Nursing Care of Patients with Upper Gastrointestinal Disorders The Digestive System Nursing Care of Patients with Upper Gastrointestinal Disorders

Nausea and Vomiting Therapeutic Interventions Nausea- urge to vomit, Vomiting- expel contents None- may be self-limited Protect Airway- prevent aspiration Medications- benadryl, vistaril, zofran, compazine IV Fluids NG Tube Clear Liquids, Dry Toast

Nausea and Vomiting Nursing Diagnoses Nausea Risk for Aspiration Deficient Fluid Volume

Anorexia Nervosa Eating disorder- lack of appetite Females- Age 12-18 Years Severe weight loss, low self-esteem, compulsive dieting, altered body image Treatment- restore nutritional health 18% Die

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

Bulimia Nervosa Compulsive eating/ self-induced vomiting Enamel erosion of front teeth, metabolic alkalosis Treatment: restore nutritional health Nursing: theraputic relationship Vital signs Daily weights Intake/output of foods and fluids

Obesity Weight 20% or Greater Than Ideal Body Weight Caloric intake exceeds energy expenditure Comorbidities: diseases associated with obesity Morbid obesity: BMI above 40, 100 pds overweight

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

Surgical Management Bariatric Surgery Limits How Much Stomach Can Hold Decreased Calorie/Nutrient Absorption Roux-en-Y Gastric Bypass- food bypasses most of stomach and duodenum and goes to jejunum Vertical Banded Gastroplasty (VBG)- small stomach pouch is made, when it fills, feeling of fullness even with small meals

Roux-en-Y Gastric Bypass Vertical Banded Gastroplasty

Complications of Gastric Restrictive Surgeries Vomiting/ erosion of gastric tissue Breakdown of Staple Line Leaking of Stomach Secretions Infection or Death Postoperative care-clear liquid diet, progress to full liqs, pureed food, reg diet at 6 weeks

Oral Health Care Important to overall health/ often neglected Oral hygiene with chlorhexidine gluconate Prevents Pneumonia Reduces Ventilator Associated Pneumonia Candidiasis- tx with nystatin swish/swallow

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

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

Radical Neck Dissection

Oral Cancer Nursing Care Referral: Alcohol/Tobacco Cessation Preop Teaching- communication if trach Post-op Airway- control secretions Communication Nutrition- tube feeding

Esophageal Cancer Risk: Alcohol or Tobacco Use Detected Late, Metastasizes Difficulty Swallowing, Feeling Full, Pain in Chest, Foul Breath, Food Regurgitation Dx:EGD, Biopsy Tx: Radiation, chemo, surgery Esophagogastrostomy, dacron esophagus replacement or esophagoenterostomy

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

Hiatal Hernia Lower Esophagus/Stomach Slides up Through Hiatus of Diaphragm into Thorax Common: women>60, obese, pregnant s/s hernia: pain, heartburn, full feeling, reflux, possible bleeding, ulceration. s/s worsen lying down. Dx: x-ray, fluoroscope

Hiatal Hernia (cont’d)

Hiatal Hernia Therapeutic Interventions Antacids Eating small meals No reclining 1 hour after eating Raise head of ed 6-12 Inches No bedtime snacks, spicy foods, alcohol, caffeine, smoking Surgery- fundoplication: assess for dysphagia with 1st meal

  Fundoplication

Gastroesophageal Reflux Disease (GERD) Gastric secretions reflux into esophagus, becomes damaged, lower esophageal sphincter does not close tightly s/s: heartburn, regurgitation, dysphagia, bleeding Complications: esophagitis, Barrett’s esophagus cancer, aspiration pneumonia Barium swallow, esophagoscopy

GERD Therapeutic Interventions Lifestyle changes- exercise, low fat diet Medications Antacids- Tums, Mylanta, Gaviscon H2 Receptor Antagonists- Tagamet, pepcid, Zantac, Axid Proton Pump Inhibitors- Nexium, prilosec Prokinetic Agents-Reglan, Maxalon

Gastroesophageal Reflux Disease (cont’d) Nursing Dx: Acute pain Nursing Education Lose Weight Low-Fat, High-Protein Diet Avoid Caffeine, Milk Products, Spicy Foods Sleep with HOB > 4-6 inches Eat small meals, avoid lying down 1-2hrs p eating

Mallory-Weiss Tear Longitudinal tear in mucous membrane of esophagus at stomach junction. Tears from sudden or prolonged force,usually hiatal hernia present s/s bright red bloody emesis or bloody stools Dx with EGD, hemoglobin/hematocrit Usually self heal, antiemetics, avoid alcohol

Gastritis Inflammation of the stomach, protective mucosal barrier is broken down s/s: abdominal pain, nausea, anorexia Remove irritating substance Bland diet of liquids/soft foods- will recover in 24 hrs Antacids

Gastritis Inflammation of stomach mucosa, protective mucosa barrier broken down, acute or chronic s/s: Abd pain, N/V, anorexia, feeling of fullness, abd tenderness, reflux, belching. Tx cause, bland diet of liquids/soft foods, antacids, antiemetics

Chronic Gastritis Type A- Autoimmune gastritis, occurs in fundus of stomach, often asymptomatic, leads to pernicious anemia. Type B- infection with Heliobacter pylori, occurs in lower stomach. s/s heartburn, poor appetite, belching, sour taste, N/V. Treatment is antibiotics.

Peptic Ulcer Disease Erosion of GI lining, primary cause is H. pylori, curable. Risk factors include smoking, stress, medications and caffeine s/s Gastric- high left epigastric/upper abd burning/gnawing pain, > 1-2hrs pc or with food. s/s Duodenal-Midepigastric/upper abd pain, burning/cramping, > 2-4 hrs after meal/middle of night. Relieved with food or antacids Dx- upper GI, urea breath test, IgG antibody test

Peptic Ulcer Disease Therapeutic Interventions Antibiotics Proton pump inhibitors- Histamine H2 antagonists Bismuth subsalicylate Sucralfate (carafate) Antacids, bland diet Complications- bleeding, perforation, obstruction

Stress Ulcers The stress response to illness causes< in blood flow to stomach and small intestines, results in ischemia, allows acid secretions to create ulcers. Preventive treatment- Quick trauma care, early feedings. Test gastric pH- keep > 5, antacids, histamine blockers

Gastric Bleeding Caused by ulcer perforation, tumor, gastric surgery, occult or observable Symptoms vary by severity Treat hypovolemic shock if present NPO, IV Fluids, Blood, NG Tube, Oxygen Nsg Dx: Deficient fluid volume

Gastric Cancer Malignant Lesion in Stomach, 2nd most common. Seen in men more than women H. pylori Infection risk factor Poor prognosis as metastasizes No early s/s, late s/s like peptic ulcers- indigestion, anorexia, pain relieved by antacids, wt loss N/V Surgery, chemo, radiation

Subtotal Gastrectomy Partial removal of stomach Billroth I Procedure (gastroduodenostomy) Distal 75% stomach removed Anastomosed to duodenum Billroth II procedure (gastrojejunostomy) Distal 50% of stomach, anastomosed to jejunum

Subtotal Gastrectomy (cont’d)

Total Gastrectomy Total Stomach Removal, tx gastric cancer Anastomosis of esophagus to jejunum Vagotomy (vagus nerve is cut) may be performed with total gastrectomy. This eliminates vagal stimulation for hydrochloric acid and gastrin hormone secretion and slows gastric motility

Total Gastrectomy (cont’d)

Nursing Care After Gastric Surgery Monitor vital signs and resp status Control pain Intake and output Incisional site Assess bowel sounds, abd distention NG tube care Ambulate early Education

Complications of Gastric Surgery Hemorrhage Gastric Distention Nutritional Problems Pernicious Anemia Steatorrhea Pyloric obstruction Dumping syndrome