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A Client CARE Study

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A CLIENT CARE STUDY OFA 72 YEAR OLD MAN WITH PEPTIC

ULCER

BY

EYANG, IMMACULATA SAMUEL

INDEX NO: 20/PNCA/005

SUBMITTED TO

DEPARTMENT OF PUBLIC HEALTH NURSING

COLLEGE OF HEALTH TECHNOLOGY CALABAR.

CROSS RIVER STATE.

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JULY, 2021

CERTIFICATION

This is to certify that the work titled “A client care study of a 72 year old man with peptic ulcer” carried
out by Eyang, Immaculata Samuel with Index no: 20/PNCA/005 Of the Department of Public Health
Nursing College of Health Technology, Calabar, under the supervision of:

Eyang, Immacula ta Samuel Sige

(Student)

Department of Public health Nursing,

College of Health Technology Date: Q3-D-202

Calabar.

Mrs. Eko Inyang Enebieng Sign: Aly

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(Supervisor)

Department of Public health Nursing,

College of Health Technology Date:

Calabar.

ECHNO

Mrs. Eko Inyang Enebieni Sign:.. .PUELIC HENLTA

(Head of Department) SIGN

Department of Public health Nursing, Date:.

College of Health Technology

Calabar

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TABLE OF CONTENTS

Title page i

Certification ii

CHAPTER ONE: INTRODUCTION

1.1 Brief introduction of client 1

1.2 Family Background

1.3 Objectives Of The Study 4

CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction 5

2.2 Causes 6

2.3 Pathophysiology 7

2.4. Signs and symptoms 8

2.5 Diagnostic investigation 9

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2.6 Management

2.6.1 Medical Management

2.6.2 Surgical management 10

2.6.3 Nursing management 10

2.7 Prevention 13

2.8 Public health intervention/ prevention 13

2.9 Complications 13

CHAPTER THREE: HOME VISIT

3.1 First visit 15

3.2 Second visit 17

3.3 Third visit19

3.4 Fourth Visit21

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3.5 Fifth Visit22

CHAPTER FOUR: SUMMARY, CONCLUSION AND RECOMMENDATION

4.1 Summary and conclusion

4.2 Recommendation 24

CHAPTER ONE

INTRODUCTION

1.1 Brief introduction of client

This is a care study of Mr. O.R.M, a 72 year old man with peptic ulcer who is married to Mrs. R.M, lives at
No. 15 Ikot Enebong Street, 8 Miles Calabar Municipality. Mr. O. R. M was brought to the clinic by his son
on 25/09/2020 at Ikot Omin Health Care Centre, 8 Miles. PPatien Presented with the. Following
complaints. Intermittent, burning, Epigastric, pain, which radiates to the back, nausea and vomiting,
blood Stained sputum x 1 month.

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He is said to have taken antacid and Gestid syrup for ulcer treated. Client was also sent for investigation
such as full blood count, sputum Analysis, occult blood, PCV, malaria parasite, WWBC, ESR, Neutrophils,
lymphocytes.

History taking from client reveals this:

Family history: Nil history of peptic ulcer in the family

Past medical history: except for malaria and typhoid, client has no record of serious health disorder or
health issues

Vital signs on admission recorded:

Temperature: 37.2°C

Pulse: 86b/m

Respiration: 26c/m

Blood pressure: 120/80 mmgh

Client was examined and a diagnosis of peptic ulcer was made. Laboratory investigation revealed

Tests Result

Mararia Negative

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PCV 38%

WBC 4.4 x 10L

ESR 37mm/hr

Neutrophils 69%

Lymphocyte 30%

1.2 Family Background

Introduction of my client and family data

Mr. O.R.M is from Akamkpa local Government Area of Cross River State. Father is a retired soldier and
mother: a retired civil servant. He is the second child in a family of 3, 2 male and 1 female. My client Mr.
O.R.M is a monogamist whose family is an extended family made up of Wife, his two children and their
two grand children.

Father:

Name: Mr. E.0. M

Age: 93 years

Religion: Christian

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Occupation: retired soldier

Address: Mbarakom, Akamkpa village

Mother

Name: Mrs. E. O. M

Age: 92 years

Religion: Christian

Occupation: retired civil servant

Address: Mbarakom, Akamkpa village

1.3 Objectives Of The Study

• To acquire more knowledge about peptic ulcer

• To educate patients on the cause/risk factors, signs and symptom and prevention of peptic ulcer

• To provide information on patient family about the prognosis and Management of peptic ulcer.

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CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

Peptic ulcer disease (PUD) is a break in the lining of the stomach, first part of the small intestine or
occasionally the lower esophagus. This is a condition in which painful sores or ulcers develop in the lining
of the stomach or the duodenums.

Normally, a thick layer of mucus protects the stomach lining from the Effects of its digestive juices. But
many thins can reduce this protective layers, allowing stomach acid to damage the tissue (Julia Fashrner,
MD, And Alfred C. Gitu, 2015).

Types of peptic ulcer

There are three (3) types of peptic ulcers.

Gastric Ulcers: Ulcers that inside the stomach

Oesophageal Ulcers: Ulcers that develop inside the oesophagus

Duodenal Ulcers: Ulcers that develops in the upper section if the small intestine called the duodenum.
The most common symptoms of a duodenal ulcer are waking at night with upper abdominal pain or

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upper abdominal pain that progresses with Eating. With a gastric ulcer the pain may worsen with eating
(Snowden, 2008). The pain is often described as a burning c: dull ache. Other

Symptoms include belching, vomiting, weight loss, or poor appetite. Complications may include
bleeding, perforation, and blockage of the stomach. Bleeding occurs in as many as 15% of people
(American College of Gastwenterology Peptic Ulcer Disease, 2020).

2.2 Causes

Peptic ulcers can be caused by the following:

1. A Bacterium: Helicobacter pylori bacteria commonly live in the Mucous layer that covers and
protects tissue that lines the stomach And small intestine. Helicobacter pylori is a major causative factor
(60% of gastric and up to 50-75% of duodenal ulcers) is chronic Inflammation due to helicobacter pylori
that colonizes that antral Mucosa (Yoman, Mark, 2011). The immune system is unable to clear the
infection, despite the appearance of antibodies. Thus, the Bacterium can cause a chronic active gastritis
(type 8 gastritis)Gastrin stimulates the production of gastric acid by parietal cells. In [Link] colonization
responses to increased gastrin, the increase in Acid can contribute to the erosion of the mucosa and
therefore ulcer formation.

2. NSAIDs: Another major cause is the use of NSAIDs, Such as Ibuprofen and aspirin. The gastric
mucosa protects itself from gastric Acid with a layer of mucus, the secretion of which is stimulated by
Taine prostaglandins. NSAIDs block the function of cyclo-Oxygenase (COX-1) which is essential for the
production of these Matories (such as celecoxib or the since withdrawn rofecoxib). Preferentially inhibits
COX-2 selective anti-inflammatories (such as Celecoxib, or the since withdrawn refecoxib) preferentially
inhibits Cox-2, which is less essential in the gastric mucosa, and roughly have the risk of NSAID-related
gastric ulceration

3. Stress: Stress due to serious health problems such as those requiring treatment in an intensive
care unit as well described as a cause of Peptic ulcer which are termed stress ulcers. While chronic life
stress was once believed to be the main cause of ulcers, this is no longer the case. It is however, still
occasionally believed to play a role. This may be by increasing the risk in those with other causes such as
[Link] or NSAID use (Teomans Henry, 2011).

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4. Diet: Dietary factors such as spice consumption were hypothesized to cause ulcer until late in the
20th century, but have been shown to be relatively of minor importance. Caffeine and coffee, also
commonly thought to cause or exacerbate ulcers, appears to have little effect. Similarly, while studies
have found that alcohol consumption increases risk when associated with [Link] infection, it does not
seem to independently increase risk. Even when. Couples with [Link] infection, the increase are
modest in comparison to the primary factors.

5. Smoking: Smoking may increase the risk of peptic ulcer in people who are infected with [Link].
Peptic ulcer disease can also occur if you have a rare condition called Zolinger-Ellison syndrome
(gastorinomia). This condition forms a tumor of acid producing cells in the digestive tract. These tumors
can be cancerous or non-cancerous. The cells produce excessive amount of acid that damages stomach
tissue.

2.3 Pathophysiology

The mechanism of occurrence of peptic ulcer disease (PUD) results from an imbalance between gastric
mucosal protective and destructive factors. Risk factors predisposing to the development of PUD are
[Link] infection, NSAID use, first degree elative with PUD, diet and stress.

With peptic ulcers, there is usually a defect in the mucosa that extends to the muscularis mucosa. Once
the protective superficial mucosal layer is damaged, the inner layers are susceptible to acidity. Further,
the ability of the mucosal ‘cells to secrete bicarbonate is compromised.

[Link] is known to colonize the gastric mucosa and causes Inflammation. The [Link] also impairs the
secretion of bicarbonate, promoting the development of acidity and gastric metaplasia.

2.4. Signs and symptoms

1. Abdominal pain, classically epigastric strongly correlate mealtimes. In case of duodenal ulcers
the pain appears about three hours after taking a meal.

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2. Bloating and abdominal fullness

3. Nausea and copious vomiting

4. Loss of appetite and weight loss

5. Water brash (rush of saliva after an episode of regurgitation to dilute the acid in oesophagus
although this is more associated with Gastroesophageal (reflux disease)

6. Hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or
from damage to the oesophagus from severe/continuing vomiting.

7. Heart burn

8. Melena (tarry, foul-smelling faeces due to presence of oxidized iron from hemnoglobin);

2.5 Diagnostic investigation

To establish the diagnosis of peptic ulcer. The following assessment and laboratory studies should be
carried out:

1. Endoscopy: Endoscopy is the preferred diagnostic procedure because it allows direct

visualization of inflammatory changes, ulcers and lesion.

2. Esophago-gastro duodenoscopy: It confirms the presence of an ulcer and allows cytologic

studies and biopsy to rule out [Link] or cancer.

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3. Physical examination: A physical examination may reveal pain, epigastric tenderness, or

abdominal distention.

4. Occult blood: Stool may be tested periodically until they are, negative for occult blood

5. Barium study: A barium study of the upper GI tract may show an ulcer.

6. Carbon 13 (13c): Urea breath test. Reflects activity of [Link] (Yeomans,2011)

2.6 Management

2.6.1 Medical Management

Once diagnosis is established, the patients are informed that the condition can be controlled.

Pharmacologic Therapy: currently, the most commonly used therapy for peptic ulcers is a combination of
antibiotics, portion pump inhibitors, and bismuth salts that suppress or eradicate the infection.

Stress reduction and rest: Reducing environmental stress requires physical and psychological
modifications on the patient’s part as well as the aid and co-operation of family members and significant
others.

Smoking cessation: Studies have shown that smoking decreases the secretion of bicarbonate from the
pancreas into the duodenum resulting in increased acidity of the duodenum.

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Dietary modification: Avoid extreme of temperature of food and beverages and overstimulation from
consumption of meat extracts,alcohol, coffee and other caffeinated beverages and diets rich in Cream
and milk should be implemented.

2.6.2 Surgical Management

The introduction of antibiotics to eradicate [Link] and H2 receptor Antagonists (histamine) as

treatment for ulcers has greatly reduced the need for surgical intervention.

Pyioroplasty: It involve transecting nerves that stimulate acid secretion and opening the pyloris

Anterectomy: Anterectomy is the removal of the pyloric portion of the stomach with anastromosis to
either the duodenal or jejunum.

2.6.3 Nursing management

• Administer prescribed medications, Medications may include antacids, anticholinergics,

histamine-Receptor antagonist, proton-pump inhibitors and mucosal protective agent.

• Medication for ulcers caused by [Link] include bismuith, subsalicylate, metronidazole and
tetracycline. These medications administered together eradicate [Link] bacteria in the gastric mucosa.

• Provide client and family teaching.

• Instruct the client to quit smoking, which decreases the secretion of Bicarbonate from the
pancreas into the duodenum, resulting in Increased acidity in the duodenum.

• Teach the client about necessary lifestyle modifications aimed at

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• Decreasing stress and maximizing effective coping, Biofeedback, Hypinosis, or behaviour

modification may be suggested.

• Teach the client methods to minimize symptoms while maintaining adequate nutrition.

• Avoid foods that previously have caused pain. Specific dietary restrictions vary from client to
client.

• Eat three regular meals a day, small, frequent meals are unnecessary as long as the medication is
taken before meals.

• Avoid a diet rich in milk and creams, which are acid stimulants.

• Prepare the client for diagnostic procedures and provide post

Procedure care.

Prepare for barium swallow includes no oral intake after midnight and possible laxative to clean the GÍ
tract.

Stools are monitored until all barium has been eliminated.

Follow up care

Assist the patient in understanding the condition and factors that help or aggravate it.

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Teach patient about prescribed medications, including name, dosage, frequency and possible side
effects. Also identify medication such as aspirin that patient should avoid.

Instruct patient about particular foods that will upset the gastric ulcer, such as coffee, tea, colas and
alcohol, which have acid-Producing potential.

Encourage patient to eat regular meals in a relaxed setting and to avoid overeatingoseeuet

Explain that smoking may interfere with ulcer healing: refer patient to programs to assist with smoking
cessation

Alert patient to signs and symptoms of complications to be Reported. These complication includes;
hemorrhage (cold skin, confusion, increased heart rate, labored breathing, and blood in the stool),
penetration and perforation (server abdominal pain, rigid and tender abdomen, vomiting, elevated
temperature and increased meal Rate), and Pyloric obstruction (nausea, vomiting, distended abdomen
and abdominal pain). To identify obstruction, insert and monitor nasagastriebTube, more than 400ml
residual suggests obstruction (ulcer disease facts and Myth, 2013).

Advice on discharge

The patient should be taught self-care before discharge factors that affect: The

Nurse instructs the patient about factors that relieve and those that aggrevate the condition such as;

Medications: The nurse reviews information about medications to be taken at home, including names,
dosage, frequency and possible side effects, stressing the importance of continuing to take medications
even after signs and symptoms have decreased or subsided.

Diet: Client should be instructed to avoid certain medications and foods that exacerbate symptoms as
well as substances that have acid-producing potential.

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Lifestyle: Counsel Patient to eat meals at regular times and in a relaxed setting and to avoid overeating.

2.7 Prevention

The following should be prevented or avoided

1. Alcohol

2. Common Source of Helicobacter pylori bacteria (example contaminated food and water, flood
water, raw sewage)

3. Long term use of non-steroidal anti-inflammatory drugs (NSAIDS), smoking

2.8 Public health intervention/ prevention

Increased awareness on causes, signs and symptoms and complication of peptic ulcer to the public

2.9 Complications

Gastric outlet obstruction is a narrowing of the pyloric canal by scarring and swelling of the gastric
antrum and duodenum due to peptic ulcers. The persons often presents with severe vomiting without
bile.

Gastrointestinal bleeding is the most common complications, sudden large bleeding can be life-
threatening. It occurs when the ulcers erodes one of the blood vessels, such as the gastro-duodenal
artery perforation (a hole in the wall of the Gastrointestinal tract) often leads to catastrophic
consequences if left untreated. Penetration is a form of Peforation in which the hole leads to and the

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ulcer continue into adjacent organs such as the liver and pancreas cancer is included in the differential
diagnosis (elucidated by biopsy).

Helicobacter pylori as the etiological factor making it 3 to 6 times more likely to develop stomach cancer
from the ulcer.

CHAPTER THREE

HOME VISITS

3.1 FIRST VISIT

3.2 Date: 4 Oct, 2020

Objectives of visit

• To assess client’s home, environment, compliance to treatment

• To health educate where necessary

• To follow-up care

House hold description

Type of construction: The house was built with blocks

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Type of roofing: Corrugated iron sheets

Number of rooms and sleeping arrangement: It is a four bedroom.

Apartment: The parents and children sleep in separate rooms

Number of household in the building: SixX people are living in the house.

Source of water: They drink sachet water (Blue Rose).

Lighting: The house is well lighted

Kitchen facility: There is a well equipped kitchen with gas cooker and utensils and well ventilated with a
window and an exit door. The kitchen is separated from the four rooms and its well equipped

Type of ventilation: The house is well ventilated, spaced out, not close to other houses and each room
has two windows.

Refuse disposal: The facility dumps their refuse in the general refuse bin outside the compound.

Condition of the floor: The floor of the rooms, parlour and kitchen are all tiled. It is not slippery.

Toilet facilities: The four bedrooms have functional water closet system.

Bathroom: One bathroom is attached to each room

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Housekeeping efficiency: Client’s family is well organized and they have cordial relationship with
neighbors

Relationship with client family: Client have a good relationship with other members of the family

Observation of the client: On home visit to Mr. O.R.M. compound, he was met at home, looking better,
taking the drugs as prescribed. I observed him taking the afternoon dose in my presence.

Environment: Their environment is clean and tidy

Problems identified

• Poor eating habit

• Looking depressed

Vital Signs

Temperature 36.6°c

Pulse 76/m

Respiration 18/,

Blood Pressure 120/8Ommhg

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Nursing diagnosis

Imbalanced nutrition related to changes in diet evidenced by patient losing weight

Objective

Patient’s nutritional status will be restored to normal within 2-3 days of my

Nursing intervention

1. Encourage patient to eat regularly spaced meals in a relaxed atmosphere.

2. Encourage patient to eat foods rich in protein and carbohydrate.

3. Ensure daily weighing of patient

Scientific rationale

1. To prevent erosion of the gastric mucosa by hydrochloric acid.

2. To meet constant energy demand by the body.

3. To prevent daily assessment of improvement in weight of patient

Evaluation

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Client will be evaluated on the second visit since nursing interventions will last for 3 days.

3.3 SECOND VISIT

Date: 6” Oct, 2020

Objectives of the visit

1. To review the client’s condition

2. To assess the level of compliance to medication

3. To instruct client and family on side effects of drugs contraindication and signs and to report
observation

On my arrival at client’s home around 4pm, I met him on the veranda sitting outside receiving fresh air. I
Greeted the family and they welcomed me. Mr. 0.R.M. however, complied with the health information
given to him on first visit. He confirmed adhering to good nutrition. Also visited his physician and
reduced stressful activities.

Client was encouraged to reduce work and psychological stress and comply with drug usage and his vitals
were checked.

Vital Signs

Temperature 36°c

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Pulse 80/M

Respiration 20°/%

Blood pressure 120/8OmmHg

Nursing diagnosis

Knowledge deficit related to the prognosis as evidenced by client’s verbalization.

Objective

Client will demonstrate a better understanding of the causes of condition.

Nursing intervention

1. Explain to the client the causes, signs and symptoms, management and to how to prevent peptic
ulcer

2. Explain to client the importance of diagnostic tests and medication compliance.

3. Encourage family to participate in care

Scientific rationale

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1. It increases awareness on disease condition.

2. It promotes knowledge and compliance with drug regimen to give emotional support

Evaluation

1. Client demonstrated good understanding of causes, treatment, prognosis and prevention of

peptic ulcer.

THIRD VISIT

Date: 9th Oct, 2020

Objective

1. To follow-up the family and see how Mr. O.R.M is doing

2. To suggest a repeat of investigation and further discuss with him as planned.

Observation

On my arrival at my client’s home around 2:30pm, I met his son who welcomed me and informed him.
He came out and received me looking good and very strong. Mr. O.R.M presented the problem of poor
timing of dietary habits.

Activities

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Encourage client to improve and keen to g0od nutritional habits.

Vital Signs

Temperature 36.9c

Pulse 82 /m

Respiration 20/m

Blood pressure 130/70mmHg

Nursing Diagnosis

Anxiety related to acute illness evidenced by patient asking too many questions.

Objectives

Patient’s anxiety level will reduce within 12-24 hours of nursing intervention

Nursing intervention

1. A repeat of investigation was suggested to him

2. Discussion of family role in Health maintenance was made

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Scientific rationale

1. A suggestion of a repeat investigation was to ensure that Mr. O.R.M was completely free from
the condition.

2. Discussing the problem with the family made them to see the need to perform their roles by
providing family basic needs

Evaluation

1. Family verbalized knowledge of screening test after two hours of

Nursing Interventions

FOURTH VISIT

Nate: 12” Oct, 2020

Objective of visits

The level of improvement in the client

1. To assess client’s condition

2. To commend him for adhering to my advice

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Observation

1. Mr. and Mrs. 0.R.M were at home discussing, I was warmly welcomed and my coming was appreciated
especially as it concerns Mr. O.R.M who was doing very well.

2. I also expressed my appreciation for this ability to keep to the advice given to him.

3. I made him to understand that my appointment with him is going to be terminated after my next visit

Problem identified

Poor funding to carry out investigations, buy drugs and maintain good nutrition

Nursing intervention

1. Health education on the use of locally available food nutrients.

2. General examination was done

Vital signs

Temperature 36.7°c

Pulse 80°m

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Respiration 18°/.

Blood pressure 120/70mmHg

Evaluation

He followed the instructions given to him, investigations were within normal range condition is
satisfactory

FIFTH VISIT

Date: 14” Oct, 2020

Objectives of visits

To assess the client state of health

Observation

Mr. O.R.M and his grand daughter were met at home and they welcomed me to their home. I asked
about his health and he happily informed me that he was doing great.

I observed that he looked stronger than when I visited last. I asked him what he ate before I came and he
responded that he ate rice and vegetable sauce.

I asked generally and he said they are all good and about the family’s health, no compliant. Appointment
with him is

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I made him to understand that the …… Going to be terminated. He expressed his appreciation and
prayed for me.

Vital Signs

Temperature 36C

Pulse 84/m

Respiration 20°/m

Blood pressure 120/70mmHg

Evaluation

1. Mr. 0.R.M was very cooperative and willing to take advice

2. Finally I wished the entire family good health, peace and joy. I assure him that by the grace of God, I
will be coming from time to time to see Him and the family.

CHAPTER FOUR

SUMMARY, CONCLUSION AND RECOMMENDATION

Summary

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This case study Was carried out on Mr. O.R.M with the diagnosis of pepu …… Use of no knowledge of the
ulcer. This was predisposal by fasting, alcohol consumption, indiscriminate of NSAIDs and stressful
conditions. He has predisposing factors of the disease condition, He was duly management at lkot Omin
Health Care Centre through medications, rests and follow up visit. In his home, he was eating highly
spiced food, irregular feeding habits, emotional stress due to poor economic situation and ignorance.

Public health nurses play roles with the community as a public health worker with intermittent and
expert management.

Conclusion

I was able to intervene with the problems of Mr. 0.R.M after putting in necessary measures, he was
adequately cared for with no complications. This improvement was achieved through shared effort and
cooperation of the family. Mr. O.R.M (client) was properly treated and follow-up, the family became
aware of the measure to prevent peptic ulcer, and improve on their lifestyle. They were left happy finally.

Recommendations

Based case study of the client with peptic …….. on the experience derived from the ulcer, the following
are hereby recommended …. Patients with peptic ulcer who are older than 57 years, have …… symptoms
or have ulcers that fail to respond to treatment should promptly undergo upper endoscopy. To facilitate
healing and to decrease the risk of recurrence of gastric and duodenal ulcers,

Helicobacter pylori should be eradicated in patients/client with peptic ulcers disease proton pump
inhibitors offer suppression of acid secretion, healing and symptom relief in patients with peptic ulcers,
that are superior to those associated with other anti-secretory therapies.

Those with bleeding peptic ulcers and positive Helicobacter pylori testing should have eradication
therapy prescribed ….. Clients should go for periodic medical check-up.

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REFERENCES

AmericaC

College of Gastroenterology, peptic ulcer disease (2020)

Julia F Fashner, MD and Alfred C. Gitu, 2015

Teomans Henry, 2011

Ulcer Disease facts and myth, 2014

Yoman Mark 2011

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