Case Study Peptic Ulcer

CONCEPT MAP Nursing Diagnosis Nursing Diagnosis Fluid volume deficit related to acute bleeding as evidenced by black stools and low Hgb Acute pain related to an acute bleeding ulcer as evidenced by patient reported “worsen epigastric pain and maroon stools” Subjective Data: The patient reports having “ black/maroon stools” Subjective Data: The patient complains of “heartburn, , discomfort like a burning and gnawing pain, increased abdominal pain that often awakes him at night” Objective Data: BP 88/52, pulse 121 bpm, RR 20 EGD results: active bleeding duodenal ulcer, Hgb 8.4 g/Dl, Hct 26%. Objective Data: abdomen is rigid and tender, acute bleeding ulcer, HR 121, RR 20, patient is guarding, grimacing. Reason for Seeking Health Care (Acute Bleeding Duodenal Ulcer) JM 52 Years Male Nursing Diagnosis Fatigue related to acute bleeding as evidenced by low Hgb and black stools Subjective Data: The patient complains of being “fatigued and weak” Nursing Diagnosis Anxiety related to stress as evidenced by the patient stating his: health condition may be due to stress at work” Subjective Data: The patient reports “being under stress at work” Objective Data: BP 88/52, hr 121, RR 20, Hgb 8.4 g/dL, Hct 26%, black and marron stools. Objective Data: HR 121, RR 20, the patient has an active bleeding peptic ulcer that is adding more anxiety and physiological stress to the patient. PLAN OF CARE PRIORITY #1 Nursing Diagnosis: Fluid Volume Deficit Intervention (s) The nurse will Insert and IV catheter to have IV access. Administer parenteral fluids as prescribed. Administer blood products as prescribed Educate patient about possible cause and effect of fluid losses. Rationale Parenteral fluid replacement is indicated to prevent or treat hypovolemic complications. Fluids are necessary to maintain hydration status. Blood transfusions may be required to correct fluid loss from active gastrointestinal bleeding. Enough knowledge aids the patient to take part in his or her plan of care. Expected Outcome: The patient will be normovolemic as evidenced by systolic BP greater than or equal to 90 mm Hg , HR 60 to 100 bpm, adequate Hgb and Hct, and a normal skin turgor. PRIORITY #2 Nursing Diagnosis: Acute Pain Intervention (s) The nurse will Assess the client’s pain, including the location, precipitating factors, onset, duration, frequency, quality, intensity, and severity. Instruct the client to avoid NSAIDs such as aspirin or ibuprofen Instruct the client that meals should be eaten at regularly paced intervals in a relaxed setting. Administer the prescribed drug therapy that will include proton pump inhibitor and antibiotics. Rationale The client with duodenal ulcers demonstrates pain 2 to 4 hours after eating or in the middle of the night These medications may cause irritation of the gastric mucosa. An irregular schedule of meals may worsen the condition and its symptoms. Antibiotics treat the Helicobacter pylori infection and promote healing of the ulcer. Proton pump inhibitors block the secretion of gastric acid and reduce gastric pain Expected Outcome: The patient will report satisfactory pain control at a level less than 2 to 4 on a scale of 0 to 10 PRIORITY #3 Nursing Diagnosis: Fatigue Intervention (s) The nurse will Assist the client in planning and prioritizing activities of daily living (ADL). Assist the client in developing a schedule for daily activities and reinforce the importance of adequate rest periods. Anticipate the need for the transfusion of packed RBCs. Educate energy-conservation techniques Rationale This will allow the client to maximize his time for accomplishing important activities A plan that balances periods of activity with periods of rest can help the client complete activities without getting fatigued Packed RBCs increase oxygen-carrying capacity of the blood, therefore increase energy levels Organization and time management can help the client conserve energy and reduce fatigue. Expected Outcome: The patient will verbalize reduction of fatigue, as evidenced by reports of increased energy levels. PRIORITY #4 Nursing Diagnosis: Anxiety Intervention (s) The nurse will Assess client’s level of anxiety. Encourage to express fears openly Decrease sensory stimuli by maintaining a quiet environment. Provide emotional support to client. Rationale Clients with peptic ulcers are anxious, but their anxiety level is not visible. Open communication enables the client to develop a trusting relationship that aids in reducing anxiety and stress. Anxiety may escalate to a panic state with excessive conversation, noise, and equipment around the client. Providing emotional support will give a client calming and relaxing mood that will lower anxiety, and stress related to the condition. Expected Outcome: The patient will demonstrate ways of reducing anxiety and stress level. Narrative Nurse’s Note Date/Time Nurse’s Note Signature 6/4/2020 Received pt at outpatient clinic AAOx3. Reported heartburn, eating or taking antacids relives the pain for a few hours, then pain start again. Also, he cannot sleep at night because of the 0930 pain. Vitals signs were assed BP105/60, temperature 36.9 C (98.4 F), Pulse 88, RR 18 Spo2 96% on room air. Patient states discomfort as burning and gnawing. States that it hurts between umbilicus and his sternum. medication at home Ibuprofen (Motrin) daily for pain and headaches. Pt reported changes in his stools black and sticky he thinks that the caused is stress. Esophagogastroduodenoscopy (ECG) was performed without any complications. HCP prescribe famotidine (Pepcid) 20 mg PO BID. Education was given. Two days later pt reports at emergency dept felling fatigue and states pain was having worsened. Stools are now marron in color. Vitals signs BP 88/52, pulse 121, RR 20. Urgent EGD was performed which indicate an actively bleeding duodenal ulcer. Admitted to the medical/ surgical unit. HCP orders 1 unit of red blood cells and triple therapy. Labs: Hgb 8.4 g/dL, HCT 26%, and biopsy positive for pylori. Pt complains of increased abdominal pain. Abdomen rigid and tender. Educated was given about H. Pylory and lifestyle management of ulcers. Pt left in the lowest position, call light within reach, side rails up 2. -------------------------------------------------------------------------------------------------------------------------------------- Narrative Nurse’s Note Date/Time Nurse’s Note Signature