• Save
GI System Lecture 3
Upcoming SlideShare
Loading in...5
×
 

Like this? Share it with your network

Share

GI System Lecture 3

on

  • 750 views

 

Statistics

Views

Total Views
750
Views on SlideShare
750
Embed Views
0

Actions

Likes
3
Downloads
0
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

GI System Lecture 3 Presentation Transcript

  • 1. Learning Objectives:At the end of this lecture, you will be able to:1. Compare the etiology, clinical manifestations, andmanagement of acute gastritis, chronic gastritis, andpeptic ulcer.2. Use the nursing process as a framework for care ofpatients with gastritis.JOFRED M. MARTINEZ, RN
  • 2. 3. Use the nursing process as a framework for care ofpatients with peptic ulcer.4. Describe the dietary, pharmacologic, and surgicaltreatment of peptic ulcer.5. Describe the nursing management of patients whoundergo surgical procedures to treat obesity.6. Use the nursing process as a framework for care ofpatients with gastric cancer.7. Use the nursing process as a framework for care ofpatients undergoing gastric surgery.Learning Objectives (Cont’d.):
  • 3. 8. Identify the complications of gastric surgery and theirprevention and management.9. Describe the home health care needs of the patientwho has had gastric surgery.Learning Objectives (Cont’d.):
  • 4. GASTRITIS• Gastritis is the inflammation of the gastric or stomachmucosa is a common GI problem.• Gastritis may be acute, lasting several hours to a fewdays, or chronic, resulting from repeated exposure toirritating agents or recurring episodes of acute gastritis.• Acute gastritis is often caused by food that iscontaminated with disease-causing microorganisms orthat is irritating or too highly seasoned.• Other causes of acute gastritis include overuse ofaspirin and other nonsteroidal anti-inflammatory drugs(NSAIDs), excessive alcohol intake, bile reflux, andradiation therapy.Gastritis
  • 5. GASTRITIS• A more severe form of acute gastritis is caused by theingestion of strong acid or alkali, which may cause themucosa to become gangrenous or to perforate.• Chronic gastritis and prolonged inflammation of thestomach may be caused by either benign or malignantulcers of the stomach or by the bacteria Helicobacterpylori.• Chronic gastritis is sometimes associated withautoimmune diseases such as pernicious anemia.Gastritis
  • 6. Gastritis
  • 7. GastritisCLINICAL MANIFESTATIONS• The patient with acute gastritis may have abdominaldiscomfort, headache, lassitude, nausea, anorexia,vomiting, and hiccupping.• The patient with chronic gastritis may complain ofanorexia, heartburn after eating, belching, a sour tastein the mouth, or nausea and vomiting.• Patients with chronic gastritis from vitamin deficiencyusually have evidence of malabsorption of vitamin B12caused by antibodies against intrinsic factor.
  • 8. GastritisASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnosis can be determined by endoscopy, upper GIradiographic studies, and histologic examination of atissue specimen obtained by biopsy.• Other diagnostic measures for detecting H. pyloriinclude serologic testing for antibodies against the H.pylori antigen, a 1-minute ultrarapid urease test, and abreath test.
  • 9. GastritisMEDICAL MANAGEMENT• Acute gastritis is also managed by instructing thepatient to refrain from alcohol and food until symptomssubside. After the patient can take nourishment bymouth, a nonirritating diet is recommended.• If the symptoms persist, fluids may need to beadministered parenterally.• If bleeding is present, management is similar to theprocedures used for upper GI tract hemorrhage.• If gastritis is caused by ingestion of strong acids oralkalis, treatment consists of diluting and neutralizingthe offending agent.
  • 10. GastritisMEDICAL MANAGEMENT• To neutralize acids, common antacids (eg, aluminumhydroxide) are used; to neutralize an alkali, dilutedlemon juice or diluted vinegar is used. If corrosion isextensive or severe, emetics and lavage are avoidedbecause of the danger of perforation and damage tothe esophagus.• Therapy is supportive and may include nasogastric(NG) intubation, analgesic agents and sedatives,antacids, and intravenous (IV) fluids.• In extreme cases, emergency surgery may be requiredto remove gangrenous or perforated tissue.
  • 11. GastritisMEDICAL MANAGEMENT• Gastrojejunostomy or gastric resection may benecessary to treat pyloric obstruction, a narrowing ofthe pyloric orifice.• Chronic gastritis is managed by modifying the patient’sdiet, promoting rest, reducing stress, and initiatingpharmacotherapy.• H. pylori may be treated with antibiotics (eg,tetracycline or amoxicillin, combined withclarithromycin) and a proton pump inhibitor (eg,lansoprazole [Prevacid]), and possibly bismuth salts(Pepto-Bismol).
  • 12. Gastric and Duodenal Ulcers• A peptic ulcer is an excavation that forms in themucosal wall of the stomach, in the pylorus, in theduodenum, or in the esophagus.• A peptic ulcer is frequently referred to as a gastric,duodenal, or esophageal ulcer, depending on itslocation, or as peptic ulcer disease.• Peptic ulcers are more likely to be in the duodenumthan in the stomach.• Chronic gastric ulcers tend to occur in the lessercurvature of the stomach, near the pylorus.
  • 13. Gastric and Duodenal Ulcers• Peptic ulcer disease occurs with the greatest frequencyin people between the ages of 40 and 60 years.• It is relatively uncommon in women of childbearing age,but it has been observed in children and even ininfants. After menopause, the incidence of peptic ulcersin women is almost equal to that in men.Clients should not take NSAIDs and prednisone atthe same time due to ↑ risk of GI irritation.
  • 14. Gastric and Duodenal Ulcers
  • 15. Gastric and Duodenal Ulcers
  • 16. Gastric and Duodenal Ulcers
  • 17. Gastric and Duodenal Ulcers• Peptic ulcer disease occurs with the greatest frequencyin people between the ages of 40 and 60 years.• It is relatively uncommon in women of childbearing age,but it has been observed in children and even ininfants. After menopause, the incidence of peptic ulcersin women is almost equal to that in men.• Ulcers seem to develop more commonly in people whoare tense.• The ingestion of milk and caffeinated beverages,smoking, and alcohol also may increase HCl secretion.
  • 18. Gastric and Duodenal Ulcers• Familial tendency may be a significant predisposingfactor. People with blood type O are more susceptibleto peptic ulcers.• Other predisposing factors associated with peptic ulcerinclude chronic use of NSAIDs, alcohol ingestion, andexcessive smoking.• Rarely, ulcers are caused by excessive amounts of thehormone gastrin, produced by tumors.• Zollinger-Ellison syndrome (ZES) consists of severepeptic ulcers, extreme gastric hyperacidity, and gastrin-secreting benign or malignant tumors of the pancreas.
  • 19. Gastric and Duodenal UlcersGastric and duodenal ulcers have differentiating features:• Gastric ulcers: common in women in labor; clients aremalnourished in appearance; pain occurs 1/2 to 1 hourafter meals; food doesn’t help but vomiting does;clients tend to vomit blood (hematemesis).• Duodenal ulcers: common in executive typepersonalities (type A); clients are well nourished inappearance; pain occurs at night and 2 to 3 hours aftermeals; food helps; blood appears in stool (melena).• Duodenal ulcers are the most common to rupture.Gastric—eating leads to pain.Duodenal—eating lessens pain.
  • 20. Gastric and Duodenal UlcersASSESSMENT AND DIAGNOSTIC FINDINGS• A physical examination may reveal pain, epigastrictenderness, or abdominal distention.• A barium study of the upper GI tract may show anulcer; however, endoscopy is the preferred diagnosticprocedure because it allows direct visualization ofinflammatory changes, ulcers, and lesions.• Stools may be tested periodically until they arenegative for occult blood.• Gastric secretory studies are of value in diagnosingachlorhydria and ZES. H. pylori infection may bedetermined by biopsy and histology with culture.
  • 21. Gastric and Duodenal UlcersMEDICAL MANAGEMENTMethods used include medications, lifestyle changes,and surgical intervention.PHARMACOLOGIC THERAPY• Currently, the most commonly used therapy in thetreatment of ulcers is a combination of antibiotics,proton pump inhibitors, and bismuth salts thatsuppresses or eradicates H. pylori; histamine 2 (H2)receptor antagonists and proton pump inhibitors areused to treat NSAID-induced and other ulcers notassociated with H. pylori ulcers.
  • 22. Gastric and Duodenal UlcersSTRESS REDUCTION AND REST• Biofeedback, hypnosis, or behavior modification maybe helpful.SMOKING CESSATION• Studies have shown that smoking decreases thesecretion of bicarbonate from the pancreas into theduodenum, resulting in increased acidity of theduodenum.DIETARY MODIFICATION• Avoiding extremes of temperature and overstimulationfrom consumption of meat extracts, alcohol, coffee andother caffeinated beverages, and diets rich in milk andcream.
  • 23. Gastric and Duodenal UlcersSURGICAL MANAGEMENT• Surgical procedures include vagotomy, with or withoutpyloroplasty, and the Billroth I and Billroth IIprocedures.
  • 24. Gastric and Duodenal UlcersSURGICAL MANAGEMENT
  • 25. The Patient with Ulcer DiseaseASSESSMENT• The nurse asks the patient to describe the pain and themethods used to relieve it (e.g., food, antacids).• The patient usually describes peptic ulcer pain as burningor gnawing; it occurs about 2 hours after a meal andfrequently awakens the patient between midnight and 3AM.• Taking antacids, eating, or vomiting often relieves the pain.• Is the vomitus it bright red, does it resemble coffeegrounds, or is there undigested food from previous meals?NURSING PROCESS:
  • 26. The Patient with Ulcer DiseaseASSESSMENT• Has the patient noted any bloody or tarry stools?• The nurse also asks the patient to list his or her usual foodintake for a 72-hour period and to describe food habits.• Does the patient use irritating substances?• The nurse inquires about the patient’s level of anxiety andhis or her perception of current stressors.• How does the patient express anger or cope with stressfulsituations?• Is the patient experiencing occupational stress orproblems within the family?NURSING PROCESS:
  • 27. The Patient with Ulcer DiseaseASSESSMENT• Is there a family history of ulcer disease?• The nurse assesses vital signs and reports tachycardiaand hypotension, which may indicate anemia from GIbleeding.• The stool is tested for occult blood, and a physicalexamination, including palpation of the abdomen forlocalized tenderness, is performed as well.NURSING PROCESS:
  • 28. The Patient with Conditions in the Oral CavityNURSING DIAGNOSES• Acute pain related to the effect of gastric acid secretionon damaged tissue• Anxiety related to coping with an acute disease• Imbalanced nutrition related to changes in diet• Deficient knowledge about prevention of symptoms andmanagement of the condition
  • 29. The Patient with Conditions in the Oral CavityPLANNING AND GOALS• The goals for the patient may include relief of pain,reduced anxiety, maintenance of nutritionalrequirements, knowledge about the management andprevention of ulcer recurrence, and absence ofcomplications.
  • 30. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONS• RELIEVING PAIN• REDUCING ANXIETY• MAINTAINING OPTIMAL NUTRITIONAL STATUS• PROMOTING HOME AND COMMUNITY-BASEDCARE
  • 31. The Patient with Conditions in the Oral CavityPOTENTIAL COMPLICATIONSPotential complications may include the following:• Hemorrhage• Perforation• Penetration• Pyloric obstruction
  • 32. The Patient with Conditions in the Oral CavityEVALUATIONEXPECTED PATIENT OUTCOMES1. Reports freedom from pain between meals2. Feels less anxiety by avoiding stress3. Complies with therapeutic regimena. Avoids irritating foods and beveragesb. Eats regularly scheduled mealsc. Takes prescribed medications as scheduledd. Uses coping mechanisms to deal with stress4. Maintains weight5. Is free of complications
  • 33. Morbid Obesity• Morbid obesity is the term applied to people who aremore than two times their ideal body weight or whosebody mass index (BMI) exceeds 30 kg/m2.• Another definition of morbid obesity is body weight thatis more than 100 pounds greater than the ideal bodyweight.• Patients with morbid obesity are at higher risk forhealth complications, such as cardiovascular disease,arthritis, asthma, bronchitis, and diabetes. Theyfrequently suffer from low self-esteem, impaired bodyimage, and depression.
  • 34. Morbid ObesityMEDICAL MANAGEMENT• Conservative management consists of placing theperson on a weight loss diet in conjunction withbehavioral modification and exercise.• There is a belief that depression may be a contributingfactor to weight gain, and treatment of the depressionwith bupropion hydrochloride (Wellbutrin).• Some physicians recommend acupuncture andhypnosis before recommending surgery.
  • 35. Morbid ObesityPHARMACOLOGIC MANAGEMENT• Several medications have recently been approved forobesity they include sibutramine HCl (Meridia) andorlistat (Xenical).SURGICAL MANAGEMENT• Bariatric surgery, or surgery for morbid obesity, isperformed only after other nonsurgical attempts atweight control have failed.• The first surgical procedure to treat morbid obesity wasthe jejunoileal bypass.
  • 36. Morbid ObesitySURGICAL MANAGEMENT• Bariatric surgery, or surgery for morbid obesity, isperformed only after other nonsurgical attempts atweight control have failed.• The first surgical procedure to treat morbid obesity wasthe jejunoileal bypass.• Gastric bypass and vertical banded gastroplasty arethe current operations of choice. These proceduresmay be performed laparoscopically or by an opensurgical technique.
  • 37. Morbid Obesity
  • 38. Morbid ObesityNURSING MANAGEMENT• Complications that may occur in the immediatepostoperative period include peritonitis, stomalobstruction, stomal ulcers, atelectasis and pneumonia,thromboembolism, and metabolic imbalances resultingfrom prolonged vomiting and diarrhea.• After bowel sounds have returned and oral intake isresumed, the nurse provides six small feedingsconsisting of a total of 600 to 800 calories per day andencourages fluid intake to prevent dehydration.• Patients are usually discharged in 4 to 5 days withdetailed dietary instructions.
  • 39. Morbid ObesityNURSING MANAGEMENT• The nurse instructs patients to report excessive thirst orconcentrated urine, both of which are indications ofdehydration.• Efforts are directed toward helping them modify theireating behaviors and cope with changes in bodyimage.• The nurse explains that noncompliance by eating toomuch or too fast or eating high calorie liquid and softfoods results in vomiting and painful esophagealdistention.
  • 40. Morbid ObesityNURSING MANAGEMENT• Long-term side effects may include increased risk ofgallstones, nutritional deficiencies, and potential toregain weight.
  • 41. Gastric Cancer• Most of these cases occur in people older than 40years of age, but they occasionally occur in youngerpeople. Men have a higher incidence of gastric cancersthan women do.• The incidence of gastric cancer is much greater inJapan, which has instituted mass screening programsfor earlier diagnosis.• Diet appears to be a significant factor.• A diet high in smoked foods and low in fruits andvegetables may increase the risk of gastric cancer.
  • 42. Gastric Cancer• Other factors related to the incidence of gastric cancerinclude chronic inflammation of the stomach, perniciousanemia, achlorhydria, gastric ulcers, H. pylori infection,and genetics.
  • 43. Gastric CancerCLINICAL MANIFESTATIONS• In the early stages of gastric cancer, symptoms may beabsent.• Symptoms of progressive disease may includeanorexia, dyspepsia (indigestion), weight loss,abdominal pain, constipation, anemia, and nausea andvomiting.
  • 44. Gastric CancerASSESSMENT AND DIAGNOSTIC FINDINGS• Endoscopy for biopsy and cytologic washings is theusual diagnostic study, and a barium x-ray examinationof the upper GI tract may also be performed.• Because metastasis often occurs before warning signsdevelop, a computed tomography (CT) scan, bonescan, and liver scan are valuable in determining theextent of metastasis.• A complete x-ray examination of the GI tract should beperformed when any person older than 40 years of agehas had indigestion (dyspepsia) of more than 4 weeks’duration.
  • 45. Gastric CancerMEDICAL MANAGEMENT• There is no successful treatment for gastric carcinomaexcept removal of the tumor.• Effective palliation to prevent discomfort caused byobstruction or dysphagia may be obtained by resectionof the tumor.• If a radical subtotal gastrectomy is performed, thestump of the stomach is anastomosed to the jejunum,as in the gastrectomy for ulcer. When a totalgastrectomy is performed, GI continuity is restored bymeans of an anastomosis between the ends of theesophagus and the jejunum.
  • 46. Gastric CancerMEDICAL MANAGEMENT• If surgical treatment does not offer cure, treatment withchemotherapy may offer further control of the diseaseor palliation.• Commonly used chemotherapeutic medications includecisplatin, irinotecan, or a combination of 5-fluorouracil,doxorubicin (Adriamycin), and mitomycin-C.• Radiation therapy also may be used for palliation.
  • 47. Gastric CancerMEDICAL MANAGEMENT• If surgical treatment does not offer cure, treatment withchemotherapy may offer further control of the diseaseor palliation.• Commonly used chemotherapeutic medications includecisplatin, irinotecan, or a combination of 5-fluorouracil,doxorubicin (Adriamycin), and mitomycin-C.• Radiation therapy also may be used for palliation.
  • 48. The Patient with Gastric CancerASSESSMENT• The nurse elicits a dietary history from the patient,focusing on recent nutritional intake and status.• Has the patient lost weight?• If so, how much and over what period of time?• Can the patient tolerate a full diet?• If not, what foods can he or she eat?• What other changes in eating habits have occurred?Does the patient have an appetite?• Is the patient in pain?NURSING PROCESS:
  • 49. ASSESSMENT• Do foods, antacids, or medications relieve the pain,make no difference, or worsen the pain?• Is there a history of infection with H. pylori bacteria?• Other health information to obtain includes the patient’ssmoking and alcohol history and the family history.• A psychosocial assessment, including questions aboutsocial support, individual and family coping skills, andfinancial resources, will help the nurse plan for care inacute and community settings.NURSING PROCESS:
  • 50. ASSESSMENT• After the interview, the nurse performs a completephysical examination, carefully assesses the patient’sabdomen for tenderness or masses, and also palpatesand percusses to detect ascites.NURSING PROCESS:
  • 51. The Patient with Conditions in the Oral CavityNURSING DIAGNOSES• Anxiety related to the disease and anticipated treatment• Imbalanced nutrition, less than body requirements,related to anorexia• Pain related to tumor mass• Anticipatory grieving related to the diagnosis of cancer• Deficient knowledge regarding self-care activities
  • 52. The Patient with Conditions in the Oral CavityPLANNING AND GOALS• The major goals for the patient may include reducedanxiety, optimal nutrition, relief of pain, and adjustmentto the diagnosis and anticipated lifestyle changes.
  • 53. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONS• REDUCING ANXIETY• MAINTAINING OPTIMAL NUTRITIONAL STATUS• RELIEVING PAIN• PROVIDING PSYCHOSOCIAL SUPPORT• PROMOTING HOME AND COMMUNITY-BASEDCARE
  • 54. The Patient with Conditions in the Oral CavityEVALUATIONEXPECTED PATIENT OUTCOMES1. Reports less anxietya. Expresses fears and concerns about surgeryb. Seeks emotional support2. Attains optimal nutritiona. Eats small, frequent meals high in calories, iron, andvitamins A and Cb. Complies with enteral or parenteral nutrition asneeded3. Has less pain
  • 55. The Patient with Conditions in the Oral CavityEVALUATIONEXPECTED PATIENT OUTCOMES4. Performs self-care activities and adjusts to lifestylechangesa. Resumes normal activities within 3 monthsb. Alternates periods of rest and activityc. Manages tube feedings
  • 56. Gastric Surgery• Gastric surgery may be performed on patients withpeptic ulcers who have life-threatening hemorrhage,obstruction, perforation, or penetration or whosecondition does not respond to medication.• Surgical procedures include a vagotomy andpyloroplasty, a partial gastrectomy, and a totalgastrectomy with either an end-to-end or an end-to-side esophagojejunal anastomosis.
  • 57. Gastric SurgeryOBSTACLES TO ADEQUATE NUTRITIONDYSPHAGIA AND GASTRIC RETENTION• Dysphagia may occur in patients who have had truncalvagotomy, a surgical procedure that can result intrauma to the lower esophagus.• Gastric retention may be evidenced by abdominaldistention, nausea, and vomiting. Regurgitation mayalso occur if the patient has eaten too much or tooquickly. If gastric retention occurs, it may be necessaryto reinstate NG suction; pressure must be low to avoiddisrupting the suture line.
  • 58. Gastric SurgeryOBSTACLES TO ADEQUATE NUTRITIONBILE REFLUX• Bile reflux gastritis and esophagitis may occur with theremoval of the pylorus, which acts as a barrier to thereflux of duodenal contents.• Burning epigastric pain and vomiting of bilious materialmanifest this condition. Eating or vomiting does notrelieve the situation. Agents that bind with bile acid,such as cholestyramine (Questran), may be helpful.Aluminum hydroxide gel (an antacid) andmetoclopramide hydrochloride (Reglan) have beenused with some success.
  • 59. Gastric SurgeryOBSTACLES TO ADEQUATE NUTRITIONDUMPING SYNDROME• The term dumping syndrome refers to an unpleasantset of vasomotor and GI symptoms that sometimesoccur in patients who have had gastric surgery or aform of vagotomy.• It may be the mechanical result of surgery in which asmall gastric remnant is connected to the jejunumthrough a large opening.
  • 60. Gastric SurgeryOBSTACLES TO ADEQUATE NUTRITIONDUMPING SYNDROME• Early symptoms include a sensation of fullness,weakness, faintness, dizziness, palpitations,diaphoresis, cramping pains, and diarrhea. Later, thereis a rapid elevation of blood glucose, followed byincreased insulin secretion.• Vasomotor symptoms that occur 10 to 90 minutes aftereating are pallor, perspiration, palpitations, headache,and feelings of warmth, dizziness, and evendrowsiness.
  • 61. Gastric SurgeryOBSTACLES TO ADEQUATE NUTRITIONDUMPING SYNDROME• Anorexia may also be a result of the dumpingsyndrome.• Steatorrhea also may occur in the patient with gastricsurgery.
  • 62. Gastric SurgeryOBSTACLES TO ADEQUATE NUTRITIONVITAMIN AND MINERAL DEFICIENCIES• Malabsorption of organic iron, which may requiresupplementation with oral or parenteral iron, and a lowserum level of vitamin B12, which may requiresupplementation by the intramuscular route.• Total gastrectomy results in lack of intrinsic factor, agastric secretion required for the absorption of vitaminB12 from the GI tract.• This complication is avoided by the regular monthlyintramuscular injection of 100 to 1000 μg (usual dose is300 μg) of vitamin B12.