by a gastrointestinal the procedure.
surgeon as an open or laparoscopic ● Administer pre op
surgery. Patients with peptic ulcer medications, as
disease complications (e.g., bleeding, ordered.
perforation, or blockage) or persistent ● Secure blood
symptoms like pain who are not products and
responding well to medical treatments crossmatching, as
are candidates for a vagotomy (Shiel, ordered.
 2020). ● Teach patient
breathing and
Truncal This procedure cuts out the two main
coughing exercises.
Vagotomy trunks (anterior and posterior) of the
● Obtain baseline vital
vagus nerve above the place where
signs.
the esophagus joins the stomach at the
● Remind the patient to
gastroesophageal junction. The nerve
take a bath prior to
that runs through the entire
the procedure.
gastrointestinal system, including the
● Perform skin prep.
liver, gallbladder, pancreas, and
● Remove nail polish,
bowels, is removed during this
underwear, dentures,
procedure. Because the digestive
and jewelry.
system loses its peristaltic function, it is
● Ask the patient to
usually accompanied by another
empty the bladder.
surgery to widen the stomach outlet
● Provide the patient
(pylorus) into the intestine called
with an OR gown.
pyloroplasty (Shiel, 2020).
Postoperative
Selective This surgery is more precise than ● Monitor vital signs
Vagotomy truncal vagotomy. The vagus nerve and pain level.
divides below the gastroesophageal ● Place the patient in a
junction and only a portion of the nerve semi fowler’s position.
that goes to the stomach is removed, ● Administer post op
and the vagus nerve connection to the medications, as
gallbladder and intestine is left in ordered.
place. A selective vagotomy is also ● Perform breathing
usually accompanied by a pyloroplasty and coughing
(Brennan, 2021). exercises.
● Turn the patient to
Highly This procedure is also called parietal
sides every 2 hours,
Selective cell vagotomy and is the most precise
as tolerated.
Vagotomy option. It involves removing part of the ● Inform the patient
vagus nerve only where it connects about his/her diet.
with the parietal cells in the stomach Clear liquids to a soft
wall that release gastric acid. The rest diet with small,
of the nerve is left there where it can frequent meals once
still stimulate the valve that connects tolerated.
your stomach to your intestine ● Watch out for signs of
(Brennan, 2021). bleeding and infection
at the incision site.
Antrectomy A surgical procedure that removes the
● Perform proper
antrum from the patient's stomach. The
wound care or
antrum is the bottom part of the
dressing.
stomach, which is located between the
patient's stomach and the pyloric
canal, which empties into the first small
intestine. Antrectomy is also known as
an incomplete or subtotal gastrectomy
since it involves the removal of a
portion of the stomach. This procedure
may be performed to treat ulcer-related
problems that haven't been addressed
in a timely manner. Out of control or
constant bleeding, as well as
blockages that prevent food from
passing through the small intestine,
and recurrences, are examples of
these issues. Because the antrum
produces gastrin, a hormone that
stimulates the production of gastric
acid, its removal reduces the quantity
 of acid secreted in the stomach (World
Laparoscopy Hospital, 2022).

Pyloroplasty Pyloroplasty is a procedure to widen

the pylorus. This is an opening near
the end of the stomach that allows food
to flow into the duodenum, the first part
of the small intestine. It can help
manage numerous disorders that affect
the stomach and gastrointestinal
nerves, such as peptic ulcer disease or
vagus nerve injury, which is frequently
caused by vagotomy, in addition to
enlarging an extremely small pylorus.
Pyloroplasty is nearly never done on its
own. It is almost often used in
conjunction with another technique,
most commonly vagotomy (Huizen,
2018).

Billroth I or Procedures that have been performed

II for tumor or severe ulcer disease in the
distal stomach. The establishment of
an end-to-end anastomosis between
the proximal residual stomach and
duodenal stump is a key feature of a
Billroth I reconstruction (Morgan,
2020).
The Billroth II reconstruction procedure
consists of removal of the diseased
region of the distal stomach and a
 side-to-side anastomosis of the
remnant stomach to the jejunum. An
antecolic or retrocolic anastomosis can
be used to perform the procedure
(Salahshour, 2020).

Nursing Management

Prognosis - Rubio

Discharge Planning - Aguilar

DISCHARGE PLANNING

MEDICATIONS ● Advise the patient to report by the

physician immediately when a side or
adverse effect of the medications
shows.
Rationale: To take appropriate action
immediately to the patient and avoid further
complications.
● Instruct the patient to continue taking
the prescribed medications at home as
directed.
Rationale: It should take prescribed
medications, such as antibiotics, antiulcer
medicines, and antacids, which help relieve
pain and heal or prevent ulcers. Also, simply
not taking medicine as prescribed could
worsen the disease.
● Educate patients about their
 medications.
Rationale: This will help patients determine
whether a medication is working appropriately.
It will also help patients identify undesired side
effects that may require intervention.

EXERCISE ● Encourage the client to do reposition

and to ambulate.
Rationale: Early ambulation after endoscopy
is an evidence supported way to prevent post
endoscopy problems. This promotes flow of
oxygen through one’s body, strengthens
muscle tone and improves blood flow to help
with wound healing in the gastrointestinal.
● Encourage patients to do moderate
exercise such as walking will help
deflate the bloat.
Rationale: However, it has been suggested
that exercise induces an increase in
vasodilation and tissue blood flow, which may
potentially facilitate ulcer healing.
● Encourage the patient to do physical
activities such as yoga and
stair-climbing.
Rationale: Physical activity improves
cardiorespiratory fitness during and after the
endoscopy, decreases subjective symptoms
and physiologic effects during treatment, and
increases energy levels after treatment.

TREATMENT ● Advise the parent to provide a

 comfortable environment for the patient.
Rationale: A healing environment can help
reduce the stress that patients encounter
during a period of hospitalization and thereby
help them in their recovery.
● Follow-up care should also address the
patient's quality of life, such as
developmental, physical or emotional
concerns.
Rationale: This helps keeping a medical
support system in place is essential for
maintaining physical and emotional health.
● Educate the patient to avoid or stop
smoking and drinking alcohol.
Rationale: This would put a great risk of
recurrence of an increase the chance of
gastric ulcer and it can make that ulcer slower
to heal.

HYGIENE
● Encourage them to take a bath daily.
Thank you sa nag add
No worries po Rationale: Washing the body helps keep it
free of disease-causing germs.

● Advice the patient and their family to

always wash their hands or perform
proper hand washing daily.

Rationale: To avoid the spread of

microorganisms and prevent infection
 ● Instruct patient to avoid hot baths
Rationale: Hot baths increase the risk of
fainting and dizziness.

OUTPATIENT REFERRAL ● Instruct the patient to have regular

check-ups and schedule appointments
for follow-up care.
Rationale: Follow-up appointments should be
attended when the physician performed an
upper endoscopy and the state of the
gastrointestinal tract.
● Refer the patient for counseling, if
necessary and teach the patient when
to notify the physician of the need for
follow-up testing for H.pylori bacteria
and anxiety and to report any sudden
severe pain in the stomach.
Rationale: To have immediate treatment to
determine the severity of a patient’s condition.
● Instruct the patient if any time may
develop or bright red blood in the bowel
movement, fast breathing or call an
911 ambulance or seek immediate
medical care at the Emergency
Department.
Rationale: It’s essential to seek immediate
emergency medical attention to prevent
permanent damage or death.

DIET ● Advised the patient to eat small meals

more often rather than big meals less
 often.
Rationale: An empty stomach may make the
symptoms worse.
● Instruct the patient to increase fluid
intake.
Rationale: Preventing dehydration also helps
regulate body temperature and gets rid of
wastes through urination, perspiration, and
bowel movements.
● Advised the patient to avoid specific
foods that may precipitate dyspepsia
Rationale: The rate of digestion is reduced as
the production of natural digestive enzymes
and stomach acids are negatively affected. It
may develop the habit of eating food that can
manifest other symptoms of indigestion.

Nursing Theory - Emellano & Aguilar

Jean Watson – Theory of Human Caring

Jean Watson's Theory of Human Caring describes that nursing is concerned with
promoting health, preventing illness, caring for the sick, and restoring health. Primarily,
nurses' concerns revolve around how they care for their patients and how much care
leads to improved plans to promote health and wellness, prevent illness, and recover
health that focuses on health promotion and the treatment of diseases. Caring is central
to nursing practice and promotes health better. Clients with gastric ulcers commonly
experience burning in the center of the tummy (abdomen). But stomach ulcers aren't
always painful, and some people may experience other symptoms, such as indigestion,
heartburn and acid reflux, and feeling sick. Using the theory in patients with gastric
ulcers, nurses will promote and encourage the patient. They are likely to understand
more about their illness when they feel cared for and for the health workers to have a
more efficient and open approach to the client, which is essential to achieve holistic
health care.
 Hildegard Peplau’s
“Interpersonal Relations Theory”

Hildegard Peplau's Interpersonal Relations Theory emphasized the nurse-client

relationship as the foundation of nursing practice. She defined Nursing as "An
interpersonal process of therapeutic interactions between an individual who is sick or in
need of health services and a nurse specially educated to recognize, respond to the
need for help." It is a "maturing force and an educational instrument." There are four
major concepts of this theory; the theory explains nursing's purpose is to help others
identify their difficulties and apply human relations principles to the problems that arise
at all levels of experience. She defines man as an organism that "strives in its way to
reduce tension generated by needs." Health is defined as "a word symbol that implies a
forward movement of personality and other ongoing human processes in the direction of
creative, constructive, productive, personal, and community living." Although Peplau
does not directly address society/environment, she does encourage the nurse to
consider the patient's culture and mores when the patient adjusts to the hospital routine.
Peplau conceptualized clear roles that every nurse can use with their practice. It
indicates that a nurse's duty is not just to care, but the profession encompasses every
activity that may affect the patient's care. Peplau's (1992) theory of interpersonal
relations provides a conceptual framework by which the nurse can assess, plan, and
intervene for optimal outcomes for the patient with gastric ulcer. Therefore this theory
could help patients with gastric ulcer with their routines and medications. This is what
they call building rapport with the patient for their diagnostic test. The nurse must adapt
to different roles so that the patient's needs are met within each other phase. (Gonzalo,
2021)

Review of Related Literature - Fernando

Gastric Ulcer Perforation to the Liver Diagnosed by Endoscopic Biopsy
This study is about a 72 year old female who developed a silent gastric ulcer
perforation to the liver. The patient had severe anemia and complained of dizziness,
vomiting, insufficient oral intake, and epigastric discomfort at the time of admission. On
the other hand, her abdomen was soft and free of organomegaly and mass, and she
had neither abdominal pain nor distension. A physical examination revealed no
evidence of perforation, such as peritoneal irritation and rebound tenderness.
Surprisingly, a large ulcer was discovered during an upper gastrointestinal endoscopy,
confirmed by a CT scan. The surgical specimen was a chronic ulcer with perforation
and fibrous adhesion to the liver. After that, the patient was released without any
postoperative difficulties.
 In conclusion, peptic ulcer disease can lead to liver penetration, an uncommon
but serious complication. The gastric ulcer perforation, in this case, might be caused by
a history of painkiller use, advanced age, and Helicobacter pylori infection. When a
patient has the risk indicators of a perforated peptic ulcer, a high index of suspicion is
required to make a diagnosis since they may have a silent perforated peptic ulcer that is
not accompanied by physical symptoms (Lee, SU., Jee, Lee, H., & Lee, SH, 2020).
This study is beneficial to nursing education since it provides information that is
not commonly present in patients with gastric ulcers. For nursing research, it introduced
to us that these types of cases, although uncommon, are still present and can be a
source of information and data to those who came across them. And to nursing practice,
since it will make us more vigilant in looking out for signs that have a similar
presentation to the patient mentioned above for more straightforward diagnosis and
management.

Peptic Ulcer Disease: A Brief Review of Conventional Therapy and Herbal Treatment
Options
The focus of this study is to look at how medicinal plants may be used to treat
diseases. The most important sources of new medications are plant extracts and their
crude, and their effectiveness in treating gastric ulcers. It's well known that many drugs,
including proton pump inhibitors, anticholinergics, anti-inflammatory drugs,
antimicrobials, H2-receptor antagonists, sucralfate, and bismuth, aren't 100% effective
and cause a variety of side effects. As a result, by screening several plant extracts, new
pharmacologically active compounds were discovered that were both practical and safe
to use and have gastroprotective properties. As a primary method, plants with
antioxidant properties are utilized as herbal reservoirs to treat ulcer disease.
The eradication rates of H. pylori were increased by Korean red ginseng.
Inflammation in the stomach, oxidative DNA damage and apoptosis were all reduced. H.
pylori has been found to have an antioxidant and suppressive action in allium sativum.
In vivo pylori-induced stomach inflammation and an anti-tumorigenic impact by inducing
cell cycle arrest and death. Curcuma loga holds a significant anti-H. Pylori effect. As a
natural antioxidant against stomach ulcers, Zingiber officinalis, Zingiber zerumbetv, and
Camellia sinensis (Green tea polyphenols) showed therapeutic efficacy.
In conclusion, it's possible that combining herbal products with anti-gastric-ulcer
drugs might work together to fight H. pylori and enhance the result for individuals with
stomach ulcer disease and infection. However, with just a few human trials, it is
recommended that more clinical investigations on the efficacy and safety of antiulcer
medicinal plants with bigger sample sizes be conducted. It would also be good to
research the mechanisms of action of medicinal plants to cure or prevent peptic ulcers.
Finally, in order to improve the safety and quality of herbal products used for therapeutic
purposes, they must be licensed. As a result, pharmacists and doctors should be
especially cautious of the dangers of using herbal remedies alone or in conjunction with
other herbal or conventional therapies (Kuna, Jakab, Smolic, Lucic, Vcev, & Smolic,
2019).
This study is beneficial to nursing education since it presented various medicinal
plants that may be used to treat gastric ulcers. To nursing research, it will serve as
additional data for future researchers as they conduct similar studies like this. And to
nursing practice, if ever medicinal plants were approved to manage ulcer disease, it will
significantly help people with the disease in their treatment.

Application Value of Information-Based Health Education and Continuity of Care in

Patients with Peptic Ulcer
The purpose of this study is to see how information-based health education and
continuity of care might help patients with PU (peptic ulcer). Peptic ulcer (PU) is
characterized by a long course of the disease with a high recurrence rate. Additionally, a
lack of disease-related knowledge may harm a patient's quality of life and self-care
capabilities. Poor medication adherence and recurrence of the disease can lead to
negative mental states such as anxiety and depression, harming clinical treatment.
Changes in people's food patterns, lifestyles, and behavioral patterns have
increased the prevalence of PU in recent years. Gastric acid hypersecretion, H. pylori
infection, and a lack of gastric mucosal protection are the major causes of PU,
manifesting as epigastric pain, acid reflux, heartburn, and other symptoms that affect
the patients' quality of life. Some patients with PU frequently relapse after discharge
because of a lack of disease-related knowledge and self-management skills.
The study demonstrated that combining information-based health education with
continuity of care effectively improved patients' self-care abilities, increased medication
compliance, improved their quality of life, and increased health-related knowledge and
awareness of the disease. The nurses were able to thoroughly comprehend the
patients' mental condition, eradicate their inner anxiety of the sickness, and urge them
to have a positive attitude due to their active communication with them (Liu, Kuang,
Huang, & Ge, 2021).
This study is beneficial to nursing education since it talks about the importance of
the nurse-patient relationship in terms of continuity of care after discharge. To nursing
research, this may help provide additional information on the increased quality of life in
patients with PU who are well educated about their disease. And to nursing practice,
since it showed a positive result in terms of managing conditions that have a higher
chance of recurrence if not appropriately handled.

References
Belleza, M. (2021). Peptic Ulcer Disease. Retrieved on February 4, 2022, from
https://nurseslabs.com/peptic-ulcer-disease/.
Brennan, D. (2021). What is Vagotomy?. Retrieved on January 31, 2022, from
https://www.webmd.com/digestive-disorders/what-is-vagotomy

DeBanto, J. (2021). Peptic Ulcer Disease. Retrieved on February 4, 2022, from

https://gi.org/topics/peptic-ulcer-disease/#:~:text=Bleeding%20from%20an%20ulcer%20
can,exercise%20and%20pale%20skin%20color.

De Rosas, N. (2021). Caring for Patients Undergoing Blood Transfusions. Retrieved on

February 4, 2022, from https://rnspeak.com/blood-transfusion-nursing-responsibilities/.

DerSarkessian, C. (2020). Best and Worst Foods for Stomach Ulcers. Retrieved on
February 4, 2022, from
https://www.webmd.com/digestive-disorders/ss/slideshow-stomach-ulcers-best-worst-fo
ods

Hamdan, M., and Puckett, Y. (2022). Total Parenteral Nutrition. Retrieved on February
2, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK559036/#__NBK559036_ai__.

Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis's
medical-surgical nursing: Assessment and management of clinical problems. St. Louis,
MO. Elsevier

Herxheimer, A., & Haefeli, L. (2022). HUMAN PHARMACOLOGY OF HYOSCINE

BUTYLBROMIDE. The Lancet, 288(7460), 418–421.
https://doi.org/10.1016/s0140-6736(66)92720-6

Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's textbook of

medical-surgical nursing (14th ed.). Wolters Kluwer Health/Lippincott Williams &
Wilkins.

Huizen, J. (2018). Pyloroplasty. Retrieved on February 2, 2022, from

https://www.healthline.com/health/pyloroplasty

John Hopkins Medicine. (n.d). Gastroenterology and Hepatology. Retrieved on February

4, 2022, from
https://www.hopkinsmedicine.org/gastroenterology_hepatology/diseases_conditions/faq
s/peptic_ulcer_disease.html#:~:text=Gastric%20ulcer%20pain%20is%20usually,may%2
0have%20a%20weight%20gain.

Johnson, J. (2019). What causes acid reflux and shortness of breath? Retrieved on
February 4, 2022, from https://www.medicalnewstoday.com/articles/327359

Kizior, R. & Hodgson, K. (2019). Saunders Nursing Drug Handbook 2019. St. Louis,
MO: Elsevier.
Kuna, L., Jakab, J., Smolic, R., et al. (2019). Peptic Ulcer Disease: A Brief Review of
Conventional Therapy and Herbal Treatment Options. Retrieved on February 3, 2022,
from
https://mdpi-res.com/d_attachment/jcm/jcm-08-00179/article_deploy/jcm-08-00179.pdf

Lee, Y. B., Yu, J., Choi, H. H., Jeon, B. S., Kim, H. K., Kim, S. W., Kim, S. S., Park, Y.
G., & Chae, H. S. (2017). The association between peptic ulcer diseases and mental
health problems: A population-based study: a STROBE compliant article. Medicine,
96(34), e7828. https://doi.org/10.1097/MD.0000000000007828

Liu, A., Kuang, Y., Huang, R., et al. (2021). Application Value of Information-Based
Health Education and Continuity of Care in Patients with Peptic Ulcer. Retrieved on
February 3, 2022, from
https://www.frontiersin.org/articles/10.3389/fpubh.2021.694128/full
Martin, P. (2019). 4 Total Parenteral Nutrition (TPN Feeding) Nursing Care Plans.
Retrieved on February 2, 2022, from
https://nurseslabs.com/total-parenteral-nutrition-nursing-care-plans/.
MayoClinic. (2020). Blood transfusion. Retrieved on February 4, 20211, from
https://www.mayoclinic.org/tests-procedures/blood-transfusion/about/pac-20385168.
Medscape. (2021). What is the prevalence of peptic ulcer disease (PUD) in the US?.
Retrieved on January 31, 2022, from
https://www.medscape.com/answers/181753-13866/what-is-the-prevalence-of-peptic-ul
cer-disease-pud-in-the-us
M.I.M.S. (2021). Hyoscine: Indication, Dosage, Side Effect, Precaution | MIMS
Philippines. MIMS. Retrieved on January 31, 2022, from
https://www.mims.com/philippines/drug/info/hyoscine?mtype=generic
Morgan, M. (2020). Billroth I Reconstruction. Retrieved on February 2, 2022, from
https://radiopaedia.org/articles/billroth-i-reconstruction

Nall, R. (2018). What’s Causing My Abdominal Pain and Dizziness? Retrieved on

February 4, 2022, from https://www.healthline.com/health/abdominal-pain-and-dizziness

Pathak, N. (2021). Understanding Ulcers. Retrieved on February 4, 2022, from

https://www.webmd.com/digestive-disorders/eat-healthy-exercise
Peptic Ulcer Disease in Philippines. (2019). World Life Expectancy. Retrieved on
January 31, 2022, from
https://www.worldlifeexpectancy.com/philippines-peptic-ulcer-disease#:%7E:text=Accor
ding%20to%20the%20latest%20WHO,Philippines%20%2318%20in%20the%20world.

Prima Medicine, (n.d). 5 Signs You May Have an Ulcer. Retrieved on February 4, 2022,
from https://www.primamedicine.com/blog/5-signs-you-may-have-an-ulcer

Robinson, J. (2021). Understanding Ulcer Symptoms. Retrieved on February 4, 2022,

from https://www.webmd.com/digestive-disorders/understanding-ulcers-symptoms

Rxlist. (2021). DEXTROSE 5 IN .9 SODIUM CHLORIDE. Retrieved on February 3,

2022, from https://www.rxlist.com/dextrose-5-in-9-sodium-chloride-drug.htm#description

Salahshour, A. (2020). Billroth II Gastrojejunostomy. Retrieved on February 2, 2022,

from https://radiopaedia.org/articles/billroth-ii-gastrojejunostomy
Seon, LU., Jee, S., Lee, H., et al. (2020). Gastric Ulcer Perforation to the Liver
Diagnosed by Endoscopic Biopsy. Retrieved on February 3, 2022, from
https://www.kjg.or.kr/journal/view.html?doi=10.4166/kjg.2020.75.5.292
Shiel, W. (2020). What is the Purpose of a Vagotomy?. Retrieved on January 31, 2022,
from https://www.medicinenet.com/what_is_the_purpose_of_a_vagotomy/article.htm
Singh, P. (2018). Rebamipide - Indications, Dosage, Side Effects and Precautions.
Retrieved on February 1, 2022, from
https://www.medindia.net/doctors/drug_information/rebamipide.htm.

Sullivan, D. (2019). Coffee Ground Vomitus. Retrieved on February 4, 2022, from

https://www.healthline.com/health/coffee-ground-vomitus

Vera, M. (2021). IV Fluids and Solutions Guide & Cheat Sheet. Retrieved on February
3, 2022, from https://nurseslabs.com/iv-fluids/

Vernon, A., Ferzoco, S., and Ashley, S. (2021). Surgical Management of Peptic Ulcer
Disease. Retrieved on January 31, 2022, from
https://www.uptodate.com/contents/surgical-management-of-peptic-ulcer-disease?topic
Ref=15160&source=see_link#H1
World Laparoscopy Hospital. (2022). Antrectomy. Retrieved on January 31, 2022, from
https://www.laparoscopyhospital.com/Antrectomy.html