Primary Nursing Diagnosis

Pain (acute) related to inflammation and irritation

OUTCOMES. Comfort level; Pain control behavior; Pain level; Symptom severity

INTERVENTIONS. Analgesic administration; Anxiety reduction; Environmental management: Comfort; Pain management; Medication management; Patient-controlled analgesia assistance

712 Peptic Ulcer Disease

^ PLANNING AND IMPLEMENTATION Collaborative

The treatment of choice for patients with peptic ulcers is generally pharmacologic. Drugs can be used to buffer or inhibit acid secretion that leads to ulceration and causes symptoms. Nutritional therapy is also prescribed. The current treatment is to eliminate foods that cause discomfort and symptoms. There is no evidence that bland or soft diets reduce gastric acid, promote healing, or relieve symptoms. Instruct the patient to avoid alcohol, coffee, and other caffeine-containing beverages. Refer patients with significant weight loss to a dietitian.

Most patients do not require surgery. However, in the event of the primary complications of hemorrhage, perforation, or obstruction, surgery may be necessary. Hemorrhage occurs in 15% of patients with duodenal ulcers and occurs more frequently in patients with NSAID-associated ulcers who have no prior symptoms. Perforation into the peritoneal cavity, which occurs in 6% of patients, happens when the ulcer erodes through the entire thickness of the gastric or duodenal wall. Obstruction occurs in 2% to 4% of patients with duodenal or pyloric ulcers. Treatment begins conservatively with gastric suction and fluid and electrolyte therapy. Pyloroplasty may follow.

The most common surgical interventions that are required for persons who do not respond to medical treatments are vagotomy with antrectomy, vagotomy with pyloroplasty, and parietal cell vagotomy (also called superselective or proximal gastric vagotomy). Several important complications can occur after surgery. Bile reflux gastritis, which occurs because of a reflux of duodenal contents into the stomach, occurs after a pyloroplasty or when the pylorus is bypassed or removed. Marginal ulcers are those that develop where gastric acids contact the operative site, usually at the site of anastomosis. Acute gastric dilation occurs in the postoperative period when dilation of the stomach causes reflex hypotension, pain, and tachycardia. The symptoms are relieved with vomiting or gastric suction.

Pharmacologic Highlights

General Comments: Most duodenal ulcers heal In 4 to 6 weeks, and treatment seldom extends past 8 weeks. Maintenance drug therapy Is Indicated for at least 1 year for patients with frequent recurrences. Gastric ulcers should heal In 8 to 12 weeks, more rapidly when acid is completely suppressed with use of a proton pump inhibitor such as omeprazole (Prilosec). If gastric ulcers do not heal with treatment, malignancy is

suspected.

Medication or Drug Class

Dosage

Description

Rationale

H2 antagonist

Triple therapies: Antibiotics (for patients with Helicobacter pylori bacteria) and proton pump inhibitor

Varies with drug

Omeprazole (Prilosec), 20 mg PO bid for 14 days with clarithromycin (Biaxin) 500 mg PO bid for 14 days and amoxicillin (Amoxil) 1 g PO bid for 14 days

Cimetidine, rantidine, famotidine, nizatidine

Other protein pump inhibitors may be used: Lansoprazole (Prevacid); rabeprazole (Aciphex); esomeprazole (Nexium)

Reduces acid secretion to optimize ulcer healing

Antibiotics eradicate H. pylori and protein pump inhibitor reduces acid secretion; triple therapy may also consist of antibiotics and bismuth-based therapy such as Pepto-Bismol

Independent

Provide information about the cause and contributing factors as they pertain to the individual patient. Explain the relationship of gastric acidity, mucosal damage, and the significance of the symptoms of ulcer formation (pain, bleeding, nausea and vomiting, black stools). Discuss possible complications of peptic ulcer disease as it progresses: hemorrhage, perforation, and obstruction because of repeated ulcerations and scarring. Emphasize the need to adhere to the medication schedule, even when symptoms subside, to ensure complete healing and to prevent recurrence. Encourage the patient to avoid aspirin and other NSAIDs for aches and pains and suggest alternatives, such as acetaminophen (Tylenol). Provide a list of OTC drugs that contain aspirin.

Explore ways to reduce stress, and emphasize the importance of emotional and physical rest to reduce gastric secretion. Teach relaxation exercises to use during rest periods that fit into daily routines. Explain why elimination of smoking facilitates healing and reduces recurrence. Provide a list of community agencies that have smoking cessation programs. Discuss the patient's concerns openly. Identify attitudes and situations that could interfere with the needed lifestyle changes. Involve the family or significant others in these discussions and plans to gain their support.

0 0

Post a comment