Chpt 51: Disorders of Upper GI

1. Medical Surgical I Chpt 51: Disorders of Upper GI

3. Anorexia S/S Eventually will show vitamin deficiency, especially of water soluable as not stored in the body. Dry skin, brittle hair, sore mouth, bleeding gums, and easy bruising Wound healing is poor and mental state may deteriorate Bones soften and taste and smell diminish Weak, tired, reduced stool, bowel irregularity and constipation

4. Medical Management High calorie diet, high calorie supplemental feedings, tube feedings, total parenteral nutrition and psychiatric care may all be used to treat.

5. Nursing Management Obtain complete medical and allergy history Find out eating patterns and preferences Keep a record of BMs, may have either diarrhea or constipation May need to dilute formula until he is regulated, increasing dietary fiber and giving stool softener

6. Anorexia Box 51-1 pg. 822 Provide foods he likes Offer between snacks, milk shakes, ensure Do daily calorie counts Keep serving sizes and containers small Serve and keep hot foods hot and cold foods cold Encourage eating with others

7. Anorexia formulate a nutritional plan with dietitian to promote wt gain (600 calories per meal Prevent unpleasant odors do not do painful or unsightly procedures before meals

8. Nausea and Vomiting If prolonged, weakness, weight loss, nutritional deficiency, dehydration, and electrolyte and acid-base balance may occur common causes are drugs, infection of GI tract, intestinal obstruction, systemic infections, lesions of the CNS, food poisoning, emotional stress, early pregnancy and uremia

9. Nausea Vomiting usually produced by distention of duodenum. Nausea is accompanied by increased salivation and peripheral vasoconstriction causing cold, clammy skin and tachycardia. Vomiting center located in the medulla is sensitive to parasympathetic neurotransmitters released in response to gastric irritation.

10. Nausea Valsalva maneuver which accompanies the forceful expulsion of stomach contents causes dizziness, hypotension and bradycardia Fluid loss causes dehydration and leads to excessive thirst and decreased urine Eyes and oral mucus membranes will be dry or dull and fluid loss causes poor skin turgor

11. Nausea and vomiting Ingestion of large amounts of alcohol, consuming contaminated food or drugs that cause GI side effects, bacterial or viral infection are common causes If caused by intestinal obstruction the abdomen is distended, tender, and firm to touch. Bowel sounds are hypoactive or absent.

12. Nursing Care Get good history Find out symptoms that occur prior to N/V Frequency,color ,amount are all important assessments List of foods eaten last 24 hours and where he has eaten Assess general appearance, weight, vitals, I&O, and fluid volume deficit Review Nsg care in fundamentals book

13. Cancer of Oral Cavity Smoking, chewing tobacco, drinking alcohol in excess can cause oral cancer. Lip Ca caused by pipe smoking and prolonged exposure to wind and sun May distort appearance and make it hard to masticate and cause local pain may have dysphagia May invade surrounding tissue including carotid and cause hemorrhage and death

14. Oral Cancer

15. Oral Cancer Early stage of oral cancer is symptom free. becomes concerned about lump, lesion or abnormality of lip or mouth. Pain, soreness and bleeding occur late If on tongue may have trouble tasting food or difficulty in eating. Pain, numbness and loss of feeling also occur Leukoplakia , a white patch on tongue or inner cheek may become cancerous

16. Nursing Care Same as any other patient with Ca focus is on maintaining patent airway, promoting adequate fluid and food intake, and communication--repeat or clarify what he has said and substitute written, give a magic slate, alphabet board or paper & pencil

17. Nursing for Oral Cancer After surg, place on side or abdomen with head turned to the side to facilitate drainage After fully awake, elevate HOB so can breathe easier and cough up secretions and control edema of site Keep suction, O2, trach set available Do not irrigate mouth until awake and alert, then turn head to side and gently irrigate into an emesis basin. Instill small amt only

18. Nursing Care Must have order before giving anything by mouth. Observe as he swallows small amount. If coughing then suction out of mouth stat. suction mouth PRN to remove secretions, blood, or irrigating fluids Give antiemetics for nausea and maintain patency of gastric tube. No straws as distention of abdomen from air

19. Oral Cancer Nurse needs to promote effective coping and therapeutic grieving. May cry, refuse to talk and extreme sadness Allow time to adjust to loss and change in appearance Let him ventilate feelings some may be suicidal Avoid hot and cold or spicy foods

20. Gastointestinal Intubation NG tube or gastric decompression may be needed. Review fundamentals Should have adequate nutrition, appropriate stooling patterns (amount, consistency, and frequency) and preservation of intact skin and nasal mucosa. Keep membranes moist discomfort from dryness and unpleasant taste may be relieved with frequent mouth care

21. Nursing Care Ice chips and analgesic throat lozenges, gargles, or sprays may help if mouth and throat become sore always give mouth care after removing tube...may have sore throat for several days At risk for fluid volume deficit. Observe for dehydration Protect from infections that stem from micros within formula or tube

22. Nursing Care for NG feedings Signs of infection include diarrhea, fever or abnormal WBC count. Keep feeding formula refrigerated and unopened until ready to use. Warm to room temp before giving Hang volume for 4 to 6 hours at a time Flush with water before adding more formula. Discard after 24 hrs. Wash equipment after each use

23. Care Plan Prevent vomiting by checking tube position and gastric residual before instilling more Place in semi-fowlers during feeding and for 30 min after. Never get below 30 degrees clamp feeding after bolus or intermittent feeding

24. Prevent aspiration of any draining liquid during tube removal by instilling a small amt. of air to clear secretions and formula from tube, pinch the tube closed and have him hold his breath while removing Always refeed gastric contents as has electrolytes Monitor weight

25. Percutaneous Endoscopic Gastrostomy Before a PEG tube is inserted, the nurse should weigh him, assess vitals, auscultate bowel sounds and let him void. After should continue to monitor vitals, observe breathing, inspect skin and dressing. Examine appearance and volume of secretions during first 24 hours when attached to gravity drainage. Auscultate bowel sounds and palpate for distention

26. PEG Tube

27. PEG Note tolerance for formula. report abd. distention, vomiting, fever, and severe pain. Monitor the characteristics and pattern of bowel elimination and trends in daily wt. If tube falls out, insert a foley cath and inflate balloon and clamp it to keep stoma from sealing. Notify Dr. feedings can be given thru foley cath inserted into abdomen until replaced.

28. Gastroesophageal Reflux Disease (GERD) Develops when gastric contents flow in an upward direction into esophagus. Everyone has some but if excessive, or causes pain or resp distress then considered a disease Cardiac sphincter does not close completely allowing contents of stomach to go into esophagua. Obesity, preg can increase it.

29. GERD S/S Epigastric pain or discomfort (dyspepsia) and regurgitation. May have difficulty in swallowing (dysphagia), painful swallowing (odynophagia), inflammation of the lining of esophagus (esophagitis), aspiration pneumonia, and respiratory distress. May bleed and vomit blood or have tarry stools (melena). May lead to anemia. can cause chest pain and be mistaken for MI

30. GERD Evaluate lifestyle changes needed to reduce GERD Avoid alcohol, peppermint, licorice, and caffeine. Weight loss helps and avoid tight fitting clothing elevate HOB, stop smoking and avoid eating or drinking for several hours before bedtime

31. Esophageal Diverticulum Weakness of esophageal wall. The diverticula trap food and secretions which then narrows the lumen, interferes with the passage of food and exerts pressure on trachea. Trapped food decomposes within the esophagus causing esophagitis or ulceration in the mucosa

32. Signs and Symptoms Has foul breath and has difficulty or pain when swallowing, belching, regurgitation, or coughing Gurgling sounds may be heard when auscultating the mid-upper chest Bland, soft, or semisoft or liquid diet given. Small meals eaten 4 to 6 times a day Oral hygeine will not alter the foul breath...review care of hiatal hernia

33. Hiatal Hernia Hiatal or diaphragmatic hernia is a protrusion of part of the stomach into esophagus. A portion of the stomach protrudes thru diaphragm into chest cavity Caused by defect in the diaphragm where esophagus passes thru Factors which increase intra-abdominal pressure (multiple preg or obesity) contributes to development

34. Hiatal Hernia Can cause GERD Will have heartburn, belching and a feeling of substernal or epigastric pressure or pain after eating and when lying down. If scars form, swallowing becomes difficult. as food distends the esophagus, vomiting may occur Review care page 838 and 839

35. Cancer of Esophagus Correlation between alcohol abuse and cigarette smoking Signs and symptoms usually develop slowly Beginning symptoms are mild, vague feelings of discomfort and difficulty in swallowing some foods. Weight loss accompanies progressive dysphagia. solid foods may become impossible to swallow so drinks liquids

36. Cancer of Esophagus By the time swallowing difficulty is pronounced it has usually invaded surounding tissues and lymphatics. May have back pain and respiratory distress Pain is a late symptom Major nursing goal is improved nutrition and weight gain.Consult with dietitian. Avoid foods or drinks with lots of gas, such as souffles or carbonated beverages. No straws or narrow necked bottles to avoid air

37. Cancer of Esophagus May need NG tube, Gastrotomy tube, or TPN Must care for skin around tube insertion site, prevent infection, maintain patency of tube and teaching how to manage tube after discharge. If surgery done, teach how to support surgical incision for coughing and deep breathing

38. Gastritis pg. 840 Inflammation of stomach lining Submucosal layers of stomach can become inflamed when mucous layer is reduced or penetrated by irritating substances. May have epigastric discomfort or heartburn. The mucous producing cells heal and regenerate in 3 to 5 days so gets better chronic irritation leads to ulceration

39. Gastritis s/s Complains of epigastric fullness, pressure, pain, anorexia, N/V When gastritis is caused by bacterial or viral infection may have vomiting, diarrhea, fever and abdominal pain. Drugs, poisons, toxic substances and corrosives can cause gastric bleeding

40. Medical Management avoid irritating substances such as spicy foods, alcohol and caffeine Observe color and characteristics of any vomitus or stools Teach about diet, drug therapy and need for continued medical follow-up

41. Peptic Ulcer Disease Circumscribed loss of tissue in an area of the GI tract that is in contact with HCL and pepsin. Most occur in the duodenum but may also occur at lower end of esophagus, in the stomach or in jejunum Gastric ulcers are more likely to recur and become cancerous. 80-90% are caused by Helicobacter pylori. Smoking and chronic use of Asa or NSAIDS also cause

42. Helicobacter pylori

43. H. Pylori A gram-negative microorganism, is present in the gastric or duodenal mucosa of 80% or 90% of clients with peptic ulcers. This bacteria, which shelters itself in the bicarbonate-rich mucus, is a factor in chronic gastritis and peptic ulcer disease. Secretes an enzyme that theoretically depletes gastric mucus, making it more vulnerable to injury.

44. Peptic Ulcer S/S Location of pain is in mid-epigastrium, does not radiate Pain most often occurs when stomach is empty should monitor for hemorrhage, obstruction and perforation signs of bleeding: Coffee-ground appearing emesis and black tarry stools (melena)

45. Peptic Ulcer Most often described as having a burning quality. Complains of pain that disturbs sleep and occurs one to several hours after eating. Pain may be releived by eating Back pain may be irritation of pancreas by ulcer. Protracted vomiting may occur if symptoms ignored as causes obstruction

46. Dumping syndrome If a total gastrectomy done, must receive vitamin B12 injections for life to prevent pernicious anemia Clients with gastrojejunostomy are at risk for dumping syndrome when eating solid food. Will have weakness, dizziness, sweating, palpitations, abdominal cramps and diarrhea due to rapid emptying or dumping of large amounts of partly digested food into jejunium

47. Dumping Syndrome The presence of this concentrated solution in the gut draws fluid from the circulating blood into intestine, causing hypovolemia. The drop in BP can produce syncope. Sudden appearance of CHO in jejunum stimulates pancreas to secrete excessive insulin and hypoglycemia. To help dumping syndrome, eat carbohydrates, especially simple sugars in moderation

48. Nursing Management Determine type of pain, onset in relation to eating, location and duration Get dietary Hx and foods that cause distress. Does eating relieve pain? If receiving tube feedings, re-instill gastric residual because it has enzymes, electrolytes and partially digested nutrients. If surgery, follow guidelines same as gastric surgery page 835

49. Cancer of Stomach Heredity and chronic inflammation of the stomach appear to contribute. Foods preserved with nitrates may predispose Early symptoms are vague. As tumor enlarges symptoms include a prolonged feeling of fullness after eating, anorexia, weight loss, and anemia and melena. Pain is late sign

50. Cancer of Stomach Surgery and chemotherapy done. Nursing should teach prevention...how to change dietary habits to reduce causes. Teach early warning signs

51. Post-op Care Inspect surgical dressing for drainage and tubes or catheters for placement, patency, and type of drainage. Carefully observe NG tube drainage for bleeding. May contain small amount of dark blood when first returns from OR the drainage should promptly return to yellow-green

52. Complications to Observe For Change in vitals, especially low BP, rapid pulse, and elevated temp Extreme restlessness Difficulty breathing, increased resp rate, cyanosis Severe pain, especially after pain med given; pain in another site and not operative site (leg, head, chest)

53. Complications Abdominal distention or rigidity Urinary output less than 35 ml per hour if cath or failure to void within 8 hours of surgery Failure to pass flatus or stool more than 48 hours postop Profuse diaphoresis

54. Complications Excessive bloody drainage from NG tube, surgical drains, or surgical dressing Separation of surgical wound edges Unusual color or odor of drainage