Teaching on peptic

Submitted by, Mrs Bibi Baby 2 nd year MSc Nursing Medical Surgical Nursing PION.

practice

ulcer

Submitted to, Mrs. Prasanna Balaji HOD of Medical Surgical Nursing PION.

Peptic ulcer

Introduction Ulcers develop when digestive juices produced in the stomach, intestines, and digestive glands damage the lining of the stomach or duodenum. The word "peptic" comes
from the Latin word pepticus, meaning "to digest". The word "ulcer" comes from the Latin word ulcus , meaning "a sore, a wound, an ulcer".

Definition
A peptic ulcer is a hole in the lining of the stomach, duodenum, or esophagus. An ulcer is a sore or erosion that forms when the lining of the digestive system is corroded by acidic digestive juices.

Peptic ulcer is a erosion of gastro- intestinal mucosa resulting from the digestive action of hydrochloric acid and pepsin.
Peptic ulcers that occur on the inside of the stomach are called gastric ulcers. Peptic ulcers that occur inside the hollow tube (esophagus) where food travels from your throat to stomach are called esophageal ulcers. Peptic ulcers that affect the inside of the upper portion of small intestine (duodenum) are called duodenal ulcers.

Incidence
It is estimated that between 5% and 10% of adults globally are affected by peptic ulcers at least once in their lifetimes.

Etiology

Helicobacter pylori- bacterial infection . Over 25% of people in Western Europe and North America carry H pylori. The bacterium spreads through food and water. As it is present in human saliva it can spread through mouth-to-mouth contact, such as kissing. It lives in the mucus that coats the lining of the stomach and duodenum and produces urease, an enzyme that neutralizes stomach acid by

making it less acidic. To compensate for this the stomach makes more acid, which irritates the stomach lining. H pylori also weakens the defense system of the stomach and causes inflammation. Patients with peptic ulcers caused by H pylori need treatment to get rid of the bacterium from the stomach to prevent recurrences.

NSAIDs (non-steroidal anti-inflammatory drugs) These are medications for headaches, period pains, and other minor pains. Examples include aspirin and ibuprofen. Many NSAIDs are over the counter medications, while others, such as diclofenac, naproxen and meloxicam can only be acquired with a doctor's prescription. Non-steroidal anti-inflammatory drugs lower the stomach's ability to make a protective layer of mucus, making it more susceptible to damage by stomach acids. NSAIDs can also affect the flow of blood to the stomach, undermining the body's ability to repair cells. Genetics - a significant number of individuals with peptic ulcers have close relatives with the same problem, suggesting that genetic factors may also be involved. Smoking - people who regularly smoke tobacco are more likely to develop peptic ulcers compared to non-smokers. Alcohol consumption - regular heavy drinkers of alcohol have a higher risk of developing peptic ulcers. Mental stress - mental stress has not been linked to the development of new peptic ulcers. However, people with ulcers who experience sustained mental stress tend to have worse symptoms. Blood type- for unknown reasons, gastric ulcers commonly strike people with type A blood. Duodenal ulcers tend to afflict people with type O blood. Normal ageing- The pyloric sphincter may wear down in the course of aging , which permits the reflux of bile into stomach thus leads to development of gastric ulcers in older people.

Pathophysiology

Due to causative factors Damage to mucosal barrier Imbalance of aggressive and defensive factor Low function of mucosal cells, low quality of mucous, less of tight junction between cells Infection gives increased gastrin and decreased somatostatin production. Erosive gastritis, inflammation ,decreased acid and intrinsic factors. Mucousal ulceration possible bleeding. A damage mucosa could not secrete enough mucus to act as a barrier against gastric acid. Severe ulcerations- epigastric pain, hematemesis, dyspepsia.

Clinical manifestation
The most common signs or symptoms of peptic ulcers are: 1. Indigestion-like pain. The pain can..

be felt anywhere from the belly button to the breast bone last from a couple of minutes to a number of hours be more severe when the stomach is empty be worse during the night (during sleeping hours) be temporarily relieved after eating certain foods
go away and return for a few days or weeks 2. Difficulty getting food down (swallowing it) 3. Food that is eaten regurgitates (comes back up) 4. Retching after eating 5. Feeling unwell after eating

6. Weight loss 7. Loss of appetite Ulcers can cause severe signs and symptoms, such as (much less common): 8. Vomiting blood 9. Black and tarry stools, or stools with dark blood 10. Nausea and vomiting

Diagnosis
1.

Blood test - a blood test can determine whether H pylori bacteria are present. However, a blood test cannot determine whether the patient had past exposure or is currently infected. Also, if the individual has been taking antibiotics or proton pump inhibitors a blood test can give a false-negative result.

2.

Breath test - a radioactive carbon atom is used to detect H pylori. The patient drinks a glass of clear liquid containing radioactive carbon as part of a substance (urea) that the H pylori will break down. An hour later the patient blows into a bag which is subsequently sealed. If the patient is infected with H pylori the breath sample will contain radioactive carbon in carbon dioxide. The breath test is also useful in checking to see how effective treatment has been in eliminating H pylori.

3.

Esophago gastroduodenoscopy physician take the tissue specimens and treat the ulcer with either heat probe therapy or multipolar electro coagulation. Stool antigen test - this test determines whether H pylori is present in the feces (stools). This test is also useful in determining how effective treatment has been in getting rid of the bacteria.

4.

5.

Upper gastrointestinal X-ray (upper GI X-ray) - the test outlines the esophagus, stomach and duodenum. The patient swallows a liquid which contains barium. The barium coats the digestive tract and shows up on the X-ray, making the ulcer easier to see. Upper GI X-rays are only useful in detecting some ulcers.

6.

Endoscopy - a long-narrow tube with a camera attached to the end is threaded down the patient's throat and esophagus into the stomach and duodenum. The doctor can see the

upper digestive tract on a monitor and identify an ulcer if one is present. Endoscopies are also performed if the patient has other signs or symptoms, such as weight loss, vomiting (especially if blood is present), black stools, anemia, and swallowing difficulties. If an ulcer is detected the doctor may take a biopsy - a small sample of tissue is taken near the ulcer. The sample is examined under a microscope to rule out cancer. A biopsy can also be used to test for the presence of H pylori. Sometimes another endoscopy is performed a few months later to determine whether the ulcer is healing.

Medical management
Treatments for peptic ulcer can include:
1.

Antibiotic medications to kill H. pylori. If H. pylori is found in your digestive tract, your doctor may recommend a combination of antibiotics to kill the bacterium. Antibiotic include amoxicillin, clarithromycin (Biaxin), metronidazole (Flagyl) and tetracycline. Antibiotic to be taken for two weeks.

2.

Medications that block acid production and promote healing. Proton pump inhibitors reduce acid by blocking the action of the parts of cells that produce acid. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix). Long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip, wrist and spine fracture, calcium supplement may reduce this risk.

3.

Medications to reduce acid production. Acid blockers also called histamine (H-2) blockers reduce the amount of acid released into digestive tract, which relieves ulcer pain and encourages healing. Available by prescription or over-the-counter (OTC), acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid).

4.

Antacids that neutralize stomach acid. Antacids neutralize existing stomach acid and can provide rapid pain relief. Side effects can include constipation or diarrhea, depending on the main ingredients.

5.

Medications that protect the lining of your stomach and small intestine. Cytoprotective agents that help protect the tissues that line your stomach and small intestine. They include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Adequate rest- benefits the patient to elimination of stressors, help to decrease the

6.

stimulus for over production of HCL acid.

7.

Dietary modification-it may be necessary so that foods and beverages irritating to

the patient can be avoided or eliminated(alcohol and caffeine contents). A bland diet consisting of six small meals may be suggested.
8.

Avoid smoking- smoking has an irritating effect on the mucosa, increases gastric

motility, and delays mucosal healing . so, it should be eliminated. Surgical management 1. Partial gastrectomy- with removal of the distal two thirds of the stomach and anstomosis of the gastric stump to the duodenum is called gastroduodenostomy or billroths operation. Partial gastrectomy with removal of the distal two- third of the stomach and anastomosis of the gastric stump to the jejunum is called gastrojejunostomy or Billroths II operation. In both procedures the antrum and pylorus are removed, because the duodenum is by passed. The Billrooths II is preferred to prevent recurrence of duodenal ulcers.

2. Vagotomy -In truncal vagotomy the nerve is served bilaterally in both the anterior and the posterior trunk. Selective vagotomy consists of cutting the nerve at a particular branch of vagus nerve. 3. Pyloroplasty - It consists of surgical enlargement of the sphincter to facilitate the easy passage of contents from the stomach. It is most commonly done after vagotomy. Complications
The risk of complications is much greater if the ulcer is left untreated, or if treatment was not completed.

Internal bleeding - slow blood loss can lead to anemia, while severe blood loss requires hospitalization and blood transfusions.

Infection - a peptic ulcer can bore a hole through the wall of the stomach or small intestine, significantly increasing the risk of infection in the abdominal cavity peritonitis.

Scar tissue - scar tissue caused by peptic ulcers can obstruct the passage of food through the digestive tract, making the patient feel full more easily. Scarring may also cause vomiting and weight loss.

Pyloric stenosis - chronic inflammation in the lining of the stomach or duodenum caused by a peptic ulcer can result in a narrowing of the pylorus (small passage that links the stomach and the duodenum). Pyloric stenosis is the narrowing of the pylorus. Food will not pass through to the intestines, causing vomiting and weight loss.

Dumping syndrome- it is the term used for a group of unpleasant vasomotor and gastrointestinal system that occurs after surgery. The onset of symptoms occurs at the end of a meals or within 15 to 30 minutes after eating. The patient usually describes feeling of generalized weakness, sweating, palpitation and dizziness.

Post prandial hypoglycemia- it is considered a variant of the dumping syndrome, since it is the result of uncontrolled gastric emptyingof a bolus of fluid high in carbohydrate into the small intestine . the bolus of fluid concentrated, carbohydrateresults in hypoglycemia and the release of excessive amount of insulin into circulation.The

symptoms experienced are swelling , weakness, mental confusion, palpitations, tachycardia and anxiety.

Bile reflux gastritis-Bile reflux gastritis occurs when surgery that involves the pylorus.
Prolongued contact with bile damage, the gastric mucosa may cause bile reflex gastritis. The symptoms associated with epigastric distress that increases after meals, vomiting.

Nursing management 1. Teach the patient about peptic ulcer disease and help to recognize its signs and symptoms. Explain scheduled diagnostic tests and ordered therapies. 2. Emphasize the importance of complying with treatment, even after symptoms disappear. 3. Review the proper use of prescribed drugs, discussing the desired actions and possible adverse effects of each drug. 4. Tell the patient to take antacids 1 hour after meals. If the patient is a cardiac patient. 5. Warn the patient to avoid aspirin containing drugs. 6. Encourage the patient to make lifestyle changes. 7. Explain that emotional tension can participate on ulcer attack and prolongue healing. Help the patient to identify anxiety producing situations and teach him to perform relaxation techniques such as meditation. 8. If the patient smokes urge him to stop smoking because smoking stimulates gastric acid secretion. Refer the patient to smoking cessation program.

Nursing diagnosis 1. Acute pain related to exacerbation of disease process and inadequate comfort measures. 2. Vomiting related to acute exacerbation of disease process. 3. Imbalanced nutrition less than body requirement related to adverse GI effects. 4. Risk for fluid volume deficit related to bleeding. 5. Knowledge deficit related to therapeutic management and lifestyle changes. Bibliography 1) Suzanne C, Brend G. Medical surgical nursing. 10th edition. Philadelphia: Lippincott William & Wilkins; 2004 . 2) Lewis, Heitkemper, Dirksen, OBrien, Bucher. Medical surgical nursing. 7th edition. Missouri: Elsevier; 2008. 3) Ignatavicius D, Workman L, Mishler A. Medical surgical nursing. 2nd edition. Philadelphia: W.B Saunders company; 2000. 4) Doenges E, Moorhouse F, Murr C. Nursing care plans. 7th edition. New delhi: Jaypee Brothers; 2007.

Teaching practice on Haemmorhoids

Submitted by, Mrs Bibi Baby 2 nd year MSc Nursing Medical Surgical Nursing PION.

Submitted to,

Mrs. Prasanna Balaji HOD of Medical Surgical Nursing PION.

HAEMMORHOIDS
Introduction The major function of the rectum is to store feces until evacuation. When feces enter the rectum, peristalsis occurs. Many disorders in the rectal area result from constipation or failure to empty the rectum when peristalsis occurs. At the mucocutaneous junction border of the anal canal, the mucous membrane changes to skin that has cutaneous somatic nerve endings. Because of this anatomic structure, lesions of the external anal canal are very painful. The two most common manifestations are bleeding and pain, drainage of mucus and fecal matter and irritation of the skin by organisms can cause intense itching. Definition A precise definition of hemorrhoids does not exist, but they can be described as masses or clumps ("cushions") of tissue within the anal canal that contain blood vessels and the surrounding, supporting tissue made up of muscle and elastic fibers.
Hemorrhoids are swollen and inflamed veins around the anus or in the lower rectum. The rectum is the last part of the large intestine leading to the anus. The anus is the opening at the end of the digestive tract where bowel contents leave the body. Incidence

About 75 percent of people will have hemorrhoids at some point in their lives. Hemorrhoids are most common among adults ages 45 to 65.Hemorrhoids are also common in pregnant women.

Etiology
1. Swelling in the anal or rectal veins causes hemorrhoids. Several factors may cause this swelling, including

chronic constipation or diarrhea straining during bowel movements sitting on the toilet for long periods of time

2. Another cause of hemorrhoids is the weakening of the connective tissue in the rectum and anus that occurs with age. 3. Pregnancy can cause hemorrhoids by increasing pressure in the abdomen, which may enlarge the veins in the lower rectum and anus. For most women, hemorrhoids caused by pregnancy disappear after childbirth.

Types
1. External hemorrhoids are located under the skin around the anus. 2. Internal hemorrhoids develop in the lower rectum. Internal hemorrhoids may protrude, or prolapse, through the anus. Most prolapsed hemorrhoids shrink back inside the rectum on their own. Severely prolapsed hemorrhoids may protrude permanently and require treatment.

Pathophysiology Due to etiological factors

Tenesmus increases intra abdominal pressure and hemorrhoidal pressure Distension of the hemorrhoidal veins. When the rectal ampulla with filled with stool Venous obstruction occurs Because of repeated obstruction and construction Hemorrhoidal veins permanently dilated Distension, thrombosis, bleeding occur. Clinical manifestation
The most common symptom of Internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement. Internal hemorrhoids that are not prolapsed are usually not painful. Prolapsed hemorrhoids often cause pain, discomfort, and anal itching. Blood clots may form in external hemorrhoids. A blood clot in a vein is called a thrombosis. Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus. When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch. Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse. Hemorrhoids are not dangerous or life threatening. Symptoms usually go away within a few days, and some people with hemorrhoids never have symptoms.

Diagnosis

1. Physical examination to look for visible hemorrhoids. A digital rectal exam with a
gloved, lubricated finger and an anoscopea hollow, lighted tubemay be performed to view the rectum. The doctor will examine the anus and rectum to determine whether a person has hemorrhoids. Hemorrhoid symptoms are similar to the symptoms of other anorectal problems, such as fissures, abscesses, warts, and polyps. Additional exams may be done to rule out other causes of bleeding, especially in people age 40 or older:

2. Colonoscopy. A flexible, lighted tube called a colonoscope is inserted through the anus,
the rectum, and the upper part of the large intestine, called the colon. The colonoscope transmits images of the inside of the rectum and the entire colon.

3. Sigmoidoscopy. This procedure is similar to colonoscopy, but it uses a shorter tube

called a sigmoidoscope and transmits images of the rectum and the sigmoid colon, the lower portion of the colon that empties into the rectum.

4. Barium enema x ray. A contrast material called barium is inserted into the colon to
make the colon more visible in x-ray pictures.

Medical management Medical therapy is used for small uncomplicated hemorrhoids with mild manifestations. 1. Prevent constipation: dietary changes used to treat constipation include increasing fluids and fiber in the diet. Constipation unrelieved by diet may require use of a stool softener(docusate sodium). 2. Relieve pain : for pain, initial application of cold packs, followed by warm sitz baths three or four times a day, should help. A topical anesthetic or steroid preparation such as lidocaine or steroid cream, also reduces pain and itching.

Surgical management 1. Internal hemorrhoids include the following:

Rubber band ligation. The doctor places a special rubber band around the base of the hemorrhoid. The band cuts off circulation, causing the hemorrhoid to shrink. This procedure should be performed only by a doctor.

Sclerotherapy. The doctor injects a chemical solution into the blood vessel to shrink the hemorrhoid. Infrared coagulation. The doctor uses heat to shrink the hemorrhoid tissue.

2. Large external hemorrhoids or internal hemorrhoids that do not respond to other treatments can be surgically removed. Hemorrhoidectomy : the vein is excised, and the area either is left open to heal by granulation or closed with sutures.

Complications Hemorrhage. Urinary retention. Infection. Stricture formation. Nursing management 1. Prevent constipation Encourage client to take bulk laxatives, stool softeners or mineral oils as prescribed to promote stool passage. Monitor stool consistency and blood.

 Encourage the client to eat fibre containing foods and drink ample fluids to prevent straining. Remind the client not to sit in toilet longer than necessary; this position impairs blood flow and puts added pressure on anal vessels. 2. Relieve pain Encourage 15 minutes warm sitz baths three or four times per day for 15 minutes. Post operative pains can be relieved by oral analgesics. Warn the client to avoid vigorous perianal wiping during immediate post operative period. 3. Promote healing Encourage the client to wash the area after defecation and to pat it dry. Local moist heat, applied with a wash cloth or piece of cotton to the anal opening for few minutes , cleans, soothes, and promotes healing. Never apply heat in the immediate post operative days, because of the increased risk of hemmorahage. Nursing diagnosis 1. Constipation related to ignoring the urge to defecate because of pain during elimination. 2. Anxiety related to impending surgery and embarrassment. 3. Acute pain related to irritation, pressure, and sensitivity in the anorectal area from
anorectal disease and sphincter spasms after surgery .

4. Urinary retention related to postoperative reflex spasm and fear of pain.. 5. Risk for ineffective therapeutic regimen management.

Conclusions
Hemorrhoids are swollen and inflamed veins around the anus or in the lower rectum. Hemorrhoids are not dangerous or life threatening, and symptoms usually go away within a few days. A thorough evaluation and proper diagnosis by a doctor is important any time a person notices bleeding from the rectum or blood in the stool. Simple diet and lifestyle changes often reduce the swelling of hemorrhoids and relieve hemorrhoid symptoms. If at-home treatments do not relieve symptoms, medical treatments may be needed.

Bibliography 1) Suzanne C, Brend G. Medical surgical nursing. 10th edition. Philadelphia: Lippincott William & Wilkins; 2004 . 2) Lewis, Heitkemper, Dirksen, OBrien, Bucher. Medical surgical nursing. 7th edition. Missouri: Elsevier; 2008. 3) Ignatavicius D, Workman L, Mishler A. Medical surgical nursing. 2nd edition. Philadelphia: W.B Saunders company; 2000. 4) Doenges E, Moorhouse F, Murr C. Nursing care plans. 7th edition. New delhi: Jaypee Brothers; 2007.