Care of Client with Problems in
Nutrition
(Acute & Chronic)
MALNUTRITION
Management of client with:
Malnutrition (undernutrition and over
nutrition)
Malnutrition affects body composition
and functional status. Imbalances in
macronutrients (carbohydrates,
proteins, fat) or micronutrients
(electrolytes, minerals, vitamins)
Etiology:
 Starvation-related malnutrition
 Chronic disease–related
malnutrition (organ failure,
cancer)
 Acute disease– or injury-related
malnutrition (e.g., major
infection, burns, trauma, closed
head injury).
Clinical Manifestations
1. skin (dry and scaly skin, brittle
nails, rashes, hair loss),
2. mouth (crusting and ulceration,
changes in tongue),
3. muscles (decreased mass and
weakness)
4. CNS (mental changes such as
confusion, irritability).
Pathophysiology
• As protein intake is severely
reduced, the muscles, which are
the largest store of protein in the
body, become wasted and flabby,
leading to weakness and
fatigability.
• Decreased protein is available for
repair, and as a result, wound
healing may be delayed.
• The person is more susceptible to
infections. Both humoral and cell-
mediated immunity are deficient
in malnutrition.
• There is a decrease in leukocytes
in the peripheral blood.
Phagocytosis is altered because
of the lack of energy necessary to
drive the process.
Management
1. Assess the patient’s nutritional state
2. Identify nutritional RF and why they
might exist.
 Increased stress: surgery, severe
trauma, and sepsis more calories
and protein is needed
 Wound healing req increased
protein synthesis.
 Undergoing major surgery to
promote healing postoperatively.
3. When fever is present, the metabolic
rate is increased and nitrogen loss is
accelerated. Despite the return of body
temp to normal, the rate of protein
breakdown and resynthesis may be
increased for several weeks.
Teach the patient and caregiver the
importance of good nutrition and the
rationale for recording the daily weight,
intake, and output.
4. Daily wt can give an ongoing record
of BW gain or loss. Rapid gains and
losses due to shifts in fluid balance. The
BW, accurate recording of food and fluid
intake, provides a clearer picture of the
patient’s fluid and nutritional state.
Weigh: same time each day, same
scale, same type or amt of clothing, and
pref with the bladder recently emptied.
5. If the patient is able to take food by
mouth, obtain a daily calorie count and
diet diary to give an accurate record of
food intake.
6. Preparation of foods preferred by the
patient enhances the daily intake.
Encourage the family to bring the
patient’s favorite foods from home while
the patient is hospitalized.
7. The undernourished patient usually
needs to have between meal
supplements (commercially prepared
products). Eating these items between
meals provides extra calories, proteins,
fluids, and nutrients.
8. If the patient is unable to consume
enough nutrition with a high-calorie,
high-protein diet, oral liquid nutritional
supplements can be added.
Appetite stimulants: megestrol acetate
(Megace) or dronabinol (Marinol)
9. If the patient is still unable to take in
enough calories, enteral feedings may
be considered.
10. Parenteral nutrition (PN) might need
to be initiated if enteral feedings are not
feasible
Contraindications for enteral nutrition:
GI obstruction, prolonged ileus, severe
diarrhea or vomiting
OBESITY
overabundance of body fat, measured
by BMI (weight in kilograms divided by
height in meters squared). A BMI
greater than 30 is considered obese.
Pathophysiology and Etiology
1. Heredity and genetic factors.
2. Environmental factors.
3. Psychological factors.
4. Physiologic factors.
5. Pharmacologic factors.
Diagnostic Evaluation
1. Nutritional assessment
2.
Anthropometric and physical assessment
3. Selected hormonal studies (thyroid,
adrenal)
Management
1. Diet therapy- well-balanced diet with
all the major food groups
a. A 1,000-cal deficit/day is req to lose
2.2 lb (1 kg) of body wt/ week.
b. Diet therapy should be individualized
to the patient;
c. A balance of food groups is essential Poor nutrition, soft drink consumption,
to maintain vitamin and nutrient genetic predisposition. improper
balance. Nutrient supplementation (Ca, brushing & diet.drug induced
vit D, iron, B, zinc, and folate).
Extent of damage depends on:
d. Food preparation: seasoning with
• dental plaque.
herbs, onion, garlic, and pepper, and
foods should be baked, broiled, • acids length of time
steamed, or sautéed using minimal oil.
• strength of acids & saliva’s ability to
e. Food attractively arranged on smaller neutralize
plates, using whole rather than
• susceptibility to tooth decay.
processed foods and eaten slowly, will
assist the overall process. Dental decay -----small hole----- extends
3. Behavior modification
a. Identify and eliminate situations
leading to overeating or high-calorie
foods (food diary).
b. Positive reinforcement of proper
dietary habits.
c. Should a lapse in diet habits occur,
focus on a prompt and positive return to
appropriate dietary habits. to the dentin------- pulp of the tooth.
d. Stress-reduction tech: visual imagery
or progressive muscle relaxation; peer
support Treatment
fillings, dental implants, or extraction
Prevention
effective mouth care, reducing the
intake of starches & sugars, applying
DISORDERS OF THE TEETH fluoride to the teeth or drinking
fluoridated water, refraining smoking,
DENTAL PLAQUE AND CARIES
controlling diabetes, & using pit and
Tooth decay- bacteria on fermentable fissure sealants. Regular dental visits
carbohydrates ---- acids ---- dissolve
Mouth Care
tooth enamel.
1.Brushing and flossing
Etiology
Normal mastication (chewing) and the • Internal derangement of the joint: a
normal flow of saliva also aid greatly in dislocated jaw
keeping the teeth clean.
• Degenerative joint disease: in the jaw
Inadequate food amounts-----less joint
saliva------reduce tooth-cleaning
Joints misalignment in the jaw---- tissue
process. Brushing, most effective
damage and muscle tenderness.
method mechanical cleansing
Clinical Manifestations
2. If brushing is impossible, wipe the
teeth with a gauze pad, then swish an jaw pain: dull, throbbing, debilitating
antiseptic mouthwash several times pain radiate to the ears, teeth, neck,
before expectorating into an emesis and facial sinuses. restricted jaw motion
basin. To prevent drying, the lips may and locking of the jaw.
be coated with a water-soluble gel.
sudden change in the way the upper
Diet and lower teeth fit together
decrease sugar and starch. choose less clicking, popping, and grating sounds
cariogenic alternatives, such as fruits, when mouth is opened, and diff
vegetables, nuts, cheeses, or plain chewing & swallowing. headaches,
yogurt, freq brushing, flossing earaches, dizziness, and hearing
Fluoridation
Fluoridation of public water. Dentist
apply a concentrated gel or solution of
fluoride to the teeth; adding fluoride to
home water supplies; using fluoridated
toothpaste or mouth rinse; or using
sodium fluoride tablets, drops, or
lozenges.
Pit and Fissure Sealants
problem.
Dentists apply a special coating to fill
and seal. These sealants can last 5 to 10
years. Assessment and Diagnostic Findings
DISORDERS OF THE JAW report of pain, limitations ROM,
TEMPOROMANDIBULAR DISORDERS difficulty: swallowing, chewing, speech,
• Myofascial pain: jaw, neck and hearing difficulties.
shoulder muscles Dx: MRI and x-ray studies
Medical Management
1.Stress management. (to reduce PAROTITIS
grinding and clenching of teeth).
Inflammation of the salivary glands
2. ROM exercises.
Mumps (epidemic parotitis), viral
3.Pain mgmt: (NSAIDs), opioids, muscle infection and Staphylococcus aureus
relaxants travel from the mouth through the
salivary duct.
4.Intraoral orthotics (a plastic guard
worn over the upper and lower teeth) Manifestations:
may be worn to reposition the condyle
Fever. swelling and tenderness of the
head in the joint space to a more
glands, pain in the ear, and swollen
normal position, which allows healing.
glands interfere with swallowing. The
Jaw Disorders Requiring Surgical swelling increases rapidly, and the
Management overlying skin soon becomes red and
shiny.
Jaw reconstruction
Nursing Management
1. The patient who has had rigid fixation
should be instructed not to chew food in
the first 1 to 4 weeks after surgery.
2. A liquid diet is recommended, and
dietary counseling should be obtained to
ensure optimal caloric and protein
intake.
Medical management
Promoting Home and Community-Based
1. Adeq nutritional & fl intake (soft diet),
Care
good oral hygiene, and d/c meds (eg,
1. Mouth irritations should be tranquilizers, diuretics) that can diminish
reported salivation.
2. Keeping scheduled appointments
2. Antibiotic, analgesics.
to assess the stability of the
fixation appliance Ciprofloxacin 500mg BID x 10-14
3. Consultation with a dietitian: days or
foods high in essential nutrients
and its preparations through a Cephalexin 500mg QID x 10- 14
straw or spoon while remaining days
palatable. If antibiotic therapy is not effective, the
4. Nutritional supplements gland may need to be drained by a
DISORDERS OF THE SALIVARY GLANDS surgical procedure (parotidectomy).
3.Scrotal elevation and apply cold
compress
DISORDERS OF THE ESOPHAGUS
HIATAL HERNIA
Hiatus (or hiatal) hernia, the opening in
the diaphragm through which the
esophagus passes becomes enlarged,
and part of the upper stomach tends to
move up into the lower portion of the
thorax.
Two types of hiatal hernias:
1. Sliding, or type I- upper stomach and
the gastroesophageal junction are
displaced upward and slide in and out of
the thorax.
2. Paraesophageal hernia occurs when
all or part of the stomach pushes
through the diaphragm beside the
esophagus.
Etiology:
1. injury or damage may weaken
muscle tissue.
2. putting too much pressure
(repeatedly) on the muscles around
your stomach (coughing, vomiting,
straining during bowel movements,
lifting heavy objects)
3. born with an abnormally large hiatus.
4. RF: obesity, aging, smoking
Clinical Manifestations
sliding hernia:
heartburn, regurgitation, and dysphagia
paraesophageal hernia: sense of
fullness or chest pain after eating,
Hemorrhage, obstruction, and
strangulation can occur with any type of
hernia.
Assessment and Diagnostic Findings
x-ray studies, barium swallow, and
fluoroscopy.
Management
1. freq, small feedings that can pass
easily thru the esophagus.
2. advised not to recline for 1 hour after
eating, to prevent reflux or movement
of the hernia,
3. elevate the head of the bed on 4- to
8-inch
4. paraesophageal hernias may require
emergency surgery to correct torsion
(twisting) of the stomach or other body
organ that leads to restriction of blood
flow to that area.
DIVERTICULUM
A diverticulum is an outpouching of
mucosa and submucosa that protrudes
through a weak portion of the
musculature.
Clinical Manifestations
difficulty swallowing, fullness in the
neck, belching, regurgitation of
undigested food, and gurgling noises
after eating.
The diverticulum (pouch), becomes
filled w/ food or liq.
When the patient assumes a recumbent
position, undigested food is
regurgitated, and coughing may be
caused by irritation of the trachea.
Halitosis and a sour taste in the mouth
are also common because of the
decomposition of food retained in the
diverticulum.
FOREIGN BODIES
dentures, fish bones, pins, small
batteries that might injure the
esophagus or obstruct its lumen ---must
be removed.
Dx: x-ray
Manifestations:
Pain and dysphagia, dyspnea due to
pressure on the trachea. The foreign
body may be identified by. Perforation
may have occurred
Mgmt:
Glucagon, because of its relaxing effect
on the esophageal muscle, may be
injected intramuscularly. An endoscope
may be used to remove the impacted
food or object from the esophagus.
CHEMICAL BURNS
intentionally or unintentionally, swallows
a strong acid or base undissolved
medications in the esophagus, after
swallowing of a battery, which may
release a caustic alkaline.
Clinical Manifestations
severe burns of the lips, mouth, and
pharynx, with pain on swallowing,
difficulty in breathing due to either
edema of the throat or a collection of
mucus in the pharynx. febrile, and in
shock, is treated immediately for shock,
pain, and respiratory distress.
Diagnostic Findings
Esophagoscopy and Ba swallow to
determine extent and severity of
damage.
Managements
1.NPO, and IVF are adm. A NGT may be
inserted.
2. Vomiting and gastric lavage are
avoided to prevent further injury
4. Antibiotics, corticosteroids
5. Nutritional support: enteral or
parenteral feedings.
6. In bougienage, cylindrical rubber
tubes of different sizes, are advanced
into the esophagus via the oral cavity.
7. Some strictures require rigid dilators,
such as Savory dilators.
8. Reconstruction may be accomplished
by esophagectomy and colon
interposition to replace the portion of
esophagus removed.
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CANCER OF THE ESOPHAGUS
Pathophysiology
RF: chronic esophageal irritation:
ingestion of alcohol use of tobacco,
ingestion of hot liquids or foods,
nutritional deficiencies, poor oral
hygiene, exposure to nitrosamines in the
environment or food
Clinical Manifestations
dysphagia, w/ solid foods later liq;
sensation of a mass in the throat;
painful swallowing; substernal pain or
fullness; regurgitation of undigested
food with foul breath and hiccups.
As the tumor grows and the obstruction
becomes complete, even liq cannot pass
to the stomach.
Regurgitation of food and saliva occurs,
hemorrhage may take place, and
progressive loss of wt & strength occurs
from inadeq nutrition.
Sx: substernal pain, persistent hiccup,
resp difficulty, & foul breath.
Assessment and Diagnostic Findings
 The biopsy for cell differentiation.
 Computed Tomography (CT) of
the chest and abdomen to detect
any metastatic disease, especially
of the lungs,liver, and kidney.
 Positron emission tomography
(PET) may help detect metastasis
with more sensitivity than CT.
 Endoscopic ultrasound is used to
determine whether the cancer
has spread to the lymph nodes
and other mediastinal structures;
 size and invasiveness of the status is monitored throughout
tumor. treatment.
Medical Management 2. The patient is informed about the
nature of the postop equipment that will
surgery, radiation, chemotherapy, or a
be used: closed chest drainage,
combination of these modalities,
nasogastric suction, parenteral fluid
depends on: type of cancer cell, extent
therapy, and gastric intubation
of the disease, & pt’s condition.
3. Low Fowler’s position, and later in a
Standard tx:
Fowler’s position, to help prevent reflux
newly dx: preoperative combination of gastric secretions. The patient is
chemotherapy and radiation therapy for observed carefully for regurgitation and
4 to 6 wks; followed by a period of no dyspnea.
medical intervention for 4 wks; and,
4. Incentive spirometry, sitting up in a
lastly, surgical resection of the
chair, and, if necessary, nebulizer
esophagus.
treatments. Chest physiotherapy is
Standard surgical management: total avoided due to the risk of aspiration
resection of the esophagus (pulmonary cx)
(esophagectomy) with removal of the
5. Monitor temp to detect any elevation
tumor plus the lymph nodes in the area.
that may indicate aspiration or seepage
Postoperatively, NGT should not be of fluid through the operative site into
manipulated. the mediastinum, which would indicate
an esophageal leak. Drainage from the
NPO until x-ray studies confirm that the
cervical neck wound, usually saliva, is
anastomosis is free from an esophageal
evidence of an early esophageal leak.
leak, there is no obstruction, and there
is no evidence of pulmonary aspiration.
Palliative treatment may be necessary to
keep the esophagus open, to assist with
nutrition, and to control saliva.
Nursing Management
1. Promote wt gain based on a high-
calorie and high-protein diet, in liquid or
soft form, is provided if adeq food can
be taken by mouth.
6. NPO and parenteral or enteral
If this is not possible, parenteral or
support
enteral nutrition is initiated. Nutritional
7. During surgery, NGT is inserted and
taped in place. It is connected to low
intermittent suction. The NGT is not
manipulated; if displacement occurs, it
is not replaced, because damage to the
anastomosis may occur.
The NGT is removed 5 to 7 days after
surgery; before the patient is allowed to
eat, a barium swallow is performed to
assess for any anastomotic leak.
8. Once feeding begins, encourage to
swallow small sips of water. Then to a
soft diet. When the patient can increase
his or her food and fluid intake to an
adeq amt, parenteral fluids are d/c.
9. After each meal, the patient remains
upright for at least 2 hrs to allow the
food to move through the GIT.
10. Family involvement and home-
cooked favorite foods may help the
patient to eat.
11. Antacids may help patients with
gastric distress. Metoclopramide is
useful in promoting gastric motility.
12. Liq supplements. However, Boost
and Ensure should be avoided because
they promote vagotomy syndrome
(dumping syndrome), which can occur
with each meal or approx 20 mins to 2
hrs after eating due to interruption of
vagal nerve fibers, which causes an
alteration in the storage function of the
stomach and the pyloric emptying
mechanism.
As a result, large amounts of solids
and liq rapidly “dump” into the
duodenum. Severe abd cramping,
followed by a liq BM asso with
diaphoresis, rapid HR or rapid
respirations, or both.
13. Recovery: soft foods and remains in
an upright position for 2 hrs after
eating, the freq and severity of episodes
decrease.
14. Oral suction may be used if the
patient cannot handle oral secretions, or
a wick-type gauze may be placed at the
corner of the mouth to direct secretions
to a dressing or emesis basin. Patient
may aspirate saliva into the
tracheobronchial tree and develop
pneumonia
15. When the patient is ready to go
home, the family is instructed about
how to promote nutrition, what
observations to make, what measures to
take if complications occur, how to keep
the patient comfortable, and how to
obtain needed physical and emotional
support.
DISORDERS OF THE STOMACH
GASTRITIS
repeated exposure to irritating agents
food that is irritating, too highly
seasoned, or contaminated w/ dse-
causing microorg.
overuse of aspirin & (NSAIDs), excessive
alcohol intake, bile reflux, & radiation tx.
ingestion of strong acid or alkali, which
may cause the mucosa to become
gangrenous or to perforate.
Scarring---- stenosis or obstruction.

Pathophysiology
Gastric mucous membrane becomes
edematous & hyperemic (congested
with fl & bld) & undergoes superficial
erosion. It secretes a scanty amt of
gastric juice, containing very little acid
but much mucus.
Superficial ulceration may occur and can
lead to hemorrhage.
Clinical Manifestations
Acute: abdominal discomfort, headache,
N/V, anorexia, & hiccupping
Chronic: anorexia, heartburn after
eating, belching, a sour taste in the
mouth, N/V. mild epigastric discomfort
or report intolerance to spicy or fatty
foods or slight pain that is relieved by
eating. Malabsorption of vitamin B12
Assessment and Diagnostic Findings
upper GI x-ray series or endoscopy and
histologic examination of a tissue
specimen pylori infection
Medical Management
1. Refrain from alcohol and food until
symptoms subside.
2. Non irritating diet
3. Adm IVF
4. Dilute and neutralizing the offending
agent.
To neutralize:
acids--- common antacids (eg,
aluminum hydroxide)
Alkali ---diluted lemon juice or diluted
vinegar is used.
5. Therapy is supportive. analgesic and
sedatives, antacids, and IV fluids.
6. Chronic gastritis: modifying the
patient’s diet, promoting rest, reducing
stress, recommending avoidance of
alcohol and NSAIDs, and initiating
pharmacotherapy.
H. pylori may be treated with selected
drug combinations
Reducing Anxiety
If the patient has ingested acids or
alkalis:
Offer supportive therapy to the patient
and family
Prepare for additional diagnostic studies
(endoscopies) or surgery. Use a calm
approach to assess the patient and to
answer all questions
Explain all procedures and treatments
based on the patient’s level of
understanding.
Promoting Optimal Nutrition
1. NPO—for a few days—until acute
sx subside, thus allowing the
gastric mucosa to heal.
2. If IV therapy is necessary,
monitor I/O along with serum
electrolyte values.
3. After the sx subside, offer ice
chips then clear liquids.
Introducing solid food asap may
provide adeq oral nutrition,
decrease the need for IV therapy,
 and minimize irritation to the
gastric mucosa.
4. As food is introduced, evaluates and
reports any sx that suggest a repeat
episode of gastritis.
5. Discourages the intake of caffeinated
beverages, because caffeine is a CNS
stimulant that increases gastric activity
and pepsin secretion. Discourage
alcohol use.
6. Discouraging cigarette smoking
because nicotine reduces the secretion
of pancreatic bicarbonate, which inhibits
the neutralization of gastric acid in the
duodenum
Initiates and refers the patient for
alcohol counseling and smoking
cessation programs.
Promoting Fluid Balance
Monitor fluid I/O daily detect early signs
of dhn (minimal fl intake of 1.5 L/day,
minimal output of 30 mL/h).
If food and oral fluids are withheld, IVF
(3 L/day).
Record of fl intake plus caloric value (1 L
of 5% dextrose in water 170 cal of
carbohydrate) needs to be maintained.
Electrolyte values (sodium, potassium,
chloride) are assessed every 24 hrs to
detect any imbalance.
Be alert for any indicators of
hemorrhagic gastritis: hematemesis,
tachycardia, and hypotension. If these
occur, the physician is notified and the
patient’s VS are monitored
Teaching Patients Self-Care
Evaluates the patient’s knowledge about
gastritis and develops an individualized
teaching plan that includes information
about stress management, diet, and
medications. Dietary instructions take
into account the patient’s daily caloric
needs, food preferences, and pattern of
eating. The nurse and patient review
foods and other substances to be
avoided (eg, spicy, irritating, or highly
seasoned foods; caffeine; nicotine;
alcohol). Consultation with a dietitian
may be recommended.
Providing information about prescribed
antibiotics, bismuth salts, medications to
decrease gastric secretion, and
medications to protect mucosal cells
from gastric secretions may help the
patient to better understand why these
medications assist in recovery and
prevent recurrence. The importance of
completing the medication regimen as
prescribed to eradicate H. pylori
infection must be reinforced to the
patient and any caregivers.
Continuing Care
The nurse reinforces previous teaching
and conducts ongoing assessment of
the patient’s symptoms and progress.
Patients with malabsorption of vitamin
B12 need information about lifelong
vitamin B12 injections; the nurse may
instruct a family member or caregiver
how to administer the injections or
make arrangements for the patient to
receive the injections from a health care
provider. Finally, the nurse emphasizes
the importance of keeping follow-up
appointments with health care
providers.
GASTRIC AND DUODENAL ULCERS
A peptic ulcer (gastric, duodenal, or
esophageal ulcer)
Etiology:
1. gram
-negative bacteria H.pylori, from food
and water
2. excessive secretion of HCl in the
stomach due to : stress, ingestion of
milk and caffeinated beverages,
smoking, alcohol. and eating spicy foods
3. Familial tendency. blood type O
4. Co morbidities: chronic pulmonary
disease or chronic renal disease.
5. NSAIDs, alcohol ingestion, and
excessive smoking.
Pathophysiology
 PU occur in the gastroduodenal
mucosa because this tissue
cannot withstand the digestive
action of gastric acid (HCl) and
pepsin.
 The erosion is caused by the
increased concentration or
activity of acid–pepsin or by
decreased resistance of the
mucosa.
 A damaged mucosa cannot
secrete enough mucus to act as a
barrier against HCl.
 The use of NSAIDs inhibits the
secretion of mucus that protects
the mucosa. duodenal ulcers
secrete more acid than normal,
 gastric ulcers tend to secrete
normal or decreased levels of
acid.
 Damage to the gastroduodenal
mucosa results in decreased
resistance to bacteria, and thus
infection from H. pylori bacteria
may occur
Clinical Manifestations
 dull, gnawing pain or a burning
sensation in the midepigastrium
or the back.
 pain due to increased acid
content of the stomach and
duodenum erodes the lesion and
stimulates the exposed nerve
endings.
 Contact of the lesion with acid
stimulates a local reflex
mechanism that initiates
contraction of the adjacent
smooth muscle.
 Pain is relieved by eating,
because food neutralizes the
acid, or by taking alkali; however,
once the stomach has emptied or
the alkali’s effect has decreased,
the pain returns.
 Pyrosis (heartburn), vomiting,
constipation or diarrhea, and
bleeding.
Pyrosis-burning sensation in stomach
and esophagus that moves up to the
mouth, accompanied by sour eructation,
or burping,
 Vomiting. It results from
obstruction of the pyloric orifice,
 caused by either muscular spasm
of the pylorus or mechanical
obstruction from scarring or
acute swelling of the inflamed
mucous membrane adjacent to
the ulcer. It follows a bout of
severe pain and bloating, which is
relieved by vomiting. Emesis
often contains undigested food
eaten many hours earlier.
 Constipation or diarrhea as a
result of diet and medications.
 GI bleeding as evidenced by the
passage of melena.
Assessment and Diagnostic Findings
1. pain, epigastric tenderness, or abd
distention.
2. A barium study of the upper GI tract
may show an ulcer
3. Endoscopy(preferred), it allows direct
visualization of inflammatory changes,
ulcers, and lesions.
-biopsy of the gastric mucosa and
suspicious lesions, size or location,
4. Periodic testing of the stools until
they are negative for occult blood.
Gastric secretory studies- achlorhydria
and H. pylori infection
Medical Management
Antibiotics to eradicate H. pylori
Goals: to eradicate H.pylori and to
manage gastric acidity.
Methods: medications, lifestyle changes,
and surgical intervention.
Pharmacologic Therapy
1. Combination of antibiotics, proton
pump inhibitors, and bismuth salts that
suppress or eradicate H. pylori.
Recommended therapy for 10 to 14
days includes triple therapy with two
antibiotics (eg, metronidazole [Flagyl] or
amoxicillin [Amoxil] and clarithromycin
[Biaxin]) plus a proton pump inhibitor
(eg, lansoprazole [Prevacid],
omeprazole [Prilosec], or rabeprazole
[Aciphex]), or quadruple therapy with
two antibiotics (metronidazole and
tetracycline) plus a proton pump
inhibitor and bismuth salts (Pepto-
Bismol).
2. Complete the medication regimen to
ensure complete healing of the ulcer so
that the healing process can continue
uninterrupted and the return of chronic
ulcer symptoms can be prevented.
3. Rest, sedatives, and tranquilizers may
be added for the patient’s comfort and
are prescribed as needed.
4. Maintenance dosages of H2 receptor
antagonists are usually recommended
for 1 year.
Stress Reduction and Rest
Reducing environmental stress requires
physical and psychological modifications
on the patient’s part as well as the aid
and cooperation of family members and
significant others.
identify situations that are stressful or
exhausting. Hectic lifestyle and an
irregular schedule The patient may
benefit from regular rest periods during
the day, at least during the acute phase
of the disease.
Biofeedback, hypnosis, behavior
modification, massage, or acupuncture
Smoking Cessation
Studies have shown that smoking
decreases the secretion of bicarbonate
from the pancreas into the duodenum,
resulting in increased acidity of the
duodenum. Research indicates that
continued smoking may significantly
inhibit ulcer repair
Dietary Modification
 to avoid over secretion of acid
and hypermobility in the GI tract.
 avoiding extremes of temperature
of food and beverage and
overstimulation from
consumption of meat extracts,
alcohol, coffee (including
decaffeinated coffee, which also
stimulates acid secretion) and
other caffeinated beverages, and
diets rich in milk and cream
(which stimulate acid secretion).
 Neutralize acid by eating three
regular meals a day.
 Small, frequent feedings are not
necessary as long as an antacid
or a histamine blocker is taken.
 Eats foods that are tolerated and
avoids those that produce pain.
Surgical Management
Antibiotics to eradicate H. pylori and of
H2 receptor antagonists as treatment
for ulcers has greatly reduced the need
for surgical intervention.
Recommended for patients with
intractable ulcers (those that fail to heal
after 12 to 16 weeks of medical
treatment), life-threatening
hemorrhage, perforation, or obstruction
that is unresponsive to medications.
Surgery: vagotomy with or without
pyloroplasty (transecting nerves that
stimulate acid secretion and opening the
pylorus),
Antrectomy- removal of the pyloric
(antrum) portion of the stomach with
anastomosis (surgical connection) to
either the duodenum
(gastroduodenostomy or Billroth I) or
jejunum (gastrojejunostomy or Billroth
II).
Follow-Up Care
Recurrence of peptic ulcer disease
within 1 year may be prevented with the
prophylactic use of H2 receptor
antagonists taken at a reduced dose.
Prescribed with:
two or three recurrences per year,
had a complication such as bleeding or
gastric outlet obstruction,
candidates for gastric surgery but for
whom it poses too high a risk.
Recurrence is reduced if: avoids
smoking, coffee (including decaffeinated
coffee) and other caffeinated beverages,
alcohol, and ulcerogenic medications
(eg, NSAIDs).

THE PATIENT WITH PEPTIC ULCER
DISEASE
Assessment
 describe the pain and strategies
used to relieve it (eg, food,
antacids).
 peptic ulcer pain- burning or
gnawing; 2 hours after a meal
and frequently awakens the
patient between midnight and 3
AM.
 Taking antacids, eating, or
vomiting often relieves the pain.
If the patient reports a recent
history of vomiting, the nurse
determines how often emesis has
occurred and notes important
characteristics of the vomitus: Is
it bright red, does it resemble
coffee grounds, or is there
undigested food from previous
meals?
 Has the patient noted any bloody
or tarry stools?
List his or her usual food intake for a
72-hour period and to describe food
habits
(eg, speed of eating, regularity of
meals, preference for spicy foods, use of
seasonings, use of caffeinated
beverages and decaffeinated coffee).
 Does the patient use irritating
substances? Does he or she
smoke cigarettes? If yes, how
many? Does the patient ingest
alcohol? If yes, how much and
how often? Are NSAIDs used?
 Patient’s level of anxiety and his
or her perception of current
stressors. How does the patient
express anger or cope with
stressful situations? Is the patient
experiencing occupational stress
or problems within the family?
 Is there a family history of ulcer
disease? Digestive and
Gastrointestinal Function.
Lifestyle and other habits are a
concern as well.
 The nurse assesses VS and
reports tachycardia and
hypotension, which may indicate
anemia from GI bleeding. The
stool is tested for occult blood,
and a physical examination,
including palpation of the
abdomen for localized
tenderness, is performed.
Nursing Diagnosis
• Acute pain related to the effect of
gastric acid secretion on damaged tissue
• Anxiety related to an acute illness
• Imbalanced nutrition related to
changes in diet
• Deficient knowledge about prevention
of symptoms and management of the
condition
Planning and Goals
Relief of pain, reduced anxiety,
maintenance of nutritional
requirements, knowledge about the
management and prevention of ulcer
recurrence, and absence of
complications.
Nursing Interventions
Relieving Pain
Pain relief can be achieved with
prescribed medications.
Avoid aspirin, foods and beverages that
contain caffeine, and decaffeinated
coffee.
Meals should be eaten at regularly
paced intervals in a relaxed setting.
Learn relaxation techniques to help
manage stress and pain.
Reducing Anxiety
Assess the patient’s level of anxiety.
Patients with peptic ulcers are usually
anxious, but their anxiety is not always
obvious.
Appro info is provided at the patient’s
level of understanding, all questions are
answered, and the patient is
encouraged to express fears openly.
Explaining diagnostic tests and
administering medications as scheduled
also help reduce anxiety. The nurse
interacts with the patient in a relaxed
manner, helps identify stressors, and
explains various coping techniques and
relaxation methods, such as
biofeedback, hypnosis, or behavior
modification.
The patient’s family is also encouraged
to participate in care and to provide
emotional support.
Maintaining Optimal Nutritional Status
Assess for malnutrition and weight loss.
Importance of complying with the
medication regimen and dietary
restrictions.
Monitoring and Managing Potential
Complications
Hemorrhage.
Gastritis and hemorrhage
The vomited blood can be bright red, or
it can have a dark “coffee grounds”
appearance from the oxidation of
hemoglobin to methemoglobin. When
the hemorrhage is large (2000 to 3000
mL),
immediate correction of blood loss may
be required to prevent hemorrhagic
shock. When the hemorrhage is small,
much or all of the blood is passed in the
stools, which appear tarry black because
of the digested hemoglobin.
Management
1. Assesses for faintness or dizziness
and nausea, accompanied with bleeding.
2. Monitor vital signs freq and to
evaluate the patient for tachycardia,
hypotension, and tachypnea.
Monitor the hgb and hct, testing the and acid, to prevent N/V, and to provide
stool for gross or occult blood, and a means of monitoring further bleeding
recording hourly urinary output to
3. Administering an NG lavage of saline
detect anuria or oliguria (absence of or
solution. The temperature of the
decreased urine production).
solution (cold or room temp)
3. Bleeding from a peptic ulcer may
4. Inserting an indwelling urinary
stops spontaneously; however, the
catheter and monitoring urinary output
incidence of recurrent bleeding is high.
Because bleeding can be fatal, the 5. Monitoring oxygen saturation and
cause and severity of the hemorrhage administering oxygen therapy
must be identified quickly and the blood
6. Placing the patient in the recumbent
loss treated to prevent hemorrhagic
position with the legs elevated to
shock.
prevent hypotension, or placing the
Monitor carefully so that bleeding patient on the left side to prevent
can be detected quickly. If bleeding aspiration from vomiting
recurs within 48 hours after medical
7. Treating hemorrhagic shock
therapy has begun, or if more than 6 to
10 units of blood are required within 24 Collaborative Problems/Potential
hours to maintain blood volume, the Complications
patient is likely to require surgery.
Hemorrhage, Perforation, Penetration, •
4. The area of the ulcer is removed or Pyloric obstruction
the bleeding vessels are ligated.
GASTROESOPHAGEAL REFLUX DISEASE
Procedures: vagotomy and pyloroplasty, (GERD)
gastrectomy aimed at controlling the
Excessive reflux may occur because of
underlying cause of the ulcers
an incompetent lower esophageal
Other related nursing and sphincter, pyloric stenosis, or a motility
collaborative interventions disorder.
1. Inserting a peripheral IV line for the Clinical Manifestations
infusion of saline or lactated Ringer’s
Pyrosis, dyspepsia (indigestion),
solution and blood products. Blood
regurgitation, dysphagia hypersalivation,
component therapy is initiated if there
and esophagitis.
are signs of shock (eg, tachycardia,
sweating, coldness of the extremities). The symptoms may mimic those of a
heart attack.
2. Inserting an NG tube to distinguish
fresh blood from “coffee grounds”
material, to aid in the removal of clots
Assessment and Diagnostic Findings
endoscopy or barium swallow to
evaluate damage to the esophageal
mucosa.
esophageal pH monitoring to evaluate
the degree of acid reflux.
Bilirubin monitoring (Bilitec) to measure
bile reflux patterns.
Management
1. Avoid situations that decrease lower
esophageal sphincter pressure or cause
esophageal irritation. The patient is
instructed to eat a low-fat diet; to avoid
caffeine, tobacco, beer, milk, foods
containing peppermint or spearmint,
and carbonated beverages;
2. Avoid eating or drinking 2 hours
before bedtime; to maintain normal
body weight;
3. Avoid tight-fitting clothes;
4. Elevate the head of the bed on 6- to
8-inch blocks; and to elevate the upper
body on pillows.
1. If reflux persists, antacids or H2
receptor antagonists, such as famotidine
(Pepcid), nizatidine (Axid), or ranitidine
(Zantac), may be prescribed.
Proton pump inhibitors (medications
that decrease the release of gastric acid,
such as lansoprazole [Prevacid],
rabeprazole [AcipHex], esomeprazole
[Nexium], omeprazole [Prilosec], and
pantoprazole [Protonix]) may be used;
These products may increase
intragastric bacterial growth and the risk
of infection.
2. Prokinetic agents, which accelerate
gastric emptying.
bethanechol(Urecholine), domperidone
(Motilium), and metoclopramide
(Reglan) may cause EPS
3. If medical management is
unsuccessful, surgical intervention may
be necessary.
Surgical management involves a Nissen
fundoplication (wrapping of a portion of
the gastric fundus around the sphincter
area of the esophagus).
NASOGASTRIC (NG) INTUBATION
refers to the insertion of a tube through
the nasopharynx into the stomach NG
intubation has multiple purposes
including stomach decompression,
stomach lavage (irrigation due to active
bleeding or poisoning), medication
administration, and short-term feeding.
Nursing and Patient Care
Considerations
1. Unconscious: advance the tube
between respirations to make sure it
does not enter the trachea.
a. stroke the unconscious patient’s neck
to facilitate passage of the tube down
the esophagus.
b. Watch for cyanosis while passing the
tube in an unconscious patient. Cyanosis
indicates the tube has entered the
trachea.
2. If patient has a nasal condition that b. Clamp the tube for 30 to 45 minutes
prevents insertion through the nose, the to ensure medication absorption before
tube is passed through the mouth. reconnecting to suction, if ordered.
a. Remove dentures, slide the distal end 9. Check GI function by auscultating for
of the tube over the tongue, and bowel sounds on a regular basis after
proceed the same way as a nasal the tube has been clamped for 30
intubation. minutes.
b. Make sure to coil the end of the tube
and direct it down ward at the pharynx.
3. Pain or vomiting after the tube is
inserted indicates tube obstruction or
incorrect placement.
4. If the NG tube is not draining, the
nurse should reposition tube by
advancing or withdrawing it slightly.
After repositioning, always check for
placement.
5. Recognize the cx when the tube is in
for prolonged periods: nasal erosion,
sinusitis, esophagitis, esophagotracheal
fistula, gastric ulceration, and
pulmonary and oral infections.
6. Extended-use NG tubes are made of PERCUTANEOUS ENDOSCOPIC
a flexible, soft plastic material with GASTROSTOMY (PEG)
manufacturer’s recommendations that provides a more permanent means of
may include leaving the tube in place for access to the stomach to enable longer
up to 30 days before changing term enteral feeding (>6 weeks). It
7. Assess the color, consistency, and provides safe access directly into the
odor of gastric contents. Coffee ground– stomach through the dev’t of a fistula
like contents may indicate GI through the abdominal wall.
bleeding.Report findings immediately. Types:
8. The tube should be irrigated before PEG(common),
and after medication administration
through the tube. Radiologically inserted gastrostomy,

a. Medications should be given in liquid Balloon gastrostomy,

form, if possible. Button or low-profile device
The surgical opening is sutured tightly
around the tube or catheter to prevent
leakage. Care of this opening before it
heals requires surgical asepsis. The
catheter has an external bumper and an
internal inflatable retention balloon to
maintain placement. When the tract is
established (about 1 month), the tube
or catheter can be removed and
reinserted for each feeding.
Alternatively, a skin-level tube can be
used that remains in place. A feeding
set is attached when needed.