A case presentation on a patient with

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A case presentation on a patient with

• UPPER GASTROINTESTINAL BLEEDING

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DEMOGRAPHIC DATA

• Case no. 195
• Name Patient X
• Age 72 y.o
• Sex Male
• Nationality Syrian
• Marital Status Married
• Date of Admission February 4,2013
• Date of Discharge February 7,2013

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PHYSICAL ASSESSMENT

• GCS 15/15
• E Opens eyes spontaneously
• V Oriented and converses normally
• MObeys commands
• Dizziness and nausea upon assessment
• VITAL SIGNS BP100/70MMHG
• T 37 c
• HR 125CPM
• RR 25BPM
• SpO291
• GRBS 190mg/dl
• WT 116kgs
• Skin Light complexion, Warm to touch,smooth,
• hair evenly distributed
• EYES slightly sunken eyeballs,no redness, no
  discharges, pupils reactive to light and
  accommodation

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• MOUTH oral cavity is pale in color,
  buccal mucosa is dry but no
  ulcers,lips are pale and dry
• THORAX thorax is symmetric, slight
  retraction of theIntercostal
  muscles during inspiration
• MUSCULOSKELETAL generalized weakness with
  residual Left SidedWeakness
• GASTROINTESTINALmoderate-severe epigastic
  pain (PS8/10)
• Passage of soft, black stool

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LABORATORY FINDINGS (Feb 4, 2013)
RESULT REFERENCE
WBC 21.63 4.23-9.07
NEUT 76.6 34-67.9
RBC 2.68 4.63-6.08
HGB 8.2 13.7-17.5 g/dl
PLT 238 163-337
PT 16.3 10.9-16.3 SECS
APTT 30 27-39 SECS
UREA 23.2 3.2-7.1 mmol/L
CREATININE 121 46-110 mmol/L
SODIUM 141 137-145 mmol/L
POTASSIUM 5.1 3.5-5.1 mmol/L
CHLORIDE 114 98-107 mmol/L
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Past medical history

• 3 months prior to consult, the patient
  experienced left sided weakness and had
  hypertension recorded a 190/100mmhg BP, sought
  consult and was diagnosed of CVA, treated
  medically started medications of Valsartan
  (Diovan) 160 mg OD to control elevation of his
  BP, Aspirin 80 mg OD, Plavix 75 mg OD,
  Simvastatin 20 mg OD and Piracetam 800mg OD. Also
  the patient has a long diagnosed type 2 DM (non
  insulin dependent diabetes mellitus) and
  continuously taking Glimipride 1mg BID. Long been
  diagnosed of degenerative arthritis and
  chronically took Diclofenac 50 mg BID since many
  years ago. Same incident of suspected GI
  bleeding,wherein the patient passed soft blak
  stool,happened 10 years ago as stated by the
  relative but endoscopy was not done.Only
  prescribed with medications. He is a known smoker
  and consumes caffeine containing drinks on a
  regular basis.

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Present medical history

• Patient was brought to the Emergency Department,
  presenting with symptoms of dizziness, body
  weakness and epigastric pain for 2 days, passed
  black colored loose stool 3-4 times. Patient was
  conscious and oriented but with obvious body
  weakness. Upon interview, reveals that morning
  prior to consult, he had passage of black loose
  stool moderate to large amount as observed. In
  the emergency department, patient was immediately
  given IV Infusion of NSS 500 ml, and given
  Omeprazole 80 mg TIV STAT as ordered by the
  treating physician. Blood sample was collected,
  sent to laboratory, reveals a low HGB level of
  8.2. ECG was done and noted sinus tachycardia.
  Also Chest xray done no significant finding as
  explained by the physician. Gastroenterology
  consult was done and advised for admission for
  monitoring and correction of blood loss. Patient
  was admitted in Surgery Ward. Started omeprazole
  infusion 8 mg/hr and continuous IV fluid infusion
  and was put on NPO. Then after a series of
  investigations, later that day, was shifted to
  ICU (4/2/13)due to rapid decrease of blood
  pressure to 60/ 40 regardless of continuous fluid
  replacement, Voluven infusion given and was
  scheduled for an urgent Upper GI Endoscopy on OR
  , alongside blood transfusion of PRBC was done.
  Endoscopy shows duodenal ulcer on the anterior
  wall of the bulb and a large amount of black
  material (digested blood) inside the stomach
  cavity. 15 ml of Adrenaline was injected around
  the ulcer to control bleeding. Patient was
  monitored in ICU w/ regular checking of RBS and
  CBC.Oral anticoagulants and other medications are
  withheld. After stabilization and a total of 4
  units PRBC transfusion was transferred back to
  ward (5/2/13). Omeprazole infusion was then
  shifted to Omperazole 40 mg TIV BID, started soft
  diabetic diet.Patient was discharged last 7/2/13
  with home medications of Nexium, Amoxicillin,
  Clarithromycin, Amlor, Simvastatin and Panadol.
  Instructed to avoid aspirins and NSAIDs.
•  

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Actual image of ulcer seen after endoscopy
Digested blood
Ulcer
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Topic presentation

• Gastrointestinal bleeding is not just a
  gastroduodenal disorder but may occur anywhere
  along the alimentary tract. Bleeding is a symptom
  of an upper or lower GI disorder. It may be
  obvious in emesis or stool or it may be occult or
  hidden.Upper gastrointestinal (GI) bleeding
  refers to hemorrhage in the gastrointestinal
  tract.Patients with upper GI hemorrhage often
  present with hematemesis,coffee ground vomiting,
  and melena. The presentation of bleeding depends
  on the amount and location of hemorrhage. Melena
  refers to the black, "tarry" feces that are
  associated with gastrointestinal hemorrhage. The
  black color is caused by oxidation of the iron in
  hemoglobin during its passage through the ileum
  and colon. Bleeding may be caused by a lot of
  factors. One of which is a peptic ulcer which is
  an erosion in the gastronintestinal lining
  wherein lining is exposed to acid secretion
  causing inflammation, it may be seen as a small,
  red crater on the inside lining of the gut.
  Peptic ulcer is classified according to its
  origin It may be classified as gastric wherein
  ulcer develops in the stomach lining and duodenal
  if it arise on the duodenum. In this case the
  duodenum which is the most common site of peptic
  ulcer. Peptic ulcer is the end result of an
  imbalance between digestive fluids in the stomach
  and duodenum.. It is estimated that between 5
  and 10 of adults globally are affected by peptic
  ulcers at least once in their lifetimes.

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anatomy

• Upper gastrointestinal tract The upper
  gastrointestinal tract extend from the
  mouth,esophagus, stomach, until the duodenum.The
  exact demarcation between "upper" and "lower" can
  vary.

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Mouth, oral cavity, and pharynx

• The mouth leads to the oral cavity, which has a
  vestibule lying between the lips, the cheeks and
  gums (gingivae), and the teeth. The main oral
  cavity also lies between the hard and soft palate
  above, the tongue below, and the alveoli and
  teeth. The oral cavity leads to the pharynx
  through the fauces, which contain pharyngeal
  tonsils (adenoids) and palatine tonsils. Salivary
  glands (parotid, submandibular, and sublingual)
  open into the oral cavity.
• The pharynx extends from the base of the skull
  above to the cricoid cartilage (at the level of
  C6) below. It has 3 parts the nasopharynx (from
  the base of the skull above to the soft palate
  below), the oropharynx (from the soft palate
  above to the hyoid bone below), and the
  laryngopharynx (from the hyoid bone above to the
  cricoid cartilage below). The nasal cavity, oral
  cavity, and larynx open into the nasopharynx,
  oropharynx, and laryngopharynx, respectively. The
  laryngopharynx also has a piriform fossa on
  either side.

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esophagus

• The esophagus (gullet) is one of the few organs
  traversing 3 regions of the body--namely, the
  neck, thorax, and abdomen. Accordingly, it is
  divided into 3 parts cervical, thoracic, and
  abdominal. The esophagus is a 25-cm-long vertical
  muscular tube that which normally remains
  collapsed and that runs from the laryngopharynx
  (throat or hypopharynx) in the neck through the
  thorax (chest) to the stomach in the abdomen.

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stomach

• The stomach is a muscular, hollow, dilated part
  of the digestion system located between the
  esophagus and the small intestine. It secretes
  protein-digesting enzymes called protease and
  strong acids to aid in food digestion, (sent to
  it via esophageal peristalsis) through smooth
  muscular contortions (called segmentation) before
  sending partially digested food (chyme) to the
  small intestines.

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duodenum

• The duodenum is the first section of the small
  intestine and is the shortest part of the small
  intestine, where most chemical digestion takes
  place. The duodenum is largely responsible for
  the breakdown of food in the small intestine,
  using enzymes. The duodenum also regulates the
  rate of emptying of the stomach via hormonal
  pathways

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Lower gastro intestinal tract

• The lower gastrointestinal tract includes most of
  the small intestine and all of the large
  intestine. According to some sources, it also
  includes the anus.

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Small intestine

• Duodenum Here the digestive juices from the
  pancreas (digestive enzymes) and hormones and the
  gall bladder (bile) mix. The digestive enzymes
  break down proteins and bile and emulsify fats
  into micelles. The duodenum contains Brunner's
  glands which produce bicarbonate. In combination
  with bicarbonate from pancreatic juice, this
  neutralizes HCl of the stomach.
• Jejunum This is the midsection of the intestine,
  connecting the duodenum to the ileum. It contains
  the plicae circulares, and villi to increase the
  surface area of that part of the GI Tract.
  Products of digestion (sugars, amino acids, fatty
  acids) are absorbed into the bloodstream.
• Ileum Has villi and absorbs mainly vitamin B12
  and bile acids, as well as any other remaining
  nutrients.

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Large intestine

• Caecum The Vermiform appendix is attached to the
  caecum.
• Colon Includes the ascending colon, transverse
  colon, descending colon and sigmoid Flexure The
  main function of the Colon is to absorb water,
  but it also contains bacteria that produce
  beneficial vitamins like vitamin K.
• Rectum

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physiology

• The major processes occurring in the GI system
  are that of motility, secretion, regulation,
  digestion and circulation. The function and
  coordination of each of these actions is vital in
  maintaining GI health, and thus the digestion of
  nutrients for the entire body.
• In the uppermost portion, the teeth begin the
  process of digestion by grinding food into small
  fragments. The esophagus delivers the food to the
  stomach where strong acid further breaks up and
  degrades the swallowed material. Small amounts of
  the liquified food called chyme are then
  delivered in spurts from the stomach into the
  duodenum where they are mixed with bile from the
  liver (via the bile ducts) and pancreatic juice
  (via the pancreatic duct). Bile aids in the
  breakdown and digestion of fat, while the
  pancreatic enzyme amylase fragments starches into
  smaller molecules. The pancreas also releases a
  fluid into the duodenum, which neutralizes the
  acidic stomach contents. This neutral
  bile/amylase/fragmented food substance passes to
  the upper small intestine for the next phase of
  digestion. It is moved along by peristalsis,
  worm-like contractions of the intestine.

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• The small intestine is so named because its
  calibre is small, about one inch in diameter. The
  term small creates some confusion because, in
  terms of length, it is not small at all. In fact,
  it normally measures nearly 23 feet in length!
  The small intestine's job is absorption of food.
  The body gains access to the food that we consume
  by means of absorption of microscopic particles
  of food through the wall of the small intestine.
  Vitamins and minerals and large amounts of fluid
  are also absorbed by the small intestine and pass
  into the bloodstream for distribution to the rest
  of the body.
• Small amounts of the liquified food called
  chyme are then delivered in spurts from the
  stomach into the duodenum where they are mixed
  with bile from the liver (via the bile ducts) and
  pancreatic juice (via the pancreatic duct). Bile
  aids in the breakdown and digestion of fat, while
  the pancreatic enzyme amylase fragments starches
  into smaller molecules. The pancreas also
  releases a fluid into the duodenum, which
  neutralizes the acidic stomach contents. This
  neutral bile/amylase/fragmented food substance
  passes to the upper small intestine for the next
  phase of digestion. It is moved along by
  peristalsis, worm-like contractions of the
  intestine.
• By the time the intestinal contents reach the
  large intestine, most of its nutritional value
  has been extracted, leaving a watery waste
  product. The role of the large intestine is fluid
  absorption from the remaining waste and
  compaction and storage of what is left. Expulsion
  of the waste (feces, stool) is generally under
  voluntary control and is undertaken when socially
  convenient

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etiology

• There are many possible causes of bleeding,
  Causes are usually anatomically divided into
  their location in the upper gastrointestinal
  tract. It may be a result of trauma anywhere
  along the GI tract, rupture of an enlarged vein
  such as a varicosity (esophageal or gastric
  varices),inflammation such as esophagitis,gastriti
  s,inflammatory bowel disease and bacterial
  infection. Alcohol and drugs (aspirin-containing
  compounds,NSAIDS, anticoagulants,corticosteroids),
  cancers, or even anal disorders, and erosions
  and ulcers.

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DRUG CLASSIFICATION ACTION ADVERSE REACTIONS
Aspirin/Acetylsalicylic acid/ASA NSAID Produces analgesia and exert anti inflammatory effect by inhibiting prostaglandin and other substance that sensitize pain receptor. Interferes with clotting by keeping a platelet-aggregating substance from forming. GI nausea, GI bleeding, GI distress Hematologic prolonged bleeding time
Clopidogrel bisulfate/Plavix Antiplatelet Reduces thrombotic events in patient with atherosclerosis, documented by recent stroke or MI GI hemorrhage,abdominal pain, ulcers
Diclofenac NSAID Inhibits prostaglandin synthesis to produce anti inflammatory, analgesic and antipyretic effects GI abdominal distention, abdominal pain, bleeding,peptic ulceration
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• Bleeding may be classified as
• -massive it may be acute, wherein there is
  bright red hematemesis or large amount of melena
  with clots in the stool, rapid pulse,drop in BP,
  hyppovolemia and shock
• -subacuteintermittent melena or coffe ground
  emesis,hypotension,weakness and dizziness
• -chronicintermittent appearance of
  bleed,increased weakness,paleness or shortness of
  breath,occult blood and iron deficiency anemia.
• Upper gastrointestinal bleeding is a result of
  the ulceration of the mucosal lining of the
  stomach. This is due to infection with a
  bacterium (germ) called H. pylori or chronic use
  of Anti-inflammatory medicines used to treat
  various medical conditions. The diagnosis of
  upper GI bleeding is assumed when there is the
  presence of at least two factors among black
  stool, age gt 50 years, and high blood urea
  nitrogen/creatinine ratio.

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Signs and symptoms

• emphasized items are those noted in the patient)
• fatigue, weakness, or lack of energy
• Lightheadedness may occur if a person stands too
  quickly, since the body isn't able to pump
  oxygen-carrying red blood cells fast enough to
  the brain
• abdominal pain/burning pain, classically
  epigastric strongly correlated to mealtimes. In
  case of duodenal ulcers the pain appears about
  three hours after taking a meal
• bloating and abdominal fullness
• nausea, and copious vomiting
• loss of appetite and weight loss
• 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
• melena (tarry, foul-smelling feces due to
  oxidized iron from hemoglobin)
• Pallor of oral and nasal mucosa due to blood loss
• Low blood hemoglobin level (8.6)
• Breathing difficulties and low O2 saturation
• Decreased Blood pressure
• Tachycardia

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pathophysiology
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Formation and liberation of antihistamine
Increased acid production
Further mucosal erosion-uleration
Acute, massive GI bleeding
Compensatory constriction of peripheral
arteries-pallor of skin and nail beds
Blood volume depletion
Dec cardiac output hypotension and tachycardia
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Interventions and treatment

• The initial focus is on resuscitation beginning
  with airway management and fluid resuscitation
  using either intravenous fluids and or blood
  transfusion. Based on evidence from people with
  other health problems crystalloid and colloids
  are believed to be equivalent for peptic ulcer
  bleeding.
• Bowel rest Bed rest and clear fluids with no
  food at all for a few days. This gives the ulcer
  a chance to start healing without being
  irritated.
• Also endoscopy is the priority management, both a
  diagnostic and a treatment for GI bleeding,
  wherein after seeing the area where bleeding is
  originating, adrenalin can be injected to
  control the bleeding.
• Acid suppressing medication following a 4-8 week
  course of a medicine that greatly reduces the
  amount of acid that your stomach makes is usually
  advised. The most commonly used medicine is a
  proton pump inhibitor (PPI). These are a class
  (group) of medicines that work on the cells that
  line the stomach, reducing the production of
  acid. Proton pump inhibitors may reduce mortality
  in those with severe disease as well as the risk
  of re-bleeding and the need for surgery. They
  include esomeprazole, lansoprazole, omeprazole,
  pantoprazole and rabeprazole, and come in various
  brand names.
• Sometimes another class of medicines called H2
  blockers is used. They are also called histamine
  H2-receptor antagonists but are commonly called
  H2 blockers. H2 blockers work in a different way
  on the cells that line the stomach, reducing the
  production of acid. They include cimetidine,
  famotidine, nizatidine and ranitidine, and come
  in various brand names. As the amount of acid is
  greatly reduced, the ulcer usually heals.
• Surgical Interventions may also be indicated for
  hemorrhage caused by ulcer.

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Upper gi endoscopy

• Upper endoscopy is a procedure that enables the
  examiner (usually a gastroenterologist) to
  examine the esophagus (swallowing tube), stomach,
  and duodenum (first portion of small bowel) using
  a thin, flexible tube through which the lining of
  the esophagus, stomach, and duodenum can be
  viewed using a TV monitor

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complications

• Prolonged bleeding detectable in a microscopic
  study can lead to the loss of iron in the
  individual. This can cause anemia. Red blood
  cells contain a protein called hemoglobin. It is
  required to carry oxygen to the tissues of the
  body. A lack of hemoglobin and a lack of red
  blood cells can occur during constant GI
  bleeding, causing anemia. Symptoms of anemia
  include chest pain, dizziness, fatigue, weakness,
  headaches, shortness of breath and lack of mental
  clarity.
• Hypovolemia may occur as a complication of GI
  bleeding. Due to a severe loss of blood and fluid
  in acute GI bleeding, the heart finds it
  difficult to pump enough blood to the body. It is
  a life-threatening condition since it can cause
  the body's organs to stop working. Symptoms of
  this condition include cool, clammy skin
  confusion agitation decreased urine output
  weakness pale skin quick breathing and loss of
  consciousness.
• Acute and massive bleeding from the
  gastrointestinal tract can lead to a lack of
  blood flow to the body. This can damage the
  different organs of the body, causing organ
  failure. Shock is an emergency condition and if
  it is not treated immediately, it can worsen
  quickly, causing irreversible damage to the
  organs or even death. Symptoms of shock include
  an extremely low blood pressure, bluish lips and
  fingernails, chest pain, confusion, dizziness,
  anxiety, pale skin, decreased or no urine output,
  racing but weak pulse rate, shallow breathing,
  and unconsciousness.

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Prioritization of nursing problems

• Acute pain related to inflammation of gastric
  mucosa
• Fluid volume deficit related to active bleeding
  or fluid loss
• Decreased cardiac output due to active bleeding
• Fatigue related to decreased oxygen in blood
• Knowledge Deficit related to lifestyle
  modification and drug regimen

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Nursing care plan 1
ASSESMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective I have abdominal pain Objective Pain score 8/10 facial grimace assuming fetal postion to compress stomach guarding position irritable Acute Pain related to epigastric distress secondary to mucosal erosion. After 15-30 mins of nursing interventions, the patient will experience relief from pain as evidenced by a pain score of 8/10 decreased to at least 5/10, a relaxed postion, and absence of facial grimace. Provided patient. optimal pain relief with prescribed analgesics or proton pump inhibitors like Risek 80 mg TIV STAT and Scopinal 20mg TIV STAT Positioned patient comfortably on bed Instructed patient to be on NPO Taught the use of nonpharmacologic techniques (e.g., relaxation,guided imagery, music therapy, distraction, and massage) Each client has a right to expect maximum pain relief. Optimal  pain relief using analgesics includes determining the preferred  route, drug, dosage, and frequency for each individual. Proton pump medications reduce acid levels and allow the ulcer to heal Proper positioning during times of pain may give comfort to the patient Limits gastric acid production thus inhibiting irritation to the ulcer The use of noninvasive pain relief measures can increase the re- lease of endorphins and enhance the therapeutic effects of pain relief medications Goal partially met After 30 mis of nursing interventions, the patient manifested a slight relief of pain as evidenced by a pain score of 6/10 but still uncomfortable.
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Nursing care plan 2
ASSESMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective I am passing bloody stool Objective () melena low HGb count of 8.6 Pale and dry oral mucosa Tachyardia 125 bpm shortness of breath Hypotension 100/70mmhg Fluid volume deficit related to blood loss due to active bleeding. After 12 hours of nursing interventions, the patient will be able to regain fluid volume and minimize further blood loss. Administered fluid replacement through intravenous fluids as ordered Administered properly typed and crossmatched blood products as ordered Administered oxygen inhalation by face mask Witheld medications that can aggravate bleeding like aspirin maintained pt on bed rest,limit activity Monitored Intake and Output To provide replacement for the amount of fluid loss Urgently replaces blood loss To compensate for the low levels of oxygen in the blood to facilitate breathing and ventilation Prevents exacerbation of situation, prevents irritation and inflammation of ulcers that causes bleeding To prevent further fluid loss and minimize energy consumption To monitor amount of fluid loss for replacement Goal partially met. After 12 hours of nursing intervention, the patient maintained fluid volume at an acceptable level, as evidenced by normal breathing and a warm, moist skin and mucosa and increased HGb level of 13.7-17.5 g/dl
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Nursing health teaching

• Prevention of recurrence of bleeding due to
  duodenal ulcer is the priority health teaching
  by
• Instructing patient in taking gastric irritating
  medications on full stomach
• Advising to limit or quit smoking
• Having a well balanced diet with meals at regular
  intervals and avoiding dietary irritants.
• Religiously following medication regimen for
  duodenal ulcer
• Avoiding aspirins and NSAIDs instead using
  Paracetamol for pain
• Taking adequate amount of rest to prevent stress
• Advise to drink alcohol only in moderation, or
  avoid drinking alcohol. Limit alcohol to 2 drinks
  a day for men and 1 drink a day for women.
  Drinking too much alcohol and other caffeine
  containing beverages may make an ulcer heal more
  slowly and may make your symptoms worse.

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conclusion

• Early detection is important in the management
  of any disease. In this case, the patient
  developed a complication of his past medical
  condition which is CVA due to his medication
  treatment and other causes. The Upper
  Gastrointestinal Bleeding was already a
  complication of the duodenal ulcer which may be
  caused by the medication he took and his
  lifestyle and started months prior to
  hospitalization. And this case when not prompted
  early may cause death. Improvement was seen upon
  discharge as evidenced by laboratory results and
  the patients overall condition. But it is
  possible that the condition may recur if the
  patient will follow dietary and health regimens
  advised.

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Thank you!

• Maria Beverly A. Centeno,RN
• Emergency Department staff