Professional Documents
Culture Documents
Case Study PUD
Case Study PUD
Disease
PUD
Nursingcasestudy.blogspot.com
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I. INTRODUCTION
individuals in the United States each year. PUD has a major impact on our health
care system by accounting for roughly 10% of medical costs for digestive
diseases. In the last two decades, major advances have been made in the
This has led to important changes in diagnostic and treatment strategies, with the
potential for improving the clinical outcome and for decreasing health care costs.
Peptic ulcers are defects in the gastric or duodenal mucosa that extend
through the muscularis mucosa. H pylori infection and NSAID use are the most
common etiologic factors. Other less common causes are hypersecretory states,
basophilic leukemias.
secretion and gastroduodenal mucosal defense. Mucosal injury and, thus, peptic
ulcer occur when the balance between the aggressive factors and the defensive
bile salts, acid, and pepsin, can alter the mucosal defense by allowing back
diffusion of hydrogen ions and subsequent epithelial cell injury. The defensive
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II. GENERAL DATA
Name : D.D.C.
Sex : Male
Citizenship : Filipino
Religion : Christian
Status : Married
Height : 168 cm
Occupation : none
Weight : 80 kg
Occupation : Supervisor
Name of Spouse : T. R. C.
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III.HISTORY OF PRESENT ILLNESS
Patient has been having on and off epigastric pain for about a year which
was not associated with food intake. Patient took esomeprazole (Nexium) as
loss of appetite, diarrhea and a feeling of fullness in upper abdomen after eating.
He then sought consult with a private medical doctor and was advised
gastroscopy.
fever, her mother wiped her whole body to relieve the heat. He sometimes had
headache and diarrhea but he will just take a medicine for it. At the age of ten, he
had felt pain at his epigastric area and his parents brought him to the hospital for
any allergies to foods or drugs. In the year 1979, he was hospitalized due to
hypertensive.
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V. GORDON’S HEALTH PATTERN
The patient usually described his health as good but at this time,
The patient usually eats rice, egg and other processed foods during
breakfast; rice, meat and some vegetables for lunch; and, for suppertime, he eats
rice and fish. His usual fluid intake is water then sometimes, soft drinks as well,
every morning, before going at work he drinks coffee. He has no problem with his
appetite and ability to eat before he got sick. He prefers to eat fatty foods though
spicy foods.
Elimination Pattern
The patient does not have any problem with his urination and defecation.
He defecates every other day usually in the afternoon. His stools vary depending
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Activity - Exercise Pattern
shows, listening to the radio, and playing basketball with his friends. Walking
time is 5 am. He usually gains 6-7 hours of sleep excluding naptime. He takes an
The patient was conscious, responsive and coherent. He can see clearly
with an aid of an eyeglass. He can hear clearly and his other senses are
functioning well. He knows how to read and write. He was well oriented of the
The patient was concerned about his condition. His present health goals
are simply to be cooperative and being obedient to what his doctor advised him
to do concerning his health condition. Being ill does not made him feel different
about himself.
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Role- Relationship Pattern
The patient lives with his family. He can easily express himself and can
understand others as well through writing, gestures and verbal. He usually asks
help to his wife whenever he has problem and sometimes to his friends too. He is
the one who disciplines his children. In terms of making decisions, he and his
wife will have to decide for it. He has a good relationship and bonding with his
family.
always makes decisions together with his wife. If he were stress, he would just
find ways to make himself enjoy like watching television shows and bonding with
The patient’s source of strength is his family and God. For him, God is
very important to his life. He prays every day, visits churches and hears masses
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VI.FAMILY, PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY
approachable. He might look silent but he said he is talkative. During his high
school years, he loves to be with his friends and go out for gimmicks. He may
look strict but deep inside he is friendly, kind and easy to get along with other
people. He works hard especially when he became a father and a husband to his
wife. He spends his free time in watching television shows, listening to radio and
be playing basketball with his friends. He eats three times a day excluding
snacks but sometime his eating time is late because he does not want to leave
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what he is working. He usually sleeps at between 10 pm to 11 pm. His rising time
is 5 am. Whenever he had problem, he will ask for help to his wife and friends.
He does not do any exercise. He is religious and attends masses every Sunday.
C. ENVIRONMENTAL HISTORY
Patient and her family own a house at Pasar Isabel, Leyte. They live in
that silent and peaceful place for almost five years. He said that they are fine and
comfortable with their house and its place. Whenever they want to have fun, they
will just go to the leisure center near their house. In addition, there is church and
a swimming pool near the place. The space of their house is just enough for
them. They have their own comfort room, water and electrical supply. Their
Pasar Isabel, Leyte was admitted due to on and off epigastric pain at Chong Hua
Hospital. Patient was seen lying awake on bed, conscious, coherent, not in
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Vital Signs taken during the first contact with the patient:
Temperature : 36.2 0C
Skin: brown in color; has lesions on lower extremities; warm and dry; skin turgor
Hair: straight; black in color; not extremely oily; evenly distributed; negative for
lice
proportion to body
Eyes: eyelids appear symmetrical with no drooping; eyelashes are black in color
and well curved; lacrimal apparatus has no discharges upon palpation and
no pain felt; pupils are equally round and reactive to light and
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accommodation with a size of 3mm; has pink palpebral conjunctiva; with
anecteric sclerae
Ears: symmetrical and at level of eyes outer cantus; brown in color; smooth; can
discharges; airways are patent and free from obstructions; sinuses are
negative for congestion and no pain felt upon palpation; nasal mucosa is
certain microorganisms
Mouth: teeth are incomplete, with upper and lower dentures, slightly yellow in
color with no indication of any tooth decay or other tooth related problems;
the midline of the mouth, moves freely; lips are dark in color, close
Neck: patient was able to hold the neck erect at midline with symmetrical
thyroid glands; lymph nodes are not inflamed; no masses of any type were
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Chest: no lesions noted; equal chest expansion and registers a clear breath
sounds upon auscultation; respiratory rate is 18 cycles per minute from the
Heart: with normal heart sounds; has a regular rhythm with 66 beats per minute
from the normal rate of 60-100 beats per minute; no visible pulsations
Breasts: flat; have smooth contour; no redness; no dimpling; lymph nodes are not
noted
Abdomen: flabby, with normoactive bowel sounds, soft, with 3 bowel sound per
warm to touch;
Upper Extremities: equally grip; low strength; warm to touch; good skin turgor;
both hands have five fingers; nails are short slightly pinkish
Lower Extremities: equal strength; negative for edema formation; lesions are
noted; nails are clean and short; warm to touch; good skin turgor
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VIII.DEVELOPMENTAL DATA
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STAGE DEVELOPMENTAL PATIENT’S BEHAVIOR &
TASK DEVELOPMENTAL EXPLANATION
karga.”
Salivary Glands
Three pairs of salivary glands communicate with the oral cavity. Each is a
complex gland with numerous acini lined by secretory epithelium. The acini
secrete their contents into specialized ducts. Each gland is divided into smaller
The parotid glands are large, irregular shaped glands located under the
skin on the side of the face. They secrete 25% of saliva. The parotids produce a
watery secretion which is also rich in proteins. Immunoglobins are secreted help
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carbohydrates.
The submandibular glands secrete 70% of the saliva in the mouth. They
are found in the floor of the mouth, in a groove along the inner surface of the
mandible. These glands produce a more viscid (thick) secretion, rich in mucin
lubricant.
The sublinguals are the smallest salivary glands, covered by a thin layer
of tissue at the floor of the mouth. They produce approximately 5% of the saliva
and their secretions are very sticky due to the large concentration of mucin. The
Pharynx
The pharynx or throat is a tubular structure that extends from the base of
the skull to the esophagus and is situated immediately in front of the cervical
vertebrae. It serves as a passageway for the respiratory and digestive tracts and
Tongue
It is the principal organ of the sense of taste that also assist in the
Esophagus
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The esophagus is a muscular tube of approximately 25cm in length and
2cm in diameter. It extends from the pharynx to the stomach after passing
Stomach
The stomach is a J shaped expanded bag, located just left of the midline
between the esophagus and small intestine. It is divided into four main regions
and has two borders called the greater and lesser curvatures. The first section is
the cardia which surrounds the cardial orifice where the esophagus enters the
stomach. The fundus is the superior, dilated portion of the stomach that has
contact with the left dome of the diaphragm. The body is the largest section
This is where most gastric glands are located and where most mixing of
the food occurs. Finally the pylorus is the curved base of the stomach. Gastric
contents are expelled into the proximal duodenum via the pyloric sphincter. The
inner surface of the stomach is contracted into numerous longitudinal folds called
rugae. These allow the stomach to stretch and expand when food enters. The
stomach can hold up to 1.5 litres of material. The functions of the stomach
include:
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• Chemical digestion of proteins by acids and enzymes.
gastric glands in the body and fundus. Some cells are responsible for secreting
Small Intestine
The small intestine is the longest part of the digestive tract, extending for
about 7m from the pylorus of the stomach to the ileocecal junction. It is divided
into the duodenum, jejunum, and ileum. It functions in digestion and is the major
Large Intestine
The large intestine is horse-shoe shaped and extends around the small
descending and sigmoid colon, and the rectum. It has a length of approximately
1.5m and a width of 7.5cm. The cecum is the expanded pouch that receives
material from the ileum and starts to compress food products into fecal material.
Food then travels along the colon. The wall of the colon is made up of several
pouches (haustra) that are held under tension by three thick bands of muscle
(taenia coli).
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The rectum is the final 15cm of the large intestine. It expands to hold fecal
matter before it passes through the anorectal canal to the anus. Thick bands of
muscle, known as sphincters, control the passage of feces. The mucosa of the
large intestine lacks villi seen in the small intestine. The mucosal surface is flat
with several deep intestinal glands. Numerous goblet cells line the glands that
secrete mucous to lubricate fecal matter as it solidifies. The functions of the large
• Some digestion by bacteria. The bacteria are responsible for the formation
of intestinal gas.
Liver
four lobes namely the right, left, caudate and quadrate lobes. The liver has
travels from the intestinal system. It detoxifies several metabolites including the
breakdown of bilirubin and estrogen. In addition, the liver has synthetic functions,
producing albumin and blood clotting factors. However, its main roles in digestion
are in the production of bile and metabolism of nutrients. All nutrients absorbed
by the intestines pass through the liver and are processed before traveling to the
rest of the body. The bile produced by cells of the liver, enters the intestines at
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the duodenum. Here, bile salts break down lipids into smaller particles so there is
Gall Bladder
the posterior surface of the liver's right lobe. The main functions of the gall
Pancreas
The pancreas is a lobular, pinkish-grey organ that lies behind the stomach.
Its head communicates with the duodenum and its tail extends to the spleen. The
organ is approximately 15cm in length with a long, slender body connecting the
head and tail segments. It is made up of numerous acini (small glands) that
secrete contents into ducts which eventually lead to the duodenum. It secretes
fluid rich in carbohydrates and inactive enzymes. It has both exocrine and
endocrine functions.
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B. CONCEPTUAL FRAMEWORK OF THE PATHOPHYSIOLOGY OF ACID
PEPTIC DISEASE
The stomach's lining has a protective layer of cells that produce mucus.
The mucus prevents the stomach from being injured by stomach acids and
digestive juices. When this protective layer is damaged, it cannot secrete enough
mucus to act as a barrier against HCl, thus an ulcer may occur. Peptic ulcers
occur mainly in the gastroduodenal mucosa because this tissue cannot withstand
the digestive action of gastric acid (HCl) and pepsin. Normally, when the mucosa
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is damaged, the defensive forces will respond.
Helicobacter pylori (H. pylori), the most common cause of stomach ulcers;
decreased resistance of the lining of the stomach to stomach acid and increased
Stomach ulcers are more likely to occur in people who: regularly take
substances that increase the production of stomach acids, such as caffeine, may
increase the risk of ulcers and are known to worsen the pain.
gastric mucosal blood flow and to reflux of duodenal contents into the stomach.
D. SYMPTOMATOLOGY
• Loss of appetite.
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• Loss of appetite Belching: Belching either does not relieve the pain or
• Nausea and vomiting: The vomit may be clear, green or yellow, blood-
inflammation.
• Constipation or diarrhea
• Loss of appetite
• Diarrhea
• Bloating
X. MEDICAL MANAGEMENT
condition.
• Administering medications
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• Intravenous therapy
B. MEDICATIONS
• Lifezar 50 mg PO OD
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C. DIAGNOSTIC PROCEDURES
• Upper GI endoscopy
02-24-09
• Tissue report
02-24-09
Diagnosis
Gross description
4x4x2mm. (ALL)
Microscopic description:
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congestion. No cryptitis is observed. Few H. pylori like organisms
D.DIET
The physician advised the patient to take full, low sodium, low fat, low
purine diet. It is to prevent continually high blood pressure. And so it would not
exacerbate condition.
As the patient was admitted to Chong Hua Hospital, care was given in
order for the patient to be relieved from the present condition. Nursing care was
given which includes the following: assessment of patient’s health status, taking
of Vital Signs for the baseline data of the patient, intake and output of the patient
was monitored, measured and recorded on the patient’s chart, checking patient’s
intravenous fluid and regulated at prescribed rate. Giving medications were done
sleep.
quality nursing care. The patient was very obliging as well as cooperative and
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was very aware of his health needs and status. I was able to perform the needed
Restorative measures were done and performed for it is very important for
the patient to recover from the discomforts and aggravating factors from his
and stable blood circulation throughout the system. He was advice to take
D. EVALUATION
The evaluation of care depends on the effort exerted both by the nurse
components in order to know if the nursing care given was effective or not. As
the patient was discharged from the health care facility, the patient was under
normal condition and reports absence of any discomfort. Vital signs were stable.
E. PATIENT TEACHING
him the importance of having adequate rest, avoiding stress and having lifestyle
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the benefits he could get out from quitting smoking and the reasons why he
needs to do it. I encouraged him not to forget the medications prescribed by the
physician. I also taught him on what kind of food that he needs to be avoided,
which includes the salty, spicy and acidic food, because these can stimulate acid
secretion.
XII. A. CONCLUSION
assessed of what he feels especially if there is pain. As we all know pain is very
teachings in order for him to avoid those factors that may worsen his condition.
After caring for my patient, I realized that nurses are very much important.
Unlike other medical personnel, nurses are able to get close to patient which is
important for patient to feel that there is someone who is willing to help them at
times they are sick. Patients usually keep what they feel inside. Having a nurse,
help patients to verbalize their feelings about the situation they are in right now.
This is like hitting two birds in one stone, not only will the patient feel relieved but
also this will give the nurse an idea what he/she must can do to provide care to
the patient.
B. RECOMMENDATION
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good nurse: knowledge, skills, and attitude. These will help us to become
effective and efficient nurses who know how to deal with patients of different
disease conditions in different situations. A lack of even one of these will be very
difficult to a nurse, and it is expected that he/she will not be able to provide the
voice out their concerns and ask if they are curious and/or unsure about doing
procedures for them not to commit mistakes. Besides, there is nothing wrong in
asking. Not asking will only endanger your patient and yourself.
A. NURSING EDUCATION
this case study to nursing education is to broaden, upgrade, and maximize the
knowledge and skills of the nurses (especially the student nurses) in terms of
challenge to nurses and to the other health care team members. Changes and
evolution of care concerning this kind of disease was brought about by the rapid
knowing about acid peptic disease will help us know what we should do and what
attitude we should make in dealing with clients having this kind of disease, since
giving optimal care is one of our goals as nurses. We are dealing with lives, so
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every action we make is very vital to our patient; therefore making mistakes can
put our patient in grave danger. So to avoid making mistakes, it is good to have
things that we already did; same as “We cannot bring back the dead to life.”
Moreover, when reading this case study, this will help you not only become
B. NURSING PRACTICE
utilization of nursing concepts, which includes nursing care plan, nursing process
etc. This is important in nursing practice because in this stage where nursing
patient and also to broaden the concept of the student nurse in rendering care. In
this way, the student nurse will be able to prioritize his or her focus of care and
apply the principles in the clinical setting, which he or she learns. Nursing is
Prioritizing care, which learned, developed and evolved in this phase. The ever-
changing role of the nurses in terms of giving care plays an important role in
caring for the sick. Its role is to broaden the knowledge of the people in terms of
good health to patients. As a conclusion, the student nurses can emphasize their
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skills in terms of giving care. The important is to serve and give care even in the
evolution of trends and technology of new care settings and the changes and
C. NURSING RESEARCH
Every day, illnesses and disease conditions continue to evolve to the next
level. And same can be said to interventions and medications to treat these
the facts of the previous disease conditions are used as basis. And so I consider
this case study as an important part of this research. I believe that this case
study will help researchers discover something that will not only treat a disease
but more importantly on how to prevent acquiring diseases. This case study is
important for us to know more about acid peptic disease and how to deal with it.
Therefore, we must be open minded to whether old or new trends about things
because this trends will always help us. Who knows, we might be able to
discover something new that will be of great help in the future just by giving time
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