Nursing Care of Patients with Upper Gastrointestinal Disorders Chapter 33 Nursing Care of Patients with Upper Gastrointestinal Disorders

Nausea and Vomiting Nausea: Urge to Vomit Vomiting: Expelling Stomach Contents Through Esophagus and Mouth Nausea and Vomiting

Therapeutic Interventions None Protect Airway Medications IV Fluids NG Tube Clear Liquids, Dry Toast

Nausea Risk for Aspiration Deficient Fluid Volume Nursing Diagnoses

Lack of Appetite Anorexia

Anorexia Nervosa Bulimia Nervosa Eating Disorders

Anorexia Nervosa Females Treatment goal 18% Die Age 12 to 18 Years Restore Nutritional Health 18% Die Anorexia Nervosa

Anorexia Nervosa (cont’d) Symptoms Severe Weight Loss Low Self-esteem Compulsive Dieting Disturbed Body Image Anorexia Nervosa (cont’d)

Anorexia Nervosa (cont’d) Nursing Care Therapeutic Relationship Vital Signs Daily Weights Intake/Output of Food and Fluids Anorexia Nervosa (cont’d)

Anorexia Nervosa (cont’d) Complications Poor Nutrition, Electrolyte Imbalances Decreased Vital Signs Osteoporosis Muscle Loss Diabetes Anorexia Nervosa (cont’d)

Bulimia Nervosa Compulsive Eating, Self-induced Vomiting Laxatives “Binge–purge” Young Women Enamel Erosion of Front Teeth Metabolic alkalosis Bulimia Nervosa

Bulimia Nervosa (cont’d) Treatment Goal Restore Nutritional Health Nursing Care Therapeutic Relationship Vital Signs, Daily Weights Intake/Output of Food and Fluids Bulimia Nervosa (cont’d)

Nursing Diagnoses: Eating Disorders Imbalanced Nutrition: Less Than Body Requirements Body Image, Disturbed

Obesity Weight 20% or Greater Than Ideal Body Weight BMI Overweight: 25 to 29.9 Kg/m2 Obese: >30 Kg/m2 Obesity

Body Mass Index (BMI)

Obesity (cont’d) Caloric Intake Exceeds Energy Expenditure Comorbidites: Diseases Associated with Obesity Morbid Obesity: BMI >40 Obesity (cont’d)

Therapeutic Interventions Weight Loss Through Exercise and Calorie Restriction Support Groups Behavior Modification Therapeutic Interventions

Surgical Management Types of Bariatric Surgery Restrictive Limits How Much Stomach Can Hold Malabsorption Decreases Calorie/Nutrient Absorption Combination Restrictive and Malabsorption Surgical Management

Surgical Management (cont’d) Restrictive Laparoscopic Adjustable Gastric Banding  Vertical Banded Gastroplasty (VBG) Combination Roux-en-Y Gastric Bypass Surgical Management (cont’d)

Roux-en-Y Gastric Bypass Vertical Banded Gastroplasty

Complications of Gastric Restrictive Surgeries Vomiting Erosion of the Gastric Tissue Breakdown of Staple Line Leaking of Stomach Secretions Infection or Death

Postoperative Care Clear, Liquid Diet Progresses to Full Liquids, Pureed Foods Regular Foods at 6 Weeks Postoperative Care

Nursing Diagnosis: Obesity Imbalanced Nutrition: More Than Body Requirements

Oral Health Care Important to Overall Health Often Neglected in Daily Care Oral Hygiene with Chlorhexidine Gluconate Prevents Pneumonia Reduces Ventilator-associated Pneumonia Oral Health Care

Oral Health Care (cont’d) Prophylactic Antibiotics Xerostomia (Dry Mouth) Artificial Saliva Substitute Dentures Gingival Recession Fluoride Gel or Rinse Oral Health Care (cont’d)

Oral Health Care (cont’d) Gingivitis Flossing Daily Candida Albicans (Yeast Infection) Nystatin Angular Cheilosis Oral Health Care (cont’d)

Stomatitis Inflammation of Oral Cavity Causes Aphthous Stomatitis (Canker Sores) Herpes Simplex Virus Type I (Cold Sores) Stomatitis

Oral Cancer Risk: Alcohol or Tobacco Use Detected Early, Curable Painless Difficulty in Chewing, Swallowing, Speaking Biopsies Radiation, Chemotherapy, Surgery Oral Cancer

Radical Neck Dissection

Oral Cancer Nursing Care Referral: Alcohol/Tobacco Cessation Preoperative Teaching Postoperative Airway Communication Nutrition Oral Cancer Nursing Care

Esophageal Cancer Risk: Alcohol or Tobacco Use Detected Late, Metastasizes Difficulty Swallowing, Feeling Full, Pain in Chest, Foul Breath, Food Regurgitation EGD, Biopsy Esophageal Cancer

Esophageal Cancer (cont’d) Radiation Chemotherapy Surgery Esophagogastrostomy Dacron Esophageal Replacement Esophagoenterostomy Esophageal Cancer (cont’d)

Esophageal Cancer (cont’d) Nursing Diagnoses Pain Risk for Deficient Fluid Volume Imbalanced Nutrition: Less Than Body Requirements Esophageal Cancer (cont’d)

Lower Esophagus/Stomach Slides up Through Hiatus of Diaphragm into Thorax Hiatal Hernia

Hiatal Hernia (cont’d) Occurs In Women Those over 60 Obesity Pregnancy Hiatal Hernia (cont’d)

Hiatal Hernia (cont’d)

Hiatal Hernia (cont’d) Signs and Symptoms None Pain Heartburn Fullness Reflux Hiatal Hernia (cont’d)

Hiatal Hernia (cont’d) Diagnosis X-Ray Fluoroscopy Hiatal Hernia (cont’d)

Therapeutic Interventions Antacids Small Meals No Reclining 1 Hour After Eating Raise Head of Bed 6 to 12 Inches No Bedtime Snacks, Spicy Foods, Alcohol, Caffeine, Smoking

Hiatal Hernia (cont’d) Surgical Management Fundoplication Hiatal Hernia (cont’d)

  Fundoplication

Hiatal Hernia (cont’d) Nursing Care Teaching Preoperative Care Postoperative Dysphagia with Eating Hiatal Hernia (cont’d)

Gastroesophageal Reflux Disease (GERD) Pathophysiology Gastric Secretions Reflux into Esophagus Esophagus Damaged Lower Esophageal Sphincter Does Not Close Tightly

Gastroesophageal Reflux Disease (GERD) (cont’d) Signs and Symptoms Heartburn Regurgitation Dysphagia Bleeding

Gastroesophageal Reflux Disease (GERD) (cont’d) Complications Aspiration Scar Tissue Diagnosis Barium Swallow Esophagoscopy

Therapeutic Interventions Lifestyle Changes Medications Antacids H2 Receptor Antagonists Proton Pump Inhibitors Prokinetic Agents

Gastroesophageal Reflux Disease (GERD) (cont’d) Esophy X Endoscopic Procedures Fundoplication

GERD Complications Esophagitis Barrett's Esophagus (Precancerous) Esophageal Cancer Bronchospasm Larygeospasm Aspiration Pneumonia

Barrett's Esophagus Precancerous Radiofrequency Ablation

Gastroesophageal Reflux Disease (GERD) (cont’d) Nursing Diagnosis Acute Pain

Gastroesophageal Reflux Disease (GERD) (cont’d) Nursing Care Education Lose Weight Low-fat, High-protein Diet Avoid Caffeine, Milk Products, Spicy Foods

Mallory-Weiss Tear Pathophyisiology Longitudinal Tear in Mucous Membrane of Esophagus at Stomach Junction Tears from Sudden, Powerful, or Prolonged Force Hiatal Hernia Present Mallory-Weiss Tear

Mallory-Weiss Tear (cont’d) Signs and Symptoms Bright Red, Bloody Emesis Bloody or Tarry Stools Mallory-Weiss Tear (cont’d)

Mallory-Weiss Tear (cont’d) Diagnosis EGD Hemoglobin and Hematocrit Mallory-Weiss Tear (cont’d)

Mallory-Weiss Tear (cont’d) Therapeutic Interventions Self-heal PPI Anti-emetic Avoid Alcohol Mallory-Weiss Tear (cont’d)

Mallory-Weiss Tear (cont’d) Nursing Care Report Bleeding Teaching Avoid Alcohol Medications Mallory-Weiss Tear (cont’d)

Esophageal Varices Dilated Blood Vessels in Esophagus Portal Hypertension Rupture Life-threatening Esophageal Varices

Gastritis Inflammation of the Stomach Acute or Chronic Abdominal Pain, Nausea, Anorexia Remove Irritating Substance Bland Diet of Liquids/Soft Foods Antacids Gastritis

Inflammation of Stomach Mucosa Acute Chronic Gastritis (cont’d)

Gastritis (cont’d) Pathophysiology Protective Mucosal Barrier Broken Down Autodigestion Severe Perforation Scarring Gastritis (cont’d)

Gastritis (cont’d) Signs and Symptoms Abdominal Pain Nausea, Vomiting Anorexia Abdominal Tenderness Feeling Of Fullness Gastritis (cont’d)

Signs and Symptoms (cont’d) Reflux Belching Gastritis (cont’d)

Gastritis (cont’d) Therapeutic Interventions Treat Cause Bland Diet Antacids Anti-emetics Gastritis (cont’d)

Chronic Gastritis Type A Autoimmune Gastritis Fundus Asymptomatic Leads to Pernicious Anemia Chronic Gastritis Type A

Chronic Gastritis Type B Pathophysiology From Infection with Helicobacter pylori Lower Stomach Chronic Gastritis Type B

Chronic Gastritis Type B (cont’d) Signs and Symptoms Anorexia, Heartburn, Belching, Sour Taste, Nausea/Vomiting Treatment Antibiotics

Peptic Ulcer Disease Erosion of GI lining Primary Cause: Bacterium H. pylori Curable Influenced by Smoking Peptic Ulcer Disease

Peptic Ulcer Disease (cont’d) Gastric High Left Epigastric/Upper Abdominal Burning/Gnawing Pain Increased 1 to 2 Hours After Meals or with Food Peptic Ulcer Disease (cont’d)

Peptic Ulcer Disease (cont’d) Duodenal Midepigastric/Upper Abdominal Burning/Cramping Pain Increased 2 to 4 Hours After Meal/ Middle of Night Relieved with Food or Antacids Peptic Ulcer Disease (cont’d)

Peptic Ulcer Disease (cont’d) Signs and Symptoms Anorexia Nausea/Vomiting Bleeding Peptic Ulcer Disease (cont’d)

Peptic Ulcer Disease (cont’d) Diagnosis Helicobacter pylori Upper GI Series EGD Peptic Ulcer Disease (cont’d)

Therapeutic Interventions Antibiotics Proton Pump Inhibitors Histamine H2 Antagonists Bismuth Subsalicylate Sucralfate (Carafate) Antacids

Peptic Ulcer Disease (cont’d) Treatment Bland Diet Avoid Irritants: Smoking, Caffeine, Alcohol Peptic Ulcer Disease (cont’d)

Peptic Ulcer Disease (cont’d) Complications Bleeding Perforation Obstruction Peptic Ulcer Disease (cont’d)

Peptic Ulcer Disease (cont’d) Nursing Diagnoses Acute Pain Risk for Injury Deficient Knowledge Peptic Ulcer Disease (cont’d)

Stress Ulcers Ischemia Damaging Mucous Barrier Acid Secretions Create Ulcers Stress Ulcers

Stress Ulcers (cont’d) Preventive Treatment Quick Trauma Care Early Feeding Testing Gastric Ph – Keep Above 5 Antacids, Histamine Blockers, Sucralfate Stress Ulcers (cont’d)

Gastric Bleeding From Ulcer Perforation, Tumor, Gastric Surgery Occult or Observable Symptoms Vary by Severity Treat Hypovolemic Shock if Present NPO, IV Fluids, Blood, NG Tube, Oxygen Gastric Bleeding

Gastric Bleeding (cont’d) Nursing Diagnosis Deficient Fluid Volume Gastric Bleeding (cont’d)

Gastric Cancer Malignant Lesion in Stomach Second Most Common Cancer Men Greater Than Women H. Pylori Infection Risk Factor Poor Prognosis as Metastasizes Gastric Cancer

Gastric Cancer (cont’d) Signs and Symptoms No Early Symptoms Late Symptoms Indigestion Anorexia Pain Relieved by Antacids Gastric Cancer (cont’d)

Gastric Cancer (cont’d) Late Symptoms (cont’d) Weight Loss Nausea and Vomiting Anemia Gastric Cancer (cont’d)

Gastric Cancer (cont’d) Diagnosis X-Ray Gastroscopy Gastric Fluid Analysis Serum Gastrin Gastric Cancer (cont’d)

Gastric Cancer (cont’d) Surgery Chemotherapy Radiation Gastric Cancer (cont’d)

Subtotal Gastrectomy Partial Removal of Stomach Gastroduodenostomy (Billroth I) Distal Stomach Removed Anastomosed to Duodenum Treats Gastric Problems

Subtotal Gastrectomy (cont’d)

Subtotal Gastrectomy (cont’d) Gastrojejunostomy (Billroth II) More Distal Stomach Removed Anastomosed to Jejunum Treats Duodenal Problems

Total Gastrectomy Total Stomach Removal Extensive Gastric Cancer Anastomosis of Esophagus to Jejunum Total Gastrectomy

Total Gastrectomy (cont’d)

Nursing Diagnoses: Gastric Surgery Acute Pain Fear

Nursing Care After Gastric Surgery Monitor Vital Signs Respiratory Status Control Pain Intake and Output Incisional Site

Nursing Care After Gastric Surgery (cont’d) NG Tube Care Ambulate Early Monitor Abdominal Status Education

Complications of Gastric Surgery Hemorrhage Gastric Distention Dumping Syndrome Nutritional Problems Pernicious Anemia

Complications of Gastric Surgery (cont’d) Steatorrhea Pyloric Obstruction