Chapter 29

1. Chapter 29 Care of Patients with Disorders of the Upper Gastrointestinal System

2. Theory Objectives • Discuss obesity and its management, including bariatric surgery. • Compare the signs and symptoms of oral, esophageal, and stomach cancer. • Illustrate the cause of gastroesophageal reflux disease (GERD).

3. Theory Objectives (cont.) • Explain the etiology and prognosis for Barrett’s esophagus. • Describe the pathophysiology, means of medical diagnosis, and treatment for gastritis. • Compare and contrast the treatment and nursing care of the patient with GERD and a patient with a peptic ulcer.

4. Theory Objectives (cont.) • 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.

5. Clinical Practice Objectives • Prepare 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.

6. Clinical Practice Objectives (cont.) • Manage a tube feeding for the patient receiving formula via a feeding pump. • Devise a nursing care plan for the patient with a gastrointestinal disorder.

7. Anorexia Nervosa • The patient with anorexia nervosa refuses to eat adequate quantities of food and is 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

8. Bulimia Nervosa • The bulimic patient consumes large quantities of food and then induces vomiting to get rid of it so that weight is not gained • Laxatives • Some patients with anorexia nervosa also are bulimic • Some individuals practice bulimia occasionally without harm

9. Bulimia Nervosa (cont.) • It can lead to severe fluid and electrolyte imbalances, starvation, and death • Treatment of bulimia includes psychotherapy, antidepressant medication, and behavior modification

10. Obesity • Etiology and pathophysiology • Signs and symptoms • Diagnosis • Height and weight chart • Waist and hip circumference • Body mass index (BMI)

11. Obesity Treatment • Bariatric surgery • Extensive counseling and assessment • Modify lifestyle and stringent regimen required to lose weight and keep weight off • Types • Gastric restrictive • Malabsorptive • Gastric restrictive combined with malabsorptive surgery

12. Bariatric Surgery • Preoperative care • There is greater risk of pulmonary and thrombus formation, as well as death, for the obese patient

13. 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

14. 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

15. Gastric Bypass

16. Vertical Banded Gastroplasty

17. Circumgastric Banding

18. 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

19. Complications • Leakage of stomach contents • Gastric stretching • Dumping syndrome • Nutritional deficiencies—iron, vitamin B12, calcium, and folate

20. 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

21. Assessment • Family history • Contributing factors • Record of eating patterns for a 7-day period • Weight and height • BMI • Skinfold thickness measurement • General health assessment

22. Expected Outcomes • Patient will make positive statements about decreasing body size • Patient will verbalize feelings of self-worth

23. 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, low-calorie diet • Commercial programs on weight reduction

24. Upper GI Disorders • Stomatitis • Dysphagia • Causes • Diagnosis • Treatment • Nursing management

25. Implementation • Aspiration • Suctioning • Nutrition and gastrostomy

26. Cancer of the Oral Cavity • Etiology • Pathophysiology • Signs and symptoms • Diagnosis—physical examination and biopsy • Treatment—radiation, chemotherapy, and surgery • Nursing management

27. 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

28. Cancer of the Esophagus (cont.) • Gastroesophageal reflux disease (GERD) is a cause of Barrett’s esophagus, which is a precancerous condition

29. Cancer of the Esophagus (cont.) • Signs, symptoms, and diagnosis • Treatment • Esophagectomy • Nursing management • Postoperative care • Nutrition

30. 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.) • “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?”

31. Hiatal Hernia (Diaphragmatic Hernia) • Etiology and pathophysiology • Signs and symptoms • Treatment

32. Treatment of Hiatal Hernia • Reduce weight • Avoid tight-fitting clothes around the abdomen • Take antacids and histamine (H2)-receptor antagonists • Elevate head of the bed on 6- to 8-inch blocks • Take proton pump inhibitors

33. Treatment of Hiatal Hernia (cont.) • Instruct not to eat within several hours of going to bed • Limit intake of alcohol, chocolate, caffeine, and fatty foods • Avoid smoking

34. 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

35. Nursing Management (cont.) • If the head of the bed cannot be raised, a wedge pillow should be used to elevate the upper body; this position helps prevent reflux and assists gravity in maintaining the stomach in the abdominal cavity • H2 or proton pump inhibitors • Avoid foods that cause bloating

36. Gastroesophageal Reflux Disease (GERD) • Etiology and pathophysiology • Signs and symptoms • Diagnosis and treatment • Nursing management • Diet therapy, lifestyle changes, drug therapy, and education • Complications

37. Gastroenteritis • Caused by food or water contaminated with a virus, a pathogenic bacteria, or parasites • Signs and symptoms • Management

38. Gastritis • Etiology • Pathophysiology • Signs and symptoms • Diagnosis • Treatment

39. Treatment for Gastritis • Acute versus chronic gastritis • Chronic gastritis • Antispasmodics • Antacids • H2-receptor antagonist such as ranitidine • Proton pump inhibitor • Antibiotic therapy for H. pylori

40. Peptic Ulcers • Etiology • Helicobacter pylori • Duodenal ulcers and some pre-pyloric ulcers • Gastric ulcers • Tension, anxiety, and prolonged stress • Drug-induced ulcers

41. Peptic Ulcers (cont.) • Pathophysiology • Signs and symptoms • Daily pattern of pain • Gastrointestinal bleeding • Diagnosis • Endoscopy • Gastric acid analysis

42. Peptic Ulcers (cont.)

43. Treatment • Antacids • Gastric bleeding and normal saline lavage • H2-receptor antagonist • Proton pump inhibitors • Presence of H. pylori—administration of clarithromycin (Biaxin) plus another antibiotic, an H2 inhibitor, and a proton pump inhibitor

44. Nursing Management • Complications • Hemorrhage • Perforation • Obstruction

45. Surgical Treatment of Peptic Ulcer • Pyloroplasty with truncal or proximal gastric vagotomy • Subtotal gastrectomy (gastric resection) • Total gastrectomy

46. Nursing Care of the Patient Undergoing Gastric Surgery • Preoperative care • Postoperative care • Specific patient teaching • Diet restrictions   • Dumping syndrome

47. Gastric Cancer • Etiology • Signs and symptoms • Pathophysiology • Diagnosis • Treatment • Nursing management

48. Gastric Cancer (cont.) • Treatment • Surgical intervention • Radiation therapy • Chemotherapy • Adjuvant therapy

49. Common Therapies for Disorders of the Gastrointestinal System • Gastrointestinal decompression • Enteral nutrition • Total parenteral nutrition

50. Small-Bore Feeding Tube Placement