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 Gastric Ulcer

Age 30-60 Usually 50 and over

Male: female= 2-3:1 Male: female=1:1
80% of peptic ulcers are duodenal 15% of peptic ulcers are gastric

Signs, Symptoms, and Clinical Findings

Duodenal Ulcer Gastric 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
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

MALIGNANCY POSSIBILITY

Duodenal Ulcer Gastric Ulcer

Rare Occasionally

RISK FACTORS

Duodenal Ulcer Gastric Ulcer

H. Pylori, Alcohol, Smoking, cirrhosis, stress H. pylori, gastritis, alcohol, smoking, use of
NSAIDs, stress
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 ulcer-
causing 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: Potulin, Miguel Llusi

Address: #52 Roadman Street Area A Talanay Batasan Hills

Age: 58

Sex: Male

Occupation: Fisherman – province (past) /

Latero – Manila (present)

Civil Status: Married – Civil Wedding

Birthday: 05/11/1950

Birthplace: Cariraga, Leyte

Religion: Roman Catholic

Room No: 4015 - D

Present Admission: 12/27/2008

Admission Diagnosis: Abdominal Pain

Final Diagnosis: 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 Methods Used Findings Interpretation

General Inspection • Conscious, coherent, on bed Patient can ambulate.

Appearance hooked with IVF D5LRS
• With longitudinal abdominal
incision covered with dry
dressing.
• O2 tank for supplemental
oxygenation.
Skin Inspection • Edema on feet and ankle and Excessive accumulation
right hand with 3+ pitting of water
edema
Respiratory • Shortness of breath Deviated from normal
Inspection
System

• With longitudinal abdominal With intact dressing

Abdomen Inspection
incision noted clean and dry

• Fingernails Dirty finger nails

Upper Inspection • Edema on the right hand with
Extremities

3+ pitting edema
Abnormal

• Both feet and ankle with 3+ Abnormal

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

RISKUCER
PEPTIC FACTORS
DISEASE
H. pylori Infection, Stress
Habitual use of NSAID’s
Cigarette Smoking
Alcohol and Carbonated drinks
Consumption
H. pylori Bile salts, aspirin, alcohol,
DUODENAL
Infection
ULCER GASTRIC ULCER
ischemia

↑Serum Damaged mucosal

↑ Urease ↑ Gastric
Gastrin barrier
Production Emptying
Levels
↑Acid ↓Function of mucosal cells
Alkalosis ↓Bicarbonat Secretion ↓Quality of mucus
e ↑Pepsin Loss of tight junctions
between cells
Neutralizati
on of Acid & Pepsin Back diffusion of acid into gastric
acidity concentration in mucosa
duodenum
↑ ↑Histamin
Pepsin e Release
Penetration in the
mucosal barrier ↑Acid
secretion

Mucosal Local
Further mucosal
injury Erosion Vasodilation
Destruction of blood
↑capillary
vessels
permeability
Bleeding
ULCERATI Loss of plasma
proteins
ON Mucosal Edema
Loss of plasma into
gastric lumen

Stimulation of
cholinergic intramural
plexus, causing
muscle spasms
 ULCERATI
ON

Stimulation of Destruction of Blood

Nociceptors Vessels

Stimulation of Nerve
Fibers Bleeding
(A & C Fibers)

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 Actual Value Normal values

RBC Male: 4.7 to 6.1 million

cells/mcL

Female: 4.2 to 5.4 million

cells/mcL
WBC 4,500 to 10,000 cells/mcL

Hct Male: 40.7 to 50.3 %

Female: 36.1 to 44.3 %

Hbg Male: 13.8 to 17.2 gm/dL

Female: 12.1 to 15.1 gm/dL

 MCV 80 to 95 femtoliter

MCH 27 to 31 pg/cell

MCHC 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 Neutralize the hydrochloric  Instruct the client to take 1

acid secreted by the stomach and 3 hours after meals and at
Aluminum hydroxide bed time; instruct him to
Calcium carbonate avoid taking them with other
medication
Dihydroxyaluminum sodium  Instruct to chew antacids
carbonate tablet (not swallow them
Magaldrate whole), and shake liquids
before taking them
Magnesium hydroxide

ANTICHOLINERGICS Inhibit the action of  Advise the client that adverse

acetylcholine at cholinergic effects include drowsiness,
Atropine sulfate receptor site, thereby and dry mouth
decreasing gastric secretion  Encourage increased fluid
Glycopyrrolate
intake
Propantheline  Caution the client to avoid
activity, such as driving, that
Scopolamine require alertness and
concentration until the effects
of the drug are known
HISTAMINE RECEPTORS Block receptions that control  Instruct the client to continue
ANTAGONISTS the secretion of hydrochloric taking the medication
acid by the parietal cells regularly, even after pain
Climitidine subsides
Famotidine  When administering IV dilute
the medication and monitor
Ranitidine the client closely
 Emphasize the importance of
adhering to all aspects of
therapy

MUCOSAL PROTECTIVE Protect the ulcer from
AGENTS destructive action of the
digestive enzyme pepsin by
Misoprostol changing stomach acid into
viscous materials that binds to
Sucralfate
protein in ulcerated tissue
PROTON PUMP INHIBITOR Prevent the final transport of
hydrogen into the gastric
Omeprazole lumen by binding an enzyme
on gastric parietal cells
Pantoprazole
 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
 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 PAGE 1 TO 3 - NCP

NURSING CARE PLAN

CUES NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Pain(acute) Short term: Independent:
related to the ♥After 15- ♥Perform a comprehensive ♥Obtain a baseline ♥The client will
“Madalas sumakit ang effect of 30mins of assessment of pain to include data and determine or report improvement/
tyan ko mapakumain man increased gastric nursing location, characteristics, rule out worsening of lessened sensation of
ako o hindi, sa sobrang acid secretion interventions, onset/duration, frequency, underlying condition/ pain as evidenced by
sakit halos hindi ko leading to client will quality, severity (0 to 10 or development of (-)facial grimace,
ulceration on verbalized/ faces scale), and precipitating/ complications (-)irritability, feeling
mawari, walang oras kung
damaged tissue as demonstrate aggravating factors of comfort and stable
ito’y sumungpungin at manifested by the lessened vs
tsaka ko ito iniinuman 7 parameters of sensation of
mefenamic acid o kaya pain. pain ♥Relaxation of
naman linalagyan ko ito ng ♥Encourage activities that muscles decreases ♥The client
mainit na tubig o kaya Long term: promote rest and relaxation peristalsis and prevented the
naman iinuman ko ito ng ♥After 1- avoidance of strenuous decreases gastric pain reoccurrence of pain
maligamgam na tubig at sa 3days of physical activity as evidenced by
nursing arrange the environment, improvement of
kalaunan natatanggal
interventions, such as, dimly & quiet lifestyle,
naman, as verbalized by client will modification of diet
environment
mang miguel. prevent the and effective
massage the abdominal
reoccurrence area treatment regimen
♥Verbal or Coded report of pain. leading to healing of
 DU: pain occurs on ♥The relationship gastric or mucosal
empty stomach, 2-3 between stress and injury
hours after meals or peptic ulcer disease
in middle of night
♥Teach diversional techniques is based on the higher
 GU: pain occurs for stress reduction and pain incidence of peptic
30mins-1 hour after relief such as deep breathing ulcers in those with
meal exercises, watching tv, listening chronic anxiety
OBJECTIVE: to mellow music
♥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
♥Promote relaxation
of the abdominal
muscle
♥Place client in a supine or
semi-fowlers position ♥Hydrochloric acid PAGE 2 TO 3 - NCP
(HCl) presumably is
♥Explain the relationship an important variable
between hydrochloric acid in the appearance of
secretion and onset of pain peptic ulcer disease,
control of HCl
secretion is
considered an
essential aim of
treatment
♥NSAIDS cause
♥Explain the risks of superficial irritation
nonsteroidal anti-inflammatory of the gastric mucosa
drugs (NSAIDS) (e.g. Motrin, and inhibit the
Aleve, Advil) production of
prostaglandins that
protect gastric
mucosa
♥Help the client to identify ♥Avoidance of
irritating irritating substances
Substances (e.g., fried foods, can help to prevent
spicy foods, coffee, milk, cola) the pain response
(stimulates acid secretion)
♥Encourage the client to avoid ♥Gastric acid
intake of caffeine-containing secretion may be
and alcohol beverages stimulated by
 caffeine ingestion.
♥Pain Scale 7/10 Alcohol can cause
gastritis
♥Expressive Behavior: ♥Encourage the client to avoid
irritability smoking ♥Smoking decreases
discomfort pancreatic secretion
restlessness of bicarbonate; this
increases duodenal
♥Pyrosis (heartburn) acidity. Tobacco
delays the healing of
gastric duodenal
PAGE 2 TO 3 - NCP
ulcers and increases
their frequency
♥Advise the client to eat
regularly and to avoid bedtime ♥Contrary to popular
snacks 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
 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

Short term: Independent:

After 15- Perform a
PAIN - pain related 30mins of comprehensive - to obtain a -the patient will be able to state
to the nursing assessment of pain baseline data that pain is relieve/controlled
Subject: surgical and to establish
interventions, including the
procedures Mang Miguel
or to exclude -the patient able to demonstrate
– “di pa ako maka-galaw characteristics,
done will be able to inferior use of relaxation kills and
masyado kasi masakit pa tong location, duration,
report that pain underlying activities
tahi ko, medyo hirap tuloy frequency, severity
is relieved/ condition/
akong magkikilos” as (0 to 10 or pain
controlled. development - The client will state the
verbalized by Mang Miguel. scale), and the
Obj. Mang Miguel of enhancement/ reducing
aggravating factors
will be able to complications sensation of pain as
– reduce interaction with people demonstrate evidenced by (-)frowning,
– beaten look use of -monitor vital sign of -vital signs are (-)irritability, feeling of
– Sighing relaxation skills the patient -provide very important comfort and stable vital signs
and diversion non-pharmacology to assess if the
activities pain management like: patient is
experiencing
Long term: • Patient pain
After 1-3days positioning
of nursing
intervention • Back rub
After nursing
• Heat and cold
interventions,
application
Mang Miguel
will be able to
state that pain
is
tolerable/reliev
-encourage adequate
ed.
rest period

• Taking a nap

-provide
pharmacology pain
management (as
doctor’s order) - NSAIDS
cause
• Explain the superficial
risks of irritation of the
gastric mucosa
nonsteroidal
and inhibit the