MedicalSurgical Nursing Concepts Practice 3 rd edition Chapter

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Medical-Surgical Nursing: Concepts & Practice 3 rd edition Chapter 28 Care of Patients with

Medical-Surgical Nursing: Concepts & Practice 3 rd edition Chapter 28 Care of Patients with Disorders of the Upper Gastrointestinal System Copyright © 2017, Elsevier Inc. All rights reserved.

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Theory Objectives Discuss eating disorders and their management, including bariatric surgery. Compare the signs

Theory Objectives Discuss eating disorders and their management, including bariatric surgery. Compare the signs and symptoms of oral, esophageal, and stomach cancer. Illustrate the cause of gastroesophageal reflux disease (GERD). Explain the etiology and prognosis for Barrett’s esophagus. Describe the pathophysiology, means of medical diagnosis, and treatment for gastritis. Copyright © 2017, Elsevier Inc. All rights reserved. 4

Theory Objectives (Cont. ) Compare and contrast the treatment and nursing care of the

Theory Objectives (Cont. ) Compare and contrast the treatment and nursing care of the patient with GERD and a patient with peptic ulcer. Review the difference in the care of the patient with a nasogastric tube for decompression and care of the patient with a feeding tube. Compare the care for a patient receiving total parenteral nutrition with care of the patient receiving enteral feedings. Copyright © 2017, Elsevier Inc. All rights reserved. 5

Clinical Practice Objectives Implement a teaching plan for a patient who has GERD. Plan

Clinical Practice Objectives Implement a teaching plan for a patient who has GERD. Plan postoperative care for a patient having gastric surgery. Demonstrate proper care of the patient with a Salem sump tube for gastric decompression. Copyright © 2017, Elsevier Inc. All rights reserved. 6

Clinical Practice Objectives (Cont. ) Manage a tube feeding for the patient receiving formula

Clinical Practice Objectives (Cont. ) Manage a tube feeding for the patient receiving formula via a feeding pump. Review a nursing care plan for the patient with a gastrointestinal disorder. Write a nursing care plan for the patient with an upper gastrointestinal disorder. Copyright © 2017, Elsevier Inc. All rights reserved. 7

Anorexia Nervosa – Psych Disorder Patients with anorexia nervosa refuse to eat adequate quantities

Anorexia Nervosa – Psych Disorder Patients with anorexia nervosa refuse to eat adequate quantities of food and are in danger of literally starving to death. Diagnosis requires extensive interviewing and treatment, including behavior modification and nutrition support, which may take months to years. Copyright © 2017, Elsevier Inc. All rights reserved. 8

Bulimia Nervosa Patients with bulimia consume large quantities of food and then induce vomiting

Bulimia Nervosa Patients with bulimia consume large quantities of food and then induce vomiting to get rid of it so that weight is not gained. Laxatives – purge after the eating binge Some patients with anorexia nervosa also have bulimia. Some individuals practice bulimia occasionally without harm. Copyright © 2017, Elsevier Inc. All rights reserved. 9

Bulimia Nervosa (Cont. ) Bulimia can lead to severe fluid and electrolyte imbalances, dental

Bulimia Nervosa (Cont. ) Bulimia can lead to severe fluid and electrolyte imbalances, dental problems, starvation, and death. Treatment of bulimia includes psychotherapy, antidepressant medication, and behavior modification. Copyright © 2017, Elsevier Inc. All rights reserved. 10

Obesity Etiology and pathophysiology – diet, lack of exercise and overconsumption of food Signs

Obesity Etiology and pathophysiology – diet, lack of exercise and overconsumption of food Signs and symptoms – obsese 20% over ideal weight Diagnosis Ø Ø Ø Height and weight chart Waist and hip circumference Body mass index (BMI) Copyright © 2017, Elsevier Inc. All rights reserved. 11

Older Adult - Obesity Decreased mobility from arthritis Snacking on junk foods to replace

Older Adult - Obesity Decreased mobility from arthritis Snacking on junk foods to replace meals Metabolic rate slows – need less calories than before 12

Obesity Treatment Bariatric surgery – reduces gastric capacity Ø Ø Ø Extensive counseling and

Obesity Treatment Bariatric surgery – reduces gastric capacity Ø Ø Ø Extensive counseling and assessment Modify lifestyle and stringent regimen required to lose weight and keep weight off Types – see page 646 • • • Gastric restrictive Malabsorptive Gastric restrictive combined with malabsorptive surgery Copyright © 2017, Elsevier Inc. All rights reserved. 13

Bariatric Surgery Preoperative care Ø There is greater risk of pulmonary embolism and thrombus

Bariatric Surgery Preoperative care Ø There is greater risk of pulmonary embolism and thrombus formation, as well as death, for obese patients. Copyright © 2017, Elsevier Inc. All rights reserved. 14

Restrictive Procedures Laparoscopic adjustable gastric banding is performed by placing an inflatable band around

Restrictive Procedures Laparoscopic adjustable gastric banding is performed by placing an inflatable band around the fundus of the stomach. The band is inflated and deflated via a subcutaneous port to change the size of the stomach as the patient loses weight. Copyright © 2017, Elsevier Inc. All rights reserved. 15

Restrictive Procedures (Cont. ) For vertical banded gastroplasty, the surgeon creates a small stomach

Restrictive Procedures (Cont. ) For vertical banded gastroplasty, the surgeon creates a small stomach pouch by placing a vertical line of staples. A band is placed to provide an outlet to the small intestine. Copyright © 2017, Elsevier Inc. All rights reserved. 16

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Malabsorptive and Combination Procedures The total gastric bypass procedure causes severe nutritional deficiencies and

Malabsorptive and Combination Procedures The total gastric bypass procedure causes severe nutritional deficiencies and is no longer recommended. The roux-en-Y gastric bypass (RYGB) limits the stomach size, and the duodenum and part of the jejunum are bypassed. This limits the absorption of calories. Copyright © 2017, Elsevier Inc. All rights reserved. 18

Complications Leakage of stomach contents Gastric stretching Dumping syndrome – nausea, weakness, sweating, and

Complications Leakage of stomach contents Gastric stretching Dumping syndrome – nausea, weakness, sweating, and diarrhea that occurs after meals Nutritional deficiencies—iron, vitamin B 12, calcium, and folate Approx 1/3 of the bariatric patients develop gallstones because of the rapid weight loss Copyright © 2017, Elsevier Inc. All rights reserved. 19

Healthy People 2020 Goals Related to Losing Weight and Obesity Increase the proportion of

Healthy People 2020 Goals Related to Losing Weight and Obesity Increase the proportion of adults who are at a healthy weight. Reduce the proportion of adults who are obese. Reduce the proportion of children and adolescents who are overweight or obese. Copyright © 2017, Elsevier Inc. All rights reserved. 20

Assessment Family history Contributing factors Record of eating patterns for a 7 -day period

Assessment Family history Contributing factors Record of eating patterns for a 7 -day period Weight and height BMI Skinfold thickness measurement General health assessment Copyright © 2017, Elsevier Inc. All rights reserved. 21

Expected Outcomes Patient will make positive statements about decreasing body size. Patient will verbalize

Expected Outcomes Patient will make positive statements about decreasing body size. Patient will verbalize feelings of self-worth. Copyright © 2017, Elsevier Inc. All rights reserved. 22

Implementation Diet and exercise plan Lifestyle and preferences Eating and exercise diary Guidance and

Implementation Diet and exercise plan Lifestyle and preferences Eating and exercise diary Guidance and support Discourage fad diets and emphasize the importance of a well-balanced, nutritious, lowcalorie diet. Commercial programs on weight reduction Copyright © 2017, Elsevier Inc. All rights reserved. 23

Upper GI Disorders Stomatitis – inflammation of the mucous membranes of the mouth Causes

Upper GI Disorders Stomatitis – inflammation of the mucous membranes of the mouth Causes – smoking, excessive alcohol, pathogenic organisms, radiation therapy and drugs (chemotherapy) Dysphagia – difficulty swallowing Ø Ø Causes –inflammation, tumors, neurologic Dos, stroke Diagnosis – eval by speech therapist Treatment – select foods, liquids (thickened) Nursing management – have patient “practice swallowing” prior to eating meals Copyright © 2017, Elsevier Inc. All rights reserved. 24

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Cancer of the Oral Cavity Etiology – unknown cause, smoking, alcohol Pathophysiology – Leukoplakia

Cancer of the Oral Cavity Etiology – unknown cause, smoking, alcohol Pathophysiology – Leukoplakia (usually seen by a dentist) lesion on tongue or mucosa Signs and symptoms – sores on lips/in mouth that don’t heal in 2 weeks Diagnosis—physical examination and biopsy Treatment—radiation, chemotherapy, and surgery Nursing management – monitor airway, tube feedings Copyright © 2017, Elsevier Inc. All rights reserved. 26

Cancer of the Esophagus Cigarette smoking is a major cause of esophageal cancer in

Cancer of the Esophagus Cigarette smoking is a major cause of esophageal cancer in the United States. When combined with heavy alcohol consumption, the risk for esophageal cancer greatly increases. Esophageal cancer is the second most common cancer in China but is seen less in North America. Copyright © 2017, Elsevier Inc. All rights reserved. 27

Cancer of the Esophagus (Cont. ) GERD is a cause of Barrett’s esophagus, which

Cancer of the Esophagus (Cont. ) GERD is a cause of Barrett’s esophagus, which is a precancerous condition. Copyright © 2017, Elsevier Inc. All rights reserved. 28

Barretts esophagus 29

Barretts esophagus 29

Cancer of the Esophagus (Cont. ) Signs, symptoms, and diagnosis – dysphagia, hoarseness, persistent

Cancer of the Esophagus (Cont. ) Signs, symptoms, and diagnosis – dysphagia, hoarseness, persistent cough Treatment Ø Esophagectomy – removal of sections of the esophagus then reconstructed with stomach parts Nursing management Ø Ø Postoperative care – maintain patent airway. Nutrition – parental fluids initially, gradually bland foods, small, frequent meals Copyright © 2017, Elsevier Inc. All rights reserved. 30

Audience Response Question 1 When screening for the presence of risk factors for oral

Audience Response Question 1 When screening for the presence of risk factors for oral and pharyngeal cancers, the nurse would ask which question(s)? (Select all that apply. ) 1. 2. 3. 4. 5. “How much alcohol do you consume? ” “Have you had any oral lesions? ” “Do you have family members who have cancer? ” “What do you smoke? ” “Have you been exposed to hepatitis virus? ” Copyright © 2017, Elsevier Inc. All rights reserved. 31

Hiatal Hernia (Diaphragmatic Hernia) Etiology and pathophysiology- defect in the wall of the diaphragm

Hiatal Hernia (Diaphragmatic Hernia) Etiology and pathophysiology- defect in the wall of the diaphragm where the esophagus passes through. Protrusion of part of the stomach or lower part of the esophagus up into the thoracic cavity. Signs and symptoms – none there may be reflux of stomach acid, feeling of pressure after eating from reflux, worse when lying down. Copyright © 2017, Elsevier Inc. All rights reserved. 32

Treatment of Hiatal Hernia Reduce weight. Avoid tight-fitting clothes around the abdomen. Take antacids

Treatment of Hiatal Hernia Reduce weight. Avoid tight-fitting clothes around the abdomen. Take antacids and histamine (H 2)-receptor antagonists. Elevate head of the bed on 6 - to 8 -inch blocks. Take proton pump inhibitors (PPIs). Copyright © 2017, Elsevier Inc. All rights reserved. 33

Treatment of Hiatal Hernia (Cont. ) Instruct not to eat within several hours before

Treatment of Hiatal Hernia (Cont. ) Instruct not to eat within several hours before going to bed. Limit intake of alcohol, chocolate, caffeine, and fatty foods. Avoid smoking. Copyright © 2017, Elsevier Inc. All rights reserved. 34

Nursing Management Teach ways to prevent pain and reflux. Encourage weight reduction. Remind the

Nursing Management Teach ways to prevent pain and reflux. Encourage weight reduction. Remind the patient to stay upright for 2 hours after eating and not to eat for 3 hours before bedtime. Copyright © 2017, Elsevier Inc. All rights reserved. 35

Gastroesophageal Reflux Disease Etiology and pathophysiology – transient relaxation of the lower esophageal sphincter

Gastroesophageal Reflux Disease Etiology and pathophysiology – transient relaxation of the lower esophageal sphincter – may accompany hiatal hernia Signs and symptoms – heartburn (dyspepsia) reflux, dysphagia Diagnosis and treatment Nursing management Ø Diet therapy, lifestyle changes, drug therapy, and education Complications Copyright © 2017, Elsevier Inc. All rights reserved. 36

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Gastroenteritis Caused by food or water contaminated with a virus, a pathogenic bacteria, or

Gastroenteritis Caused by food or water contaminated with a virus, a pathogenic bacteria, or parasites Signs and symptoms – vomiting, elevated WBCs, abdominal cramping, diarrhea, blood or mucus in stool Management – NPO until vomiting stops, then fluids with glucose and electrolytes, after 24 to 48 hrs, medication may be given if vomting/diarrhea continues Copyright © 2017, Elsevier Inc. All rights reserved. 38

Gastritis Etiology –Helicobacter pylori bacteria (could also be viruses or other bacteria) Pathophysiology –

Gastritis Etiology –Helicobacter pylori bacteria (could also be viruses or other bacteria) Pathophysiology – acute or chronic inflammation of the lining of the stomach Signs and symptoms – anorexia, nausea, vomiting, pain and tenderness in stomach Diagnosis – hx, physical exam & endoscopy Treatment – Antispasmodics, antacids, H 2 receptor antagonist, proton pump inhibitor to decrease hydrochloric acid Copyright © 2017, Elsevier Inc. All rights reserved. 39

Treatment for Gastritis Acute versus chronic gastritis Chronic gastritis Ø Ø Ø Antispasmodics Antacids

Treatment for Gastritis Acute versus chronic gastritis Chronic gastritis Ø Ø Ø Antispasmodics Antacids H 2 -receptor antagonist such as ranitidine PPIs Antibiotic therapy for Helicobacter pylori Copyright © 2017, Elsevier Inc. All rights reserved. 40

Peptic Ulcers – loss of tissue of the upper GI tract Etiology Ø Ø

Peptic Ulcers – loss of tissue of the upper GI tract Etiology Ø Ø Ø H. pylori is the major cause – smoking and NSAID use are other causes Duodenal ulcers and some pre-pyloric ulcers Gastric ulcers Tension, anxiety, and prolonged stress does have impact of the progression of ulcers Drug-induced ulcers Stress ulcers – different from peptic ulcer –more acute and more likely to produce hemorrhagehazard for patients in ICU for extensive periods Copyright © 2017, Elsevier Inc. All rights reserved. 41

Peptic Ulcers (Cont. ) Pathophysiology – mucosa cannot protect itself from corrosive substances. Signs

Peptic Ulcers (Cont. ) Pathophysiology – mucosa cannot protect itself from corrosive substances. Signs and symptoms Ø Ø Daily pattern of pain Gastrointestinal bleeding – c/o weakness, feeling faint, N&V, restlessness, thirst, confusion. Vomit bright red blood, or coffee ground look (blood with gastric juices) or appears in stool. Diagnosis Ø Ø Endoscopy Gastric acid analysis Copyright © 2017, Elsevier Inc. All rights reserved. 42

Peptic Ulcers (Cont. ) page 655 The most common site is the duodenum just

Peptic Ulcers (Cont. ) page 655 The most common site is the duodenum just beyond the pyloric muscle Copyright © 2017, Elsevier Inc. All rights reserved. 43

Treatment Antacids Gastric bleeding and normal saline lavage H 2 -receptor antagonist PPIs Presence

Treatment Antacids Gastric bleeding and normal saline lavage H 2 -receptor antagonist PPIs Presence of H. pylori—administration of clarithromycin (Biaxin) plus another antibiotic, an H 2 inhibitor, and a PPI Copyright © 2017, Elsevier Inc. All rights reserved. 44

Safety Alert page 656 PPI drug interactions PPI slow liver’s ability to metabolize and

Safety Alert page 656 PPI drug interactions PPI slow liver’s ability to metabolize and clear drugs from the bloodstream CAUTION with patients taking Valium, Dilantin, and Coumadin. Watch for signs of toxicity 45

Peptic ulcer 46

Peptic ulcer 46

Nursing Management Complications Ø Ø Ø Hemorrhage – the ulcer erodes vessels, causing bleeding

Nursing Management Complications Ø Ø Ø Hemorrhage – the ulcer erodes vessels, causing bleeding into the stomach Perforation –sudden/severe pain upper abdomen erosion of ulcer through the walls of stomach/intestine into the peritoneal cavity spilling contents of the GI tract Obstruction – persistent vomiting from scarring at the pylorus –narrow the stomach outlet Copyright © 2017, Elsevier Inc. All rights reserved. 47

Surgical Treatment of Peptic Ulcerpage 657 Pyloroplasty with truncal or proximal gastric vagotomy (severe

Surgical Treatment of Peptic Ulcerpage 657 Pyloroplasty with truncal or proximal gastric vagotomy (severe 10 cranial nerve that stimulates acid secretion) – widen the pylorus Subtotal gastrectomy (gastric resection) Total gastrectomy – total removal of stomach. Esophagus is joined to the small intestine Copyright © 2017, Elsevier Inc. All rights reserved. 48

Nursing Care of the Patient Undergoing Gastric Surgery Preoperative care – liquid diet, day

Nursing Care of the Patient Undergoing Gastric Surgery Preoperative care – liquid diet, day of surgery NPO, NG tube all stomach contents suctioned out in OR Postoperative care – gradual addition of food Ø Ø Specific patient teaching Diet restrictions   Dumping syndrome Copyright © 2017, Elsevier Inc. All rights reserved. 49

Dumping syndrome 50

Dumping syndrome 50

Gastric Cancer Etiology acholorhydria (absence of hydrochloric acid) pernicious anemia, diet high in nitrates,

Gastric Cancer Etiology acholorhydria (absence of hydrochloric acid) pernicious anemia, diet high in nitrates, H. pylori, genetics, type A blood type Signs and symptoms – no symptoms until far advanced, indigestion, loss of appetite, N&V Pathophysiology - tumors arise in pyloric area. Spreads to layers of stomach, lymph nodes, the liver and ovaries in women Copyright © 2017, Elsevier Inc. All rights reserved. 51

Gastric Cancer Diagnosis –upper GI series, endoscopy with biopsy Treatment – removal of tumors,

Gastric Cancer Diagnosis –upper GI series, endoscopy with biopsy Treatment – removal of tumors, lymph node dissection, radiation/chemo 52

Common Therapies for Disorders of the Gastrointestinal System Gastrointestinal decompression – abdominal distention from

Common Therapies for Disorders of the Gastrointestinal System Gastrointestinal decompression – abdominal distention from excess fluids and gases. Insertion of NG tube used to remove. If using Salem Sump Tube – keep the tube above the level of the stomach Enteral nutrition –small bore tube inserted confirmed placement with xray before feedings start Total parenteral nutrition – IV feeding using a large central line such as superior vena cava Copyright © 2017, Elsevier Inc. All rights reserved. 53

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Small-Bore Feeding Tube Placement Copyright © 2017, Elsevier Inc. All rights reserved. 55

Small-Bore Feeding Tube Placement Copyright © 2017, Elsevier Inc. All rights reserved. 55

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