Chapter 28 Care of Patients with Disorders of the Upper Gastrointestinal System - PowerPoint Presentation

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Chapter 28Care of Patients with Disorders of the Upper Gastrointestinal System

Medical-Surgical Nursing: Concepts & Practice3rd edition

Copyright © 2017, Elsevier Inc. All rights reserved.Slide2

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Discuss eating disorders and their management, including bariatric surgery.Compare the signs and symptoms of oral, esophageal, and stomach cancer.Illustrate the cause of gastroesophageal reflux disease (GERD).Explain the etiology and prognosis for Barrett’s esophagus.Describe the pathophysiology, means of medical diagnosis, and treatment for gastritis.

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Theory ObjectivesSlide5

Compare and contrast the treatment and nursing care of the patient with GERD and a patient with peptic ulcer.Review the difference in the care of the patient with a nasogastric tube for decompression and care of the patient with a feeding tube.Compare the care for a patient receiving total parenteral nutrition with care of the patient receiving enteral feedings.

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Theory Objectives (Cont.)Slide6

Implement a teaching plan for a patient who has GERD.Plan postoperative care for a patient having gastric surgery.Demonstrate proper care of the patient with a Salem sump tube for gastric decompression.

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Clinical Practice ObjectivesSlide7

Clinical Practice Objectives (Cont.)Manage a tube feeding for the patient receiving formula via a feeding pump.Review a nursing care plan for the patient with a gastrointestinal disorder.Write a nursing care plan for the patient with an upper gastrointestinal disorder.

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Anorexia Nervosa – Psych DisorderPatients with anorexia nervosa refuse to eat adequate quantities of food and are in danger of literally starving to death.Diagnosis requires extensive interviewing and treatment, including behavior modification and nutrition support, which may take months to years.

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Bulimia NervosaPatients with bulimia consume large quantities of food and then induce vomiting to get rid of it so that weight is not gained.Laxatives – purge after the eating bingeSome patients with anorexia nervosa also have bulimia.

Some individuals practice bulimia occasionally without harm. 9Slide10

Bulimia Nervosa (Cont.)Bulimia can lead to severe fluid and electrolyte imbalances, dental problems, starvation, and death.Treatment of bulimia includes psychotherapy, antidepressant medication, and behavior modification.

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ObesityEtiology and pathophysiology – diet, lack of exercise and overconsumption of foodSigns and symptoms – obsese 20% over ideal weight

DiagnosisHeight and weight chartWaist and hip circumferenceBody mass index (BMI) 11Slide12

Older Adult - ObesityDecreased mobility from arthritisSnacking on junk foods to replace mealsMetabolic rate slows – need less calories than before

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Obesity TreatmentBariatric surgery – reduces gastric capacityExtensive counseling and assessmentModify lifestyle and stringent regimen required to lose weight and keep weight off

Types – see page 646Gastric restrictiveMalabsorptiveGastric restrictive combined with malabsorptive surgery 13Slide14

Bariatric SurgeryPreoperative careThere is greater risk of pulmonary embolism and thrombus formation, as well as death, for obese patients.

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Restrictive ProceduresLaparoscopic adjustable gastric banding is performed by placing an inflatable band around the fundus of the stomach.The band is inflated and deflated via a subcutaneous port to change the size of the stomach as the patient loses weight.

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Restrictive Procedures (Cont.)For vertical banded gastroplasty, the surgeon creates a small stomach pouch by placing a vertical line of staples.A band is placed to provide an outlet to the small intestine.

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The total gastric bypass procedure causes severe nutritional deficiencies and is no longer recommended.The roux-en-Y gastric bypass (RYGB) limits the stomach size, and the duodenum and part of the jejunum are bypassed. This limits the absorption of calories.

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ComplicationsLeakage of stomach contentsGastric stretchingDumping syndrome – nausea, weakness, sweating, and diarrhea that occurs after mealsNutritional deficiencies—iron, vitamin B

12, calcium, and folateApprox 1/3 of the bariatric patients develop gallstones because of the rapid weight loss 19Slide20

Healthy People 2020 Goals Related to Losing Weight and ObesityIncrease the proportion of adults who are at a healthy weight.Reduce the proportion of adults who are obese.Reduce the proportion of children and adolescents who are overweight or obese.

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AssessmentFamily historyContributing factorsRecord of eating patterns for a 7-day periodWeight and height

BMISkinfold thickness measurementGeneral health assessment 21Slide22

Expected OutcomesPatient will make positive statements about decreasing body size.Patient will verbalize feelings of self-worth.

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ImplementationDiet and exercise planLifestyle and preferencesEating and exercise diaryGuidance and support

Discourage fad diets and emphasize the importance of a well-balanced, nutritious, low-calorie diet.Commercial programs on weight reduction 23Slide24

Upper GI DisordersStomatitis – inflammation of the mucous membranes of the mouth Causes – smoking, excessive alcohol, pathogenic organisms, radiation therapy and drugs (chemotherapy)Dysphagia – difficulty swallowing

Causes –inflammation, tumors, neurologic Dos, strokeDiagnosis – eval by speech therapistTreatment – select foods, liquids (thickened)Nursing management – have patient “practice swallowing” prior to eating meals

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Cancer of the Oral CavityEtiology – unknown cause, smoking, alcoholPathophysiology – Leukoplakia (usually seen by a dentist) lesion on tongue or mucosaSigns and symptoms – sores on lips/in mouth that don’t heal in 2 weeks

Diagnosis—physical examination and biopsyTreatment—radiation, chemotherapy, and surgeryNursing management – monitor airway, tube feedings 26Slide27

Cancer of the EsophagusCigarette smoking is a major cause of esophageal cancer in the United States.When combined with heavy alcohol consumption, the risk for esophageal cancer greatly increases.Esophageal cancer is the second most common cancer in China but is seen less in North America.

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Cancer of the Esophagus (Cont.)GERD is a cause of Barrett’s esophagus, which is a precancerous condition.

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Barretts esophagus

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Cancer of the Esophagus (Cont.)Signs, symptoms, and diagnosis – dysphagia, hoarseness, persistent coughTreatmentEsophagectomy

– removal of sections of the esophagus then reconstructed with stomach partsNursing managementPostoperative care – maintain patent airway-Nutrition – parental fluids initially, gradually bland foods, small, frequent meals 30Slide31

Audience Response Question 1When screening for the presence of risk factors for oral and pharyngeal cancers, the nurse would ask which question(s)? (Select all that apply.)

“How much alcohol do you consume?”“Have you had any oral lesions?”“Do you have family members who have cancer?”“What do you smoke?”“Have you been exposed to hepatitis virus?”

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Hiatal Hernia (Diaphragmatic Hernia)Etiology and pathophysiology- defect in the wall of the diaphragm where the esophagus passes through. Protrusion of part of the stomach or lower part of the esophagus up into the thoracic cavity.Signs and symptoms – none there may be reflux of stomach acid, feeling of pressure after eating from reflux, worse when lying down.

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Treatment of Hiatal HerniaReduce weight.Avoid tight-fitting clothes around the abdomen.Take antacids and histamine (H2

)-receptor antagonists.Elevate head of the bed on 6- to 8-inch blocks.Take proton pump inhibitors (PPIs). 33Slide34

Treatment of Hiatal Hernia (Cont.)Instruct not to eat within several hours before going to bed.Limit intake of alcohol, chocolate, caffeine, and fatty foods.Avoid smoking.

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Nursing ManagementTeach ways to prevent pain and reflux.Encourage weight reduction.Remind the patient to stay upright for 2 hours after eating and not to eat for 3 hours before bedtime.

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Gastroesophageal Reflux DiseaseEtiology and pathophysiology – transient relaxation of the lower esophageal sphincter – may accompany hiatal herniaSigns and symptoms – heartburn (dyspepsia) reflux, dysphagia

Diagnosis and treatmentNursing managementDiet therapy, lifestyle changes, drug therapy, and educationComplications 36Slide37

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GastroenteritisCaused by food or water contaminated with a virus, a pathogenic bacteria, or parasitesSigns and symptoms – vomiting, elevated WBCs, abdominal cramping, diarrhea, blood or mucus in stoolManagement – NPO until vomiting stops, then fluids with glucose and electrolytes, after 24 to 48

hrs, medication may be given if vomting/diarrhea continues 38Slide39

GastritisEtiology –Helicobacter pylori bacteria (could also be viruses or other bacteria)Pathophysiology – acute or chronic inflammation of the lining of the stomachSigns and symptoms – anorexia, nausea, vomiting, pain and tenderness in stomach

Diagnosis – hx, physical exam & endoscopyTreatment – Antispasmodics, antacids, H2 receptor antagonist, proton pump inhibitor to decrease hydrochloric acid 39Slide40

Treatment for GastritisAcute versus chronic gastritisChronic gastritisAntispasmodics

AntacidsH2-receptor antagonist such as ranitidinePPIsAntibiotic therapy for Helicobacter pylori

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Peptic Ulcers – loss of tissue of the upper GI tractEtiologyH. pylori is the major cause – smoking and NSAID use are other causesDuodenal ulcers and some pre-pyloric ulcers

Gastric ulcersTension, anxiety, and prolonged stress does have impact of the progression of ulcersDrug-induced ulcersStress ulcers – different from peptic ulcer –more acute and more likely to produce hemorrhage- hazard for patients in ICU for extensive periods

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Peptic Ulcers (Cont.)Pathophysiology – mucosa cannot protect itself from corrosive substances.Signs and symptomsDaily pattern of pain

Gastrointestinal bleeding – c/o weakness, feeling faint, N&V, restlessness, thirst, confusion. Vomit bright red blood, or coffee ground look (blood with gastric juices) or appears in stool.DiagnosisEndoscopyGastric acid analysis

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Peptic Ulcers (Cont.) page 655 43

The most common site is the duodenum just beyond the pyloric muscleSlide44

TreatmentAntacidsGastric bleeding and normal saline lavageH2-receptor antagonist

PPIsPresence of H. pylori—administration of clarithromycin (Biaxin) plus another antibiotic, an H2 inhibitor, and a PPI 44Slide45

Safety Alert page 656PPI drug interactionsPPI slow liver’s ability to metabolize and clear drugs from the bloodstreamCAUTION with patients taking Valium, Dilantin, and Coumadin. Watch for signs of toxicity

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Peptic ulcer 46Slide47

Nursing ManagementComplicationsHemorrhage – the ulcer erodes vessels, causing bleeding into the stomachPerforation –sudden/severe pain upper abdomen erosion of ulcer through the walls of stomach/intestine into the peritoneal cavity spilling contents of the GI tract

Obstruction – persistent vomiting from scarring at the pylorus –narrow the stomach outlet 47Slide48

Surgical Treatment of Peptic Ulcer- page 657Pyloroplasty with truncal or proximal gastric vagotomy (severe 10 cranial nerve that stimulates acid secretion) – widen the pylorus

Subtotal gastrectomy (gastric resection)Total gastrectomy – total removal of stomach. Esophagus is joined to the small intestine 48Slide49

Nursing Care of the Patient Undergoing Gastric SurgeryPreoperative care – liquid diet, day of surgery NPO, NG tube all stomach contents suctioned out in ORPostoperative care – gradual addition of food

Specific patient teachingDiet restrictions  Dumping syndrome 49Slide50

Dumping syndrome

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Gastric CancerEtiology acholorhydria (absence of hydrochloric acid) pernicious anemia, diet high in nitrates, H.pylori, genetics, type A blood type

Signs and symptoms – no symptoms until far advanced, indigestion, loss of appetite, N&VPathophysiology - tumors arise in pyloric area. Spreads to layers of stomach, lymph nodes, the liver and ovaries in women 51Slide52

Gastric CancerDiagnosis –upper GI series, endoscopy with biopsyTreatment – removal of tumors, lymph node dissection, radiation/chemo

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Common Therapies for Disorders of the Gastrointestinal SystemGastrointestinal decompression – abdominal distention from excess fluids and gases. Insertion of NG tube used to remove. If using Salem Sump Tube – keep the tube above the level of the stomachEnteral nutrition –small bore tube inserted confirmed placement with

xray before feedings startTotal parenteral nutrition – IV feeding using a large central line such as superior vena cava 53Slide54

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Small-Bore Feeding Tube Placement 55Slide56

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