Ncm103 28th Gi II

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jcmendiola_Achievers2013

Care of Clients with Problems In Oxygenation,

Fluids and Electrolytes, Metabolism and Endocrine

(NCM103)

Patients With Gastrointestinal Alterations II

Alterations of the Esophagus

Gastroesophageal Reflux

Disease (GERD) Chronic symptoms or mucosal damage

produced by abnormal reflux of gastric

contents into the esophagus which may

result to esophagitis

Causes:1. Incompetent Lower Esophageal Sphincter (LES)2. Impaired gastric emptying, partial gastric outlet obstruction3. Achalasia and impaired expulsion of gastric reflux (Hiatal Hernia)

Signs and Symptoms1. Heartburn characterized by burning sensation behind the sternum, 30 60 minutes after meals

with reclined position

2. Dysphagia (difficulty swallowing), a less common symptom3. Chest pain, hoarseness, cough4. Odynophagia Sharp Substernal pain or swallowing

Pathophysiology

Diagnostic Procedure1. Endoscopy Most IMPORTANT2. Esophageal Manometry

a. Measures LES pressureb. Determines if esophageal peristalsis is adequate (Should be done prior surgery)

3. pH Monitoring

Topics Discussed Here Are:

1. Alterations of the Esophagusa. Gastroesophageal Reflux Disease (GERD)b. Hiatal Herniac. Achalasiad. Esophagitis

2. Alterations in Digestiona. Gastric Bleedingb. Gastritisc. Peptic Ulcer Disease

LOOKY

HERE

Chest pain should be ruled out for possible cardiac dysphagia, odynophagia or weight loss (rule out

cancer or esophageal stricture)

Give minimum nitroglycerin; if pain is relieved then it must be a cardiac condition and not a

esophageal disorder

Incompetent (LES), impaired gastric

emptying, partial outlet obstruction,

achalasia and impaired expulsion of

gastric reflux Hiatal Hernia

Drug produced by abnormal reflux of

gastric contents into the esophagus

Hiatal Hernia, characterized by burningsensation behind the...

Nursing Interventions:

1. Instruct patient to avoid stimulus that increasestomach pressure and decrease GES pressure

2. Instruct to avoid spices, coffee tobacco3. Instruct to eat FAT, FIBER

FAT = To DELAY gastric emptying4. Avoid foods and drinks 2 hours before bedtime5. Elevate the head of bed with approximately 8

inches

6. Administer prescribed H2 Blocker, PPI,Prokinetic medications like Metoclopramide

7. Advise proper weight reduction

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4. Barium esophagography5. Acid fast perfusion test

Management

1. Lifestyle Changes1. Head elevation (6 8 inches, to prevent backflow)2. Do not Lie DOWN!3. Bland diet / avoid overeating

i. No spicy food, sweetsii. Over eating

iii. Chocolates, increased protein, fats4. Avoid caffeine, alcohol, mint, chocolate, colas5. Weight Control (As increased food causes pressure to LES)6. Smoking Cessation (Has effect on pressure of LES)

Hiatal Hernia (HH) Protrusion of a portion of the stomach through the hiatus of the diaphragm and into the thoracic

cavity

The following are possible causes / contributing factors for having a Hiatal Herniao

Obesityo Poor seated posture (Such as slouching)o Frequent coughingo Straining with constipationo Frequent bending over / heavy liftingo Heredityo Smoking

2 Typesa. Sliding

90%: The stomach and gastro-esophageal junction Slip up in to the chestb. Para-Esophageal Hernia / Rolling Hernia

Part of the greater curvature of the stomach Rolls through the diaphragmaticdefect

Pathophysiology

Signs And Symptoms

1. Heart Burn2. Regurgitation3. Dysphagia4. Chest pain / may be

asymptomatic (depends on size of

hernia) [50% without symptoms]

Diagnostic Tests:1. Barium Study of the esophagus

(Outlines Hernia)

2. Endoscopic Evaluationvisualizes defect

Management:1. Elevation of head of bead (6-8

inches)

2. Antacid therapy3. H2 Receptor antagonist4. Surgical Repair of hernia if

symptoms are severe

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Nursing Intervention and Patient Education Instruct patient on the prevention of reflux of gastric contents into the esophagus by:

a. Eat smaller mealsb. Avoid caffeine, alcohol and smokingc. Avoid fatty foods

Eating such: Promotes reflux and delays gastric emptyingd.

Avoid lying down directly after meals (At least 1 hour)e. Losing weight if obese

f. Avoid bending from the waist or wearing tight fitting clothesg. Advise patient to report to the health care immediately for onset of chest pain

which may indicate incarceration of a large para-esophageal hernia

Achalasia Excessive resting tone of the LES, incomplete relaxation of the LES with swallowing, and failure

of normal peristalsis in the lower thirds of the esophagus

Cause:o Defective innervations of the mesenteric plexus innervating the involuntary muscles of

the esophagus

Signs and Symptoms1. Gradual onset of dysphagia with solid and liquids2. Substernal discomfort or a feeling of fullness3. Regurgitation of undigested food during a meal / within several hours after a meal4. Weight loss

Diagnostic Tests:1. Chest X-Ray To locate the site of

esophagus or with enlargement

2. Barium esophagography3. Endoscopic ultrasound or a chest CT scan

Management

1.

Drug therapy using calcium channelblockers such as Nifedipine to reduce

LES pressure

2. Esophagomytomy: Esophageal dilationusing a balloon-tipped catheter (preferred

treatment)

3. Surgical therapy for patients who do notrespond to balloon dilation

Complications:

1. Malnutrition Due to lack of absorption of nutrients2. Lung abscess, pneumonia, Bronchiectasis from nocturnal regurgitation3. Esophagitis, esophageal diverticula4. Perforation from dilation procedure5. Peptic stricture from severe erosive esophagitis

Nursing Assessment: Assess for difficulty with swallowing, vomiting, weight loss, chest pain associated with

eating

Inquire as to what facilitates passage of food, such as position changesPossible Nursing Diagnoses: Altered nutrition: less than body requirements related to dysphagia

Implication in reflux Hemorrhage /

obstruction, strangulation

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o Improve nutritional status1. Direct client to eat sitting in an upright position: eat slowly and CHEW

FOOD THOROUGHLY

2. Avoid SPICY, very HOT and very COLD food to minimize symptoms3. Suggest client to sleep with head of bed ELEVATED to avoid

REFLUX / ASPIRATION

4. Provide BLAND diet and avoid ALCOHOL, ketchup, tomato products,chocolates, mine and caffeine

Alteration in comfort: pain related to surgical procedure heart burn to regurgitationo Promoting comfort

1. Assess client for discomfort, chest pain, regurgitation and cough andincision pain

2. Provide appropriate post-op care3. Administer analgesics as ordered4. Assess for effectiveness of pain medications

Patient Education and Health Maintenance1. Encourage lifestyle and activity changes2. Advise client to EAT SLOWLY, chew very well, drink plenty of water after meal and

avoid eating near bedtime

3. Advise client to AVOID medications with ANTI-CHOLINERGIC properties (Histamine)o Which LES pressure and dysphagia

4. Provide information on all diagnostic procedures or surgeriesEsophagitis

a. Is an acute or chronic inflammation of the esophagusb. Causes:

GERD Most common, reflux esophagitis Other causes of esophagitis include: Infections (Most commonly candida, herpes simplex,

and cytomegalovirus. These infections are typically seen in Immunocompromised people

such as those with AIDS)

Chemical injury by alkaline/acid solutions may also be seen in children and adultsattempting suicide

Physical injury resulting from radiating therapy or by NGT may also be responsible Signs and Symptoms and Nursing Interventions is similar WITH GERD!!

Alterations or Disturbances in Digestion (Gastric Bleeding) Upper GI Bleeding:

o Bleeding in the: Esophagus (Ex: Esophageal varices [rupture may occur] due to portal HTN) Stomach Duodenum Due to ulcer, gastritis

Lower GI Bleeding:o Bleeding from:

Jejunum

Ileum Colon Rectum

Acute Blood LOSS is (150 300 mL of blood, SEVERE is 1 LITER!!)a. Characterized by HEMATEMESISb. HEMATOCHECIA Frank bleeding from the rectumc. MELENA Dark, tarry stoolsd. OCCULT BLEEDINGe. Guaiac Test

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Laboratory Tests:a. CBC If RBCs are depletedb. ABGs For F&E imbalance

Pathophysiology

Gastritis Diffuse or localized inflammation of the gastric mucosa It is the common pathologic condition of the stomach Two Types:

o Acute Gastritis Short Term INFLAMMATORY PROCESSo Chronic Gastritis LONG Term / Chronic form of ACUTE

Type A = Autoimmune (Least common, 10%) Type B =Helicobacter Pylori (More common, 90%)

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AssessmentAcute Chronic

Abdominal Distention Headache Anorexia Nausea and Vomiting

Pyrosis Singultus (Hiccup) Sour taste in the mouth Dyspepsia

Nausea and Vomiting / Anorexia Pernicious Anemia

Acute Gastritisis related to: Ingestion of chemical agents and food products that IRRITATE and ERODE gastric mucosa

o (Food seasonings and spices, alcohol, drugs (NSAIDS), aspirin) Corrosive Agents

o Cleaning fluids or kerosene insecticides, pesticides Or some bacteria that can also produce acute gastritis if they contaminate food

o (Salmonella, Staphylococci, Clostridium botulinum)Pathophysiology

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Chronic GastritisChronic Gastritis Type A Basically AUTOIMMUNE

In nature and involves all of the

ACID SECRETING GASTRIC TISSUE,

particularly the tissue in the fundus.

Circulating antibodies are produced thatattack the gastric parietal cells and

eventually may cause pernicious anemia

from loss of intrinsic factor (IF)

Chronic Gastritis Type B Associated with infection byHelicobacter Pylori, which is currently believed to be a direct cause

of the gastritis. It involves the fundus and the antrum of the stomach. the infection damages the

mucosal protective mechanism and leaves the mucosa vulnerable to the side effects of alcohol,

smoking, gastric acid and alkaline reflux from the duodenum

Some of these symptoms may accompany gastritis:o Abdominal pain / discomforto Gastric hemorrhageo Appetite losso Belchingo Nausea / Vomitingo Fatigue

NURSING INTERVENTION

(FOR BOTH Type A & B)1. Provide information to reduce anxiety

especially on emergency cases

2. Promote nutrition It will be on NPOGive ice chips then clear liquids then

solids as soon as possible or symptoms

have subsided

3. Maintain fluid balance Hydration eitherorally or IV4. Lifestyle modification Discouragementof alcohol, caffeine, smoking

5. Administer medications as ordered torelieve pain, to gastric acidity and treatinfection

6. Teach the effects of medications thatirritate the gastric mucosa

Gastric Irritant Infection ofH. Pylori

Impairment of the HCl

and IF secretion

Atrophy of the gastricgland and thinning of

the mucosa

Damaged mucosa

(Inflammation)

General Signs

and Symptoms

Gastritis Type B Pathophysiology

MEDICATIONS for Type B- Erythromycin- Ranitidine- Prostaglandin inhibitors- Antacid-regenerate cells

** Treat effects of meds that irritates

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Diagnostic Procedures EGD To visualize the gastric mucosa for inflammation Absent (Achlorhydria) or LOW levels of HCl (Hypochlorhydria) or INCREASED levels

of HCl (Hyperchlorhydria)

Biopsy to establish correct diagnosis whether acute or chronicNursing Intervention (Additional)1. Give BLAND diet

2. Monitor for signs of complications like: Bleeding, obstruction and pernicious anemia3. Instruct to avoid spicy foods, irritating foods, alcohol and caffeine, NSAIDS4. Administer prescribed medications H2 Blocker, antibiotics, mucosal protectants5. Inform the need for Vitamin B12 injection if deficiency is present

Peptic Ulcer Disease (PUD) Refers to ulceration in the mucosa of the lower esophagus, stomach to duodenum Duodenal ulcers are more common! Causes:

a. H. pylori infection present in most clients with PUDb. Ulcergenic drugs like NSAIDSc. Zollinger-Ellison syndrome and other hypersecretory syndromes

Rare islet tumor cells: GASTRIN = GASTRIC ACID Secretion!! XD Theres presence of FAT MALABSORPTION

RISK FACTORSa. Prolonged NSAIDS / Corticosteroidsb. Stress, low socio-economic statusc. Alcohol, caffeine, family history (Type O are more prone)

Clinical Manifestations (Assessment Findings) Gnawing / Burning Epigastric pain 1 3 hours after meal (can be nocturnal)

Gastric Aggravation of pain with food: 1 cm pyloric sphincter Duodenal Right Upper Epigastria, pain with empty stomach (2 3 hours after meal);

1.5 cm of pyloric area Early satiety, anorexia, weight loss, heart burn, belching (may indicate reflux) Dizziness, syncope, hematemesis, or melena (Hemorrhage) Anemia

ALERT!!! Sudden intense mid-epigastric pain radiating to the right shoulder may indicate ULCER

PERFORATION

A PEPTIC ULCER may arise at various locationsStomach Called Gastric Ulcer

Duodenum Called Duodenal Ulcer

Esophagus Called Esophageal Ulcer

Signs and Symptoms Gastric Ulcer

Weight loss

Burning left (epigastric pain)

Food frequently aggravate pain

Pain at bedtime

Duodenal UlcerEpigastric pain at bedtime

Burning / Cramping, mid epigastric pain

Abdominal pain, classically epigastric withseverity related to meal times

Duodenal Ulcers are classically

relieved by food,

Gastric Ulcers are exacerbated by it

A Gastric Ulcer could give epigastric pain

during the meal as gastric acid is secreted

or after the meal as the alkaline duodenal

contents reflux in to the stomach

Symptoms of Duodenal Ulcers wouldmanifest mostly BEFORE the meal, when

acid (produced stimulated by ____) ispassed into the duodenum

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Pain 2 4 hours, pressure meal, eating painWeight gain

Nausea / Vomiting

Pathophysiology

Diagnostic Examination Upper GI Endoscopy with possible biopsy and cytology (More accurate to detect Ca on ulcer) Upper GI Radiologic Exam (Barium) Serial Stool Exam to detect occult blood (Fecal Occult Blood Test) Gastric Secretion Test Serology Test forH. pylori Antibodies

Management General Measures

1. Eliminate use of NSAIDS / other causative drugs2. Eliminate cigarette smoking3. Well-balanced diet with regular meal intervals

Drug Therapy Ex. Proton Pump Inhibitors (PPI) + Metronidazole (Antibiotics), Ranitidine,

Clarithromycin

Surgery Vagotomy

Cutting (Removal) of the vagus Tunical Acid reduction ; removal of entire connection of vagus nerve Highly selective Selective Removal of vagus nerve connection in stomach

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Highly selective parietal vagotomy Gastrectomy

Removal of some parts of the stomach Gastroduodenostomy (Billroth I) Gastrojejunostomy (Billroth II) Stomach straight to jejunum Total Gastrectomy (Esophagojejunostomy) Esophagus straight to Jejunum Gastric resection (Antrectomy)

Complications1. GI Bleeding2. Ulcer Perforation Leads to peritonitis, perforation is an EMERGENCY CASE3. Gastric outlet obstruction (Pyloric sphincter)

Nursing Assessment (PQRST) Assess for pain Eating pattern: Type of food/current medications History of illness (Previous GI Bleeding) Obtain psychosocial physical examination STRESS VS Especially BP (Orthostatic HTN Possible BLEEDING)!

Possible Nursing Diagnoses Fluid volume deficit related to active bleeding Pain related to epigastric distress secondary to hypersecretion of acid, mucosal erosion /

perforation

Altered nutrition: less then body requirements related to mucosal erosion Knowledge deficit related to physical, dietary and pharmacological treatment

Medical Management Pharmacologic: Combination of antibodies, PPI and Bismuth salt to eradicateH. pylori for 10 14

days, H2 receptor antagonist and PPI are used to treat NSAID induced ulcer

Stress reduction

Nursing Interventions Prevention

1. Monitor I&O, stools2. Monitor: H/H and electrolytes3. Administer IV fluids / blood as ordered4. Insert NGT as ordered and to monitor drainage for signs and symptoms of blood5. Administer meds via NGT to neutralize acid as ordered

Cushings Ulcer- Common in clients with

head injury and braintrauma, more penetrating

and deeper than stress ulcer,

involves esophagus,

stomach and duodenum

- Observed about 72 hoursafter ********* , involves

stomach and duodenum

Duodenal Ulcer

Age: 30 60 years old M/F = 3:1 80% of peptic ulcer are duodenal Weight gain Hypersecretion of HCl Acid Pain occurs 2 3 hours after meal Ingestion of food relieved pain Vomiting is uncommon

Gastric Ulcer

Usually 50 and over M/F = 1:1 Weight loss Pain occurs to 1 hour after meal

Hemorrhage is Less likelyMelena is more common than

Hematemesis- Most likely to perforate- Possibility of malignancy is

rare

RISK FACTOR: Alcohol, smoking, stress

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6. Prepare client for lavage7. Observe client for PR, BP (SHOCK)8. Prepare client for diagnostic procedure / surgery to determine / stop source of bleeding

Pain Relief1. Administer prescribed pain medications2. Provide small frequent meals to prevent gastric distention if not on NPO3.

Advise client about the irritating effects of some foods / medications

Education About Treatment Regimen1. Explain all tests and procedures to increase knowledge and cooperation to decrease

anxiety

2. Allow client to ask questions and clarify misunderstandings: Review diet, activities,medication and treatment

3. Give client listing / medications, dosage, line of administration and desired effects topromote compliance

4. Teach client the signs and symptoms of bleeding and when to notify health care provider Post-Gastric Surgery Education

To prevent signs and symptoms of dumping syndrome following Billroth surgeries

1. Advise client to chew food and eat slowly2. Instruct client to drink ample amount of fluid after meals and not during3. Instruct client to eat several small meals a day; in CHO to prevent diarrhea

Pharmacotherapy H2 Receptor Antagonist (PO/IV) Antibiotics: To eradicateH. pylori Mucosal Barrier Antacids

Gastric acidity Taken 1 hour after medications

Maalox Diarrhea

Calcium Carbonate Uric Acid Aluminum Hydroxide Constipation

PPI Acid secretion of the PC 4 8 week medication

Mga nacopy ko na KULANG KULANG XD

Vagotomy Severing of the Vagus Nerve GA Diminish cholinergic stimulation to the PC - Response to gastric

Billroth I Removal of the lower portion of the antrum Antrum contains the cells that secrete juices Small portion of the duodenum and pylorus Remaining portion is anastomosed to the duodenum

Billroth II Remaining portion is anastomosed to the jejunum

ComplicationsBillroth I Feeling of fullness

Dumping syndrome Diarrhea / anemia Recurrence rate is < 1 %

Billroth II Dumping syndrome Anemia Malabsorption Weight loss Recurrence rate of ulcer is 10 15%

SurgicalWALA XD- Total Gastrectomy---- Vagotomy- Pyloroplasty- Billroth I (Gastroduodenostomy)- Billroth II (Gastrojejunostomy)

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Nursing Intervention1. Give BLAND diet2. H2 Blocker3. Monitor complications of bleeding4. Provide teaching

Bleeding1. NPO2. Hematocrit and hemoglobin3.4. Assist in saline lavage5. Insert NGT for decompression6. Prepare to administer blood transfusion7. Prepare to give vasopressin

Surgical Procedure for PUD1. Monitor VS2. Fowler: Post Op! Position3. NPO until peristalsis returns!4.

Monitor bowel sounds (BOWEL SOUNDS 1

st

BEFORE FLATUS!)5. Monitor for complication of surgery6. Monitor I&O, IVF7. Maintain NGT8. Diet progressive: Clear liquid Full Liquid Bland9. Manage Dumping Syndrome!

Ncm103 28th Gi II

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