Presentation on theme: "Nursing Care of Patients WithUpper GI Disturbances"— Presentation transcript:
1 Nursing Care of Patients WithUpper GI Disturbances Nursing Management IIWhen we talk about upper GI disturbances we usually are discussing structures and disease processes including the mouth, the esophagus, the stomach, and the duodenum. We will be covering the topics found in your readings which included GERD, achalasia, hiatal hernia, gastritis, peptic ulcer disease and cancers of the esophagus and the stomach.
2 Knowing Gastroesophageal Reflux Backward flow of the gastric contents into the esophagusHeartburn is hallmark symptomPressure differences between stomach and lower esophagusContributing factorsIncreased gastric volumePositioning (bending over, lying down)ObesityTight clothingHiatal herniaCauses: Transient relaxation of the lower esophageal sphincterIncompetent lower sphincterIncreased pressure within the stomachFactors contributingIncreased volume after a large mealPositioning which allows acids to remain close to gastroesophageal junctionIncreased gastric pressure obesity or wearing tight clothingWhat is in gastric juices? Acid, pepsin, bile and all are corrosive!Normally esophageal peristalsis along with salivary bicarbonate clear the esophagus of refluxed gastric secretions.ResultsEsophageal mucosa can become damaged by gastric juices that can cause an inflammatory response.Prolonged exposure can result in esophagitis.Superficial ulcers may develop and the mucosa may begin to bleed.If this is not treated, the esophagus can become scarred and sometimes strictures can develop.
3 Manifestations of GERD Have you ever had heartburn???Regurgitation into the esophagus and sometimes regurgitation of sour material into mouth. Can also have difficulty swallowing or pain with swallowing.Atypical chest pain (beware that cardiac pain many times cannot be differentiated from heartburn)BelchingSore throatAspiration of gastric contents can cause hoarseness or respiratory symptoms
4 Complications with the Esophagus Esophageal stricturesBarrett’s esophagusBarrett’s esophagus has changes in the cells lining the esophagusAlso places the client at an increased risk for esophageal cancer! Adenocarcinoma is commonly associated with Barrett’s esophagus.Esophageal cancer – rare in the US. High mortality rate because of late diagnosis.Squamous cell is the most common.Most common symptom is progressive dysphagia.Manifestations include weight loss, regurgitation, chest pain, anemia, GERD – like symptoms, anorexia, persistent cough.Diagnostic tests include – barium swallow, esophagoscopy, chest x-ray, CBC, liver function testsHealth promotion – dangers of cigarette smoking, and alcohol consumption.Nursing Diagnosis:Impaired swallowing – Aspiration precautions, positioningImbalanced Nutrition: Less than Body Requirements fluid monitoring, nutrition managementFear/ Anticipatory GrievingRisk for Ineffective Airway clearance – coughing and deep breathing, enteral tube placement, avoid overdistentionTreatmentSurgeryRadiationChemotherapy
5 Knowing AchalasiaImpaired esophageal motility that causes dysphagia or even chest pain.Unknown etiologyImpaired peristalsis of the smooth muscle of the esophagus combined with impaired relaxation of lower esophageal sphincterGradual increasing dysphagia with foods that are solid and liquidManifestations:Fullness in chest with mealsChest painCough developing at nightDiffuse esophageal spasms (chest pain can be severe!)Treatment:Endoscopically guided injection of botulinum toxin in lower esophageal sphincterBalloon dilatation of lower esophageal sphincterLaparascopic myotomy (incision into muscle of the LES) which reduces pressure and reduces symptoms
6 Knowing Hiatal Hernias The stomach protrudes thru the esophageal hiatus of the diaphragm into the thoracic cavity. There are different types and if treatment of symptoms does not present relief, surgery can be done. Post op care is similar for that of abdominal or thoracic surgery clients.Many individuals are without symptomsfullness, reflux heartburn, occult bleeding, chest pain, dysphagia, belching, indigestionNursing Care: Chocolate or mint increases pressureAvoid spicy foodsNo tight clothingWeight reductionSmall frequent mealsElevate the HOB 6-8InchesAvoid eating three hours before bed
7 Knowing Gastritis: Acute and Chronic Manifestations of Acute:AnorexiaPain, nausea, vomitingMelena or hematemesisBelchingManifestations of Chronic:Asymptomatic or vague symptomsOnce atrophied, then digestiveand gastric emptying problemsFatigueAnemiaB12 deficiency may existH. pyloriAcute: disruption of mucosa due to a local irritant. (ASA, NSAIDS, corticosteroids, alcohol, caffeine or foods contaminated with bacteria) Iatrogenic causes include radiation, and administration of certain chemo drugs) Disruption allows HCL and pepsin to come into contact with gastric tissue, resulting in irritation, inflammation, and superficial erosions.The mucosa rapidly regenerates and limits the disorder when the problem is resolved and healing has occurred. Usually self-limited and resolves within a couple of days.Erosive: severe form of acute gastritis; also known as stress-induced gastritis.Complication of other life threatening illness like shock, trauma, surgery, sepsis, burns or a head injury.Ischemia of the gastric mucosa either from vasoconstriction and tissue injury from acid. Leads to multiple gastric tissue erosions. Keeping the gastric pH greater than 3.5 can help in prevention.Many times you will see on the patients we care for that they are placed on GI prophylaxis. May have painless GI bleedingChronic:progressive disorder;starts with superficial inflammationgradually leads to a more debilitating condition that atrophies the gastric tissue.Type A may have an autoimmune componentType B is the most common form of chronic gastritis.Incidence increases with age and is almost 100% in people over the age of 70.Caused by H. pylori infection that inflames the gastric mucosa and causes infiltration of neutrophils and lymphocytes; the outer layer thins and atrophies and provides a less effective barrier against the autodigestive properties of HCL and pepsin.Increased risk for peptic ulcer disease
8 Medications Proton pump inhibitors H 2 receptor blockers Anti-ulcer Promotility agentsAntacidsClients testing + for H. pylori will be placed on combination antibiotic and PPI therapiesProton Pump Inhibitors: Inhibit the hydrogen – potassium pump, reduce gastric acid secretionPrevacidPrilosecProtonixAciphexAdminister before breakfastDo not crushMonitor liver functionsAvoid cigarette smoking and irritantsReport signs of bleedingH2 antagonists – reduce acidity of gastric juices by blocking the ability of histamine to stimulate acid secretion by the gastric parietal cellsTagametPepcidZantacAxidDo not give an antacid within 1 hourDo not mix with other drugsRapid IV injection may cause dysrhytmias and hypotensionLong term use can lead to gynecomastasia and impotence in men, breast tenderness in womenAnti-Ulcer- reacts with gastric acid to from a thick paste which adheres to damaged mucosa protects and promotes healingCarafateAdminister on an empty stomachDo not crush or chewIncrease intake of fluids and fiber to prevent constipation.Promotility: Acts on CNS to stimulate motility and emptyingReglan – give 30 minutes before meals or at bedtimeDo not administer if obstruction, bleeding, history of seizures, pheochromocytoma or Parkinson’sMonitor for extrapyramidal side effects – difficulty speaking, or swallowing, loss of balance, gait disturbances, twitching or twistingOr tardive dyskinesia: rhytthmic facial movement, lip smacking, tongue rollingMay be given undiluted IV push over 1 – 2 minutesAntacids – Buffer or neutralize gastric acidMay interfere with absorption of other drugs take 1 – 3 hours after meals, 2 hours before or 1 hour after other meds.
9 Upper EndoscopyModern scopes allow photographs to be taken to document findings.Also called esophagogastroduodenoscopy (EGD)
10 Commonly Used Diagnostic Test Allows direct visualization of the esophagusCan also biopsyUses conscious sedationCulture for H. pylori (bacteria linked to chronic gastritis & peptic ulcer disease)Nursing implications:no special prep for EGD – schedule 2 days after barium studies,Keep NPOEducation on procedure and what to expect afterInformed consent signedRemove dentures, glasses, and provide mouth care before testingNurses assisting with the procedure will monitor VS, pulse ox, LOC, GCS scoreEducate after procedure on when to notify the physicianDifficulty swallowing, bleeding, epigastric pain, shoulder pain, chest pain, black stools
11 Common Nursing Diagnosis Imbalanced Nutrition Less than Body RequirementsPainIneffective Health MaintenanceOthers may include:Deficient Fluid volume with acute gastritisRisk for Ineffective Airway Clearance post op esophageal cancerFear- CancerAnticipatory Grieving- Cancer
12 Knowing Peptic Ulcer Disease Peptic Ulcers may occur in the esophagus, stomach or duodenumDuodenal most common.Gastric more often affect older adultsRisk FactorsH Pylori InfectionUse of NSAIDSCigarette SmokingFamily HistoryPeptic ulcer disease – break in the mucous lining of the GI tract
14 Manifestations and Complications Pain is classic symptomComplicationsHemorrhageGastric Outlet obstructionPerforationPain usually occurs when the stomach is empty.Classic pain- food- relief pattern. May also have heart burn or regurgitationPresentation less clear in older adult vague abdominal discomfort, chest pain, weight loss, anemiaHemorrhage in % Symptoms of anemiaGastric outlet obstruction secondary to edema surrounding the ulcerMost lethal complication is perforation leading to peritonitis.Zollinger Ellison is peptic ulcer caused by gatrinoma or gastin secreting tumor of pancreas, stomach or intestines.Symptoms are pain and may have steattorhea.
15 Collaborative Care Diagnostics Upper GI Gastroscopy H. Pylori Testing Biopsy Urease testUrea breath testBiopsy urease – specimen placed in gel If H. Pylori is present the urease produced by H. Pylori changes the gel colorUrea breath test - radiolabeled urea used bacteria converts to ammonia and carbon dioxide that can be measured when the patient exhales. Also used to evaluate treatment.
16 Collaborative Care Treatments Dietary management Surgery Management of complicationsMedicationsEradicate H. PyloriDecrease gastric acid contentAgents that protect the mucosaCombination two antibiotics plus bismuth or proton pump inhibitors. Erythromycin or Tetracycline.Prostaglandin analogs misoprostal promotes healing by stimulating mucous and bicarb secretions. And inhibiting
17 Knowing Stomach Cancer Risk FactorsH. Pylori InfectionsGenetic PredispositionChronic GastritisPernicious anemiaGastric polypsCarcinogenic factors in the diet such assmoked food and nitratesAdenocarcinoma is the most common formMost frequently found in the distal portionMetastasize early because of lymph and blood supplyUsually find mets to liver, lungs, ovaries, and peritoneumFew symptoms usually advanced at time of diagnosis may have vague feelings of fullness, early satiety no appetite, often look cachectic. May have blood in stool.Prognosis is poor
18 Collaborative Care Diagnostics Surgery Partial gastrectomy Billroth I (duodenum)Billroth II (jejunum)Total gastrectomyPostoperative Nursing CareCBC, Upper GI, endoscopyComplicationsDumping Syndrome- common complication undigested food bolus rapidly enters the duodenum or jejunum water is pulled in because hypertonicresulting in increasing intestinal motility.Symptoms occur within 30 minutes of eatingTreatment: small frequent meals, increase protein and fat, decrease carbs, semirecumbent after meals may get antispasmodics and sedatives.Second complication is B12 deficiency pernicious anemiaPoor absorption of calcium and weight loss.May require insertion of feeding tubes.In addition to surgery may have chemo and or radiation.