Patient_Education_Plan

Patient Education Plan Beatrice Williamson University of Phoenix Health and Chronic Disease Management NUR427 Deborah Lilly RN MSN CCRN February 08, 2010 Patient Education Plan The disease process chosen for the patient education plan is a gastrointestinal diagnosis of peptic ulcer disease. Content will include a hypothetical patient scenario including defining characteristics of the disease, challenges in management of the disease process, patient education, treatment plan, efficacy of plan development, success of patient adaptation, and application to current lifestyle. The patient scenario is as follows: Mary K. is a 62 year old female widowed for nine months after 35 years of marriage directly out of high school. She is currently working a secretarial job. She was diagnosed with arthritis four years ago to the lower back as a result of an MVA with back injury five years ago. She has been taking an NSAID (naproxen) for pain management for three years, drinks alcohol daily in moderation for the majority of her adult life, and has smoked cigarettes for 40 years. Recently, she has been experiencing loss of appetite and burning stomach pain off and on for about a month. The pain can last from minutes or hours, and disappears and returns for several days or weeks at a time. She has noticed the pain is worse one half to one hour after a meal, and has a feeling of fullness after drinking a small amount of fluid. She has upper gastric pain towards the left side between her breastbone and naval. She now is experiencing nausea with occasional pink tinged vomit. Mary’s doctor suspects she may have peptic ulcer disease and is referring her to a gastroenterologist for further testing. A peptic ulcer is a condition where a sore or erosion affects the mucous lining of the stomach, duodenum, or both simultaneously where pepsin and hydrochloric acid are present. The esophagus can have ulcers as well from uncontrolled gastroesophageal reflux disease (GERD). According to the University of Maryland Medical Center (2008) states “one in ten Americans will develop at least one ulcer during their lifetime affecting about five million people each year. More than 40,000 people a year have surgery because of persistent symptoms or problems from ulcers, and each year about 6,000 people die of ulcer-related complications. Ulcers can develop at any age, but they are rare among teenagers and even more uncommon in children. Duodenal ulcers occur for the first time usually between the ages of 30 and 50 in men. Stomach ulcers are more likely to develop in people over age 60 and develop more often in women than men” (2008, p. 3). Risk for peptic ulcer disease (PUD) is attributed to family history, alcohol consumption, and tobacco use (smoking and chewing). Risks associated with formation of a peptic ulcer are not related to consumption of spicy, rich foods or stress, but can discourage healing or intensify the condition. See Figure 1 display of anatomy affected by peptic ulcer disease according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). [pic] An antecedent for PUD is the use of non-steroidal anti-inflammatory drugs (NSAID’s) used for reduction of pain and inflammatory conditions. Most do not require a prescription and are purchased over the counter such as aspirin (Bayer), ibuprofen (Motrin, Advil), and naproxen (Aleve). Often individuals will take more than the recommended dosage unaware of the potential for damage to the stomach from NSAID’s which can “cause ulcers by interrupting the ability of the stomach and the duodenum to protect themselves from naturally occurring stomach acid” (Schafer, 2010, p. 2). Another factor contributing towards PUD is the bacteria Helicobacter pylori (H. pylori), a common gastrointestinal infection. ”About 20 percent of people under 40 years old and half of those over 60 years have it. Most infected people, however, do not develop ulcers. Why H. pylori does not cause ulcers in every inflected person is not known” (National Institute of Health, 2004, p. 1). It is not known how the bacteria get into the body or why some people with H. pylori become ill while others do not. The bacteria most likely spread from person to person through the fecal-oral route (when infected fecal matter comes in contact with hands, food or water) or the oral-oral route (when infected saliva or vomit comes in contact with hands, food or water). According to Ignatavicius, D., Workman, M., Mishler, M. an uncommon ulcer condition Zollinger-Ellison syndrome occurs in people between the ages of 20 – 50 years of age. It is characterized by severe peptic ulceration, gastric hyper secretion, elevated serum gastrin, and gastrinoma of the pancreas or the duodenum. Two thirds of the tumors are malignant. If medical interventions are unsatisfactory, a vagotomy and pylorplasty may be indicated. If all therapies fail, a total gastrectomy is recommended. (Ignatavicius, Workman, & Mishler, 1999, p. 1399). A comprehensive work-up is performed in order to gather information in order to diagnose and treat the patient’s symptoms and disease process. The most general complications of PUD are perforation, hemorrhage, pyloric obstruction, and intractable disease. The most common assessment tools are a hemoglobin and hematocrit lab value or stool sample to check for bleeding and a breath test which checks for antibodies to H. pylori bacteria. A barium swallow known as an upper GI may show proof of an ulcer if there are not any severe symptoms as in an emergency situation evidenced by blood-tinged vomit. If bleeding is suspected or evident, further testing is required with an EGD. If an EGD is indicated, the patient is moderately sedated with Versed or Valium instead of general anesthesia for quicker recovery and less possible complications associated with general anesthesia. According to National Institute of Health (2009) an “esophagogastroduodenoscopy (EGD) is “a special test performed by a gastroenterologist in which a thin tube with a camera on the end is inserted through your mouth and into the GI tract to see your stomach and small intestine” (MedlinePlus, p. 2). A tissue sample (biopsy) is taken to check for bleeding, cancer, and Helicobacter pylori, a bacterium that lives in the mucous layer that covers and protects stomach tissue lining and the small intestine. It can sometimes alter the mucous layer causing inflammation resulting in an ulcer. Upon completion of tests, Mary is informed of her diagnosis of gastric peptic ulcer with H. pylori present without evidence of hemorrhage or perforation. She is concerned about her lifestyle (food choices, smoking, drinking, stress) and is unsure of how she is to approach and handle her new diagnosis. The nurse’s responsibility for the newly diagnosed patient is to teach Mary about the new diagnosis. In her case, she requires education regarding the anatomy and location of her ulcer. She is taught a gastric ulcer is the result of hydrochloric acid penetrating the stomach lining and responsible for mucosal inflammation. With her circumstance, the ulcer was located on the lesser curve of the stomach which is depicted by an illustration (refer to Fig. 1 p. 3). She is taught restriction to alcohol consumption is advised because it can irritate and cause further break down of the mucous lining, inhibit the healing process, and further the inflammation resulting in the possibility of bleeding. Smoking should be stopped due to increased stomach acid production negating a cure or stabilization. Dietary restrictions are a highly controversial subject. Caffeinated beverage products such as coffee, tea, colas, energy drinks, and spicy, rich, bland, foods are no longer shunned from the diet. It is believed with drug therapy, many foods can be enjoyed without return of gastric pain. The patient can resume her regular diet, and if certain foods cause distress, then the offending food is avoided. It is an individualized process by trial and error, and may take time to figure what foods to avoid for the future. Drug therapy is initialized to first annihilate the H. pylori infection and for the stomach to rest and heal. Dual antibiotics such as clarithromycin, amoxicillin, metronidazole, or tetracycline are integrated to kill infection. H2 antagonists such as ranitidine, famotidine, nizatidine, and cimetidine are incorporated into therapy. Caution must be used with cimetidine use as the side effect of confusion may occur with the elderly population. H2 blockers prevent over production of stomach acid by blocking histamine. Antacids such as Mylanta, Maalox, and Tums must be used cautiously. Many of the ingredients have sugar and sodium, decrease the effects of some antibiotics, and must be used carefully if renal problems are a factor. A mucosal barrier fortifier such as sucralfate reacts to gastric acid by forming a barrier to protect the ulcer (Deglin & Vallerand, 2003, p. C48). It is advisable for Mary to check with her physician to find alternative therapy for her arthritic condition. It is advisable to reduce if not stop use of NSAID’s for healing to occur and for pain relief. The patient will be given brochures, pamphlets, names of organizations, government websites to further her knowledge base; information on counseling centers for assistance in coping with her recent loss of her husband, and workshops for smoking cessation. Information will be provided on local AA groups for future reference. She will also be assessed by social services for qualification of financial assistance and services available to help with her current needs. Patient objectives: 1. Patient will verbalize three or more measures needed to heal and maintain control of peptic ulcer disease. She will identify foods that cause symptoms of epigastric pain, identify blood in stool, and identify types of pain relievers to avoid. 2. Patient will stop smoking, avoid daily consumption of alcohol, take medications prescribed by physician as directed, report changes in bowel function, wash hands with warm soap and water prior to meals, and keep appointment for follow –up. The patient Mary will have a positive outcome by adhering to the medication regimen appointed by her physician. Controlling foods eaten, smoking cessation, reduction or avoidance of alcohol beverages can help Mary live for many years. A major factor for Mary’s condition was use of NSAID’s, smoking, and alcohol consumption. Without further complications, her ulcer can heal and not return by watching her diet, not smoking again, and use other medication for her arthritic pain, such as acetaminophen. She and her physician will devise a plan personalized for her management by reducing the amount of NSAID’s used and can possibly take with meals if she and her physician feel the acetaminophen is not working for her. Today, Mary is well without further complications or symptoms. She is well and looking forward to retirement. References (2008, January 24). Digestive disorders. Baltimore: University of Maryland, Division of Gastroenterology & Hepatology. Deglin, J. H., & Vallerand, A. H. (2003). Davis’s drug guide for nurses (8th ed.). Philadephia PA: F. A. Davis Company. Ignatavicius, D. D., Workman, M. L., & Mishler, M. A. (1999). Medical-surgical nursing across the health care continuum (3rd ed.). Philadelphia: W. B. Saunders. National Institute of Health (2009) MedlinePlus. Retrieved February 7, 2010 from http://www.nlm.nih.gov/medlineplus/ency/article/000206.htm National Institute of Health. (2004). H. pylori and peptic ulcer. Retrieved Februar 5, 2010 from http://www.digestive.niddk.nih.gov/ddiseases/pubs/hpylori/ Neighbors, M., & Tannehill-Jones, R. (2006). Human diseases (2nd ed.). Clifton Park NY: Thomas Delmar Learning. Schafer, T. W. (2010). Peptic ulcer disease. Retrieved February 5, 2010 from American College of Gastroenterology: http://www.gi.org/patients/gihealth/peptic.asp'mode=print&