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
Signs and Symptoms 1. Heartburn characterized by burning sensation behind the sternum, 30 60 minutes after meals with reclined position 2. Dysphagia (difficulty swallowing), a less common symptom 3. Chest pain, hoarseness, cough 4. Odynophagia Sharp Substernal pain or swallowing
Pathophysiology
Diagnostic Procedure 1. Endoscopy Most IMPORTANT 2. Esophageal Manometry a. Measures LES pressure b. Determines if esophageal peristalsis is adequate (Should be done prior surgery) 3. pH Monitoring Topics Discussed Here Are: 1. Alterations of the Esophagus a. Gastroesophageal Reflux Disease (GERD) b. Hiatal Hernia c. Achalasia d. Esophagitis 2. Alterations in Digestion a. Gastric Bleeding b. Gastritis c. 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 burning sensation behind the...
Nursing Interventions: 1. Instruct patient to avoid stimulus that increase stomach pressure and decrease GES pressure 2. Instruct to avoid spices, coffee tobacco 3. Instruct to eat FAT, FIBER FAT = To DELAY gastric emptying 4. Avoid foods and drinks 2 hours before bedtime 5. Elevate the head of bed with approximately 8 inches 6. Administer prescribed H 2 Blocker, PPI, Prokinetic medications like Metoclopramide 7. Advise proper weight reduction
jcmendiola_Achievers2013 4. Barium esophagography 5. Acid fast perfusion test
Management 1. Lifestyle Changes 1. Head elevation (6 8 inches, to prevent backflow) 2. Do not Lie DOWN! 3. Bland diet / avoid overeating i. No spicy food, sweets ii. Over eating iii. Chocolates, increased protein, fats 4. Avoid caffeine, alcohol, mint, chocolate, colas 5. 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 Hernia o Obesity o Poor seated posture (Such as slouching) o Frequent coughing o Straining with constipation o Frequent bending over / heavy lifting o Heredity o Smoking 2 Types a. Sliding 90%: The stomach and gastro-esophageal junction Slip up in to the chest b. Para-Esophageal Hernia / Rolling Hernia Part of the greater curvature of the stomach Rolls through the diaphragmatic defect Pathophysiology
Signs And Symptoms 1. Heart Burn 2. Regurgitation 3. Dysphagia 4. 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 Evaluation visualizes defect
Management: 1. Elevation of head of bead (6-8 inches) 2. Antacid therapy 3. H 2 Receptor antagonist 4. Surgical Repair of hernia if symptoms are severe
jcmendiola_Achievers2013 Nursing Intervention and Patient Education Instruct patient on the prevention of reflux of gastric contents into the esophagus by: a. Eat smaller meals b. Avoid caffeine, alcohol and smoking c. Avoid fatty foods Eating such: Promotes reflux and delays gastric emptying d. 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 clothes g. 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 Symptoms 1. Gradual onset of dysphagia with solid and liquids 2. Substernal discomfort or a feeling of fullness 3. Regurgitation of undigested food during a meal / within several hours after a meal 4. Weight loss
Diagnostic Tests: 1. Chest X-Ray To locate the site of esophagus or with enlargement 2. Barium esophagography 3. Endoscopic ultrasound or a chest CT scan
Management 1. Drug therapy using calcium channel blockers such as Nifedipine to reduce LES pressure 2. Esophagomytomy: Esophageal dilation using a balloon-tipped catheter (preferred treatment) 3. Surgical therapy for patients who do not respond to balloon dilation
Complications: 1. Malnutrition Due to lack of absorption of nutrients 2. Lung abscess, pneumonia, Bronchiectasis from nocturnal regurgitation 3. Esophagitis, esophageal diverticula 4. Perforation from dilation procedure 5. 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 changes
Possible Nursing Diagnoses: Altered nutrition: less than body requirements related to dysphagia Implication in reflux Hemorrhage / obstruction, strangulation
jcmendiola_Achievers2013 o Improve nutritional status 1. 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 symptoms 3. 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 regurgitation o Promoting comfort 1. Assess client for discomfort, chest pain, regurgitation and cough and incision pain 2. Provide appropriate post-op care 3. Administer analgesics as ordered 4. Assess for effectiveness of pain medications
Patient Education and Health Maintenance 1. Encourage lifestyle and activity changes 2. 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 surgeries
Esophagitis a. Is an acute or chronic inflammation of the esophagus b. 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 adults attempting 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 HEMATEMESIS b. HEMATOCHECIA Frank bleeding from the rectum c. MELENA Dark, tarry stools d. OCCULT BLEEDING e. Guaiac Test
jcmendiola_Achievers2013 Laboratory Tests: a. CBC If RBCs are depleted b. 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 PROCESS o Chronic Gastritis LONG Term / Chronic form of ACUTE Type A = Autoimmune (Least common, 10%) Type B = Helicobacter Pylori (More common, 90%)
jcmendiola_Achievers2013 Assessment Acute Chronic Abdominal Distention Headache Anorexia Nausea and Vomiting Pyrosis Singultus (Hiccup) Sour taste in the mouth Dyspepsia Nausea and Vomiting / Anorexia Pernicious Anemia
Acute Gastritis is 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
jcmendiola_Achievers2013 Chronic Gastritis Chronic 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 that attack the gastric parietal cells and eventually may cause pernicious anemia from loss of intrinsic factor (IF)
Chronic Gastritis Type B Associated with infection by Helicobacter 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 / discomfort o Gastric hemorrhage o Appetite loss o Belching o Nausea / Vomiting o 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 NPO Give ice chips then clear liquids then solids as soon as possible or symptoms have subsided 3. Maintain fluid balance Hydration either orally or IV 4. Lifestyle modification Discouragement of alcohol, caffeine, smoking 5. Administer medications as ordered to relieve pain, to gastric acidity and treat infection 6. Teach the effects of medications that irritate the gastric mucosa
Gastric Irritant Infection of H. Pylori Impairment of the HCl and IF secretion Atrophy of the gastric gland 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
jcmendiola_Achievers2013 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 chronic
Nursing Intervention (Additional) 1. Give BLAND diet 2. Monitor for signs of complications like: Bleeding, obstruction and pernicious anemia 3. Instruct to avoid spicy foods, irritating foods, alcohol and caffeine, NSAIDS 4. Administer prescribed medications H 2 Blocker, antibiotics, mucosal protectants 5. Inform the need for Vitamin B 12 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 PUD b. Ulcergenic drugs like NSAIDS c. Zollinger-Ellison syndrome and other hypersecretory syndromes Rare islet tumor cells: GASTRIN = GASTRIC ACID Secretion!! XD Theres presence of FAT MALABSORPTION
RISK FACTORS a. Prolonged NSAIDS / Corticosteroids b. Stress, low socio-economic status c. 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 locations Stomach 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 Ulcer Epigastric pain at bedtime Burning / Cramping, mid epigastric pain Abdominal pain, classically epigastric with severity 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 would manifest mostly BEFORE the meal, when acid (produced stimulated by ____) is passed into the duodenum
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 for H. pylori Antibodies
Management General Measures 1. Eliminate use of NSAIDS / other causative drugs 2. Eliminate cigarette smoking 3. Well-balanced diet with regular meal intervals Drug Therapy 4 Ex. Proton Pump Inhibitors (PPI) + Metronidazole (Antibiotics), Ranitidine, Clarithromycin Surgery 4 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
jcmendiola_Achievers2013 4 Highly selective parietal vagotomy 4 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)
Complications 1. GI Bleeding 2. Ulcer Perforation Leads to peritonitis, perforation is an EMERGENCY CASE 3. 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 eradicate H. pylori for 10 14 days, H 2 receptor antagonist and PPI are used to treat NSAID induced ulcer Stress reduction
Nursing Interventions Prevention 1. Monitor I&O, stools 2. Monitor: H/H and electrolytes 3. Administer IV fluids / blood as ordered 4. Insert NGT as ordered and to monitor drainage for signs and symptoms of blood 5. Administer meds via NGT to neutralize acid as ordered Cushings Ulcer - Common in clients with head injury and brain trauma, more penetrating and deeper than stress ulcer, involves esophagus, stomach and duodenum - Observed about 72 hours after ********* , 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 likely Melena is more common than Hematemesis - Most likely to perforate - Possibility of malignancy is rare
RISK FACTOR: Alcohol, smoking, stress
jcmendiola_Achievers2013 6. Prepare client for lavage 7. Observe client for PR, BP (SHOCK) 8. Prepare client for diagnostic procedure / surgery to determine / stop source of bleeding Pain Relief 1. Administer prescribed pain medications 2. Provide small frequent meals to prevent gastric distention if not on NPO 3. Advise client about the irritating effects of some foods / medications Education About Treatment Regimen 1. 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 to promote 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 slowly 2. Instruct client to drink ample amount of fluid after meals and not during 3. Instruct client to eat several small meals a day; in CHO to prevent diarrhea
Pharmacotherapy H 2 Receptor Antagonist (PO/IV) Antibiotics: To eradicate H. pylori Mucosal Barrier Antacids 4 Gastric acidity 4 Taken 1 hour after medications Maalox Diarrhea Calcium Carbonate Uric Acid 4 Aluminum Hydroxide Constipation PPI 4 Acid secretion of the PC 4 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
Complications Billroth 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% Surgical WALA XD - Total Gastrectomy - - -
- Vagotomy - Pyloroplasty - Billroth I (Gastroduodenostomy) - Billroth II (Gastrojejunostomy)
jcmendiola_Achievers2013 Nursing Intervention 1. Give BLAND diet 2. H 2 Blocker 3. Monitor complications of bleeding 4. Provide teaching
Bleeding 1. NPO 2. Hematocrit and hemoglobin 3. 4. Assist in saline lavage 5. Insert NGT for decompression 6. Prepare to administer blood transfusion 7. Prepare to give vasopressin
Surgical Procedure for PUD 1. Monitor VS 2. Fowler: Post Op! Position 3. NPO until peristalsis returns! 4. Monitor bowel sounds (BOWEL SOUNDS 1 st BEFORE FLATUS!) 5. Monitor for complication of surgery 6. Monitor I&O, IVF 7. Maintain NGT 8. Diet progressive: Clear liquid Full Liquid Bland 9. Manage Dumping Syndrome!