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Peptic Ulcer – Surgical, Nursing Management

SURGICAL MANAGEMENT

Surgery is usually recommended for patients with intractable ulcers (those that fail to heal after 12 to 16 weeks of medical treatment), life-threatening hemorrhage, perforation, or obstruction, and for those with ZES not responding to medications . Surgical procedures include vagotomy, with or without pyloroplasty, and the Billroth I and Billroth II procedures.

VAGOTOMY

Severing of the vagus nerve. Decreases gastric acid by diminishing cholinergic stimulation to the parietal cells, making them less responsive to gastrin. May be done via open surgical approach, laparoscopy or thoracoscopy

TRUNCAL VAGOTOMY

Severs the right and left vagus nerves as they enter the stomach at the distal part of the esophagus.

SELECTIVE VAGOTOMY

Severs vagal innervation to the stomach but maintains innervation to the rest of the abdominal organs.

PROXIMAL GASTRIC VAGOTOMY

Denervates acid-secreting parietal cells but preserves vagal innervation to the gastric antrum and pylorus.

PYLOROPLASTY

A surgical procedure in which a longitudinal incision is made into the pylorus and transversely sutured closed to enlarge the outlet and relax the muscle

ANTRECTOMY

Removal of the lower portion of theantrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum (Billroth I) or to the jejunum (Billroth II).

NURSING PROCESS

NURSING ASSESSMENT

  • The nurse asks the patient to describe the pain and the methods used to relieve it (e.g., food, antacids).
  • If the patient reports a recent history of vomiting, the nurse determines how often emesis has occurred and notes important characteristics of the vomitus.
  • The nurse also asks the patient to list his or her usual food intake for a 72-hour period and to describe food habits (e.g., speed of eating, regularity of meals, preference for spicy foods, use of seasonings, use of caffeinated beverages and decaffeinated coffee).
  • Lifestyle and habits are a concern as well.
  • The nurse inquires about the patient’s level of anxiety and his or her perception of current stressors.
  • The nurse assesses vital signs and reports tachycardia and hypotension, which may indicate anemia from GI bleeding. The stool is tested for occult blood, and a physical examination, including palpation of the abdomen for localized tenderness, is performed as well.

NURSING DIAGNOSES

  • Acute pain related to the effect of gastric acid secretion on damaged tissue
  • Anxiety related to coping with an acute disease
  • Imbalanced nutrition related to changes in diet
  • Deficient knowledge about prevention of symptoms and management of the condition

POTENTIAL COMPLICATIONS

  • Hemorrhage
  • Perforation
  • Penetration
  • Pyloric obstruction (gastric outlet obstruction)

NURSING GOALS

  • To relieve pain
  • To reduce anxiety
  • To maintain nutritional requirements
  • To impart knowledge about the management and prevention of ulcer recurrence
  • Absence of complications

NURSING INTERVENTIONS

RELIEVING PAIN

  • Avoid aspirin, foods and beverages that contain caffeine, and decaffeinated coffee
  • Meals should be eaten at regularly paced intervals in a relaxed setting
  • Teach learning relaxation techniques to help manage stress and pain
  • Enhance smoking cessation efforts
  • Pain relief can be achieved with prescribed medications

REDUCING ANXIETY

  • Assess level of anxiety
  • Appropriate information is provided at the patient’s level of understanding, all questions are answered
  • Encourage to express fears openly
  • Explain diagnostic tests and administer medications on schedule
  • Interact with the patient in a relaxed manner
  • Identify stressors and explain various coping techniques and relaxation methods, such as biofeedback, hypnosis or behavior modification.
  • The patient’s family is also encouraged to participate in care and to provide emotional support

MAINTAINING OPTIMAL NUTRITIONAL STATUS

  • Assess the patient for malnutrition and weight loss
  • After recovery from an acute phase of peptic ulcer disease, the patient is advised about the importance of complying with the medication regimen and dietary restrictions
  • Encourage blend and soft diet
  • Small and frequent meals promoted
  • Serve meals according to the liking of the patient

IMPARTING HEALTH EDUCATION

  • Instruct about the factors that will help or aggravate the condition
  • Review information about medications to be taken at home, including name, dosage, frequency, and possible side effects, stressing the importance of continuing to take medications even after signs and symptoms have decreased or subsided.
  • Instruct to avoid certain medications and foods that exacerbate symptoms as well as substances that have acid producing potential (eg, alcohol; caffeinated beverages such as coffee, tea, and colas)
  • Counsel the patient to eat meals at regular times and in a relaxed setting, and to avoid overeating
  • Inform about the irritant effects of smoking on the ulcer and provides information about smoking cessation programs.
  • Reinforce the importance of follow-up care for approximately 1 year, the need to report recurrence of symptoms, and the need for treating possible problems that occur after surgery, such as intolerance to dairy products and sweet foods.

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