T A B L E

O F

C O N T E N T S

I. INTRODUCTION
• • •

Definition of terms Risk Factors Signs and Symptoms

II. DEMOGRAPHIC DATA III. MEDICAL HISTORY

• • • •

Present Medical History Past Medical History Family Medical History Social History

IV. PHYSICAL EXAMINATION V. ANATOMY AND PHYSIOLOGY • Client Base • Book Base VI.
PATHOPHYSIOLOGY VII. DIAGNOSTIC / LABORATORY PROCEDURE VIII. MEDICAL AND SURGICAL
MANAGEMENT IX. NURSING CARE PLAN
I. INTRODUCTION PERFORATED PEPTIC ULCER ♥ A Peptic Ulcer, also known as PUD or
PEPTIC ULCER DISEASE may be referred to as a gastric, duodenal, or esophageal
ulcer, depending on its location. A person who has peptic ulcer has PUD. A peptic
ulcer is an excavation (hollowed-out area) that forms in the mucosal wall of the
stomach, in the pylorus (the opening between the stomach and the duodenum), in the
duodenum (the first part of the small intestine), or in the esophagus. ♥Peptic
ulcer disease is an ulcer (defined as mucosal erosions equal to or greater than
0.5 cm) of an area of the gastrointestinal tract that is usually acidic and thus
extremely painful. As much as 80% of ulcers are associated with Helicobacter
pylori, a spiral-shaped bacterium that lives in the acidic environment of the
stomach, however only 20% of those cases go to a doctor. Ulcers can also be caused
or worsened by drugs such as aspirin and other NSAIDs.
DUODENAL ULCER ♥Duodenal ulcers have a higher incidence than gastric ulcers. The
ulcers usually occur within 1.5 cm (0.6 inch) of the pylorus and are usually
characterized by high gastric acid secretion. Some are associated with rapid
emptying of the stomach. Hypersecretion of acid is attributed to mass of parietal
cells. Stimuli for acid secretion include protein-rich meals, alcohol consumption,
calcium, and vagal stimulation.
GASTRIC ULCER ♥Gastric ulcers which to tend to heal within a few weeks, form
within 1 inch (2.5 cm) of the pylorus of the stomach in an area where gastritis is
common. Gastric ulcers are probably caused by a break in the mucosal barrier. The
barrier, which differs from the layer of glycoprotein mucus that overlies the
gastric epithelium, normally allows hydrochloric acid to be secreted in the
stomach without injury to the epithelial cells. An incorporate pylorus may
decrease production of mucus, the usual gastric defense. The reflux of the bile
acids through an incompetent pylorus into the stomach may break the mucosal
barrier. Decrease blood flow to the gastric mucosa may also alter the defensive
barrier and may make the duodenum more susceptible to gastric acid and pepsin
trauma. The recurrence rate of gastric ulcer is lower than that of duodenal ulcer.
Comparison of Duodenal and Gastric Ulcers Incidence Duodenal Ulcer Age 30-60 Male:
female= 2-3:1 80% of peptic ulcers are duodenal Signs, Symptoms, and Clinical
Findings Duodenal Ulcer Hypersecretion of the stomach acid (HCl) May have weight
gain Pain occurs 2-3 hrs after a meal; often awakened 1-2 AM: ingestion of food
relieves pain Vomiting uncommon Hemorrhage less likely than with gastric ulcer,
but if present, melena more common than hematemesis More likely to perforate than
gastric ulcers MALIGNANCY POSSIBILITY Duodenal Ulcer Rare RISK FACTORS Duodenal
Ulcer H. Pylori, Alcohol, Smoking, cirrhosis, stress Gastric Ulcer H. pylori,
gastritis, alcohol, smoking, use of NSAIDs, stress Gastric Ulcer Occasionally
Gastric Ulcer Normal-hyposecretion of stomach acid (HCl) Weight loss may occur
Pain occurs ½ to 1 hr after a meal; rarely occurs at night; may be relieve by
vomiting; ingestion of food does not help, sometimes increases pain Vomiting
common Hemorrhage more likely to occur than with duodenal ulcer; hematemesis more
common than melena Gastric Ulcer Usually 50 and over Male: female=1:1 15% of
peptic ulcers are gastric
ETIOLOGY/ RISK FACTORS ♥ GENERAL: Heredity, smoking, Helicobacter Pylori
(H.pylori), stress, alcohol, NSAIDS. ♥ Arises without obvious exciting cause, but
is probably due to the digestive action of highly acid gastric juice on a part of
the stomach, whose nutrition has been impaired by some local disturbance on the
circulation; anemia; trauma; focal infection. Has been found in many cases of
brain lesions, and worry is not only a predisposing cause but a retarding
influence upon recovery from digestive erosions. There seems to be a decided
correlation between this condition and the nervous system. Emotional strain and
overwork are important factors to be considered. The worriers, the excitable and
emotional types are prone to digestive ulcers. Ulcer is round or oval, usually at
pylorus or duodenum, on post. Wall, near lesser curvature; has punched out
appearance. ♥CAUSES: Although stress and spicy foods were once thought to be the
main causes of peptic ulcers, doctors now know that the cause of most ulcers is
the corkscrew-shaped bacterium Helicobacter pylori (H. pylori). H. pylori lives
and multiplies within the mucous layer that covers and protects tissues that line
the stomach and small intestine. Often, H. pylori cause no problems. But sometimes
it can disrupt the mucous layer and inflame the lining of the stomach or duodenum,
producing an ulcer. One reason may be that people who develop peptic ulcers
already have damage to the lining of the stomach or small intestine, making it
easier for bacteria to invade and inflame tissues. H. pylori is the most common,
but not the only, cause of peptic ulcers. Besides H. pylori, other causes of
peptic ulcers, or factors that may aggravate them, include: Regular use of pain
relievers.  Nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate or inflame
the lining of your stomach and small intestine. The medications are available both
by prescription and over-the-counter. Nonprescription NSAIDs include aspirin,
ibuprofen (Advil, Motrin, others), naproxen (Aleve) and ketoprofen (Orudis KT). To
help avoid digestive upset, take NSAIDs with meals. NSAIDs inhibit production of
an enzyme (cyclooxygenase) that produces prostaglandins. These hormone-like
substances help protect your stomach lining from chemical and physical injury.
Without this protection, stomach acid can erode the lining, causing bleeding and
ulcers.
-

Smoking.  Nicotine in tobacco increases the volume and concentration of stomach

acid, increasing your risk of an ulcer. Smoking may also slow healing during ulcer
treatment.  Excessive alcohol consumption.  Alcohol can irritate and erode the
mucous lining of your stomach and increases the amount of stomach acid that's
produced. It's uncertain, however, whether this alone can progress into an ulcer
or whether other contributing factors must be present, such as H. pylori bacteria
or ulcercausing medications, such as NSAIDs. Stress.  Although stress per se
isn't a cause of peptic ulcers, it's a contributing factor. Stress may aggravate
symptoms of peptic ulcers and, in some cases, delay healing. You may undergo
stress for a number of reasons — an emotionally disturbing circumstance or event,
surgery, or a physical trauma, such as a burn or other severe injury.

SIGNS AND SYMPTOMS ♥EPIGASTRIC PAIN Duodenal Ulcer  occurs 2-3 hrs after a meal;
often awakened 1-2 AM(when gastric secretion tends to be greatest): ingestion of
food relieves pain Gastric Ulcer  occurs ½ to 1 hr after a meal; rarely occurs at
night; may be relieve by vomiting; ingestion of food does not help, sometimes
increases pain Involuntary spasmodic muscular contraction that causes discomfort
and pain
♥BLOATING or ABDOMINAL FULLNESS Due to excessive flatulence

♥PYROSIS (HEARTBURN) A burning sensation usually in the midsternal area caused by

reflux of gastric contents into the esophagus

♥NAUSEA AND VOMITING Nausea is the feeling of gastric uneasiness characterized by

the urge to vomit. Vomiting is the expulsion of gastric contents, most commonly an
involuntary response

♥WEIGHT LOSS
common symptom usually denoting malabsorption of nutrients and loss of appetite

♥MELENA results from bleeding or hemorrhage from digestive tract ♥HEMATEMESIS

Vomiting of blood, this can occur due to bleeding directly from a gastric ulcer,
or from damage to the esophagus from severe/continuing vomiting. ♥WATERBRASH 
Vomiting of blood, this can occur due to bleeding directly from a gastric ulcer,
or from damage to the esophagus from severe/continuing vomiting.
II. DEMOGRAPHIC DATA Name: Address: Age: Sex: Occupation: Potulin, Miguel Llusi
#52 Roadman Street Area A Talanay Batasan Hills 58 Male Fisherman – province
(past) / Latero – Manila (present) Civil Status: Birthday: Birthplace: Religion:
Room No: Present Admission: Admission Diagnosis: Final Diagnosis: Married – Civil
Wedding 05/11/1950 Cariraga, Leyte Roman Catholic 4015 - D 12/27/2008 Abdominal
Pain Perforated Peptic Ulcer

Procedure/Operation/ Anesthesia: “E” Explore Lap GETA

III. MEDICAL HISTORY A. History of Present Illness Prior to admission, the patient
has been experiencing intermittent crampy abdominal pain, most pronounced on the
epigastric region since 2001 up to the present which is relieved by mefenamic acid
500 mg/tab and drinking of warm water and also by applying hot compress on the
affected site with associated sweating, nausea and vomiting and sometimes feeling
bloated after eating. Consultation done last year at OPD of EAMC.

B. Past Medical History The patient was brought to the hospital last December 27,
2008 due to abdominal pain and was diagnosed having perforated peptic ulcer. This
is his first time to be admitted in the hospital. He had measles when he was in
elementary and he had incomplete vaccination. During his stay in the province,
when mild symptoms occur on one of their family member, they just depend on self
medication and herbal medicines. But when the symptoms become worse then that’s
the time they seek medical attention to the nearest health center.

C. Family Medical History Medical problems from blood relatives. Father of Miguel
– (+) ulcer, Grand mother of Miguel – (+) heart problem

D. Social History The client usually drinks almost a glass of liquor particularly
“tuba with egg” whenever there is an occasion or during his free time. However,
the patient has been smoking since 1968 to 2008 and he can consumed 1 ½ pack of
cigarettes in a day and he is fond of eating spicy foods. Furthermore, he is a
Roman Catholic and he stated that the most important person in his life God and
his family. As a “Latero”, his income is just enough to sustain their daily
expenses. However, to maintain their other needs his only daughter who is a
“Helper”, assist them on their extra expenses. The most important persons in his
life are, God and his family.
IV. PHYSICAL EXAMINATION The patient is conscious and coherent when we entered the
room. He is seating beside on his bed. Her skin is pale. Her height is average,
she is slim. He dress appropriately and have no body odor. Parts Examined General
Appearance Methods Used Inspection Findings • Conscious, coherent, on bed hooked
with IVF D5LRS • With longitudinal abdominal incision covered with dry dressing. •
O2 tank for supplemental oxygenation. • Edema on feet and ankle and right hand
with 3+ pitting edema • Shortness of breath • With longitudinal abdominal incision
noted • Fingernails • Edema on the right hand with 3+ pitting edema
• Both feet and ankle with 3+

Interpretation Patient can ambulate.

Skin Respiratory System Abdomen

Inspection

Excessive accumulation of water Deviated from normal With intact dressing clean
and dry Dirty finger nails Abnormal Abnormal

Inspection Inspection

Extremities

Upper

Inspection

Lower

Inspection

pitting edema
V. ANATOMY AND PHYSIOLOGY of the GASTROINTERSTINAL SYSTEM Function of the
Digestive System The function of the digestive system is digestion and absorption.
Digestion is the breakdown of food into small molecules, which are then absorbed
into the body. The digestive system is divided into two major parts:
• The gastrointestinal (GI) tract (alimentary canal) is a continuous tube with two

openings, the mouth and the anus. It includes the mouth, pharynx, esophagus,
stomach, small intestine, and large intestine. Food passing through the internal
cavity, or lumen, of the GI tract does not technically enter the body until it is
absorbed through the walls of the GI tract and passes into blood or lymphatic
vessels.
• Accessory organs include the teeth and tongue, salivary glands, liver,
gallbladder,

and pancreas. The treatment of food in the digestive system involves the following
seven processes:
• Ingestion is the process of eating. • Propulsion is the movement of food along
the digestive tract. The major means of

propulsion is peristalsis, a series of alternating contractions and relaxations of

smooth muscle that lines the walls of the digestive organs and that forces food to
move forward.
• Secretion of digestive enzymes and other substances liquefies, adjusts the pH
of, and

chemically breaks down the food.

• Mechanical digestion is the process of physically breaking down food into
smaller

pieces. This process begins with the chewing of food and continues with the
muscular churning of the stomach. Additional churning occurs in the small
intestine through muscular constriction of the intestinal wall. This process,
called segmentation, is similar to peristalsis, except that the rhythmic timing of
the muscle constrictions forces the food backward and forward rather than forward
only.
• Chemical digestion is the process of chemically breaking down food into simpler

molecules. The process is carried out by enzymes in the stomach and small
intestines.
• Absorption is the movement of molecules (by passive diffusion or active
transport)

from the digestive tract to adjacent blood and lymphatic vessels. Absorption is
the entrance of the digested food into the body.
• Defecation is the process of eliminating undigested material through the anus.

Once food has been chewed and mixed with saliva in the mouth, it is swallowed and
passes down the esophagus. The esophagus has a stratified squamous epithelial
lining (SE) which protects the esophagus from trauma; the submucosa (SM) secretes
mucus from mucous glands (MG) which aid the passage of food down the esophagus.
The lumen of the esophagus is surrounded by layers of muscle (M)- voluntary in the
top third, progressing to involuntary in the bottom third- and food is propelled
into the stomach by waves of peristalisis. The stomach is a 'j'-shaped organ, with
two openings- the esophageal and the duodenal- and four regions- the cardia,
fundus, body and pylorus. Each region performs different functions; the fundus
collects digestive gases, the body secretes pepsinogen and hydrochloric acid, and
the pylorus is responsible for mucus, gastrin and pepsinogen secretion.
The stomach has five major functions;
• • • • •

Temporary food storage Control the rate at which food enters the duodenum Acid
secretion and antibacterial action Fluidisation of stomach contents Preliminary
digestion with pepsin, lipases etc

The small intestine is the site where most of the chemical and mechanical
digestion is carried out, and where virtually all of the absorption of useful
materials is carried out. The whole of the small intestine is lined with an
absorptive mucosal type, with certain modifications for each section. The
intestine also has a smooth muscle wall with two layers of muscle; rhythmical
contractions force products of digestion through the intestine (peristalisis).
There are three main sections to the small intestine; The duodenum forms a 'C'
shape around the head of the pancreas. Its main function is to neutralise the
acidic gastric contents (called 'chyme') and to initiate further digestion;
Brunner's glands in the submucosa secrete an alkaline mucus which neutralises the
chyme and protects the surface of the duodenum. • The jejunum • The ileum. The
jejunum and the ileum are the greatly coiled parts of the small intestine, and
together are about 4-6 metres long; the junction between the two sections is not
well-defined. The mucosa of these sections is highly folded (the folds are called
plicae), increasing the surface area available for absorption dramatically.
•

The pancreas consists mainly of exocrine glands that secrete enzymes to aid in the
digestion of food in the small intestine. the main enzymes produced are lipases,
peptidases and amylases for fats, proteins and carbohydrates respectively. These
are released into the duodenum via the duodenal ampulla, the same place that bile
from the liver drains into. Pancreatic exocrine secretion is hormonally regulated,
and the same hormone that encourages secretion (cholesystokinin) also encourages
discharge of the gall bladder's store of bile. As bile is essentially an
emulsifying agent, it makes fats water soluble and gives the pancreatic enzymes
lots of surface area to work on. structurally, the pancreas has four sections;
head, neck, body and tail; the tail stretches back to just in front of the spleen.
By the time digestive products reach the large intestine, almost all of the
nutritionally useful products have been removed. The large intestine removes water
from the remainder, passing semi-solid feces into the rectum to be expelled from
the body through the anus. The mucosa (M) is arranged into tightly-packed straight
tubular glands (G) which consist of cells specialized for water absorption and
mucus-secreting goblet cells to aid the passage of feces. The large intestine also
contains areas of lymphoid tissue (L); these can be found in the ileum too (called
Peyer's patches), and they provide local immunological protection of potential
weak-spots in the body's
defenses. As the gut is teeming with bacteria, reinforcement of the standard
surface defenses seems only sensible...
VI. PATHOPHYSIOLOGY - PPU RISK FACTORS PEPTIC UCER DISEASE H. pylori Infection,
Stress Habitual use of NSAID’s Cigarette Smoking Alcohol and Carbonated drinks
Consumption DUODENAL ULCER Infection
↑ Urease Production Alkalosis Neutralizati on of acidity ↑ Gastric Emptying ↓
Bicarbonat e ↑Serum Gastrin Levels ↑Acid Secretion ↑Pepsin H. pylori
Bile salts, aspirin, alcohol, GASTRIC ULCER ischemia Damaged mucosal barrier ↓
Function of mucosal cells ↓ Quality of mucus Loss of tight junctions between cells
Back diffusion of acid into gastric mucosa ↑ Pepsin ↑Acid secretion Further
mucosal Erosion Destruction of blood vessels Bleeding Local Vasodilation
↑capillary permeability Loss of plasma proteins Mucosal Edema Loss of plasma into
gastric lumen Stimulation of cholinergic intramural plexus, causing muscle spasms
↑Histamin e Release

Acid & Pepsin concentration in duodenum Penetration in the mucosal barrier Mucosal
injury

ULCERATI ON
ULCERATI ON

Stimulation of Nociceptors

Destruction of Blood Vessels

Stimulation of Nerve Fibers (A & C Fibers)

Bleeding

Transmission of Impulses to the Brain

Blood Clotting (Risk for thrombisis)

Perception of

PAIN

Intestinal Blockage
PATHOPHYSIOLOGY (PEPTIC ULCER) Peptic Ulcer disease is a break, or ulceration, in
the protective mucosal lining of the lower esophagus, stomach, or duodenum. The
predisposing factors related to PUD are as follows: • Smoking • Habitual use of
NSAID’s drugs • Infection of the gastric and duodenal mucosa with Helicobacter
pylori • Excessive consumption of alcohol and carbonated drinks There are two
types of Peptic Ulcer Disease, Duodenal Ulcer and Gastric Ulcer. The
pathophysiology of duodenal ulcer is most commonly caused by infection of H.
pylori and NSAID’s drugs habitual use. Hypersecretion of acid and pepsin is the
primary cause of duodenal ulcers, but inadequate secretion of bicarbonate by the
duodenal mucosa also may be a factor. Factors that contribute to ulcer formation
include the following: 1. NSAID’s inhibit prostaglandin and decrease mucus
production 2. H. pylori urease leads to ammonia formation, which is toxic to
mucosal cells 3. H. pylori phospholipases and other organism-produced enzymes
damage the mucosa 4. H. pylori infection stimulates gastrin production which
stimulates acid secretion and ulcer formation 5. Rapid gastric emptying occurs,
which overwhelms the buffering capacity of the bicarbonate-rich pancreatic
secretions 6. There are a greater than usual number of parietal cells (acid-
secreting cells) in the gastric mucosa 7. Cigarette smoking stimulates acid
production 8. Mucosal bicarbonate secretion decrease All these factors, singly or
in combination, cause acid and pepsin concentration in the duodenum to penetrate
the mucosal barrier and cause ulceration. On the other hand, the pathophysiology
of gastric ulcer is also commonly caused by the use of NSAID’s and H. pylori
infection. Generally, gastric ulcer develops in the antral region, adjacent to the
acid-secreting mucosa of the body. The primary defect is an abnormality that
increases the mucosal barrier’s permeability to hydrogen ions. Gastric secretion
may be normal or less than normal. Chronic gastritis is often associated with
development of gastric ulcer and may precipitate ulcer formation by limiting the
mucosa’s ability to secrete a protective layer of mucus. Other factors include the
following: 1. Decreased mucosal synthesis of prostaglandin 2. Duodenal reflux of
bile and pancreatic enzymes 3. Use of ulcerogenic drugs
An increased concentration of bile salts disrupts the gastric mucosa and may
decrease the electrical potential across the gastric mucosal membrane. The break
permits hydrogen ions to diffuse into the mucosa, where they disrupt permeability
and cellular structure. A various cycle can be established as the damaged mucosa
liberates histamine, which stimulates the increase of acid and pepsinogen
production, blood flow, and capillary permeability. The disrupted mucosa becomes
edematous and loses plasma proteins. Destruction of small vessels causes bleeding.
VII. DIAGNOSTIC PROCEDURE Diagnostic exam

 Complete Blood count The CBC is a very common test. Many patients will have
baseline CBC tests to help determine their general health status. If they are
healthy and they have cell populations that are within normal limits, then they
may not require another CBC until their health status changes or until their
doctor feels that it is necessary. The CBC test may be performed under many
different conditions and in the assessment of many different diseases. It is a
screening test used to diagnose and manage numerous diseases. The results can
reflect problems with fluid volume (such as dehydration) or loss of blood. The
test can reveal problems with red blood cell production and destruction, or help
diagnose infection, allergies, and problems with blood clotting.

Components RBC

Actual Value

Normal values Male: 4.7 to 6.1 million cells/mcL Female: 4.2 to 5.4 million
cells/mcL 4,500 to 10,000 cells/mcL Male: 40.7 to 50.3 % Female: 36.1 to 44.3 %
Male: 13.8 to 17.2 gm/dL Female: 12.1 to 15.1 gm/dL

WBC Hct

Hbg
MCV MCH MCHC

80 to 95 femtoliter 27 to 31 pg/cell 32 to 36 gm/dL

The complete blood count, or CBC, lists a number of many important values.
Typically, it includes the following:
• • • • • • • •

White blood cell count (WBC or leukocyte count) WBC differential count Red blood
cell count (RBC or erythrocyte count) Hematocrit (Hct) Hemoglobin (Hbg) Mean
corpuscular volume (MCV) Mean corpuscular hemoglobin (MCH) Mean corpuscular
hemoglobin concentration (MCHC)

Other diagnostic exam

 Gastroscopy: An examination of the inside of the stomach using a thin, lighted
tube

(called a gastroscope) passed through the mouth and esophagus.  Endoscopy : use
of instruments for visual examination of interior structures of the body; there
are rigid endoscopes and flexible fiberoptic endoscopes for various types of
viewing for disease diagnosis and treatment; involves passing an optical
instrument along either natural body pathways such as the digestive tract, or
through keyhole incisions to examine the interior parts of the body; with advances
in imaging, endoscopes, and miniaturization of endosurgical equipment, surgery can
be performed during endoscopy.
VIII. MEDICAL & SURGICAL MANAGEMENT Once the diagnosis is established, the patient
is informed that the condition can be controlled. The goals are to eradicate
H.pylori and to manage gastric acidity. Methods used include medications,
lifestyle changes, and surgical intervention.

MANAGEMENT A. Lifestyle Changes The goals of treatment are to eradicate H.pylori

and age gastric acidity.  Stress reduction and rest are priority interventions.
The patient needs to identify situations that are stressful or exhausting (rushed
lifestyle and irregular schedules) and implement changes, such as establishing
regular rest period during the day in the acute phase of the Biofeedback,
hypnosis, or behavioral modification may also be useful. Smoking cessation is
strongly encouraged because smoking raises duodenal acidity and significantly
inhibits ulcer repair. Support groups may be helpful. Dietary modification may be
helpful. Patients should eat whatever agrees with them; small, frequent meals are
not therapy. Oversecretion and hypermotility of the gastrointestinal tract can be
minimized by avoiding extremes of temperature and overstimulation by meat
extracts. Alcohol and caffeinated beverages such as coffee (including
decaffeinated coffee, which stimulates acid secretion) should be avoided. Diets
rich in milk and cream should be avoided also because they are potent acid
stimulators. The patient is encouraged to eat three regular meals a day.

 

B. Explorative Laparotomy LAPAROTOMY is a large incision made into the abdomen.

Exploratory laparotomy is used to visualize and examine the structures inside of
the abdominal cavity. Purpose Exploratory laparotomy is a method of abdominal
exploration, a diagnostic tool that allows physicians to examine the abdominal
organs. The procedure may be recommended for a patient who has abdominal pain of
unknown origin or who has sustained an injury to the abdomen. Injuries may occur
as a result of blunt trauma (e.g., road traffic accident) or penetrating trauma
(e.g., stab or gunshot wound). Because of the nature of the abdominal organs,
there is a high risk of infection if organs rupture or are perforated. In
addition, bleeding into the abdominal cavity is considered a medical emergency.
Exploratory laparotomy is used to determine the source of pain or the extent of
injury and perform repairs if needed.
Laparotomy may be performed to determine the cause of a patient's symptoms or to
establish the extent of a disease. For example, endometriosis is a disorder in
which cells from the inner lining of the uterus grow elsewhere in the body, most
commonly on the pelvic and abdominal organs. Endometrial growths, however, are
difficult to visualize using standard imaging techniques such as x ray, ultrasound
technology, or computed tomography (CT) scanning. Exploratory laparotomy may be
used to examine the abdominal and pelvic organs (such as the ovaries, fallopian
tubes, bladder, and rectum) for evidence of endometriosis. Any growths found may
then be removed. Exploratory laparotomy plays an important role in the staging of
certain cancers. Cancer staging is used to describe how far a cancer has spread. A
laparotomy enables a surgeon to directly examine the abdominal organs for evidence
of cancer and remove samples of tissue for further examination. When laparotomy is
used for this use, it is called staging laparotomy or pathological staging. Some
other conditions that may be discovered or investigated during exploratory
laparotomy include:
• • • • • • • • • • •

cancer of the abdominal organs peritonitis (inflammation of the peritoneum, the

lining of the abdominal cavity) appendicitis (inflammation of the appendix)
pancreatitis (inflammation of the pancreas) abscesses (a localized area of
infection) adhesions (bands of scar tissue that form after trauma or surgery)
diverticulitis (inflammation of sac-like structures in the walls of the
intestines) intestinal perforation ectopic pregnancy (pregnancy occurring outside
of the uterus) foreign bodies (e.g., a bullet in a gunshot victim) internal
bleeding

MEDICAL MANAGEMENT Administer prescribed medications. Medication may include

antacids, anticholinergic, histamine receptor antagonist, proton pump inhibitors,
and mucosal protective agents.

CLASSIFICATIONS

INDICATIONS

SELECTED INTERVENTIONS

ANTACIDS Aluminum hydroxide Calcium carbonate Dihydroxyaluminum sodium carbonate

Neutralize the hydrochloric acid secreted by the stomach

 Instruct the client to take 1 and 3 hours after meals and at bed time; instruct
him to avoid taking them with other medication  Instruct to chew antacids tablet
(not swallow them
Magaldrate Magnesium hydroxide ANTICHOLINERGICS Atropine sulfate Glycopyrrolate
Propantheline Scopolamine Inhibit the action of acetylcholine at cholinergic
receptor site, thereby decreasing gastric secretion

whole), and shake liquids before taking them  Advise the client that adverse
effects include drowsiness, and dry mouth  Encourage increased fluid intake 
Caution the client to avoid activity, such as driving, that require alertness and
concentration until the effects of the drug are known  Instruct the client to
continue taking the medication regularly, even after pain subsides  When
administering IV dilute the medication and monitor the client closely  Emphasize
the importance of adhering to all aspects of therapy  Instruct the client to take
the medication 30 – 60 minute before meals and at bed time  Advise the client to
take the medication 1 hour before or after taking an antacid  Tablet may be
difficult to chew; liquid preparation are available  Instruct the client to take
medication regularly as prescribed by the health care provider  Instruct the
client to avoid any product that may cause GI irritation  Administer IV
pantropazole with a filter

HISTAMINE RECEPTORS ANTAGONISTS Climitidine Famotidine Ranitidine

Block receptions that control the secretion of hydrochloric acid by the parietal
cells

MUCOSAL PROTECTIVE AGENTS Misoprostol Sucralfate

Protect the ulcer from destructive action of the digestive enzyme pepsin by
changing stomach acid into viscous materials that binds to protein in ulcerated
tissue

PROTON PUMP INHIBITOR Omeprazole Pantoprazole

Prevent the final transport of hydrogen into the gastric lumen by binding an
enzyme on gastric parietal cells
Medication for ulcer caused by H. pylori includes bismuth subsalicylate,
metronidazole, and tretracycline. This medication administered together eradicates
H. pylori bacteria in the gastric mucosa.

SURGICAL MANAGEMENT   With the advent of H2 receptor antagonists, surgical

intervention is less common. If recommended, surgery is usually for intractable
ulcers (particyullarly with Zollinger Ellison syndrome), life threatening
hemorrhage, perforation, or obstruction. Surgical procedures include vagotomy,
vagotomy with pyloroplasty, or Billroth I or II.
X. NURSING MANAGEMENT – NURSING CARE PLAN

NCP SUBMITTED BY: Dana P. Castro

NURSING CARE PLAN CUES SUBJECTIVE: “Madalas sumakit ang tyan ko mapakumain man ako
o hindi, sa sobrang sakit halos hindi ko mawari, walang oras kung ito’y
sumungpungin at tsaka ko ito iniinuman mefenamic acid o kaya naman linalagyan ko
ito ng mainit na tubig o kaya naman iinuman ko ito ng maligamgam na tubig at sa
kalaunan natatanggal naman, as verbalized by mang miguel. ♥Verbal or Coded report 
DU: pain occurs on empty stomach, 2-3 hours after meals or in middle of night 
GU: pain occurs 30mins-1 hour after meal OBJECTIVE: NURSING DIAGNOSIS Pain(acute)
related to the effect of increased gastric acid secretion leading to ulceration on
damaged tissue as manifested by the 7 parameters of pain. PLANNING Short term:
♥After 1530mins of nursing interventions, client will verbalized/ demonstrate
lessened sensation of pain Long term: ♥After 13days of nursing interventions,
client will prevent the reoccurrence of pain. NURSING INTERVENTION Independent:
♥Perform a comprehensive assessment of pain to include location, characteristics,
onset/duration, frequency, quality, severity (0 to 10 or faces scale), and
precipitating/ aggravating factors RATIONALE ♥Obtain a baseline data and determine
or rule out worsening of underlying condition/ development of complications

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EVALUATION ♥The client will report improvement/ lessened sensation of pain as

evidenced by (-)facial grimace, (-)irritability, feeling of comfort and stable vs

♥Relaxation of muscles decreases ♥The client peristalsis and prevented the

decreases gastric pain reoccurrence of pain as evidenced by improvement of
lifestyle, modification of diet and effective treatment regimen leading to healing
of gastric or mucosal ♥The relationship injury between stress and peptic ulcer
disease ♥Teach diversional techniques is based on the higher incidence of peptic
for stress reduction and pain ulcers in those with relief such as deep breathing
exercises, watching tv, listening chronic anxiety to mellow music ♥Encourage
activities that promote rest and relaxation avoidance of strenuous physical
activity arrange the environment, such as, dimly & quiet environment massage
the abdominal area
♥Pain Characteristics -Location: near the midline in the epigastrium near the
xiphoid -Onset: DU- 2-3hr after meals or in the middle of the night GU- 30mins-1hr
after meals -Duration: DU- varying depending on the immediate management of
pain(ingestion of food relieves pain) GU- varying depending on the immediate
management of pain (may be relieved by vomiting) -Description: burning, gnawing or
cramplike -Quality: moderate or depending on the severity of the ulceration
-Frequency: intermittent ♥Place client in a supine or semi-fowlers position
♥Explain the relationship between hydrochloric acid secretion and onset of pain

♥Promote relaxation of the abdominal muscle ♥Hydrochloric acid (HCl) presumably is

an important variable in the appearance of peptic ulcer disease, control of HCl
secretion is considered an essential aim of treatment ♥NSAIDS cause superficial
irritation of the gastric mucosa and inhibit the production of prostaglandins that
protect gastric mucosa ♥Avoidance of irritating substances can help to prevent the
pain response ♥Gastric acid secretion may be stimulated by
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♥Explain the risks of nonsteroidal anti-inflammatory drugs (NSAIDS) (e.g. Motrin,

Aleve, Advil)

♥Help the client to identify irritating Substances (e.g., fried foods, spicy
foods, coffee, milk, cola) (stimulates acid secretion) ♥Encourage the client to
avoid intake of caffeine-containing and alcohol beverages
♥Pain Scale 7/10 ♥Expressive Behavior: irritability discomfort restlessness
♥Pyrosis (heartburn) ♥Encourage the client to avoid smoking

caffeine ingestion. Alcohol can cause gastritis ♥Smoking decreases pancreatic

secretion of bicarbonate; this increases duodenal acidity. Tobacco delays the
healing of gastric duodenal ulcers and increases their frequency ♥Contrary to
popular belief, certain dietary restrictions do not reduce hyperacidity. In
individual intolerances first must be identified and used as a basis for
restrictions. Avoidance of eating prior to bedtime may reduce nocturnal acid
levels by eliminating the postprandial stimulus to acid secretion. During the day,
regular amounts of food particles in the stomach help to

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♥Advise the client to eat regularly and to avoid bedtime snacks

neutralize the acidity of gastric secretions Dependent: ♥Administer antacids,
anticholinergics, sucralfate, and H2 blockers as directed Collaborative: ♥Work
with the dietician to learn the modification of diet often requires a bland,
nonirritating, low- fiber diet
NURSING CARE PLAN By: Kim Benjamin C. Antalan
CUES

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

PAIN Subject: – “di pa ako maka-galaw masyado kasi masakit pa tong tahi ko, medyo
hirap tuloy akong magkikilos” as verbalized by Mang Miguel. reduce interaction
with people beaten look Sighing

- pain related to the surgical procedures done

Short term: After 1530mins of nursing interventions,

Mang Miguel will be able to report that pain is relieved/ controlled. Mang Miguel
will be able to demonstrate use of relaxation skills and diversion activities

Obj. – – –

Independent: Perform a comprehensive assessment of pain including the

characteristics, location, duration, frequency, severity (0 to 10 or pain scale),
and the aggravating factors
-monitor vital sign of the patient -provide non-pharmacology pain management like:
• • • Patient positioning Back rub Heat and cold application

- to obtain a baseline data and to establish

-the patient will be able to state that pain is relieve/controlled -the patient
able to demonstrate use of relaxation kills and activities - The client will state
the

or to exclude inferior underlying condition/ development of complications -vital

signs are very important to assess if the patient is experiencing pain

enhancement/ reducing sensation of pain as evidenced by (-)frowning,

(-)irritability, feeling of comfort and stable vital signs

Long term: After 1-3days of nursing intervention

After nursing interventions, Mang Miguel will be able to state that pain is
tolerable/reliev ed.

-encourage adequate rest period • Taking a nap

-provide pharmacology pain management (as doctor’s order)

Explain the risks of nonsteroidal

- NSAIDS cause superficial irritation of the gastric mucosa and inhibit the