NUR 120 PEPTIC ULCER DISEASE

1. NUR 120 PEPTIC ULCER DISEASE

2. Pathophysiology Normally, a physiologic balance exists between peptic acid secretion and gastric mucosal defense The gastric mucosal barrier protects the underlying tissue from gastric acids and digestive juices When a disruption occurs with this protective barrier, the mucosal lining is exposed and corroded by acid, resulting in an ulcer

4. Causes of PUD • H pylori bacteria • Chronic use of NSAIDS • Hypersecretion of Stomach Acid • Stress • Zollinger-Ellison Syndrome

5. To Test for H Pylori • Endoscopic gastric samples • Collect medication history prior • Urea breath testing • NPO prior to test • IgG serologic test can detect antibodies • Stool sample

6. Ulcer Classification Location: ulcer on stomach=Gastric Ulcer ulcer on upper intestine=Duodenal Ulcer ulcer on esophagus=Esophageal Ulcer Duration: Acute or Chronic

7. Signs and Symptoms • o Symptoms vary from person to person • o Can be confused with GERD and dyspepsia • o Common signs and symptoms: • o Gnawing, burning and aching in the epigastrium, and • o Dyspepsia that feels like heartburn • o Bloating and nausea • o Pain

8. o Less common symptoms: • o Pyloric obstruction- vomiting after meals • o Vomiting blood that looks like coffee grounds • o Black stools that looks like tar or that has dark red in them

9. o Peptic ulcer disease can be differentiated between gastric, duodenal, and stress ulcers.

10. o Silent ulcers may occur with pts with diabetes, NSAID users such as aspirin and ibuprofen. • o If left untreated, complications may occur such as bleeding, perforation, penetration or the obstruction of the digestion tract.

11. Treatment of Peptic Ulcer Disease • Combination of lifestyle changes and pharmacotherapy best • Treatment goals • Eliminate infection by H. pylori • Promote ulcer healing • Prevent recurrence of symptoms

12. Treatment of Peptic Ulcer Disease (continued) • Drugs used in treatment • H2-receptor antagonists • Proton pump inhibitors • Antacids • Antibiotics and miscellaneous drugs

13. Treatment of H. pylori • Goals of treatment • Primary: bacteria completely eradicated • Ulcers heal more rapidly • Ulcers remain in remission longer • Very high reoccurrence when H. pylori not eradicated • Infection can remain active for life if not treated.

14. H2-Receptor Blockers • Slow acid secretion by stomach • Often drugs of choice in treating PUD • Cimetidine used less frequently • Drug-drug interactions are numerous. • Do not take antacids at same time as H2-receptor blockers. • Decreases absorption

15. H2-Receptor Blockers • Prototype drug: ranitidine (Zantac) • Mechanism of action: acts by blocking H2-receptors in stomach to decrease acid production • Primary use: to treat peptic ulcer disease • Adverse effects: possible reduction in number of red and white blood cells and platelets, impotence or loss of libido in men

16. H2-Receptor Antagonist Therapy • Dysrhythmias and hypotension have occurred with IV cimetidine • Ranitidine (Zantac) or famotidine (Pepcid) can be administered intravenously • Assess kidney and liver function • Evaluate client’s CBC for possible anemia during long-term use

17. Proton Pump Inhibitors • Prototype drug:omeprazole (Prilosec) • Mechanism of action: reduces acid secretion in stomach by binding irreversibly to enzyme H+, K+-ATPase • Primary use: for short-term, 4- to 8-week therapy for peptic ulcers and GERD • Adverse effects: headache, nausea, diarrhea, rash, abdominal pain • Long-term use associated with increased risk of gastric cancer

18. Proton Pump Inhibitor Therapy for PUD • Take 30 minutes prior to eating, usually before breakfast • May be administered at same time as antacids • Often administered in combination with clarithromycin (Biaxin)

19. Antacids • Prototype drug: aluminum hydroxide (Amphojel) • Mechanism of action: neutralizes stomach acid by raising pH of stomach contents • Primary use: in combination with other antiulcer agents for relief of heartburn due to PUD or GERD • Adverse effects: minor; constipation

20. Antibiotics • Administered to treat H. pylori infections of gastrointestinal tract • Two or more antibiotics given concurrently • Increase effectiveness • Lower potential for resistance • Regimen often includes • Proton pump inhibitor • Bismuth compounds • Inhibit bacterial growth • Prevent H. pylori from adhering to gastric mucosa

21. Miscellaneous Drugs • Several additional drugs are beneficial in treating PUD • Sucralfate • Coats ulcer and protects it from further erosion • Misoprostol • Inhibits acid and stimulates production of mucus • Pirenzepine • Inhibits autonomic receptors responsible for gastric-acid secretion

22. Peptic Ulcer Disease Nursing Interventions: • Pain Management: • Assess location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to determine appropriate intervention • Provide client with optimal pain relief by using prescribed analgesics to provide comfort. • Use a variety of measures of relief such as pharmacologic, nonpharmacologic, and interpersonal techniques to facilitate pain relief. • Teach the use of nonpharmacologic techniques which include relaxation, music therapy, guided imagery, distraction, acupressure, and massage before after and if possible during painful activities before pain occurs or increases. • Relaxation helps decrease acid production and reduces pain

23. Nursing Interventions cont’d: • Treament Regimen: • Explain the pathophysiology of the disease and how it relates to anatomy and physiology to help the patient understand the disease. • Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process. • Instruct patient on which signs and symptoms to report to the health care provider to ensure early initiation of treatment. • Hemorrhage/Bleeding: • Assess for evidence of hematemesis, bright red or melena stool, abdominal pain or discomfort, symptoms of shock (decreased BP, cool/clammy skin, dyspnea, tachycardia, decreased urine output) • If ulcer is actively bleeding, observe NG tube aspirate or emesis for amount and color to assess degree of bleeding. • Take vital signs every 15-30 mins to help determine patient’s hemodynamic status and as indicators for shock. • Maintain IV infusion line to provide ready access for blood and fluid replacement. • Monitor hematocrit and hemoglobin as indicators of severity of hemorrhage and need for fluid and blood replacement.

24. Nursing Interventions cont’d: • Perforation: • Observer for manifestations of perforation such as sudden, severe abdominal pain; rigid, boardlike abdomen; radiating pain to shoulders; increasing distention; decreasing bowl sounds. • Take vital signs every 15-30 mins. • Maintain NG tube to suction to provide continuous aspiration and gastric decompression. • Administer pain medication to promote comfort and reduce anxiety.

25. Dietary modifications • Avoid foods that cause epigastric distress. • Avoid milk, sweets, or sugars • Small, frequent meals rather than large meals. • Limit the fluid intake at one time.

26. Avoid Cigarettes and alcohol. • Avoid OTC drugs unless approved by HCP. • Take all medications as provided.

27. Report any of the following: • Increased nausea and or vomiting. • Increase in epigastric pain. • Bloody emesis or tarry stools. • Encourage stress reducing activities or relaxation strategies.