Study Notes on Peptic Ulcer Disease and Related Conditions

PEPTIC ULCER DISEASE (PUD)

  • Definition: Ulcers located in the wall of the stomach, pylorus, or duodenum.

GI Bleed Predisposing Factors

  • Infection: Caused by Helicobacter pylori (H. Pylori) bacteria.

  • Medications: Long term use of NSAIDs (non-steroidal anti-inflammatory drugs).

  • Lifestyle Factors: Alcohol use, smoking, stress.

  • Medications: Use of corticosteroids.

  • Long-term Omeprazole Use: May lead to vitamin B12, magnesium, and calcium deficiencies and increased risk of infections such as C. difficile.

Recommendations for H. Pylori Patients

  • Antibiotic Treatment: Complete course as prescribed.

  • Lifestyle Modifications: Avoid NSAIDs, alcohol, smoking, chocolate, and caffeine.

  • Stress Management: Ensure adequate rest and reduce stress levels.

H. Pylori Testing and Treatment

  • Testing Methods: Stool or blood tests, Urea Breath test.

  • *Medications:

    • Aluminum Hydroxide: High in sodium, used to treat peptic ulcers.

    • Cimetidine: Reduces acid production in the stomach (H2 blockers).

Complications of PUD

  • Possible complications include:

    • Hemorrhage

    • Perforation

    • Pyloric obstruction

  • Monitoring: Vital signs, signs of bleeding.

Treatment Protocols

  • Mucosal Barrier Protectant: To be taken 1 hour before meals.

  • Proton Pump Inhibitors (PPIs): To decrease gastric acid production.

  • Monitoring: Hemoglobin and hematocrit levels, maintain NPO status, IV fluid replacement, intake and output (I&O).

Side Effects and Adverse Effects

  • Common side effects may include:

    • Constipation

    • Diarrhea

    • Electrolyte imbalances

    • Kidney stones

    • Drug interactions.

  • Postoperative Monitoring: Complications such as hemorrhage, diabetes symptoms, hypoglycemia, and B12 deficiency should be considered.

TYPES OF ULCERS

Gastric Ulcer

  • Location: Occurs in the stomach.

  • Symptoms:

    • Hematemesis (vomiting blood) more common than melena.

    • Sharp pain in the left mid-epigastric region occurring 30-60 minutes after eating.

    • Pain increases with eating.

Duodenal Ulcer

  • Location: Occurs in the duodenum, immediately after the stomach.

  • Symptoms:

    • Burning pain in the midepigastric area occurs approximately 1.5 to 3 hours after eating, often awakening the patient during the night.

    • Melena more common than hematemesis.

    • Pain often relieved by eating.

PERFORATION AND DUMPING SYNDROME

  • Signs of Perforation: A board-like abdomen indicates peritonitis; require immediate notification of the provider.

Dumping Syndrome (Post-Gastrectomy)

  • Symptoms:

    • Tachycardia

    • Nausea

    • Vomiting

    • Weakness and dizziness

    • Palpitations

    • Cramping and diarrhea, often occurring 30 minutes post-meal.

  • Client Education:

    • Eat small meals and avoid fluids during meals.

    • Avoid sugar, salt, and milk.

    • Implement a diet high in protein and fat, while low in carbohydrates.

    • Recommended to lie down post-meal for 30 minutes.

    • Fluids should be consumed between meals.

  • Post-Gastric Surgery Care: Do not irrigate or remove the NG tube unless prescribed to avoid disruption of gastric sutures. Monitor the NG tube for proper function.

  • Return of Bowel Sounds: Indicates readiness for a liquid diet.

HYPERTHYROIDISM

Graves’ Disease

  • Metabolism: Fast metabolism characterized by hyperactivity.

  • Symptoms:

    • Heat intolerance

    • Hypertension (HTN)

    • Diarrhea

    • Anxiety

    • Weight loss

    • Fine tremors and sweating

    • Tachycardia

    • Exophthalmos (protruding eyes).

  • Risks: Thyroid storm may occur.

  • LABS: Low TSH and high T3-T4 levels.

  • Diet Considerations: High-calorie, high-protein diet recommended.

  • Medications:

    • Methimazole

    • Propylthiouracil (PTU), side effects include liver toxicity and agranulocytosis (watch for sore throat and fever).

  • Radiation Therapy: Radioactive iodine used to destroy thyroid cells to decrease hormone levels.

  • Care for Exophthalmos: Elevate the head of the bed, administer artificial tears, use dark glasses, and tape eyelids closed at night. Allow the patient to discuss body image concerns.

Thyrotoxicosis

  • Definition: Condition of excessive T3 and T4 occurring after hyperthyroidism (Graves' disease).

  • Symptoms: Tachycardia, palpitations, hypertension, and potential Atrial fibrillation (Afib), menstrual irregularities in females.

HYPOTHYROIDISM

Hashimoto’s Thyroiditis

  • Metabolism: Slow metabolism characterized by decreased activity.

  • Symptoms:

    • Cold intolerance

    • Fatigue

    • Constipation

    • Depression

    • Weight gain

    • Hair loss

    • Puffy face

    • Bradycardia

    • Memory loss.

  • Risks: Myxedema coma may be a potential outcome.

  • LABS: High TSH and low T3-T4 levels.

  • Diet Considerations: Low-calorie, low-cholesterol, low-saturated fat diet.

  • Medications: Levothyroxine is to be taken on an empty stomach each morning, 30-60 minutes before eating, and at the same time every day. Avoid calcium and iron intake for 4 hours around the time of medication. Levothyroxine should not be discontinued and is typically lifelong treatment. Monitor for tachycardia and palpitations while on this medication.

THYROIDECTOMY

Overview

  • Indication: Removal of the thyroid gland typically following uncontrolled hyperthyroidism.

Preoperative Interventions

  • Preparation Measures: Obtain vital signs (VS), weight, electrolyte levels; assess for hyperglycemia; perform deep breathing exercises; and support neck post-operation.

  • Medications: Administer antithyroid medications, iodides, propranolol, glucocorticoids to prevent thyroid storm.

Postoperative Interventions

  • Monitoring Measures: Monitor respiratory status, maintain a tracheostomy set, provide oxygen, suctioning supplies at bedside, and assess voice changes for hoarseness.

  • Patient Care: Limit talking, avoid neck flexion to prevent strain on the suture line; monitor for hypocalcemia and signs of tetany. Be prepared to administer calcium gluconate as prescribed for tetany. Monitor for signs of thyroid storm.

  • Positioning: Keep patient in semi-Fowler's position post-surgery; assess surgical site for swelling, signs of inflammation, and bleeding.

ELECTROLYTE IMBALANCES

Hypokalemia

  • Symptoms: Muscle weakness, arrhythmias, characterized by U waves on an EKG.

Hyperkalemia

  • Symptoms: Risk of cardiac arrest, peaked T waves on an EKG, dietary focus on foods high in potassium.

Hypocalcemia

  • Symptoms: Tetany, muscle cramps, and positive Chvostek and Trousseau signs; prolonged QT intervals on EKG (treat with IV calcium gluconate, also a complication in thyroidectomy).

Hypercalcemia

  • Symptoms: Muscle weakness, constipation, kidney stones, bone pain, confusion, shortened QT intervals (treated with IV fluids, diuretics, calcitonin).

PREECLAMPSIA

Definition

  • Occurrence after 20 weeks of gestation; can lead to eclampsia (seizures).

Symptoms

  • Hypertension, proteinuria, edema, right upper quadrant (RUQ) pain.

  • Complications: Risk of seizures, disseminated intravascular coagulation (DIC), HELLP syndrome, placental abruption. Risks increase in those >40 years older or primigravida.

Treatment

  • Medication: Magnesium sulfate (monitor respiratory rate, urine output, deep tendon reflexes).

  • Antidote for toxicity: Calcium gluconate.

  • Nursing Precautions: Ensure patient safety during seizure precautions, pad rails, maintain adequate fluid intake, monitor I&O, and assess for intrauterine growth restriction (IGR).

NAEGELE RULE

  • Calculation Method: To determine the estimated date of delivery (EDD):

    • Start with the first day of the last menstrual period (LMP), add 7 days, subtract 3 months, and add 1 year.

    • Example: If the LMP is June 10, 2025:

    1. Add 7 days: June 17, 2025

    2. Subtract 3 months: March 17, 2025

    3. Add 1 year: March 17, 2026

PREGNANCY TERMINOLOGY

Gravida and Parity

  • Gravida: Refers to the number of pregnancies a woman has had, including the present.

  • Parity: The number of births a woman has experienced.

GTPAL Classification

  • G: Gravida: Number of pregnancies including the present.

  • T: Term: Number of births that occurred after 37 weeks.

  • P: Preterm: Number of births that occurred before 37 weeks.

  • A: Abortions: Number of terminated pregnancies (spontaneous or elective) before 20 weeks.

  • L: Living: Number of living children, which can be greater than P if multiples were delivered or less if a loss occurred.

Pregnancy Signs

  • Presumptive Signs: Amenorrhea, nausea and vomiting, increased urinary frequency, quickening (fetal movement).

  • Probable Signs: Hegar sign, Goodell sign, Chadwick sign, ballottement.

  • Positive Signs: Fetal heart rate (FHR) detected via Doppler, ultrasound, radiography, or active fetal movement confirmed by the examiner.

DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

Definition

  • Condition characterized by many small clots in blood vessels leading to widespread bleeding.

Symptoms

  • Bleeding everywhere, including petechiae (tiny red spots), bruising, bleeding from IV sites, and gums.

Predisposing Conditions

  • Risks include placental abruption, amniotic fluid embolism, HELLP syndrome, liver disease, gestational hypertension, intrauterine fetal death, sepsis, severe postpartum hemorrhage.

Lab Findings

  • Low Platelets, Low Fibrinogen.

  • Elevated Fibrinogen, D-dimer, PTT/PT, and clotting time.

  • Signs of shock should be monitored. Urine output should exceed 30 mL/hr as renal failure is a complication of DIC.

Management

  • Treat cause, monitor bleeding, replace blood components, monitor vital signs, presence of sepsis, trauma, and others. Heparin therapy may replace clotting factors exhausted during DIC.

POSTPARTUM COMPLICATIONS

Possible Complications

  • Hemorrhage, breast infections (Mastitis), other infections, deep vein thrombosis (DVT).

  • Assessment Criteria:

    • Firmness of the uterine fundus.

    • Amount of lochia (vaginal discharge).

    • Whether the bladder is empty.

Management Strategies

  • Postpartum Laceration: Manage pain, ensure proper perineal care, monitor for bleeding, suggest sitz baths.

  • First 24 hours: Use ice packs for pain relief.

  • Post 24 hours: Switch to sitz baths as needed for comfort.

NEWBORN VISION

Assessment Criteria

  • Normal Vision Indicators: Red reflex present in both eyes, ability to see objects 8-12 inches away, presence of blink reflex, pupillary response (constriction to light), ability to visually track movements.

MASTITIS

Assessment

  • Symptoms: Fever, redness of breast, flu-like symptoms, localized pain and heat, swollen axillary lymph nodes.

Interventions

  • Emphasize good hand hygiene and breast care. Offer comfort measures, apply heat as prescribed, provide a supportive bra, and maintain lactation (pump every 3-4 hours).

  • Medications: Antibiotics as necessary.

DEEP VEIN THROMBOSIS (DVT)

Definition

  • Clot formation in the leg, commonly presenting as pain or tenderness, particularly during walking/standing.

Risks

  • DVT can lead to pulmonary embolism (PE) when clots dislodge from the leg and travel to the lungs.

  • Signs of PE: Sudden shortness of breath (SOB), chest pain (CP), tachycardia, coughing blood, low oxygen saturation, anxiety.

ABORTION TYPES

Definitions

  • Threatened Abortion: Closed cervix with bleeding.

  • Complete Abortion: Closed cervix; loss of all products of conception.

  • Inevitable Abortion: Open cervix with bleeding.

  • Incomplete Abortion: Open cervix with partial loss of conceptions.

  • Missed Abortion: Closed cervix; fetus dies in utero without expulsion.

PERIPHERAL ARTERIAL DISEASE (PAD)

Overview

  • Definition: Chronic condition resulting in partial or total arterial occlusion, depriving lower extremities of oxygen (O2) and nutrients leading to tissue damage.

Assessment

  • Assessment of peripheral pulses for diminished or absent flow, pain during walking (claudication).

Patient Education

  • Self-Care:

    • Avoid crossing legs, sitting or standing for long periods, and elevating feet above heart.

    • Promote circulation by keeping legs dependent.

    • Avoid smoking and caffeine as these worsen circulation problems.

    • Conduct daily foot checks and encourage patient to walk to the point of claudication, rest, then resume activity.

Medications

  • Clopidogrel and aspirin prescribed for management.

RAYNAUD PHENOMENON

Definition

  • Vasospasm of arteries in upper and lower extremities.

Assessment

  • Symptoms include numbness, tingling, swelling, cold fingers, blanching of the extremity, and cyanosis due to vasoconstriction.

Interventions

  • Encourage avoidance of cold exposure. Recommend warm clothing, gloves and socks when in the cold.

  • Quitting smoking and using vasodilators (e.g., Nitroglycerin skin ointment) to improve circulation to fingers. Stress management is also important.

VENOUS INSUFFICIENCY

Overview

  • Definition: Prolonged hypertension damages veins and stretches valves.

Assessment and Symptoms

  • Symptoms include brown discoloration along the ankles, edema, and ulcer formation.

Interventions

  • Leg elevation above heart during rest, use of compression stockings during the day/evening (wearing them consistently may be required). Avoid prolonged sitting, standing, and crossing legs. Compression over open ulcers may be necessary.

Medications

  • Warfarin or Heparin may be used for treatment.

OVULATION AND MENSTRUATION

Ovulation

  • Occurs approximately 14 days before the next menstrual period (with a variance of +/- 2 days).

Menstrual Pain Management (for Teens)

  • Effective methods include medications and comfort measures.

CONTRACEPTIVE TEACHING

Diaphragm

  • Usage Instructions: Insert before intercourse and must remain in place for 6 hours after sexual activity but should not be left longer than 24 hours.

Vasectomy

  • Not effective immediately until sperm count confirms zero; backup contraception required for 3 months.

ABRUPTIO PLACENTAE

Definition

  • Separation of placenta from uterus after the 20th week of gestation prior to delivery.

Symptoms

  • Symptoms include painful bleeding, uterine tenderness, pain, severe abdominal pain, fetal distress (an emergency), a rigid uterus, and dark red bleeding.

Interventions

  • Monitor maternal vital signs and fetal heart rate, administer oxygen, maintain IV access. Trendelenburg position may be used to decrease fetal pressure; side lying position preferred during monitoring. Prepare for an emergency delivery if indicated.

PREMATURE RUPTURE OF MEMBRANES

Definition

  • Fluid leakage from the amniotic sac, can lead to increased risk of infection (chorioamnionitis).

Risk Factors

  • Associated with smoking and certain genital infections.

Monitoring

  • Temperature checks for fever indicating potential infection are crucial.

NITRAZINE TEST

Overview

  • Utilized to determine the presence of amniotic fluid; a positive test turns blue-green or deeper colors on the strip, indicating amniotic fluid leakage.

C-SECTION PRIORITY

Emergency Situations

  • Prioritization based on:

    • Fetal distress

    • Umbilical cord prolapse

    • Placental abruption (abruptio placentae)

    • Placental previa (PP)

    • Cephalopelvic disproportion (CPD)

Monitoring

  • Check for bleeding (lochia), assess for hemorrhage, and ensure fundal firmness while controlling pain effectively.

MASS CASUALTY TRIAGE

Priority Levels

  • Red: Immediate care required for airway issues, severe bleeding, shock, or respiratory distress.

  • Yellow: Delay care for moderate cases such as bone fractures or stable abdominal injuries.

  • Green: Minor injuries including small cuts, sprains, and minor fractures.

  • Black: Expectant category for patients who are not breathing or have severe head trauma or cardiac arrest.

ANTHRAX

Definition

  • Caused by Bacillus anthracis, can be contracted via digestive routes, cuts through the skin, or inhalation of spores.

Transmission Methods

  • Skin: Through cuts or abrasions after contact with infected animals or products.

  • Gastrointestinal: Consumption of contaminated undercooked meat leading to symptoms like nausea and vomiting.

  • Inhalation: Breathing in spores leading to respiratory symptoms and shock, as toxins damage lung tissues.

Laboratory Testing

  • Blood cultures for Bacillus anthracis DNA via PCR testing.

  • Antibiotic Treatment: Administer appropriate antibiotics for 60 days, e.g., Ciprofloxacin, Doxycycline, Penicillin.

  • Expect Improvement: Anticipated 2-3 days after starting antibiotics.

STANDARD PRECAUTIONS

  • Required due to the non-person to person nature of anthrax transmission.

BLOOD TRANSFUSIONS

Protocol in Case of Reactions

  • Immediate action: Stop the transfusion, maintain IV access with normal saline, closely monitor vital signs, and send the blood bag for investigation.

CONTACT PRECAUTIONS DISEASES

Examples

  • MRSA (methicillin-resistant Staphylococcus aureus), VRE (vancomycin-resistant Enterococcus), C. difficile, Scabies, Impetigo.

  • Personal Protective Equipment (PPE): Required include gloves and gowns; use a private room wherever possible.

DROPLET PRECAUTIONS DISEASES

Examples

  • Influenza (Flu), Pertussis (Whooping cough), Meningitis, Mumps, Rubella.

  • Contact Precautions: Surgical mask is needed for interacting with patients.

AIRBORNE PRECAUTIONS DISEASES

Examples

  • Tuberculosis, Measles, Chickenpox (Varicella).

  • Personal Protective Equipment (PPE): N95 masks required, along with a negative pressure room setup.

FINAL NCLEX PRIORITY TIPS

  • Medication prepared in a syringe is not for the patient - do not administer, contact pharmacy, and check prescription and label accuracy.

  • Always assess the patient as soon as possible, notify healthcare providers, monitor, and document any errors.

  • Prioritize airway first, adhere to ABCs (Airway, Breathing, Circulation), ensure safety, manage pain and comfort.

  • Apply Maslow’s Hierarchy of Needs to guide care and interventions (physiological needs first).

  • Distinguish between acute vs. chronic, unstable vs. stable, and unexpected vs. expected findings.

  • Urine Output: Best indicator for perfusion; less than 30 mL should be reported.

  • Board-like Abdomen: This signifies an emergency situation.

  • LION (for obstetric fetal distress): Actions include lifting the patient's left side, administering IV fluids, providing oxygen, and notifying the healthcare provider.

  • Ulcer Patients: At risk for bleeding, vigilance is required for signs of hemorrhage.

  • Take care with Digoxin: low potassium levels raise toxicity risks.

  • Hypovolemic Shock: The first sign is often tachycardia before hypotension occurs.

  • Asthma Patients: A silent chest is an emergency situation.

  • Best Position for Orthopnea: High Fowler's or tripod position.

  • Warfarin Usage: Often prescribed for atrial fibrillation (Afib) to prevent stroke by reducing thrombus formation.

  • Unlicensed Assistive Personnel (UAP): Should never teach, assess, or administer medications; only perform activities of daily living (ADLs).

  • Unexpected or Worsening Findings: Always take action to identify and address potential complications or deteriorating patient conditions.