DESCRIPTION• The backflow of gastric and duodenal

contents into the esophagus• Caused by an incompetent lower

esophageal sphincter, pyloric stenosis, or a motility disorder

• Symptoms may mimic those of a heart attack

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.

ASSESSMENT• Pyrosis• Dyspepsia• Regurgitation• Pain and difficulty with swallowing• Hypersalivation

IMPLEMENTATION• Instruct the client to avoid factors that

decrease lower esophageal sphincter pressure or cause esophageal irritation

• Instruct the client to eat a low-fat, high-fiber diet; avoid caffeine, tobacco, and carbonated beverages; avoid eating and drinking 2 hours before bedtime; avoid wearing tight clothes; and to elevate the head of the bed on 6- to 8- inch blocks

IMPLEMENTATION• Avoid the use of anticholinergics, which delay

stomach emptying• Instruct the client regarding prescribed

medications, such as antacids, histamine H2-receptor antagonists, or gastric acid pump inhibitors

• Instruct the client regarding the administration of prokinetic medications if prescribed, which accelerate gastric emptying

IMPLEMENTATION• If medical management is unsuccessful,

surgery may be required and involves a fundoplication (wrapping a portion of the gastric fundus around the sphincter area of the esophagus); may be performed by laparoscopy

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

DESCRIPTION• Also known as esophageal or diaphragmatic

hernia • A portion of the stomach herniates through

the diaphragm and into the thorax • It results from weakening of the muscles of

the diaphragm and is aggravated by factors that increase abdominal pressure such as pregnancy, ascites, obesity, tumors, and heavy lifting

DESCRIPTION• Complications include ulceration,

hemorrhage, regurgitation and aspiration of stomach contents, strangulation, and incarceration of the stomach in the chest with possible necrosis, peritonitis, and mediastinitis

From Monahan FD, Neighbers M: Medical-surgical nursing: foundations for clinical practice, ed. 2, Philadelphia, 1998, W.B. Saunders.

ASSESSMENT• Heartburn• Regurgitation or vomiting• Dysphagia• Feeling of fullness

IMPLEMENTATION• Medical and surgical management is similar

to that for GER• Provide small, frequent meals and minimize

the amount of liquids• Advise the client not to recline for 1 hour

after eating• Avoid anticholinergics, which delay stomach

emptying

DESCRIPTION• Inflammation of the stomach or gastric

mucosa• Can be acute or chronic

ACUTE• Caused by the ingestion of food contaminated

with disease-causing microorganisms or food that is irritating or too highly seasoned, the overuse of aspirin or other nonsteroidal antiinflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, or radiation therapy

ASSESSMENT• Abdominal discomfort• Headache• Anorexia, nausea, and vomiting• Hiccuping

CHRONIC• Caused by benign or malignant ulcers, or by

the bacteria Helicobacter pylori; may also be caused by autoimmune diseases, dietary factors, medications, alcohol, smoking, or reflux

ASSESSMENT• Anorexia, nausea, and vomiting• Heartburn after eating• Belching• Sour taste in the mouth• Vitamin B12 deficiency

From Stevens A, Lowe J: Pathology, London, 1995, Mosby.

IMPLEMENTATION• Acute: Food and fluids may be withheld until

symptoms subside; then ice chips followed by clear liquids and then solid food is introduced

• Monitor for signs of hemorrhagic gastritis such as hematemesis, tachycardia, and hypotension, and notify the physician if these signs occur

IMPLEMENTATION• Instruct the client to avoid irritating foods,

fluids, and other substances such as spicy and highly seasoned foods, caffeine, alcohol, and nicotine

• Instruct the client in the use of prescribed medications, such as antibiotics and bismuth salts (Pepto-Bismol)

• Provide the client with information about the importance of vitamin B12 injections, if a deficiency is present

DESCRIPTION• An ulceration in the mucosal wall of the

stomach, pylorus, duodenum, or esophagus, in portions that are accessible to gastric secretions; erosion may extend through the muscle

• May be referred to as gastric, duodenal, or esophageal ulcer depending on location

• The most common peptic ulcers are gastric ulcers and duodenal ulcers

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 5, Philadelphia: W.B. Saunders.

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

From Wilcox CM: Atlas of clinical gastrointestinal endoscopy, Philadelphia, 1995, W.B. Saunders.

From Damjanov I, Linder J, editors: Anderson’s pathology, ed. 10, St. Louis, 1996, Mosby.

DESCRIPTION• Involves ulceration of the mucosal lining that

extends to the submucosal layer of the stomach

• Predisposing factors include stress, smoking, the use of corticosteroids, nonsteroidal antiinflammatory drugs (NSAIDs), alcohol, a history of gastritis, a family history of gastric ulcers, or infection with Helicobacter pylori

• Complications include hemorrhage, perforation, and pyloric obstruction

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

From Cotran KS, Kumar V, Collins T: Robbins’ pathologic basis of disease, ed. 6, Philadelphia, 1999, W.B. Saunders.

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.

ASSESSMENT• Gnawing, sharp pain in or left of the

midepigastric region 1 to 2 hours after eating

• Nausea and vomiting• Hematemesis

IMPLEMENTATION• Monitor vital signs and for signs of bleeding• Administer small, frequent, bland feedings

during the active phase• Administer histamine H2-receptor

antagonists as prescribed to decrease the secretion of gastric acid

• Administer antacids as prescribed to neutralize gastric secretions

IMPLEMENTATION• Administer anticholinergics as prescribed to

reduce gastric motility• Administer mucosal barrier protectants as

prescribed 1 hour before each meal• Administer prostaglandins as prescribed for

their protective and antisecretory actions

CLIENT EDUCATION• Avoid consuming alcohol and substances

that contain caffeine or chocolate• Avoid smoking• Avoid aspirin or NSAIDs• Obtain adequate rest and reduce stress

IMPLEMENTATION: ACTIVE BLEEDING• Monitor vital signs closely• Assess for signs of dehydration,

hypovolemic shock, sepsis, and respiratory insufficiency

• Maintain NPO status and administer IV fluid replacement as prescribed; monitor I&O

• Monitor hemoglobin and hematocrit

IMPLEMENTATION: ACTIVE BLEEDING• Administer blood transfusions as prescribed• Assist with the insertion of a nasogastric (NG)

tube for decompression and for lavage access• Assist with normal saline or tap water lavage at

room temperature to reduce active bleeding• Prepare to assist with administering

vasopressin (Pitressin) by IV as prescribed to induce vasoconstriction and reduce bleeding

TOTAL GASTRECTOMY• Also called esophagojejunostomy• Removal of the stomach with attachment of

the esophagus to the jejunum or duodenum VAGOTOMY

• Surgical division of the vagus nerve to eliminate the vagal impulses that stimulate hydrochloric acid secretion in the stomach

GASTRIC RESECTION• Also called antrectomy• Involves removal of the lower half of the

stomach and usually includes a vagotomy

BILLROTH I• Also called gastroduodenostomy; partial

gastrectomy, with remaining segment anastomosed to duodenum

BILLROTH II• Also called gastrojejunostomy; partial

gastrectomy, with remaining segment anastomosed to jejunum

PYLOROPLASTY• Enlarges the pylorus to prevent or

decrease pyloric obstruction, thereby enhancing gastric emptying

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

Monitor vital signs Position in Fowler's for comfort and to

promote drainage Administer fluids and electrolyte

replacements by IV as prescribed; monitor I&O

Assess bowel sounds Monitor NG suction as prescribed

Do not irrigate or remove the NG tube; assist the physician with irrigation or removal

Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns

Progress the diet from NPO to sips of clear water to 6 small, bland meals a day as prescribed when bowel sounds return

Monitor for postoperative complications of hemorrhage, dumping syndrome, diarrhea, hypoglycemia, and vitamin B12 deficiency

DESCRIPTION• A break in the mucosa of the duodenum • Risk factors and causes include alcohol intake,

smoking, stress, caffeine, the use of aspirin, corticosteroids, and NSAIDs, and infection with Helicobacter pylori

• Complications include bleeding, perforation, gastric outlet obstruction, and intractable disease

• Surgery is performed only if the ulcer is unresponsive to medications or if hemorrhage, obstruction, or perforation occurs

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

From McCance, K. & Huether, S. (2002). Pathophysiology, ed 4, St Louis: Mosby. Courtesy of David Bjorkman, MD, University of Utah, School of Medicine, Department of Gastroenterology.

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.

ASSESSMENT• Burning pain in the midepigastric area 2 to

4 hours after eating and during the night• Pain that is often relieved by eating• Melena

IMPLEMENTATION• Monitor vital signs• Perform abdominal assessment• Instruct the client in a bland diet with small,

frequent meals• Provide for adequate rest• Encourage the cessation of smoking

IMPLEMENTATION• Instruct the client to avoid alcohol intake,

caffeine, the use of aspirin, corticosteroids, and NSAIDs

• Administer antacids as prescribed to neutralize acid secretions

• Administer histamine H2-receptor antagonists as prescribed to block the secretion of acid

DESCRIPTION• Rapid emptying of the gastric contents into

the small intestine • Occurs following gastric resection

ASSESSMENT• Symptoms occurring 30 minutes after

eating• Nausea and vomiting• Feelings of abdominal fullness and

abdominal cramping • Diarrhea• Palpitations and tachycardia• Perspiration • Weakness and dizziness• Borborygmi

CLIENT EDUCATION • Eat a high-protein, high-fat, low-

carbohydrate diet• Eat small meals and avoid consuming fluids

with meals• Avoid sugar and salt• Lie down after meals• Take antispasmodic medications as

prescribed to delay gastric emptying

DESCRIPTION• Results from either an inadequate intake of

vitamin B12 or a lack of absorption of ingested vitamin B12 from the intestinal tract

• Pernicious anemia results from a deficiency of intrinsic factor, which is necessary for intestinal absorption of vitamin B12

ASSESSMENT• Severe pallor • Fatigue • Weight loss• Smooth, beefy, red tongue• Slight jaundice• Paresthesias of the hands and feet• Disturbances with gait and balance

IMPLEMENTATION• Increase dietary intake of foods rich in

vitamin B12 if the anemia is the result of a dietary deficiency

• Administer vitamin B12 injections as prescribed on a weekly basis initially, and then monthly for maintenance (lifelong) if the anemia is the result of a deficiency of the intrinsic factor

DESCRIPTION • Dilated and tortuous veins in the

submucosa of the esophagus • Caused by portal hypertension, often

associated with liver cirrhosis, and high risk for rupture if portal circulation pressure rises

• Bleeding varices is an emergency • The goal of treatment is to control bleeding,

prevent complications, and prevent the reoccurrence of bleeding

From Gitlin N, Strauss RM: Atlas of clinical hepatology, Philadelphia, 1995, W.B. Saunders.

ASSESSMENT• Hematemesis• Tarry stools, melena• Ascites• Jaundice• Hepatomegaly and splenomegaly• Dilated abdominal veins• Hemorrhoids• Signs of shock

IMPLEMENTATION• Monitor vital signs • Elevate the head of the bed• Monitor for orthostatic hypotension• Monitor lung sounds and for the presence of

respiratory distress • Administer oxygen as prescribed to prevent

tissue hypoxia • Monitor level of consciousness (LOC)

IMPLEMENTATION• Maintain NPO status• Administer IV fluids as prescribed to restore

fluid volume and correct electrolyte imbalances; monitor I&O

• Monitor hemoglobin, hematocrit, and coagulation factors

• Administer blood transfusions or clotting factors as prescribed

IMPLEMENTATION• Assist in inserting an NG tube or a balloon

tamponade as prescribed• Assist with the administration of iced saline

irrigations to achieve vasoconstriction of the varices

• Prepare to assist with administering vasopressin (Pitressin) by IV or intra-arterial infusion as prescribed to induce vasoconstriction and reduce bleeding

IMPLEMENTATION• Prepare to assist with administering

nitroglycerin (Tridil) with vasopressin (Pitressin) to prevent vasoconstriction of the coronary arteries

• Instruct the client to avoid activities that will initiate vasovagal responses

• Prepare the client for endoscopic procedures or surgical procedures as prescribed

ENDOSCOPIC INJECTION (SCLEROTHERAPY)• Injection of a sclerosing agent into and

around bleeding varices• Complications include chest pain, pleural

effusion, aspiration pneumonia, esophageal stricture, and perforation of the esophagus

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

ENDOSCOPIC VARICEAL LIGATION• Ligation of the varices with an elastic rubber

band• Sloughing, followed by superficial

ulceration, occurs in the area of ligation within 3 to 7 days

SPLENORENAL• Involves splenectomy, with anastomosis of

the splenic vein to the left renal vein PORTACAVAL

• Shunting of the blood from the portal vein to the inferior vena cava

MESOCAVAL• Involves a side anastomosis of the superior

mesenteric vein to the proximal end of the inferior vena cava

From Beare, P. & Myers, J. (1998). Adult health nursing, ed 3, St Louis: Mosby.

TRANSJUGULAR INTRAHEPATIC PORTAL/SYSTEMIC• Uses the normal vascular anatomy of the

liver to create a shunt with the use of a metallic stent

• The shunt is between the portal and systemic venous system within the liver and is aimed at relieving portal hypertension

DESCRIPTION • Ulcerative and inflammatory disease of the

bowel that results in poor absorption of nutrients

• Commonly begins in the rectum and spreads upward toward the cecum

• Characterized by various periods of remissions and exacerbations

• The colon becomes edematous and may develop bleeding lesions and ulcers; the ulcers may lead to perforation

DESCRIPTION • Scar tissue develops and causes loss of

elasticity and loss of ability to absorb nutrients

• Acute ulcerative colitis results in vascular congestion, hemorrhage, edema, and ulceration of the bowel mucosa

• Chronic ulcerative colitis causes muscular hypertrophy; fat deposits; and fibrous tissue with bowel thickening, shortening, and narrowing

DESCRIPTION • Surgical intervention involves creation of an

ostomy; the ostomy can be created within the ileum or at various sites within the large bowel

• An ileostomy is the surgical creation of an opening into the ileum or small intestine that allows for drainage of fecal matter from the ileum to the outside of the body

• A colostomy is the surgical creation of an opening into the colon that allows for drainage of fecal matter from the colon to the outside of the body

From Rosai J: Ackerman’s surgical pathology, ed. 8, St. Louis, 1996, Mosby.

From Damjanov I, Linder J, editors: Anderson’s pathology, ed. 10, St. Louis, 1996, Mosby.

ASSESSMENT• Anorexia• Weight loss • Malaise• Abdominal tenderness and cramping• Severe diarrhea that may contain blood and

mucus• Dehydration and electrolyte imbalances• Anemia• Vitamin K deficiency

IMPLEMENTATION• Acute phase: Maintain NPO status,

administer IVs and electrolytes, or total parenteral nutrition (TPN) as prescribed

• Restrict the client’s activity to reduce intestinal activity

• Monitor bowel sounds and for abdominal tenderness and cramping

• Monitor stools, noting color, consistency, and the presence or absence of blood

IMPLEMENTATION• Monitor for perforation, peritonitis, and

hemorrhage• Following the acute phase, the diet progresses

from clear liquids to low-residue as tolerated• Instruct client to consume a low-residue, high-

protein diet; vitamins and iron supplements may be prescribed

• Instruct client to avoid gas-forming foods and milk products and foods such as whole-wheat breads, nuts, raw fruits and vegetables, pepper, alcohol, and caffeine-containing products

IMPLEMENTATION• Instruct the client to avoid smoking• Administer bulk-forming agents such as

bran, psyllium, or methylcellulose, to decrease diarrhea and relieve symptoms

• Administer antimicrobial, corticosteroids, and immunosuppressants as prescribed to prevent infection and reduce inflammation

TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY• Curative and involves the removal of the

entire colon (colon, rectum, and anus with anal closure)

• The end of the terminal ileum forms the stoma, which is located in the right lower quadrant

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

KOCK ILEOSTOMY (CONTINENT ILEOSTOMY)• An intra-abdominal pouch (stores the feces)

is constructed from the terminal ileum• The pouch is connected to the stoma with a

nipple-like valve constructed from a portion of the ileum; the stoma is flush with the skin

• A catheter is used to empty the pouch, and a small dressing or adhesive bandage is worn over the stoma between emptyings

From Beare, P. & Myers, J. (1998). Adult health nursing, ed 3, St Louis: Mosby.

ILEOANAL RESERVOIR• A two-stage procedure that involves the

excision of the rectal mucosa, an abdominal colectomy, construction of a reservoir to the anal canal, and a temporary loop ileostomy

• The ileostomy is closed in approximately 3 to 4 months after the capacity of the reservoir is increased

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

ILEOANAL ANASTOMOSIS (ILEORECTOSTOMY)• Does not require an ileostomy• A 12- to 15-cm rectal stump is left after the

colon is removed and the small intestine is inserted into this rectal sleeve and anastomosed

• Requires a large, compliant rectum

From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts and clinical practice, ed. 6, St. Louis, 1999, Mosby.

Consult with enterostomal therapist to assist in identifying optimal placement of the ostomy

Instruct the client to eat a low-residue diet for a day or two prior to surgery as prescribed

Administer intestinal antiseptics and antibiotics as prescribed to cleanse the bowel and to decrease the bacterial content of the colon

Administer laxatives and enemas as prescribed

Place a petrolatum gauze over the stoma as prescribed to keep it moist, followed by a dry sterile dressing if a pouch (external) system is not in place

Place a pouch system on the stoma as soon as possible

Monitor the stoma for size, unusual bleeding, or necrotic tissue

Monitor for color changes in the stoma The normal stoma color is pink to

bright red and shiny, indicating high vascularity

A pale pink stoma indicates low hemoglobin and hematocrit levels

A purple-black stoma indicates compromised circulation, requiring physician notification

Assess the functioning of the colostomy

Expect that stool is liquid in the immediate postoperative period, but becomes more solid depending on the area of the colostomy• Ascending colon - liquid• Transverse colon - loose to semi-formed• Descending colon - close to normal

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

Monitor the pouch system for proper fit and signs of leakage

Empty the pouch when it is one-third full

Fecal matter should not be allowed to remain on the skin

Administer analgesics and antibiotics as prescribed