11

HAMDALLAH HASSAN KHALIDHAMDALLAH HASSAN KHALID

RN,BSN,MMHSRN,BSN,MMHS

IBN SINA COLLEGEIBN SINA COLLEGE

PALESTINEPALESTINE

22

Assessment of Digestive Assessment of Digestive andand

Gastrointestinal FunctionGastrointestinal FunctionFunctions of the Digestive SystemFunctions of the Digestive System The breakdown of food particles The breakdown of food particles into the into the

molecular form for digestionmolecular form for digestion The absorption into the bloodstream The absorption into the bloodstream of of

small nutrient molecules produced small nutrient molecules produced by by

digestiondigestion The elimination of undigested The elimination of undigested

unabsorbed foodstuffs and other unabsorbed foodstuffs and other waste waste

products products

33

44

Assessment:Assessment:Health History:Health History:• Past and current medication use.Past and current medication use.• Previous diagnostic studies.Previous diagnostic studies.• Treatments. Treatments. • Surgery. Surgery. • Current nutritional statusCurrent nutritional status• Serum values and complete blood count [CBC]). Serum values and complete blood count [CBC]). • Questioning about the use of tobacco and Questioning about the use of tobacco and

alcohol alcohol • Changes in appetite or eating patterns Changes in appetite or eating patterns • Unexplained weight gain or loss over the past Unexplained weight gain or loss over the past

year.year.• Psychosocial, spiritual, or cultural assessment.Psychosocial, spiritual, or cultural assessment.

55

Clinical Clinical ManifestationsManifestations::PainPain

• The character, duration, pattern, The character, duration, pattern, frequency, location, distribution of frequency, location, distribution of referred pain and time of the pain referred pain and time of the pain vary greatly depending on the vary greatly depending on the underlying cause. underlying cause.

• Other factors such as meals, rest, Other factors such as meals, rest, activity, and defecation patterns may activity, and defecation patterns may directly affect this pain.directly affect this pain.

66

DyspepsiaDyspepsia•Dyspepsia, upper abdominal Dyspepsia, upper abdominal

discomfort, or distress discomfort, or distress associated with eating associated with eating (commonly called indigestion).(commonly called indigestion).

•Typically, fatty foods, salads and Typically, fatty foods, salads and coarse vegetables as well as coarse vegetables as well as highly seasoned foods may also highly seasoned foods may also cause considerable GI distress.cause considerable GI distress.

77

Intestinal GasIntestinal Gas•The accumulation of gas The accumulation of gas in the GI tract may result in the GI tract may result in in belching belching (expulsion of (expulsion of gas from the stomach gas from the stomach through the mouth) or through the mouth) or flatulenceflatulence (expulsion of (expulsion of gas from the rectum). gas from the rectum).

88

Nausea and Nausea and VomitingVomiting• Nausea is a vague, intensely unsettling Nausea is a vague, intensely unsettling

sensation of sickness or “queasiness” sensation of sickness or “queasiness” that may or may not be followed by that may or may not be followed by vomiting.vomiting.

• It can be triggered by odors, activity, It can be triggered by odors, activity, medications, or food intake.medications, or food intake.

• The The emesis, or vomitusemesis, or vomitus, may vary in , may vary in color and content and may contain color and content and may contain undigested food particles, blood undigested food particles, blood (hematemesis),(hematemesis), or bilious material or bilious material mixed with gastric juices.mixed with gastric juices.

99

The causes of nausea and The causes of nausea and vomiting are many:vomiting are many:

(1)(1) Visceral afferent stimulation Visceral afferent stimulation

(2)(2) CNS disorders CNS disorders

(3)(3) Irritation of the Irritation of the chemoreceptor chemoreceptor

trigger zone from radiation trigger zone from radiation

therapy, systemic disorders, therapy, systemic disorders,

1010

Change in Bowel Habits and Change in Bowel Habits and Stool CharacteristicsStool Characteristics• Changes in bowel habits may signal Changes in bowel habits may signal

colonic dysfunction or disease.colonic dysfunction or disease.• DiarrheaDiarrhea,, an abnormal increase in the an abnormal increase in the

frequency and liquidity of the stool or frequency and liquidity of the stool or in daily stool weight or volumein daily stool weight or volume

commonly occurs when the contents commonly occurs when the contents move so rapidly through the intestine move so rapidly through the intestine and colon that there is inadequate and colon that there is inadequate time for the GI secretions and oral time for the GI secretions and oral contents to be absorbed. contents to be absorbed.

1111

•Constipation,Constipation, a decrease in a decrease in the frequency of stool, or stools the frequency of stool, or stools that are hard, dry, and of that are hard, dry, and of smaller volume than normal.smaller volume than normal.

•Stool is normally light to Stool is normally light to dark brown; however, dark brown; however, specific disease processes specific disease processes and ingestion of certain and ingestion of certain foods and medications may foods and medications may change the appearance of change the appearance of stoolstool

1212

•Blood in the stool can present Blood in the stool can present in various ways and must be in various ways and must be investigated. investigated.

•If blood is shed in sufficient If blood is shed in sufficient quantities into the upper GI quantities into the upper GI tract, it produces a tarry-tract, it produces a tarry-black color black color (melena)(melena)

1313

•Whereas blood entering the Whereas blood entering the lower portion of the GI tract lower portion of the GI tract or passing rapidly through it or passing rapidly through it will appear will appear bright or dark bright or dark redred..

•Lower rectal or anal bleeding Lower rectal or anal bleeding is suspected if there is is suspected if there is streaking of blood on the streaking of blood on the surface of the stool or if surface of the stool or if blood is noted on toilet blood is noted on toilet tissue.tissue.

1414

Physical AssessmentPhysical AssessmentAssessment of the mouth, Assessment of the mouth,

abdomen, and rectum and abdomen, and rectum and requires:requires:

•Good source of lightGood source of light•Full exposure of the abdomenFull exposure of the abdomen•Warm hands with short fingernailsWarm hands with short fingernails•Comfortable, relaxed patient with Comfortable, relaxed patient with

an empty bladder. an empty bladder. •The patient lies supine with knees The patient lies supine with knees

flexed slightly for inspection flexed slightly for inspection auscultation, palpation, and auscultation, palpation, and percussion of the abdomenpercussion of the abdomen

1515

Expected contours of the Expected contours of the anterior abdominal wall can anterior abdominal wall can be described as be described as flat, flat, rounded, or scaphoid. rounded, or scaphoid.

The frequency and The frequency and character of the sounds are character of the sounds are usually heard as clicks and usually heard as clicks and gurgles that occur gurgles that occur irregularly and range from 5 irregularly and range from 5 to 35 per minute.to 35 per minute.

1616

The terms normal (sounds The terms normal (sounds heard about every 5 to 20 heard about every 5 to 20 seconds)seconds)

Hypoactive (one or two Hypoactive (one or two sounds in 2 minutes).sounds in 2 minutes).

Hyperactive (5 to 6 Hyperactive (5 to 6 sounds heard in less than sounds heard in less than 30 seconds).30 seconds).

Absent (no sounds in 3 to Absent (no sounds in 3 to 5 minutes).5 minutes).

1717

PercussionPercussion is used to assess is used to assess the the size and densitysize and density of the of the abdominal organs and to detect abdominal organs and to detect the presence of the presence of air-filled, fluid-air-filled, fluid-filled, or solid massesfilled, or solid masses. .

Use of Use of light palpationlight palpation is is appropriate for identifying appropriate for identifying areas of tenderness or areas of tenderness or muscular resistance, and muscular resistance, and deep deep palpationpalpation is used to identify is used to identify masses.masses.

1818

1919

Diagnostic EvaluationDiagnostic Evaluation

General nursing interventionsGeneral nursing interventions

•Establishing the nursing diagnosisEstablishing the nursing diagnosis

•Providing needed information Providing needed information about the test and the activities about the test and the activities required of the patientrequired of the patient

•Providing instructions about Providing instructions about postprocedure care and activity postprocedure care and activity restrictionsrestrictions

2020

• Providing health information and Providing health information and procedural teaching to patients and procedural teaching to patients and significant otherssignificant others

• Helping the patient cope with Helping the patient cope with discomfort and alleviating anxietydiscomfort and alleviating anxiety

• Informing the physician or nurse Informing the physician or nurse practitioner of known medical practitioner of known medical conditions or abnormal laboratory conditions or abnormal laboratory values that may affect the procedurevalues that may affect the procedure

• Assessing for adequate hydration Assessing for adequate hydration before, during, and immediately after before, during, and immediately after the procedure, and providing education the procedure, and providing education about maintenance of hydration about maintenance of hydration

2121

Stool TestsStool Tests::• Consistency, color, and occult (not Consistency, color, and occult (not

visible) blood, fecal urobilinogen, fecal visible) blood, fecal urobilinogen, fecal fat, nitrogen, Clostridium difficile, fecal fat, nitrogen, Clostridium difficile, fecal leukocytesparasites, pathogens…..leukocytesparasites, pathogens…..

• Random specimens should be sent Random specimens should be sent promptly to the laboratory for analysis.promptly to the laboratory for analysis.

• However, the quantitative 24- to 72-However, the quantitative 24- to 72-hour collections must be kept hour collections must be kept refrigerated until transported to the refrigerated until transported to the laboratory.laboratory.

• Fecal occult blood testing (FOBT) Fecal occult blood testing (FOBT)

2222

Breath TestsBreath Tests• The hydrogen breath test was developed to The hydrogen breath test was developed to

evaluate carbohydrate absorption, in addition evaluate carbohydrate absorption, in addition to aiding in the diagnosis of bacterial to aiding in the diagnosis of bacterial overgrowth in the intestine and short bowel overgrowth in the intestine and short bowel syndrome.syndrome.

• This test determines the amount of hydrogen This test determines the amount of hydrogen expelled in the breath after it has been expelled in the breath after it has been produced in the colon.produced in the colon.

• Urea breath tests detect the presence of Urea breath tests detect the presence of Helicobacter pylori, the bacteria that can live in Helicobacter pylori, the bacteria that can live in the mucosal lining of the stomach and cause the mucosal lining of the stomach and cause peptic ulcer disease.peptic ulcer disease.

2323

•After the patient ingests a After the patient ingests a capsule of carbon-labeled urea, a capsule of carbon-labeled urea, a breath sample is obtained 10 to breath sample is obtained 10 to 20 minutes later. 20 minutes later.

•Because H. pylori metabolizes Because H. pylori metabolizes urea rapidly, the labeled carbon is urea rapidly, the labeled carbon is absorbed quickly; it can then be absorbed quickly; it can then be measured as carbon dioxide in measured as carbon dioxide in the expired breath to determine the expired breath to determine whether H. pylori is present.whether H. pylori is present.

2424

Abdominal Abdominal Ultrasonography:Ultrasonography:• Ultrasonography is a noninvasive Ultrasonography is a noninvasive

diagnostic technique in which high-diagnostic technique in which high-frequency sound waves are passed into frequency sound waves are passed into internal body structures and the internal body structures and the ultrasonic echoes are recorded on an ultrasonic echoes are recorded on an oscilloscope as they strike tissues of oscilloscope as they strike tissues of different densities.different densities.

• It is particularly useful in the detection It is particularly useful in the detection of an of an enlarged gallbladder or pancreas, enlarged gallbladder or pancreas, the presence of gallstones, an enlarged the presence of gallstones, an enlarged ovary, an ectopic pregnancy, or ovary, an ectopic pregnancy, or appendicitisappendicitis. .

• It cannot be used to examine It cannot be used to examine structures structures that lie behind bony tissue.that lie behind bony tissue.

2525

Nursing InterventionsNursing Interventions The patient is instructed to fast The patient is instructed to fast

for 8 to 12 hours before the test for 8 to 12 hours before the test to decrease the amount of gas in to decrease the amount of gas in the bowel.the bowel.

If gallbladder studies are being If gallbladder studies are being performed, the patient should performed, the patient should eat a fat-free meal the evening eat a fat-free meal the evening before the test.before the test.

2626

DNA TestingDNA TestingImaging StudiesImaging StudiesUpper Gastrointestinal Tract Upper Gastrointestinal Tract StudyStudy

•It aids in the diagnosis of ulcers, It aids in the diagnosis of ulcers, varices, tumors, regional varices, tumors, regional enteritis, and malabsorption enteritis, and malabsorption syndromes.syndromes.

•Barium swallowBarium swallow

•Barium mealBarium meal

2727

Nursing Interventions:Nursing Interventions: Clear liquid diet, with nothing by mouth Clear liquid diet, with nothing by mouth

(NPO) from midnight the night before the (NPO) from midnight the night before the studystudy

However, each physician may prefer a However, each physician may prefer a specific bowel preparation for specific specific bowel preparation for specific studies.studies.

When a patient with insulin-dependent When a patient with insulin-dependent diabetes is NPO, his or her insulin diabetes is NPO, his or her insulin requirements will need to be adjusted requirements will need to be adjusted accordingly.accordingly.

Smoking, chewing gum, and using mints Smoking, chewing gum, and using mints can stimulate gastric motilitycan stimulate gastric motility

2828

After the upper GI After the upper GI procedure:procedure:

Ensure that the patient has Ensure that the patient has eliminated most of the ingested eliminated most of the ingested barium.barium.

Fluids may be increased to Fluids may be increased to facilitate evacuation of stool facilitate evacuation of stool and barium.and barium.

2929

Lower Gastrointestinal Lower Gastrointestinal Tract StudyTract Study Visualization of the lower GI tract is Visualization of the lower GI tract is

obtained after rectal installation of obtained after rectal installation of barium. barium.

The barium enemaThe barium enema can be used to can be used to detect the presence of polyps, tumors, or detect the presence of polyps, tumors, or other lesions of the large intestine and other lesions of the large intestine and demonstrate any anatomic abnormalities demonstrate any anatomic abnormalities or malfunctioning of the bowel.or malfunctioning of the bowel.

After proper preparation and evacuation After proper preparation and evacuation of the entire colon, each portion of the of the entire colon, each portion of the colon may be readily observed.colon may be readily observed.

3030

•The procedure usually takes The procedure usually takes about 15 to 30 minutes, during about 15 to 30 minutes, during which time x-ray images are which time x-ray images are obtained.obtained.

•A double-contrast or air-contrast A double-contrast or air-contrast barium enema involves the barium enema involves the instillation of a thicker barium instillation of a thicker barium solution, followed by the solution, followed by the instillation of airinstillation of air

To detect smaller lesions.To detect smaller lesions.

3131

Nursing Nursing InterventionsInterventions•Preparation of the patient includes Preparation of the patient includes

emptying and cleansing the lower emptying and cleansing the lower bowel.bowel.

•This often necessitates a low-This often necessitates a low-residue diet 1 to 2 days before the residue diet 1 to 2 days before the test test

•A clear liquid diet and a laxative A clear liquid diet and a laxative the evening before; NPO after the evening before; NPO after midnightmidnight

3232

•Barium enemas are Barium enemas are contraindicated in patients contraindicated in patients with:with:– Active inflammatory disease.Active inflammatory disease.– Signs of perforation or obstruction; Signs of perforation or obstruction;

insteadinstead– A water-soluble contrast study may A water-soluble contrast study may

be performed. be performed. – Active GI bleeding may prohibit the Active GI bleeding may prohibit the

use of laxatives and enemas.use of laxatives and enemas.

3333

Computed Computed Tomography:Tomography:

CT may be performed with or CT may be performed with or without oral or intravenous (IV) without oral or intravenous (IV) contrastcontrast

Any allergies to contrast Any allergies to contrast agents, iodine, or shellfishagents, iodine, or shellfish

Patient's current serum Patient's current serum creatinine level, and urine creatinine level, and urine human chorionic gonadotropinhuman chorionic gonadotropin

3434

Magnetic Resonance Magnetic Resonance ImagingImaging MRI is used in gastroenterology to MRI is used in gastroenterology to supplement ultrasonography and CT. supplement ultrasonography and CT. This noninvasive technique uses magnetic This noninvasive technique uses magnetic

fields and radio waves to produce an image fields and radio waves to produce an image of the area being studied.of the area being studied.

MRI is contraindicated for patients with:MRI is contraindicated for patients with: Permanent pacemakersPermanent pacemakersArtificial heart valves and defibrillatorsArtificial heart valves and defibrillators Implanted insulin pumpsImplanted insulin pumpsBecause the magnetic field could cause Because the magnetic field could cause

malfunction.malfunction.

3535

Positron Emission Positron Emission Tomography (PET)Tomography (PET)

ScintigraphyScintigraphy

3636

Endoscopic Endoscopic ProceduresProcedures

Fibroscopy/esophagogastroduodenoscFibroscopy/esophagogastroduodenoscopy (EGD)opy (EGD)

Small-bowel enteroscopySmall-bowel enteroscopy ColonoscopyColonoscopySigmoidoscopySigmoidoscopy ProctoscopyProctoscopyAnoscopyAnoscopy LAPROSCOPYLAPROSCOPYERCPERCP

3737

3838

Nursing Nursing InterventionsInterventionsNPO for 8 hours prior to the examination.NPO for 8 hours prior to the examination.

local anesthetic gargle or spray. local anesthetic gargle or spray. Midazolam (Versed), a sedativeMidazolam (Versed), a sedativeAtropine (to reduce secretions) Atropine (to reduce secretions) Glucagon (to relax smooth muscle)Glucagon (to relax smooth muscle)left lateral position to facilitate clearance left lateral position to facilitate clearance

of pulmonary secretions and provide of pulmonary secretions and provide smooth entry of the scope.smooth entry of the scope.

• . .

3939

After gastroscopy:After gastroscopy: Assess level of consciousnessAssess level of consciousness Vital signs, oxygen saturation, Vital signs, oxygen saturation,

pain level.pain level. Monitor for signs of Monitor for signs of

perforation:perforation:

(ie, pain, bleeding, unusual (ie, pain, bleeding, unusual difficulty swallowing, and difficulty swallowing, and rapidly elevated temperature). rapidly elevated temperature).

4040

Fiberoptic ColonoscopyFiberoptic Colonoscopy

4141

Nursing InterventionsNursing Interventions Adequate colon cleansing Adequate colon cleansing Laxative for two nights Laxative for two nights

before before The use of lavage solutions The use of lavage solutions

is contraindicated in patients is contraindicated in patients with with intestinal obstructionintestinal obstruction or or inflammatory bowel diseaseinflammatory bowel disease..

4242

Gastric Analysis, Gastric Gastric Analysis, Gastric Acid Stimulation Test, and Acid Stimulation Test, and pH MonitoringpH MonitoringNPO for 8 to 12 hours beforeNPO for 8 to 12 hours beforeAny medications that affect gastric Any medications that affect gastric

secretions are withheld for 24 to 48 hours secretions are withheld for 24 to 48 hours beforebefore

Smoking is not allowed on the morning of Smoking is not allowed on the morning of the testthe test

HistamineHistamineNasogastric tubeNasogastric tubeGastric specimens are collected after the Gastric specimens are collected after the

injection every 15 minutes for 1 hourinjection every 15 minutes for 1 hour

4343

Management of Patients Management of Patients with Oral Andwith Oral And

Esophageal DisordersEsophageal Disorders

4444

Disorders of the Lips, Disorders of the Lips, Mouth, and GumsMouth, and Gums

Signs and Symptoms

Possible Causes and sequelae

Nursing Considerations

Actinic cheilitisIrritation of lips associated with scaling, crusty, fissure; white overgrowth of horny layer of epidermis (hyperkeratosis)

Exposure to sun;More common in fair-skinned people

Sun protection Protective ointment Checkup by physician

Herpes simplex 1 (cold sore or fever blister

Symptoms may be delayed up to 20 dayssingular or clustered painful vesicles that may rupture

Immunosuppressed patientsVery contagious May recur with menstruationFever, or sun exposure

Acyclovir (Zovirax) ointment or systemic Analgesics Avoid irritating foods

Abnormalities of the LipsCondition

4545

Abnormalities of the Mouth

Signs and SymptomsPossible Causes and sequelae

Nursing Considerations

Leukoplakia White patches; usually in buccal mucosa usually painless

Fewer than 2%are malignant

Common among tobacco users

Follow up if leukoplakia persists longer than 2 weeks

Eliminate risk factors

AphthousStomatitis(canker sore)

Shallow ulcer with a white or yellow center and red border

Seen on the inner side of the lip and cheek or on the tongue;

It begins with a burning or tingling sensation

Slight swelling Painful; usually lasts 7–10

days and heals without a scar

Associated with emotional or mental stress, fatigue

hormonal factors minor trauma (such as

biting) allergies acidic foods dietary deficiencies Associated with HIV

infection May recur

Comfort measures, such as saline rinses, soft diet

Antibiotics Corticosteroids

Stomatitis Mild redness (erythema) Edema Painful ulcerations Bleeding and secondary

infection

Chemotherapy Radiation therapy Severe drug allergy myelosuppression (bone

marrow depression)

Prophylactic mouth care

Use of a soft-bristled toothbrush

Avoid alcohol based mouth rinses and hot or spicy foods

Apply topical anti-inflammatory, antibiotic, and anesthetic agents as prescribed

4646

Abnormalitiesof the Gums

Signs andSymptoms

Possible Causesand sequelae

NursingConsiderations

Gingivitis Painful, inflamed, swollen gums

Usually the gums bleed in response to light contact

Poor oral hygiene: food debris, bacterial plaque, and calculus (tartar)accumulate; the gums may also swell in response to normal processes such as puberty and pregnancy

Teach patient proper oral hygiene

Necrotizinggingivitis

Gray-white pseudomembranous ulcerations affecting the edges of the gums, mucosa of the mouth, tonsils, and pharynx

Foul breath Painful, bleeding

gums Swallowing and

talking are painful

Poor oral hygiene Bacterial infection Inadequate rest Emotional stress Smoking Poor nutrition

Oral hygiene Irrigate with 2%

to 3% hydrogen peroxide or normal saline solution

Avoid irritants such as smoking and spicy foods

4747

Herpeticgingivostomatitis

Burning sensation with the appearance of small vesicles 24–48hours later;vesicles may rupture, forming sore, shallowulcers covered with a gray membrane

• Herpes simplex virus;

• streptococcal pneumonia, meningococcal meningitis, and malaria

Apply topical anesthetics

May need opioids if pain is severe

Oral care Antiviral

4848

Cancer of the Oral CavityCancer of the Oral Cavity

• occur in any part of the occur in any part of the mouth or throatmouth or throat

• curable if discovered early.curable if discovered early.

• 5-year survival rate(80%) 5-year survival rate(80%) if detected before if detected before spreading to lymph nodes.spreading to lymph nodes.

4949

Risk factors:Risk factors:Tobacco Tobacco Ingestion of alcoholIngestion of alcoholDietary deficiencyDietary deficiencyIngestion of smoked meats.Ingestion of smoked meats.Age: more than 40 yearsAge: more than 40 yearsGender: menGender: menExposure to the sun and Exposure to the sun and

wind (Lip Ca) wind (Lip Ca)

5050

Clinical ManifestationsClinical Manifestations Asymptomatic in the early Asymptomatic in the early

stages. stages. Later, the most frequent Later, the most frequent

symptom is a painless sore or symptom is a painless sore or mass that will not heal.mass that will not heal.

A typical lesion in oral cancer is A typical lesion in oral cancer is a painless indurated (hardened) a painless indurated (hardened) ulcer with raised edges.ulcer with raised edges.

5151

As the cancer As the cancer progressesprogresses TendernessTenderness Difficulty in chewing, Difficulty in chewing,

swallowing, or speakingswallowing, or speaking Coughing of blood-tinged Coughing of blood-tinged

sputumsputum Enlarged cervical lymph Enlarged cervical lymph

nodesnodes. .

5252

Assessment and Assessment and Diagnostic FindingsDiagnostic Findings Oral examination as well as Oral examination as well as

an assessment of the cervical an assessment of the cervical lymph nodes to detect lymph nodes to detect possible metastases. possible metastases.

Biopsies are performed on Biopsies are performed on suspicious lesions (those that suspicious lesions (those that have not healed in 2 weeks). have not healed in 2 weeks).

5353

Medical Medical Management:Management: Surgical resection, radiation Surgical resection, radiation

therapy, chemotherapy, or a therapy, chemotherapy, or a combination combination

Surgical procedures include Surgical procedures include hemiglossectomy (surgical hemiglossectomy (surgical removal of half of the tongue) removal of half of the tongue) and total glossectomy and total glossectomy (removal of the tongue).(removal of the tongue).

5454

Disorders of the Disorders of the EsophagusEsophagusHiatal HerniaHiatal Hernia•The opening in the diaphragm The opening in the diaphragm

through which the esophagus through which the esophagus passes becomes enlarged, and passes becomes enlarged, and part of the upper stomach tends part of the upper stomach tends to move up into the lower portion to move up into the lower portion of the thorax.of the thorax.

•Hiatal hernia occurs more often Hiatal hernia occurs more often in women than in men. in women than in men.

5555

There are two types of There are two types of hiatal herniashiatal hernias::

5656

Sliding, or type I:Sliding, or type I:Occurs when the upper Occurs when the upper

stomach and the stomach and the gastroesophageal junction gastroesophageal junction are displaced upward and are displaced upward and slide in and out of the thorax. slide in and out of the thorax.

About 90% of patients with About 90% of patients with esophageal hiatal hernia have esophageal hiatal hernia have a sliding hernia.a sliding hernia.

5757

Paraesophageal Paraesophageal herniahernia

Occurs when all or part of the Occurs when all or part of the stomach pushes through the stomach pushes through the diaphragm beside the diaphragm beside the esophagus. esophagus.

Paraesophageal hernias are Paraesophageal hernias are further classified as types II, III, further classified as types II, III, or IV, depending on the extent or IV, depending on the extent of herniation.of herniation.

5858

Clinical Clinical ManifestationsManifestationsSliding hernia:Sliding hernia:

– Heartburn, regurgitation, and dysphagiaHeartburn, regurgitation, and dysphagia– 50% of patients are asymptomatic.50% of patients are asymptomatic.

Paraesophageal hernia:Paraesophageal hernia:

•Sense of fullness after eating or chest Sense of fullness after eating or chest pain, or there may be no symptoms.pain, or there may be no symptoms.

•Reflux usually does not occur, because Reflux usually does not occur, because the gastroesophageal sphincter is intact.the gastroesophageal sphincter is intact.

5959

•Hemorrhage, Hemorrhage, obstruction, and obstruction, and strangulation can occur strangulation can occur with any type of hernia with any type of hernia

Assessment and Diagnostic Assessment and Diagnostic FindingsFindings

• Diagnosis is confirmed by x-ray Diagnosis is confirmed by x-ray studies, barium swallow, and studies, barium swallow, and fluoroscopy.fluoroscopy.

6060

Management for an Management for an axial hernia includes:axial hernia includes: Frequent, small feedings that can pass Frequent, small feedings that can pass

easily through the esophagus. easily through the esophagus. The patient is advised not to recline for The patient is advised not to recline for

1 hour after eating, to prevent reflux or 1 hour after eating, to prevent reflux or movement of the herniamovement of the hernia

Elevate the head of the bed on (10- to Elevate the head of the bed on (10- to 20-cm) blocks to prevent the hernia 20-cm) blocks to prevent the hernia from sliding upward.from sliding upward.

Surgery is indicated (15% of patients). Surgery is indicated (15% of patients).

6161

Medical and surgical Medical and surgical management of a management of a paraesophageal herniaparaesophageal hernia May require emergency May require emergency surgery to correct torsion surgery to correct torsion (twisting) of the stomach (twisting) of the stomach or other body organ that or other body organ that leads to restriction of leads to restriction of blood flow to that area.blood flow to that area.

6262

Gastroesophageal Reflux Gastroesophageal Reflux DiseaseDiseaseSome degree of gastroesophageal Some degree of gastroesophageal

reflux (back-flow of gastric or reflux (back-flow of gastric or duodenal contents into the duodenal contents into the esophagus) is normal in both adults esophagus) is normal in both adults and children. and children.

Excessive reflux may occur because Excessive reflux may occur because of an incompetent lower esophageal of an incompetent lower esophageal sphincter, pyloric stenosis, or a sphincter, pyloric stenosis, or a motility disorder.motility disorder.

6363

Clinical Clinical ManifestationsManifestations• Pyrosis (burning sensation in the Pyrosis (burning sensation in the esophagus)esophagus)

• Dyspepsia (indigestion)Dyspepsia (indigestion)

• RegurgitationRegurgitation

• Dysphagia or odynophagia (pain on Dysphagia or odynophagia (pain on swallowing)swallowing)

• HypersalivationHypersalivation

• Esophagitis.Esophagitis.

• The symptoms may mimic those of a heart The symptoms may mimic those of a heart attack. attack.

6464

Assessment and Assessment and Diagnostic FindingsDiagnostic Findings Endoscopy or barium swallow Endoscopy or barium swallow Ambulatory 12- to 36-hour Ambulatory 12- to 36-hour

esophageal pH monitoringesophageal pH monitoring

(acid reflux)(acid reflux) Bilirubin monitoring (Bilitec) Bilirubin monitoring (Bilitec)

(bile reflux)(bile reflux)

6565

ManagementManagementThe patient is instructed to:The patient is instructed to:

–Eat a low-fat diet.Eat a low-fat diet.–Avoid caffeine, tobacco, Avoid caffeine, tobacco, beer, milk, foods containing beer, milk, foods containing peppermint or spearmint, peppermint or spearmint, and carbonated beveragesand carbonated beverages

6666

– Avoid eating or drinking 2 Avoid eating or drinking 2 hours before bedtimehours before bedtime

– Maintain normal body weightMaintain normal body weight– Avoid tight-fitting clothesAvoid tight-fitting clothes– Elevate the head of the bed Elevate the head of the bed

on (15- to 20-cm) blockson (15- to 20-cm) blocks

6767

Pharmacological Pharmacological therapy:therapy:• Antacids or H2 receptor Antacids or H2 receptor

antagonistsantagonists, such as famotidine , such as famotidine (Pepcid), or ranitidine (Zantac). (Pepcid), or ranitidine (Zantac).

• Proton pump inhibitorsProton pump inhibitors (medications that decrease the (medications that decrease the release of gastric acid, such as release of gastric acid, such as esomeprazole [Nexium])esomeprazole [Nexium])

• Prokinetic agentsProkinetic agents, which accelerate , which accelerate gastric emptying. gastric emptying.

Domperidone (Motilium) and Domperidone (Motilium) and metoclopramide (Reglan).metoclopramide (Reglan).

6868

Surgical Surgical intervention:intervention:

Fundoplication (wrapping of a Fundoplication (wrapping of a portion of the gastric fundus portion of the gastric fundus around the sphincter area of the around the sphincter area of the esophagus). esophagus).

A Nissen fundoplication can be A Nissen fundoplication can be performed by the open method or performed by the open method or by laparoscopy.by laparoscopy.

6969

Cancer of the Cancer of the EsophagusEsophagusPathophysiologyPathophysiology• Esophageal cancer can be of two cell types: Esophageal cancer can be of two cell types:

adenocarcinoma and squamous cell carcinoma. adenocarcinoma and squamous cell carcinoma. • Risk factors for adenocarcinoma of the Risk factors for adenocarcinoma of the

esophagus include GERD.esophagus include GERD.• Risk factors for squamous cell carcinoma:Risk factors for squamous cell carcinoma:

– Chronic ingestion of hot liquids or foods.Chronic ingestion of hot liquids or foods.– Nutritional deficienciesNutritional deficiencies– Poor oral hygiene.Poor oral hygiene.– Cigarette smokingCigarette smoking– Chronic alcohol exposure Chronic alcohol exposure

7070

Tumor cells may spread

esophageal mucosa muscle layers lymphatics.

obstruction ofthe esophagus

possible perforation

and erosion

mediastinum

great vessels

7171

Clinical ManifestationsClinical Manifestations

• Dysphagia, initially with solid foods Dysphagia, initially with solid foods and eventually with liquidsand eventually with liquids

• Sensation of a mass in the throatSensation of a mass in the throat

• Painful swallowing.Painful swallowing.

• Substernal pain or fullnessSubsternal pain or fullness

• And, later, And, later, regurgitationregurgitation of of undigested food with foul breath and undigested food with foul breath and hiccupshiccups, , hemorrhagehemorrhage and and progressive progressive loss of weightloss of weight and and respiratory difficulty.respiratory difficulty.

7272

Assessment and Assessment and Diagnostic FindingsDiagnostic Findings

•EGD with biopsyEGD with biopsy

•CT of the chest and CT of the chest and abdomenabdomen

•Endoscopic ultrasound Endoscopic ultrasound

7373

Medical Medical ManagementManagement• Surgery, radiation, chemotherapy, or a Surgery, radiation, chemotherapy, or a combination of these modalitiescombination of these modalities

• A standard treatment plan for a person A standard treatment plan for a person who is newly diagnosed: who is newly diagnosed:

combination chemotherapy/radiation combination chemotherapy/radiation therapy for 4 to 6 weekstherapy for 4 to 6 weeks

followed by a period of no medical followed by a period of no medical intervention for 4 weeksintervention for 4 weeks

and, lastly, surgical resection of the and, lastly, surgical resection of the esophagus.esophagus.

7474

EsophagectomyEsophagectomy • A total resection of the esophagus A total resection of the esophagus • With removal of the tumor plus a wide With removal of the tumor plus a wide

tumor-free margin of the esophagus and tumor-free margin of the esophagus and the lymph nodes in the area.the lymph nodes in the area.

• When tumors occur in the cervical When tumors occur in the cervical or upper thoracic area,or upper thoracic area, esophageal esophageal continuity may be maintained by a continuity may be maintained by a free free jejunal graft transfer jejunal graft transfer

• or the or the stomach can be elevated into the stomach can be elevated into the chestchest and the proximal section of the and the proximal section of the esophagus anastomosed to the stomach.esophagus anastomosed to the stomach.

7575

Tumors of the lower Tumors of the lower thoracic esophagusthoracic esophagus

•Gastrointestinal tract Gastrointestinal tract integrity is maintained integrity is maintained by anastomosing the by anastomosing the lower esophagus to the lower esophagus to the stomachstomach

7676

7777

Nursing Nursing ManagementManagement• Intervention is directed toward improving Intervention is directed toward improving

the patient's nutritional and physical statusthe patient's nutritional and physical status• Parenteral or enteral nutrition. Parenteral or enteral nutrition. • Preparation for surgery, radiation therapy, or Preparation for surgery, radiation therapy, or

chemotherapy.chemotherapy.• Chest drainage, nasogastric suction, Chest drainage, nasogastric suction,

parenteral fluid therapy, and gastric parenteral fluid therapy, and gastric intubation.intubation.

• postoperative carepostoperative care• Chest physiotherapyChest physiotherapy• The nasogastric tube is not manipulatedThe nasogastric tube is not manipulated• The nasogastric tube is removed 5 to 7 days The nasogastric tube is removed 5 to 7 days

after surgeryafter surgery

7878

Special Nutritional Special Nutritional ModalitiesModalitiesGastrostomyGastrostomyA gastrostomy is a surgical procedure in A gastrostomy is a surgical procedure in

which an opening is created into the which an opening is created into the stomach for the purpose of administering stomach for the purpose of administering foods and fluids via a feeding tube.foods and fluids via a feeding tube.

gastrostomy is preferred for prolonged gastrostomy is preferred for prolonged enteral nutrition support (longer than 4 enteral nutrition support (longer than 4 weeks)weeks)

Gastrostomy is also preferred in comatose Gastrostomy is also preferred in comatose patient because the gastroesophageal patient because the gastroesophageal sphincter remains intact. Regurgitation and sphincter remains intact. Regurgitation and aspiration are less likely to occur aspiration are less likely to occur

Stamm (temporary and permanent)Stamm (temporary and permanent) Janeway (permanent)Janeway (permanent)

7979

Percutaneous endoscopic Percutaneous endoscopic gastrostomy (temporary)gastrostomy (temporary)

(10 to 14 days)

8080

Low-profile gastrostomy Low-profile gastrostomy device (LPGD)device (LPGD)

(3 to 6 months after initial gastrostomy tube placement)

8181

Nursing DiagnosesNursing DiagnosesImbalanced nutrition, less than body Imbalanced nutrition, less than body

requirements, related to enteral requirements, related to enteral feeding problemsfeeding problems

Risk for infection related to presence Risk for infection related to presence of wound and tubeof wound and tube

Risk for impaired skin integrity at tube Risk for impaired skin integrity at tube insertion siteinsertion site

Ineffective coping related to inability Ineffective coping related to inability to eat normallyto eat normally

Disturbed body image related to Disturbed body image related to presence of tubepresence of tube

8282

Nursing Nursing InterventionsInterventions• Meeting Nutritional Needs:Meeting Nutritional Needs:

– The first fluid nourishment is administered The first fluid nourishment is administered soon after surgery.soon after surgery.

– Usually consists of tap water and 10% Usually consists of tap water and 10% dextrose.dextrose.

– At first, only 30 to 60 mL is given at one At first, only 30 to 60 mL is given at one time, but the amount administered is time, but the amount administered is increased gradually. increased gradually.

– By the second day, 180 to 240 mL may be By the second day, 180 to 240 mL may be given at one time, provided it is tolerated given at one time, provided it is tolerated and no leakage of fluid occurs around the and no leakage of fluid occurs around the tube.tube.

8383

Water and enteral feeding can be Water and enteral feeding can be infused after 24 hours for a infused after 24 hours for a permanent gastrostomy.permanent gastrostomy.

Blenderized foods can be added Blenderized foods can be added gradually to clear liquids until a full gradually to clear liquids until a full diet is achieved. diet is achieved.

Powdered feedings that are easily Powdered feedings that are easily liquefied are commercially liquefied are commercially available.available.

8484

Providing Tube Care and Preventing Providing Tube Care and Preventing InfectionInfection

Providing Skin CareProviding Skin Care The nurse washes the area around the tube The nurse washes the area around the tube

with soap and water daily, removes any with soap and water daily, removes any encrustation with saline solution, rinses the encrustation with saline solution, rinses the area well with water, and pats it dryarea well with water, and pats it dry

Skin at the exit site is evaluated daily for Skin at the exit site is evaluated daily for signs of breakdown, irritation, excoriation, signs of breakdown, irritation, excoriation, and the presence of drainage or gastric and the presence of drainage or gastric leakage.leakage.

Enhancing Body ImageEnhancing Body Image

8585

Monitoring and Managing Monitoring and Managing Potential ComplicationsPotential Complications

Wound infectionWound infection Cellulitis Cellulitis AbscessesAbscesses BleedingBleeding Premature removal of the tubePremature removal of the tube The tract will close within 4 to 6 The tract will close within 4 to 6

hours if the tube is not replaced hours if the tube is not replaced promptly promptly

8686

Teaching Patients Self-Teaching Patients Self-CareCare Showing the patient how to check for Showing the patient how to check for

residual gastric contents before the residual gastric contents before the feeding. feeding.

The patient then learns how to check and The patient then learns how to check and maintain the patency of the tubemaintain the patency of the tube

All feedings are given at room temperature All feedings are given at room temperature or near body temperature.or near body temperature.

Raising or lowering the receptacle to no Raising or lowering the receptacle to no higher than 45 cm (18 in) above the higher than 45 cm (18 in) above the abdominal wall regulates the rate of flow.abdominal wall regulates the rate of flow.

The patient and caregiver must understand The patient and caregiver must understand that keeping the head of the bed elevated that keeping the head of the bed elevated a minimum of 45 degrees for at least 1 a minimum of 45 degrees for at least 1 hour after feeding facilitates digestion and hour after feeding facilitates digestion and decreases the risk of aspiration.decreases the risk of aspiration.

8787

Parenteral NutritionParenteral Nutrition

•Parenteral nutrition (PN) is a Parenteral nutrition (PN) is a method of providing nutrients to method of providing nutrients to the body by an IV routethe body by an IV route

•Admixture containing proteins, Admixture containing proteins, carbohydrates, fats, electrolytes, carbohydrates, fats, electrolytes, vitamins, trace minerals, and vitamins, trace minerals, and sterile water in a single container. sterile water in a single container.

8888

The goals of PN are The goals of PN are totoImprove nutritional status, Improve nutritional status, establish a positive nitrogen balance, establish a positive nitrogen balance, Maintain muscle mass,Maintain muscle mass, promote weight maintenance or promote weight maintenance or

gaingain and enhance the healing process.and enhance the healing process.

8989

Establishing Positive Establishing Positive Nitrogen BalanceNitrogen BalanceAs a state of negative nitrogen As a state of negative nitrogen

balance results.balance results. In response, the body begins to In response, the body begins to

convert the protein found in muscles convert the protein found in muscles into carbohydrates to be used to into carbohydrates to be used to meet energy needs. meet energy needs.

The result is muscle wasting, weight The result is muscle wasting, weight loss, fatigue, and, if left uncorrected, loss, fatigue, and, if left uncorrected, death.death.

9090

PN solutions, which supply nutrients PN solutions, which supply nutrients such as dextrose, amino acids, such as dextrose, amino acids, electrolytes, vitamins, minerals, and electrolytes, vitamins, minerals, and fat emulsions, provide enough fat emulsions, provide enough calories and nitrogen to meet the calories and nitrogen to meet the patient's daily nutritional needs.patient's daily nutritional needs.

In general, PN usually provides 25 to In general, PN usually provides 25 to 35 kcal/kg of ideal body weight and 35 kcal/kg of ideal body weight and 1.0 to 1.5 g of protein/kg of ideal 1.0 to 1.5 g of protein/kg of ideal body weight.body weight.

9191

Clinical IndicationsClinical Indications• The indications for PN include a 10% deficit in body The indications for PN include a 10% deficit in body

weight (compared with pre-illness weight), weight (compared with pre-illness weight), • PN is indicated in the following situations:PN is indicated in the following situations:• The patient's intake is insufficient to maintain an The patient's intake is insufficient to maintain an

anabolic state (eg, severe burns, malnutrition, anabolic state (eg, severe burns, malnutrition, sepsis, and cancer).sepsis, and cancer).

• The patient's ability to ingest food orally or by tube The patient's ability to ingest food orally or by tube is impaired (eg, paralytic ileus)is impaired (eg, paralytic ileus)

• The patient is unwilling or unable to ingest adequate The patient is unwilling or unable to ingest adequate nutrients (eg, anorexia nervosa, postoperative nutrients (eg, anorexia nervosa, postoperative elderly patients).elderly patients).

• Preoperative and postoperative nutritional needs are Preoperative and postoperative nutritional needs are prolonged (eg, extensive bowel surgery).prolonged (eg, extensive bowel surgery).

9292

FormulasFormulasA total of 2 to 3 L of solution is administered A total of 2 to 3 L of solution is administered

over a 24-hour period using a filterover a 24-hour period using a filterIntravenous fat emulsions (IVFEs, Intravenous fat emulsions (IVFEs,

Intralipids) may be infused simultaneously Intralipids) may be infused simultaneously with PN through a Y-connectorwith PN through a Y-connector

Usually 500 mL of a 10% emulsion or 250 Usually 500 mL of a 10% emulsion or 250 mL of 20% emulsion is administered over 6 mL of 20% emulsion is administered over 6 to 12 hours, one to three times a week.to 12 hours, one to three times a week.

IVFEs can provide up to 30% of the total IVFEs can provide up to 30% of the total daily calorie intake.daily calorie intake.

9393

Administration MethodsAdministration MethodsPeripheral MethodPeripheral MethodPPN formulas are not nutritionally complete: PPN formulas are not nutritionally complete:

there is typically less dextrose content. there is typically less dextrose content. Dextrose concentrations of more than 10% Dextrose concentrations of more than 10%

should not be administered through should not be administered through peripheral veins because they irritate the peripheral veins because they irritate the intima (innermost walls) of small veins, intima (innermost walls) of small veins, causing chemical phlebitis.causing chemical phlebitis.

Lipids are administered simultaneously to Lipids are administered simultaneously to buffer the PPN and to protect the peripheral buffer the PPN and to protect the peripheral vein from irritation.vein from irritation.

The usual length of therapy using PPN is 5 The usual length of therapy using PPN is 5 to 7 daysto 7 days

9494

Central MethodCentral Method

•Therefore, to prevent phlebitis Therefore, to prevent phlebitis and other venous complications, and other venous complications, these solutions are administered these solutions are administered into the vascular system through into the vascular system through a catheter inserted into a high-a catheter inserted into a high-flow, large blood vessel (the flow, large blood vessel (the subclavian vein).subclavian vein).

9595

Discontinuing Discontinuing Parenteral NutritionParenteral Nutrition•The PN solution is discontinued The PN solution is discontinued

gradually to allow the patient to gradually to allow the patient to adjust to decreased levels of adjust to decreased levels of glucose.glucose.

• If the PN solution is abruptly If the PN solution is abruptly terminated, isotonic dextrose is terminated, isotonic dextrose is administered for 1 to 2 hours to administered for 1 to 2 hours to protect against rebound protect against rebound hypoglycemia. hypoglycemia.

9696

Management of Patients Management of Patients With Gastric and Duodenal With Gastric and Duodenal DisordersDisordersGastritis:Gastritis:• Gastritis (inflammation of the gastric or Gastritis (inflammation of the gastric or

stomach mucosa) stomach mucosa)

• Gastritis may be Gastritis may be acuteacute, lasting several , lasting several hours to a few days, or hours to a few days, or chronicchronic, , resulting from repeated exposure to resulting from repeated exposure to irritating agents or recurring episodes of irritating agents or recurring episodes of acute gastritis.acute gastritis.

9797

Acute gastritis is often Acute gastritis is often caused by:caused by:Dietary indiscretion— irritating food Dietary indiscretion— irritating food Overuse of aspirin and other nonsteroidal anti-Overuse of aspirin and other nonsteroidal anti-

inflammatory drugs (NSAIDs)inflammatory drugs (NSAIDs)excessive alcohol intakeexcessive alcohol intakeBile refluxBile refluxRadiation therapy.Radiation therapy. A more severe form of acute gastritis is caused A more severe form of acute gastritis is caused

by the ingestion of strong acid or alkaliby the ingestion of strong acid or alkaliAcute illnesses, traumatic injuries; burns; major Acute illnesses, traumatic injuries; burns; major

surgery.surgery.Gastritis may be the first sign of an acute Gastritis may be the first sign of an acute

systemic infection.systemic infection.

9898

Chronic gastritisChronic gastritis::• Prolonged inflammation of the stomach may Prolonged inflammation of the stomach may

be caused:be caused:– Either by benign or malignant ulcers of the Either by benign or malignant ulcers of the

stomachstomach– Or by the bacteria Helicobacter pylori (H. pylori).Or by the bacteria Helicobacter pylori (H. pylori).

• Chronic gastritis is sometimes associated Chronic gastritis is sometimes associated withwith– autoimmune diseases such as pernicious anemiaautoimmune diseases such as pernicious anemia– dietary factors such as caffeinedietary factors such as caffeine– the use of medications such as NSAIDsthe use of medications such as NSAIDs– Alcohol; smokingAlcohol; smoking– Chronic reflux irritating of pancreatic secretions Chronic reflux irritating of pancreatic secretions

and bile into the stomach.and bile into the stomach.

9999

PathophysiologyPathophysiology

Inflammation

Edematous mucous membrane

Hyperemic

superficial erosion

gastric juice ↓ acid ↓ but mucus↑

Superficial ulceration

hemorrhage

100100

101101

Clinical Clinical ManifestationsManifestationsAcute gastritis Acute gastritis Rapid onset of symptoms, such as:Rapid onset of symptoms, such as:Abdominal discomfortAbdominal discomfortHeadacheHeadacheLassitudeLassitudeNauseaNauseaAnorexiaAnorexiaVomitingVomitingHiccupping, which can last from a few Hiccupping, which can last from a few

hours to a few days.hours to a few days.

102102

Chronic gastritisChronic gastritis

• AnorexiaAnorexia

• Heartburn after eatingHeartburn after eating

• Belching Belching

• A sour taste in the mouthA sour taste in the mouth

• Nausea and vomiting. Nausea and vomiting.

103103

Some patients may have onlySome patients may have only• Mild epigastric discomfort orMild epigastric discomfort or

• Report intolerance to spicy or fatty foodsReport intolerance to spicy or fatty foods

• Or slight pain that is relieved by eating.Or slight pain that is relieved by eating.

Chronic gastritis /pernicious Chronic gastritis /pernicious anemiaanemia

Malabsorption of vitamin B12Malabsorption of vitamin B12

•Some patients with chronic Some patients with chronic gastritis have:gastritis have:

No symptomsNo symptoms

104104

Assessment and Diagnostic Assessment and Diagnostic FindingsFindings

•Upper GI x-ray seriesUpper GI x-ray series

•Endoscopy Endoscopy

•Histologic examination/ Histologic examination/ biopsybiopsy

•H. pyloriH. pylori

105105

Medical Medical ManagementManagement

•The gastric mucosa is capable of The gastric mucosa is capable of repairing itself after a bout of repairing itself after a bout of gastritis. gastritis.

•As a rule, the patient recovers in As a rule, the patient recovers in about 1 day, although the about 1 day, although the appetite may be diminished for appetite may be diminished for an additional 2 or 3 days. an additional 2 or 3 days.

106106

Acute gastritis is also Acute gastritis is also managed by:managed by:

•Risk reductionRisk reduction

•If the symptoms persist, If the symptoms persist, intravenous (IV) fluids intravenous (IV) fluids

•If bleeding is presentIf bleeding is present

Hemorrhage Hemorrhage managementmanagement

107107

If gastritis is caused by If gastritis is caused by ingestion of strong acids or ingestion of strong acids or alkalisalkalisEmergency treatment Emergency treatment • Ddiluting and neutralizing the Ddiluting and neutralizing the

offending agentoffending agent• To neutralize acids, common antacids To neutralize acids, common antacids

(eg, aluminum hydroxide) (eg, aluminum hydroxide) • To neutralize an alkali, diluted lemon To neutralize an alkali, diluted lemon

juice or diluted vinegar. juice or diluted vinegar. • If corrosion is extensive or severe, If corrosion is extensive or severe,

emetics and lavage are avoided emetics and lavage are avoided (perforation and damage to the (perforation and damage to the esophagus).esophagus).

108108

Supportive TherapySupportive Therapy•Nasogastric (NG) intubationNasogastric (NG) intubation

•Analgesic agents and Analgesic agents and sedativessedatives

•AntacidsAntacids

•IV fluids. IV fluids.

•Fiberoptic endoscopy may be Fiberoptic endoscopy may be necessary necessary

109109

In extreme cases, In extreme cases, emergency surgeryemergency surgery

•To remove gangrenous or To remove gangrenous or perforated tissue. perforated tissue.

•A gastric resection or a A gastric resection or a gastrojejunostomy (anastomosis of gastrojejunostomy (anastomosis of jejunum to stomach to detour jejunum to stomach to detour around the pylorus) may be around the pylorus) may be necessary to treat pyloric necessary to treat pyloric obstructionobstruction

110110

111111

Chronic gastritis Chronic gastritis managementmanagement• Modifying the patient's dietModifying the patient's diet

• Promoting restPromoting rest

• Reducing stressReducing stress

• Recommending avoidance of alcohol Recommending avoidance of alcohol and NSAIDsand NSAIDs

• Initiating pharmacotherapy. Initiating pharmacotherapy.

• H. pylori may be treated with H. pylori may be treated with selected drug combinationsselected drug combinations

112112

Nursing ProcessNursing ProcessThe Patient With GastritisThe Patient With GastritisAssessmentAssessment::• History and presenting signs and symptoms. History and presenting signs and symptoms.

• OPQRST scaleOPQRST scale

• Recent weight gain or lossRecent weight gain or loss

• History of previous gastric disease or surgery?History of previous gastric disease or surgery?

• A diet history plus a 72-hour dietary recall.A diet history plus a 72-hour dietary recall.

• Signs to note during the physical examination Signs to note during the physical examination include abdominal tenderness, dehydration, include abdominal tenderness, dehydration, and evidence of any systemic disorder.and evidence of any systemic disorder.

113113

Nursing Nursing DiagnosesDiagnoses• Anxiety related to treatmentAnxiety related to treatment

• Imbalanced nutrition, less than body Imbalanced nutrition, less than body requirements, related to inadequate intake of requirements, related to inadequate intake of nutrientsnutrients

• Risk for imbalanced fluid volume related to Risk for imbalanced fluid volume related to insufficient fluid intake and excessive fluid insufficient fluid intake and excessive fluid loss subsequent to vomitingloss subsequent to vomiting

• Deficient knowledge about dietary Deficient knowledge about dietary management and disease processmanagement and disease process

• Acute pain related to irritated stomach Acute pain related to irritated stomach mucosamucosa

114114

PLANNING:PLANNING:The major goals for the patient The major goals for the patient

maymayincludeinclude reduced anxietyreduced anxiety avoidance of irritating foodsavoidance of irritating foods adequate intake of nutrientsadequate intake of nutrients maintenance of fluid balancemaintenance of fluid balance increased awareness of dietary increased awareness of dietary managementmanagement relief of painrelief of pain

115115

Nursing Nursing InterventionsInterventionsReducing AnxietyReducing Anxiety• The patient may be anxious because of The patient may be anxious because of

pain and planned treatment modalities. pain and planned treatment modalities.

• The nurse uses a calm approach to The nurse uses a calm approach to assess the patient and to answer all assess the patient and to answer all questions as completely as possible. questions as completely as possible.

• It is important to explain all procedures It is important to explain all procedures and treatments based on the patient's and treatments based on the patient's level of understanding.level of understanding.

116116

Promoting Optimal Promoting Optimal NutritionNutrition• NPO until healingNPO until healing• I @ O + Electrolytes assessmentI @ O + Electrolytes assessment• If IV therapy until oral intake toleratedIf IV therapy until oral intake tolerated• Offer the patient ice chips followed by Offer the patient ice chips followed by

clear liquids.clear liquids.• Solid food as soon as possibleSolid food as soon as possible• The nurse discourages the intake of:The nurse discourages the intake of: caffeinated beveragescaffeinated beverages alcoholalcoholcigarette smokingcigarette smoking

117117

Promoting Fluid BalancePromoting Fluid Balance • IV fluids (3 L/day) usually are IV fluids (3 L/day) usually are

prescribed and a record of fluid intake prescribed and a record of fluid intake plus caloric value (1 L of 5% dextrose plus caloric value (1 L of 5% dextrose in water = 170 calories of in water = 170 calories of carbohydrate)carbohydrate)

• Assess for Hemorrhage:Assess for Hemorrhage:Hematemesis Hematemesis TachycardiaTachycardiaHypotension.Hypotension.

118118

Relieving PainRelieving PainInstructing the patient to Instructing the patient to

avoid foods and beverages avoid foods and beverages Instructing the patient about Instructing the patient about

the correct use of medications the correct use of medications to relieve chronic gastritis. to relieve chronic gastritis.

119119

Peptic Ulcer DiseasePeptic Ulcer Disease• A peptic ulcer is an excavation (hollowed-out A peptic ulcer is an excavation (hollowed-out

area) that forms in the mucosal wall of the area) that forms in the mucosal wall of the stomach, in the pylorus, in the duodenum, or in stomach, in the pylorus, in the duodenum, or in the esophagus.the esophagus.

• Erosion of a circumscribed area of mucous Erosion of a circumscribed area of mucous membrane is the causemembrane is the cause

• This erosion may extend as deeply as the muscle This erosion may extend as deeply as the muscle layers or through the muscle to the peritoneum.layers or through the muscle to the peritoneum.

• Peptic ulcers are more likely to be in the Peptic ulcers are more likely to be in the duodenum than in the stomach.duodenum than in the stomach.

• As a rule they occur alone, but they may occur in As a rule they occur alone, but they may occur in multiples.multiples.

120120

•Chronic gastric ulcersChronic gastric ulcers tend to tend to occur in the occur in the lesser curvaturelesser curvature of of the stomach, near the pylorus.the stomach, near the pylorus.

• Esophageal ulcersEsophageal ulcers occur as a occur as a result of the backward flow of HCl result of the backward flow of HCl from the stomach into the from the stomach into the esophagus ( esophagus ( GERDGERD).).

•Peptic ulcers in the Peptic ulcers in the body of the body of the stomachstomach can occur without can occur without excessive acid secretion.excessive acid secretion.

121121

•In the pastIn the past, , stress and stress and anxiety were thought anxiety were thought to be causes of ulcersto be causes of ulcers

•But researchBut research

Infection with the Infection with the gram-negative bacteria gram-negative bacteria H. pylori H. pylori

122122

• Excessive secretion of HCl in the Excessive secretion of HCl in the stomach may contribute to the stomach may contribute to the formation of peptic ulcersformation of peptic ulcers

• Predisposing factors:Predisposing factors:Stress Stress Ingestion of milk and caffeinated Ingestion of milk and caffeinated

beverages, smoking, and alcohol also beverages, smoking, and alcohol also may may

Chronic use of NSAIDs Chronic use of NSAIDs Zollinger-Ellison syndrome Zollinger-Ellison syndrome Familial tendency Familial tendency Chronic pulmonary disease or chronic Chronic pulmonary disease or chronic

renal disease.renal disease.

123123

PathophysiologyPathophysiology•The erosion is caused by the:The erosion is caused by the:

1.1. increased concentration or increased concentration or activity of acid-pepsin,activity of acid-pepsin,

2.2. or by decreased resistance of or by decreased resistance of the mucosa.the mucosa.

• A damaged mucosa cannot secrete A damaged mucosa cannot secrete enough mucus to act as a barrier enough mucus to act as a barrier against HCl. against HCl.

• Patients with duodenal ulcer disease secrete Patients with duodenal ulcer disease secrete more acid than normal,more acid than normal, whereaswhereas patients patients with gastric ulcer tend to secrete normal or with gastric ulcer tend to secrete normal or decreased levels of acid. decreased levels of acid.

124124

• Damage to the gastroduodenal mucosa Damage to the gastroduodenal mucosa allows for decreased resistance to allows for decreased resistance to bacteria, and thus infection from H. bacteria, and thus infection from H. pylori bacteria may occur.pylori bacteria may occur.

• Stress ulcer is the term given to the Stress ulcer is the term given to the acute mucosal ulceration of the acute mucosal ulceration of the duodenal or gastric area that occurs duodenal or gastric area that occurs after physiologically stressful events, after physiologically stressful events, such as:such as:– Burns, shock, severe sepsis, and multiple Burns, shock, severe sepsis, and multiple

organ traumas. ventilator-dependent organ traumas. ventilator-dependent patients after trauma or surgery.patients after trauma or surgery.

125125

Clinical Clinical ManifestationsManifestations• Symptoms of an ulcer may last for a Symptoms of an ulcer may last for a few days, weeks, or months and may few days, weeks, or months and may disappear only to reappear, often disappear only to reappear, often without an identifiable cause. without an identifiable cause.

• Many people with ulcers have no Many people with ulcers have no symptoms, and perforation or symptoms, and perforation or hemorrhage may occur in 20% to hemorrhage may occur in 20% to 30% of patients who had no 30% of patients who had no preceding manifestations.preceding manifestations.

126126

• Dull, gnawing pain Dull, gnawing pain

• Burning sensation in the Burning sensation in the midepigastrium or in the back. midepigastrium or in the back.

• Sharply localized tenderness can be Sharply localized tenderness can be elicited by applying gentle pressure to elicited by applying gentle pressure to the epigastrium at or slightly to the the epigastrium at or slightly to the right of the midline.right of the midline.

• Pyrosis (heartburn), vomiting, Pyrosis (heartburn), vomiting, constipation or diarrhea, and bleeding. constipation or diarrhea, and bleeding.

• Fifteen percent of patients with peptic Fifteen percent of patients with peptic ulcer experience bleeding. (ulcer experience bleeding. (melenamelena). ).

127127

Comparison of Duodenal and Gastric Comparison of Duodenal and Gastric UlcersUlcers

Duodenal UlcerGastric UlcerIncidence

Age 30 to 60Usually 50 and over

Male: female 2-3:180% of peptic ulcers are duodenal

Male: female 1:115% of peptic ulcers are gastric

Signs, Symptoms, and Clinical Findings

Hypersecretion of stomach acid (HCl)May have weight gainPain occurs 2-3 hours after a meal; oftenawakened 1-2 am; ingestion of food relieves pain

Normal—hyposecretion of stomach acid (HCl)Weight loss may occurPain occurs 1/2 to 1 hour after a meal; rarely occursat night; may be relieved by vomiting; ingestion offood does not help, sometimes increases pain

Vomiting uncommonHemorrhage less likely than with gastric ulcer, butif present, melena more common thanHematemesisMore likely to perforate than gastric ulcers

Vomiting commonHemorrhage more likely to occur than with duodenalulcer; hematemesis more common than melena

Malignancy Possibility

RareOccasionally

Risk FactorsH. pylori, alcohol, smoking, cirrhosis, stress

H. pylori, gastritis, alcohol, smoking, use of NSAIDs, stress

128128

Assessment and Assessment and Diagnostic FindingsDiagnostic Findings•Physical examinationPhysical examination

•Barium study Barium study

•Endoscopy,Endoscopy,

•Stools study: occult blood, Stools study: occult blood, stool antigen test stool antigen test

•Serologic testing for H. pylori Serologic testing for H. pylori antigenantigen

•Urea breath test. Urea breath test.

129129

Medical Medical ManagementManagementPharmacologic Therapy:Pharmacologic Therapy:1.1. Recommended therapy for 10 to 14 Recommended therapy for 10 to 14

days includes days includes triple therapytriple therapy with two with two antibiotics (eg, metronidazole [Flagyl] antibiotics (eg, metronidazole [Flagyl] or amoxicillin [Amoxil] and or amoxicillin [Amoxil] and clarithromycin) plus a proton pump clarithromycin) plus a proton pump inhibitor (omeprazole) inhibitor (omeprazole)

2.2. Quadruple therapyQuadruple therapy with two with two antibiotics (metronidazole [Flagyl] and antibiotics (metronidazole [Flagyl] and tetracycline) plus a proton pump tetracycline) plus a proton pump inhibitor and bismuth salts (Pepto-inhibitor and bismuth salts (Pepto-Bismol). Bismol).

130130

3. 3. Histamine-2 (H2) receptor Histamine-2 (H2) receptor antagonists and proton pump antagonists and proton pump inhibitors are used to treat inhibitors are used to treat NSAID-induced ulcers and NSAID-induced ulcers and other ulcers not associated other ulcers not associated with H. pylori infectionwith H. pylori infection

• Maintenance dosages of H2 Maintenance dosages of H2 receptor antagonists are receptor antagonists are usually recommended for 1 usually recommended for 1 year.year.

131131

•Stress Reduction Stress Reduction and Restand Rest

•Smoking Smoking CessationCessation

•Dietary Dietary ModificationModification

132132

Surgical Surgical ManagementManagement•Surgery is usually Surgery is usually recommended for patients recommended for patients with intractable ulcers with intractable ulcers (those that fail to heal after (those that fail to heal after 12 to 16 weeks of medical 12 to 16 weeks of medical treatment)treatment)

133133

Severing of the vagus nerve.

Decreases gastric acid by diminishing cholinergic stimulation to the parietal cells, making

them less responsive to gastrin.

May be done via open surgical approach,

laparoscopy, or thoracoscopy

134134

• A surgical procedure in which a longitudinal

incision is made into the pylorus and transversely sutured closed to enlarge the outlet and relax the muscle

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• Removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus.

• The remaining segment is anastomosed to the duodenum (Billroth I) or to the jejunum (Billroth II)

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• Removal of distal third of stomach; anastomosis with duodenum or jejunum.

• Removes gastrin-producing cells in the

antrum and part of the parietal cells.

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Gastric CancerGastric Cancer

Risk factors:Risk factors:

•Age:Age:40 and 70 years of age40 and 70 years of agebut can occur in people but can occur in people

younger than 40. younger than 40.

•Gender:Gender:Men higher than womenMen higher than women

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•Dietary habits:Dietary habits:smoked, salted, or pickled foods and smoked, salted, or pickled foods and

low in fruits and vegetableslow in fruits and vegetables

•Others:Others:chronic inflammation of the stomachchronic inflammation of the stomachH. pylori infectionH. pylori infectionpernicious anemiapernicious anemiaSmokingSmokingachlorhydriaachlorhydriagastric ulcers, gastric ulcers, previous subtotal gastrectomy (more than 20 previous subtotal gastrectomy (more than 20

years ago)years ago)genetics.genetics.

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Clinical ManifestationsSome studies show that early

symptoms, such as pain relieved with antacids, resemble those of benign ulcers.

Symptoms of progressive disease may include anorexia, dyspepsia (indigestion), weight loss, abdominal pain, constipation, anemia and nausea and vomiting.

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Assessment and Diagnostic Findings

Endoscopy for biopsy Barium x-rayCTA complete x-ray examination of

the GI tract should be performed when any person older than 40 years of age has had indigestion (dyspepsia) of more than 4 weeks’ duration

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Medical ManagementNo successful treatment for gastric

carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient can be cured.

If a radical subtotal gastrectomy is performed, the stump of the stomach is anastomosed to the jejunum, as in the gastrectomy for ulcer.

ChemotherapyRadiation therapy