NURSING PROCESS:THE PATIENT WITH ULCER DISEASE
The nurse asks the patient to describe the pain and the methods used to relieve it (e.g., food, antacids). The patient usually describes peptic ulcer pain as burning or gnawing; it occurs about 2 hours after a meal and frequently awakens the patient between midnight and 3 AM. Taking antacids, eating, or vomiting often relieves the pain. If the patient reports a recent history of vomiting, the nurse determines how often emesis has occurred and notes important characteristics of the vomitus: Is it bright red, does it resemble coffee grounds, or is there undigested food from previous meals? Has the patient noted any bloody or tarry stools?
The nurse also asks the patient to list his or her usual food in-take for a 72-hour period and to describe food habits (e.g., speed of eating, regularity of meals, preference for spicy foods, use of sea-sonings, use of caffeinated beverages and decaffeinated coffee). Lifestyle and habits are a concern as well. Does the patient use irri-tating substances? For example, does he or she smoke cigarettes? If yes, how many? Does the patient ingest alcohol? If yes, how much and how often? Are NSAIDs used? The nurse inquires about the patient’s level of anxiety and his or her perception of current stres-sors. How does the patient express anger or cope with stressful sit-uations? Is the patient experiencing occupational stress or problems within the family? Is there a family history of ulcer disease?
The nurse assesses vital signs and reports tachycardia and hypotension, which may indicate anemia from GI bleeding. The stool is tested for occult blood, and a physical examination, in-cluding palpation of the abdomen for localized tenderness, is per-formed as well.
Based on the assessment data, the patient’s nursing diagnoses may include the following:
• Acute pain related to the effect of gastric acid secretion on damaged tissue
• Anxiety related to coping with an acute disease
• Imbalanced nutrition related to changes in diet
• Deficient knowledge about prevention of symptoms and management of the condition
Potential complications may include the following:
• Pyloric obstruction (gastric outlet obstruction)
The goals for the patient may include relief of pain, reduced anx-iety, maintenance of nutritional requirements, knowledge about the management and prevention of ulcer recurrence, and absence of complications.
Pain relief can be achieved with prescribed medications. The patient should avoid aspirin, foods and beverages that contain caffeine, and decaffeinated coffee, and meals should be eaten at regularly paced intervals in a relaxed setting. Some patients benefit from learning relaxation techniques to help manage stress and pain and to en-hance smoking cessation efforts.
The nurse assesses the patient’s level of anxiety. Patients with pep-tic ulcers are usually anxious, but their anxiety is not always obvi-ous. Appropriate information is provided at the patient’s level of understanding, all questions are answered, and the patient is en-couraged to express fears openly. Explaining diagnostic tests and administering medications on schedule also help to reduce anxi-ety. The nurse interacts with the patient in a relaxed manner, helps identify stressors, and explains various coping techniques and relaxation methods, such as biofeedback, hypnosis, or be-havior modification. The patient’s family is also encouraged to participate in care and to provide emotional support.
The nurse assesses the patient for malnutrition and weight loss. After recovery from an acute phase of peptic ulcer disease, the pa-tient is advised about the importance of complying with the med-ication regimen and dietary restrictions.
Gastritis and hemorrhage from peptic ulcer are the two most common causes of upper GI tract bleeding. Hemorrhage, the most common complication, occurs in about 15% of patients with peptic ulcers (Yamada, 1999). The site of bleeding is usually the distal portion of the duodenum. Bleeding may be manifested by hematemesis or melena (tarry stools). The vomited blood can be bright red, or it can have a “coffee grounds” appearance (which is dark) from the oxidation of hemoglobin to methemoglobin. When the hemorrhage is large (2000 to 3000 mL), most of the blood is vomited. Because large quantities of blood may be lost quickly, immediate correction of blood loss may be required to prevent hemorrhagic shock. When the hemorrhage is small, much or all of the blood is passed in the stools, which will appear tarry black because of the digested hemoglobin. Management depends on the amount of blood lost and the rate of bleeding.
The nurse assesses the patient for faintness or dizziness and nausea, which may precede or accompany bleeding. It is impor-tant to monitor vital signs frequently and to evaluate the patient for tachycardia, hypotension, and tachypnea. Other nursing in-terventions include monitoring the hemoglobin and hematocrit, testing the stool for gross or occult blood, and recording hourly urinary output to detect anuria or oliguria (absence or decreased urine production).
Many times the bleeding from a peptic ulcer stops sponta-neously; however, the incidence of recurrent bleeding is high. Because bleeding can be fatal, the cause and severity of the hem-orrhage must be identified quickly and the blood loss treated to prevent hemorrhagic shock. Management of upper GI tract bleeding consists of quickly determining the amount of blood lost and the rate of bleeding, rapidly replacing the blood that has been lost, stopping the bleeding, stabilizing the patient, and di-agnosing and treating the cause. Related nursing and collabora-tive interventions include the following:
• Inserting a peripheral IV line for the infusion of saline or lactated Ringer’s solution and blood products. The nurse may need to assist with the placement of a pulmonary artery catheter for hemodynamic monitoring. Blood component therapy is initiated if there are signs of shock (eg, tachycar-dia, sweating, coldness of the extremities).
• Monitoring the hemoglobin and hematocrit to assist in evaluating blood loss
• Inserting an NG tube to distinguish fresh blood from “coffee grounds” material, to aid in the removal of clots and acid, to prevent nausea and vomiting, and to provide a means of monitoring further bleeding
• Administering a room-temperature lavage of saline solution or water. This is controversial; some authorities recommend using ice lavage (Yamada, 1999).
• Inserting an indwelling urinary catheter and monitoring urinary output
• Monitoring vital signs and oxygen saturation and adminis-tering oxygen therapy
• Placing the patient in the recumbent position with the legs elevated to prevent hypotension; or, to prevent aspiration from vomiting, placing the patient on the left side
• Treating hemorrhagic shock
If bleeding cannot be managed by the measures described, other treatment modalities may be used. Transendoscopic coagulation by laser, heat probe, medication, a sclerosing agent, or a combina-tion of these therapies can halt bleeding and make surgical inter-vention unnecessary. There is much debate regarding how soon endoscopy should be performed. Some believe that endoscopy should be performed in the first 24 hours after hemorrhage has been stabilized. Others believe that endoscopy may be performed during acute bleeding, as long as the esophageal or gastric area can be visualized (blood may decrease visibility) (Yamada, 1999).
For those who are unable to undergo surgery, selective em-bolization may be used. This procedure involves forcing emboli of autologous blood clots with or without Gelfoam (absorbable gelatin sponge) through a catheter in the artery to a point above the bleeding lesion. A radiologist performs this procedure.
Rebleeding may occur and often warrants surgical intervention. The nurse monitors the patient carefully so that bleeding can be detected quickly. Signs of bleeding include tachycardia, tachypnea, hypotension, mental confusion, thirst, and oliguria. If bleeding re-curs within 48 hours after medical therapy has begun, or if more than 6 to 10 units of blood are required within 24 hours to main-tain blood volume, the patient is likely to require surgery. Some physicians recommend surgical intervention if a patient hemor-rhages three times. Other criteria for surgery are the patient’s age (massive hemorrhaging is three times more likely to be fatal in those older than 60 years of age); a history of chronic duodenal ulcer; and a coincidental gastric ulcer (Yamada, 1999). The area of the ulcer is removed or the bleeding vessels are ligated. Many patients also undergo procedures (eg, vagotomy and pyloroplasty, gastrectomy) aimed at controlling the underlying cause of the ulcers (see Table 37-3).
Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. It is an abdominal cat-astrophe and requires immediate surgery. Penetration is erosion of the ulcer through the gastric serosa into adjacent structures such as the pancreas, biliary tract, or gastrohepatic omentum. Symp-toms of penetration include back and epigastric pain not relieved by medications that were effective in the past. Like perforation, penetration usually requires surgical intervention.
Signs and symptoms of perforation include the following:
• Sudden, severe upper abdominal pain (persisting and in-creasing in intensity); pain may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm.
• Vomiting and collapse (fainting)
• Extremely tender and rigid (boardlike) abdomen
• Hypotension and tachycardia, indicating shock
Because chemical peritonitis develops within a few hours after perforation and is followed by bacterial peritonitis, the perfora-tion must be closed as quickly as possible. In a few patients, it may be deemed safe and advisable to perform surgery for the ulcer dis-ease in addition to suturing the perforation.
Postoperatively, the stomach contents are drained by means of an NG tube. The nurse monitors fluid and electrolyte balance and assesses the patient for peritonitis or localized infection (in-creased temperature, abdominal pain, paralytic ileus, increased or absent bowel sounds, abdominal distention). Antibiotic therapy is administered parenterally as prescribed.
Pyloric obstruction, also called gastric outlet obstruction (GOO), occurs when the area distal to the pyloric sphincter becomes scarred and stenosed from spasm or edema or from scar tissue that forms when an ulcer alternately heals and breaks down. The pa-tient has nausea and vomiting, constipation, epigastric fullness, anorexia, and, later, weight loss.
In treating the patient with pyloric obstruction, the first con-sideration is to insert an NG tube to decompress the stomach. Con-firmation that obstruction is the cause of the discomfort is accomplished by assessing the amount of fluid aspirated from the NG tube. A residual of more than 400 mL strongly suggests ob-struction. Usually an upper GI study or endoscopy is performed to confirm gastric outlet obstruction. Decompression of the stomach and management of extracellular fluid volume and electrolyte bal-ances may improve the patient’s condition and avert the need for surgical intervention. A balloon dilatation of the pylorus via endoscopy may be beneficial. If the obstruction is unrelieved by medical management, surgery (in the form of a vagotomy and antrectomy or gastrojejunostomy and vagotomy) may be required.
To manage ulcer disease successfully, the patient is instructed about the factors that will help or aggravate the condition (Chart 37-2). The nurse reviews information about medications to be taken at home, including name, dosage, frequency, and possible side ef-fects, stressing the importance of continuing to take medications even after signs and symptoms have decreased or subsided.
Then the patient is instructed to avoid certain medications and foods that exacerbate symptoms as well as substances that have acid-producing potential (eg, alcohol; caffeinated beverages such as coffee, tea, and colas). It is important to counsel the patient to eat meals at regular times and in a relaxed setting, and to avoid overeating. If relevant, the nurse also informs the patient about the irritant effects of smoking on the ulcer and provides infor-mation about smoking cessation programs.
The nurse reinforces the importance of follow-up care for ap-proximately 1 year, the need to report recurrence of symptoms, and the need for treating possible problems that occur after surgery, such as intolerance to dairy products and sweet foods.
Expected patient outcomes may include the following:
1) Reports freedom from pain between meals
2) Feels less anxiety by avoiding stress
3) Complies with therapeutic regimen
a. Avoids irritating foods and beverages
b. Eats regularly scheduled meals
c. Takes prescribed medications as scheduled
d. Uses coping mechanisms to deal with stress
4) Maintains weight
5) Is free of complications