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  • Stool specimens are often examined for blood, bile, pathogenic organisms, and parasites. Should deliver to the lab immediately. If stool being tested for blood, pt should not eat red meat for 2-3 days before specimen collection
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  • +Endoscopic ultrasonography is performed through the use of sound waves. Tumors can be detected. Pre and post-op care similar to endoscopic care. Pt lie still while a transducer with gel is moved back and forth over the abd to produce images.
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  • Xerostomia (dry mouth) Encourage frequent mouth care. Saliva substitute is available over the counter and is helpful, especially at night when patients complain of a choking sensation from extreme dryness.
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  • GERDS is caused by conditions that affect the ability of the lower esophageal sphincter to close tightly, such as hiatal hernia.
  • Odynophagia – pain upon swallowing.
  • Prokinetic –stimulating gastrointestinal activity.
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  • Advised not to recline for 1 hr after eating. Avoid bedtime snacks, spicy foods, alcohol, caffeine, and smoking.
  • Denervation – excision, incision, or blocking of a nerve supply.
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  • faculty.sheltonstate.edu

    1. 1. Assessment of the Gastrointestinal System
    2. 2. Overview of the Gastrointestinal Tract <ul><li>Structure </li></ul><ul><li>Function </li></ul><ul><li>Nerve supply </li></ul><ul><li>Blood supply </li></ul><ul><li>Oral cavity </li></ul><ul><li>Esophagus </li></ul><ul><li>Stomach </li></ul><ul><li>(Continued) </li></ul>
    3. 3. Overview of the Gastrointestinal Tract (Continued) <ul><li>Pancreas </li></ul><ul><li>Liver and gallbladder </li></ul><ul><li>Intestines </li></ul>
    4. 4. Assessment Techniques <ul><li>History </li></ul><ul><li>Demographic data </li></ul><ul><li>Family history and genetic risk </li></ul><ul><li>Personal history </li></ul><ul><li>Diet history </li></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Dyspepsia </li></ul></ul>
    5. 5. Current Health Problems <ul><li>Pattern of bowel movements </li></ul><ul><li>Color and consistency of the feces </li></ul><ul><li>Occurrence of diarrhea or constipation </li></ul><ul><li>Effective action taken to relieve diarrhea or constipation </li></ul><ul><li>Presence of frank blood or tarry stools </li></ul><ul><li>Presence of abdominal distention or gas </li></ul>
    6. 6. Skin Changes Related to Gastrointestinal Disorders <ul><li>Skin discolorations or rashes </li></ul><ul><li>Itching </li></ul><ul><li>Jaundice </li></ul><ul><li>Increased susceptibility to bruising </li></ul><ul><li>Increased tendency to bleed </li></ul>
    7. 7. Physical Assessment <ul><li>Mouth and pharynx </li></ul><ul><li>Abdomen and extremities </li></ul><ul><ul><li>Inspection (Cullen’s sign) </li></ul></ul><ul><ul><li>Auscultation, look for borborygmus </li></ul></ul><ul><ul><li>Percussion </li></ul></ul><ul><ul><li>Palpation </li></ul></ul>
    8. 8. Laboratory Tests <ul><li>Complete blood count </li></ul><ul><li>Clotting factors </li></ul><ul><li>Electrolytes </li></ul><ul><li>Assays of liver enzymes—aspartate and alanine aminotransferase </li></ul><ul><li>Serum amylase and lipase </li></ul><ul><li>Bilirubin: the primary pigment in bile </li></ul><ul><li>(Continued) </li></ul>
    9. 9. Laboratory Tests (Continued) <ul><li>Evaluation of oncofetal antigens CA 19-9 and CEA </li></ul><ul><li>Urine tests—amylase, urine urobilinogen </li></ul><ul><li>Stool tests—fecal occult blood test, ova parasites, Clostridium difficile infection </li></ul><ul><li>Radiographic examinations </li></ul>
    10. 10. Upper Gastrointestinal Series and Small Bowel Series <ul><li>Before test: </li></ul><ul><ul><li>Maintain NPO for 8 hr. </li></ul></ul><ul><ul><li>Withhold analgesics and anticholinergics for 24 hr. </li></ul></ul><ul><li>Client drinks 16 ounces of barium. </li></ul><ul><li>Rotate examination table. </li></ul><ul><li>(Continued) </li></ul>
    11. 11. Barium Enema <ul><li>Barium enema enhances radiographic visualization of the large intestine. </li></ul><ul><li>Only clear liquids are given 12 to 24 hr before the test; NPO the night before; bowel cleansing is done. </li></ul><ul><li>After the test, expel the barium: drink plenty of fluids; stool is chalky white for 24 to 72 hr. </li></ul>
    12. 12. Upper Gastrointestinal Series and Small Bowel Series (Continued) <ul><li>After the test: </li></ul><ul><ul><li>Give plenty of fluids. </li></ul></ul><ul><ul><li>Administer mild laxative or stool softener; stools may be chalky white for 24 to 72 hr. </li></ul></ul>
    13. 13. Percutaneous Transhepatic Cholangiography <ul><li>X-ray study of the biliary duct system </li></ul><ul><li>Laxative before the procedure </li></ul><ul><li>NPO for 12 hr before test </li></ul><ul><li>Coagulation tests, intravenous infusion </li></ul><ul><li>Bedrest for several hours after procedure </li></ul><ul><li>Assessment of vital signs </li></ul><ul><li>(Continued) </li></ul>
    14. 14. Percutaneous Transhepatic Cholangiography (Continued) <ul><li>Client positioned on right side with a firm pillow or sandbag placed against the lower ribs and abdomen </li></ul>
    15. 15. Other Tests <ul><li>Computed tomography </li></ul><ul><li>Endoscopy: direct visualization of the gastrointestinal tract by means of a flexible fiberoptic endoscope </li></ul>
    16. 16. Esophagogastroduodenoscopy <ul><li>Visual examination of the esophagus, stomach, and duodenum </li></ul><ul><li>NPO for 6 to 8 hr before the procedure </li></ul><ul><li>Conscious sedation </li></ul><ul><li>After the test, assessment of vital signs every 30 min </li></ul><ul><li>NPO until gag reflex returns </li></ul><ul><li>Throat discomfort possible for several days </li></ul>
    17. 17. Endoscopic Retrograde Cholangiopancreatography <ul><li>Visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas </li></ul><ul><li>NPO for 6 to 8 hr before test </li></ul><ul><li>Access for intravenous sedation </li></ul><ul><li>After the test, assessment of vital signs every 15 min </li></ul><ul><li>(Continued) </li></ul>
    18. 18. Endoscopic Retrograde Cholangiopancreatography (Continued) <ul><li>Return of gag reflex checked </li></ul><ul><li>Assessment for pain </li></ul><ul><li>Colicky abdominal pain </li></ul>
    19. 19. Small Bowel Capsule Enteroscopy <ul><li>Visualization of the small intestine </li></ul><ul><li>Only water for 8 to 10 hr before test </li></ul><ul><li>NPO for first 2 hr of the testing </li></ul><ul><li>Application of belt with sensors </li></ul>
    20. 20. Colonoscopy <ul><li>Endoscopic examination of the entire large bowel </li></ul><ul><li>Liquid diet for 12 to 24 hr before procedure, NPO for 6 to 8 hr before procedure </li></ul><ul><li>Bowel cleansing routine </li></ul><ul><li>Assessment of vital signs every 15 min </li></ul><ul><li>If polypectomy or tissue biopsy, blood possible in stool </li></ul>
    21. 21. Proctosigmoidoscopy <ul><li>Endoscopic examination of the rectum and sigmoid colon </li></ul><ul><li>Liquid diet 24 hr before procedure </li></ul><ul><li>Cleansing enema, laxative </li></ul><ul><li>Position client on left side in the knee-chest posture. </li></ul><ul><li>(Continued) </li></ul>
    22. 22. Proctosigmoidoscopy (Continued) <ul><li>Mild gas pain and flatulence from air instilled into the rectum during the examination </li></ul><ul><li>If biopsy was done, a small amount of bleeding possible </li></ul>
    23. 23. Gastric Analysis <ul><li>Measurement of the hydrochloric acid and pepsin content for evaluation of aggressive gastric and duodenal disorders (Zollinger-Ellison syndrome) </li></ul><ul><li>Basal gastric secretion and gastric acid stimulation test </li></ul><ul><li>NPO for 12 hr before test </li></ul><ul><li>Nasogastric tube insertion </li></ul>
    24. 24. Other Tests <ul><li>Ultrasonography </li></ul><ul><li>Endoscopic ultrasonography </li></ul><ul><li>Liver-spleen scan </li></ul>
    25. 25. Gasrointestinal Intubation <ul><li>To remove gas and fluids from the stomach or intestines (decompression). </li></ul><ul><li>To diagnose GI motility and to obtain gastric secretions for analysis. </li></ul><ul><li>To relieve and treat obstructions or bleeding within the GI tract. </li></ul>
    26. 26. Gastrointestinal Intubation cont…… <ul><li>To provide a means for nutrition ( gavage feeding), hydration, and medication when the oral route is not possible or is contraindicated. </li></ul><ul><li>To promote healing after esophageal, gastric, or intestinal surgery by preventing distension of the GI tract and strain on the suture lines . </li></ul>
    27. 27. Gastrointestinal Intubation cont…. <ul><li>To remove toxic toxic substances (lavage) that have been ingested either accidentally or intentionally and to provide for irrigation. </li></ul>
    28. 28. General Nursing Care <ul><li>Assessing tube placement must be assessed after insertion and maintenance. Assessing tube placement is essential to prevent complications or death from incorrect tube placement. </li></ul><ul><li>Nasogastric tube placement must be assessed after insertion and then intermittently to ensure that it is in the correct position and not in the lungs (most common), esophagus, pleural space, or brain. </li></ul>
    29. 29. Interventions for Clients with Oral Cavity Problems
    30. 30. Stomatitis <ul><li>Painful, single or multiple ulcerations of the oral mucosa that appear as inflammation and denudation of the oral mucosa, impairing the protective lining of the mouth </li></ul><ul><li>Primary stomatitis </li></ul><ul><li>Secondry stomatitis </li></ul><ul><li>Candidiasis </li></ul>
    31. 31. Clinical Manifestations <ul><li>Dry, painful mouth, open ulcerations, predisposing the client to infection </li></ul><ul><li>Commonly found on the buccal mucosa, soft palate, oropharyngeal mucosa, and lateral and ventral areas of the tongue </li></ul><ul><li>If candidiasis, white plaquelike lesions on the tongue; when wiped away, red sore tissue appears </li></ul>
    32. 32. Oral Hygiene <ul><li>Soft-bristled toothbrush or disposable foam swabs to stimulate gums and clean the oral cavity are recommended. </li></ul><ul><li>Frequent rinsing of the mouth with solution, not commercial mouthwash </li></ul><ul><li>Mouth care every 2 hr and twice during the night, if stomatitis is not controlled </li></ul>
    33. 33. Drug Therapy <ul><li>Antibiotics such as tetracycline syrup and minocycline (swish and swallow) </li></ul><ul><li>Antifungals such as nystatin oral suspension (swish and swallow) </li></ul><ul><li>Intravenous acyclovir for immunocompromised clients with herpes simplex stomatitis </li></ul><ul><li>(Continued) </li></ul>
    34. 34. Drug Therapy (Continued) <ul><li>Anti-inflammatory agents and immune modulators </li></ul><ul><li>Symptomatic topical agents such as gargle or mouthwash </li></ul>
    35. 35. Leukoplakia <ul><li>Slowly developing changes in the oral mucous membranes characterized by thickened, white, firmly attached patches that are slightly raised and sharply circumscribed. </li></ul><ul><li>Most common oral lesion among adults </li></ul><ul><li>(Continued) </li></ul>
    36. 36. Leukoplakia (Continued) <ul><li>Oral hairy leukoplakia is an early manifestation of HIV infection and is highly correlated with the progression from HIV to AIDS. </li></ul>
    37. 37. Erythroplakia <ul><li>Red, velvety mucosal lesions on the surface of the oral mucosa </li></ul><ul><li>Higher degree of malignant transformation in erythroplakia than in leukoplakia </li></ul><ul><li>Commonly found on the floor of the mouth, tongue, palate, and mandibular mucosa </li></ul>
    38. 38. Squamous Cell Carcinoma <ul><li>Most common oral malignancy: can be found on the lips, tongue, buccal mucosa, and oropharynx </li></ul><ul><li>Highly associated with aging, tobacco use, and alcohol ingestion </li></ul><ul><li>Tumor, node, metastasis classification system for tumors of the lips and oral cavity </li></ul>
    39. 39. Basal Cell Carcinoma <ul><li>Occurs primarily on the lips </li></ul><ul><li>Lesion is asymptomatic and resembles a raised scab; evolves into ulcer with a raised pearly border </li></ul><ul><li>Aggressively involves the skin of the face, but does not metastasize </li></ul><ul><li>Major etiologic factor is exposure to sunlight </li></ul>
    40. 40. Kaposi’s Sarcoma <ul><li>Malignant lesion arising in blood vessels </li></ul><ul><li>Usually painless </li></ul><ul><li>Raised purple nodule or plaque </li></ul><ul><li>Found on the hard palate, gums, tongue, or tonsils </li></ul><ul><li>Most often associated with AIDS </li></ul>
    41. 41. Risk for Ineffective Airway Clearance <ul><li>Interventions include: </li></ul><ul><ul><li>Excessive tumor involvement and tenacious secretions can inhibit airway patency. </li></ul></ul><ul><ul><li>Nursing measures for maintaining airway patency is primary focus. </li></ul></ul><ul><ul><li>Assessment should focus on client’s dyspnea, inability to cough effectively, or inability to swallow. </li></ul></ul>
    42. 42. Nonsurgical Management <ul><li>Airway management </li></ul><ul><li>Cough management </li></ul><ul><li>Aspiration precautions </li></ul>
    43. 43. Surgical Management <ul><li>Tracheostomy </li></ul><ul><li>Decannulation accomplished after postoperative edema resolves </li></ul>
    44. 44. Impaired Oral Mucous Membrane <ul><li>Oral cavity lesions can be treated by surgical excision, by nonsurgical treatments such as radiation or chemotherapy, or by a combination of treatments (multimodal therapy) </li></ul>
    45. 45. Nonsurgical Management <ul><li>Oral care </li></ul><ul><li>Radiation therapy </li></ul><ul><li>Chemotherapy </li></ul>
    46. 46. Surgical Management <ul><li>Preoperative care </li></ul><ul><li>Operative procedure </li></ul><ul><li>Postoperative care </li></ul><ul><ul><li>Maintaining airway patency </li></ul></ul><ul><ul><li>Protecting the operative area </li></ul></ul><ul><ul><li>Relieving pain </li></ul></ul><ul><ul><li>Promoting nutrition </li></ul></ul>
    47. 47. Acute Sialadenitis <ul><li>Inflammation of a salivary gland, caused by infectious agents, irradiation, or immunologic disorders </li></ul><ul><li>Interventions </li></ul><ul><ul><li>Hydration </li></ul></ul><ul><ul><li>Application of warm compresses </li></ul></ul><ul><ul><li>Massage of the gland </li></ul></ul><ul><ul><li>Use of saliva substitute </li></ul></ul><ul><ul><li>Use of sialagogues </li></ul></ul>
    48. 48. Postirradiation Sialadenitis <ul><li>Xerostomia results in very dry mouth caused by severe reduction in the flow of saliva. </li></ul><ul><li>Little can be done during the course of radiation, but frequent sips of water and frequent mouth care, especially before meals, are the most effective interventions. </li></ul><ul><li>(Continued) </li></ul>
    49. 49. Postirradiation Sialadenitis (Continued) <ul><li>Saliva substitutes can be used after the course of radiation therapy is complete. </li></ul>
    50. 50. Salivary Gland Tumors <ul><li>Relatively rare among oral tumors </li></ul><ul><li>Often associated with radiation of the head and neck areas </li></ul><ul><li>Assessment: ability to wrinkle brow, raise eyebrows, squeeze eyes shut, wrinkle nose, pucker lips, puff out cheeks, and grimace or smile </li></ul><ul><li>Treatment of choice: surgical excision of the parotid gland </li></ul>
    51. 51. Interventions for Clients with Esophageal Problems
    52. 52. Gastroesophageal Reflux Disease <ul><li>Occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus </li></ul><ul><li>Reflux esophagitis characterized by acute symptoms of inflammation </li></ul><ul><li>(Continued) </li></ul>
    53. 53. Gastroesophageal Reflux Disease (Continued) <ul><li>Esophageal reflux occurs when gastric volume or intra-abdominal pressure is elevated, the sphincter tone of the lower esophageal sphincter is decreased, or it is inappropriately relaxed. </li></ul>
    54. 54. Clinical Manifestations <ul><li>Dyspepsia </li></ul><ul><li>Regurgitation </li></ul><ul><li>Hypersalivation or water brash </li></ul><ul><li>Dysphagia and odynophagia </li></ul><ul><li>Others manifestations: chronic cough, asthma, atypical chest pain, eructation (belching), flatulence, bloating, after eating, nausea and vomiting </li></ul>
    55. 55. Diagnostic Assessment <ul><li>24-hr ambulatory pH monitoring </li></ul><ul><li>Endoscopy </li></ul><ul><li>Esophageal manometry </li></ul>
    56. 56. Nonsurgical Management <ul><li>Diet therapy </li></ul><ul><li>Client education </li></ul><ul><li>Lifestyle changes: elevate head of bed 6 in. for sleep, sleep in left lateral decubitus position; stop smoking and alcohol consumption; reduce weight; wear nonbinding clothing; refrain from lifting heavy objects, straining, or working in a bent-over posture </li></ul>
    57. 57. Drug Therapy <ul><li>Antacids elevate the level of the gastric contents. </li></ul><ul><li>Histamine receptor antagonists decrease acid production. </li></ul><ul><li>Proton pump inhibitors provide effective, long-acting inhibition of gastric acid secretion. </li></ul><ul><li>Prokinetic drugs increase gastric emptying and improve lower esophageal sphincter pressure and esophageal peristalsis. </li></ul>
    58. 58. Other Treatments <ul><li>Endoscopic therapies </li></ul><ul><li>Surgical therapies </li></ul>
    59. 59. Hiatal Hernia <ul><li>Protrusion of the stomach through the esophageal hiatus of the diaphragm into the thorax </li></ul><ul><li>Sliding hernia most common, occurring when esophagogastric junction and a portion of the fundus of the stomach slide upward through the esophageal hiatus into the thorax </li></ul><ul><li>Rolling hernia: fundus rolls into the thorax beside the esophagus </li></ul>
    60. 60. Assessment <ul><li>Heartburn </li></ul><ul><li>Regurgitation </li></ul><ul><li>Pain </li></ul><ul><li>Dysphagia </li></ul><ul><li>Belching </li></ul><ul><li>Worsening symptoms after eating or when in recumbent position </li></ul>
    61. 61. Nonsurgical Management <ul><li>Drug therapy: antacids, histamine receptor antagonists </li></ul><ul><li>Diet therapy: avoid eating in the late evening and avoid foods associated with reflux </li></ul><ul><li>Weight reduction </li></ul><ul><li>(Continued) </li></ul>
    62. 62. Nonsurgical Management (Continued) <ul><li>Elevate head of bed 6 -12 in. for sleep, remain upright for several hours after eating, avoid straining and vigorous exercise, avoid nonbinding clothing. </li></ul>
    63. 63. Surgical Management <ul><li>Laparoscopic Nissen Fundoplication (LNF) – is the most common surg proc. – the stomach fundus is wrapped around the lower part of the esophagus and then sutured onto itself to hold it in place. </li></ul>
    64. 64. Surgical Management <ul><li>Preoperative care </li></ul><ul><li>Operative procedures </li></ul><ul><li>Postoperative care </li></ul><ul><ul><li>Respiratory care </li></ul></ul><ul><ul><li>Nasogastric tube management </li></ul></ul><ul><ul><li>Nutritional care for complications of surgery including gas bloat syndrome and aerophagia (air swallowing) </li></ul></ul>
    65. 65. Achalasia <ul><li>Esophageal motility disorder believed to result from esophageal denervation characterized by chronic and progressive dysphagia </li></ul><ul><li>Primary symptoms: dysphagia and regurgitation of solids, liquids, or both </li></ul>
    66. 66. Drug and Diet Therapy <ul><li>Calcium channel blockers </li></ul><ul><li>Nitrates </li></ul><ul><li>Direct injection of botulinum toxin into the lower esophageal muscle </li></ul><ul><li>Semisoft foods </li></ul><ul><li>Arching the back while swallowing </li></ul><ul><li>Avoidance of restrictive clothing </li></ul>
    67. 67. Esophageal Dilation <ul><li>Passage of progressively larger sizes of esophageal bougies using polyurethane balloons on a catheter </li></ul><ul><li>Metal stents used to keep the esophagus open for longer durations </li></ul><ul><li>Complications: bleeding, signs of perforation, chest and shoulder pain, elevated temperature, subcutaneous emphysema, hemoptysis </li></ul>
    68. 68. Esophagomyotomy <ul><li>Surgical procedure for achalasia is done to facilitate the passage of food. </li></ul><ul><li>Laparoscopic approach is most common. </li></ul><ul><li>For long-term refractory achalasia, the surgeon may attempt excising the affected portion of the esophagus with or without replacement of a segment of colon or jejunum. </li></ul>
    69. 69. Esophageal Tumors <ul><li>Esophageal tumors can be benign or malignant. </li></ul><ul><li>Barrett’s esophagus is ultimately malignant. </li></ul><ul><li>Clinical manifestations include dysphagia, odynophagia, regurgitation, vomiting, foul breath, chronic hiccups, pulmonary complications, chronic cough, and hoarseness. </li></ul>
    70. 70. Imbalanced Nutrition: Less Than Body Requirements <ul><li>Interventions include: </li></ul><ul><ul><li>Nonsurgical management </li></ul></ul><ul><ul><ul><li>Nutrition therapy </li></ul></ul></ul><ul><ul><ul><li>Swallowing therapy </li></ul></ul></ul><ul><ul><ul><li>Chemotherapy </li></ul></ul></ul><ul><ul><ul><li>Radiation therapy </li></ul></ul></ul><ul><ul><ul><li>(Continued) </li></ul></ul></ul>
    71. 71. Imbalanced Nutrition: Less Than Body Requirements (Continued) <ul><ul><ul><li>Photodynamic therapy </li></ul></ul></ul><ul><ul><ul><li>Esophageal dilation </li></ul></ul></ul><ul><ul><ul><li>Endoscopic therapies </li></ul></ul></ul><ul><ul><ul><li>Surgical removal of the tumor </li></ul></ul></ul>
    72. 72. Surgical Management <ul><li>Esophagectomy: the removal of all or part of the esophagus </li></ul><ul><li>Esophagogastrostomy: the removal of part of the esophagus and proximal stomach </li></ul><ul><li>Minimally invasive esophagectomy </li></ul><ul><li>Extensive preoperative care </li></ul><ul><li>Operative procedures </li></ul>
    73. 73. Postoperative Care <ul><li>Highest postoperative priority: respiratory care </li></ul><ul><li>Cardiovascular care </li></ul><ul><li>Wound management </li></ul><ul><li>Nasogastric tube management </li></ul><ul><li>Nutritional care </li></ul><ul><li>Discharge planning </li></ul>
    74. 74. Diverticula <ul><li>Sacs resulting from the herniation of esophageal mucosa and submucosa into surrounding tissue </li></ul><ul><li>Zenker’s diverticulum most common </li></ul><ul><li>Diet therapy for size and frequency of meals </li></ul><ul><li>Surgical management </li></ul>
    75. 75. Esophageal Trauma <ul><li>Trauma to the esophagus can result from blunt injuries, chemical burns, surgery or endoscopy, or stress of protracted vomiting. </li></ul><ul><li>Nothing is administered by mouth; broad-spectrum antibiotics are given. </li></ul><ul><li>Surgical management requires resection of part of the esophagus with a gastric pull-through and repositioning or replacement by a bowel segment. </li></ul>
    76. 76. Interventions for Clients with Stomach Disorders
    77. 77. Gastritis <ul><li>Gastritis is defined as inflammation of the gastric mucosa; two types: </li></ul><ul><ul><li>Acute gastritis </li></ul></ul><ul><ul><li>Chronic gastritis </li></ul></ul><ul><ul><ul><li>Type A gastritis </li></ul></ul></ul><ul><ul><ul><li>Type B gastritis </li></ul></ul></ul><ul><ul><ul><li>Atrophic gastritis </li></ul></ul></ul><ul><li>Helicobacter pylori, Escherichia coli can cause gastritis. </li></ul>
    78. 78. Clinical Manifestations <ul><li>Abdominal tenderness </li></ul><ul><li>Bloating </li></ul><ul><li>Hematemesis </li></ul><ul><li>Melena </li></ul><ul><li>Intravascular depletion and shock </li></ul>
    79. 79. Nonsurgical Management <ul><li>Primary treatment: identification and elimination of causative factors </li></ul><ul><li>Drug therapy </li></ul><ul><ul><li>H 2 -receptor antagonists </li></ul></ul><ul><ul><li>Antacids </li></ul></ul><ul><ul><li>Antisecretory agents </li></ul></ul><ul><ul><li>Vitamin B 12 </li></ul></ul><ul><ul><li>Triple therapy for H. pylori infection </li></ul></ul>
    80. 80. Other Therapies <ul><li>Diet therapy </li></ul><ul><ul><li>Limit intake of foods and spices that cause distress (tea, coffee, cola, chocolate, mustard, paprika, cloves, pepper, and hot spices), as well as tobacco and alcohol. </li></ul></ul><ul><li>Stress reduction </li></ul>
    81. 81. Surgical Management <ul><li>Partial gastrectomy </li></ul><ul><li>Pyloroplasty </li></ul><ul><li>Vagotomy </li></ul><ul><li>Total gastrectomy </li></ul>
    82. 82. Peptic Ulcer Disease <ul><li>PUD is a mucosal lesion of the stomach or duodenum as a result of gastric mucosal defenses impaired and no longer able to protect the epithelium from the effects of acid and pepsin. </li></ul><ul><li>Acid, pepsin, and Helicobacter pylori infection play an important role in the development of gastric ulcers. </li></ul>
    83. 84. Duodenal Ulcers <ul><li>Most duodenal ulcers occur in the first portion of the duodenum. </li></ul><ul><li>Duodenal ulcers present as deep, sharply demarcated lesions that penetrate through the mucosa and submucosa into the muscularis propria. </li></ul>
    84. 85. Stress Ulcers <ul><li>Acute gastric mucosa lesions occurring after an acute medical crisis or trauma </li></ul><ul><li>Associated with head injury, major surgery, burns, respiratory failure, shock, and sepsis. </li></ul><ul><li>Principal manifestation: bleeding caused by gastric erosion </li></ul>
    85. 86. Complications of Ulcers <ul><li>Hemorrhage—hematemesis </li></ul><ul><li>Perforation—a surgical emergency </li></ul><ul><li>Pyloric obstruction—manifested by vomiting caused by stasis and gastric dilation </li></ul><ul><li>Intractable disease—the client no longer responds to conservative management, or recurrences of symptoms interfere with ADLs </li></ul>
    86. 87. Clinical Manifestations <ul><li>Epigastric tenderness usually located at the midline between the umbilicus and the xiphoid process </li></ul><ul><li>Dyspepsia </li></ul><ul><li>Typically described as sharp, burning, or gnawing pain </li></ul><ul><li>Sensation of abdominal pressure or of fullness or hunger </li></ul>
    87. 88. Acute or Chronic Pain <ul><li>One of the primary purposes for employing drug therapy is to eliminate or reduce pain. </li></ul><ul><li>Analgesics are not the mainstay of pain relief for PUD. </li></ul><ul><li>Ulcer drug regimen itself promotes relief of pain by eradicating H. pylori infection and promoting healing of the gastric mucosa. </li></ul>
    88. 89. Drug Therapy <ul><li>Four primary goals for drug therapy: </li></ul><ul><ul><li>Provide pain relief </li></ul></ul><ul><ul><li>Eradicate H. pylori infection </li></ul></ul><ul><ul><li>Heal ulcerations </li></ul></ul><ul><ul><li>Prevent recurrence </li></ul></ul>
    89. 90. Hyposecretory Drugs <ul><li>Hyposecretory drugs produce a reduction in gastric acid secretion. </li></ul><ul><ul><li>Antisecretory agents </li></ul></ul><ul><ul><li>H 2 -receptor antagonists </li></ul></ul><ul><ul><li>Prostaglandin analogues </li></ul></ul>
    90. 91. Antisecretory Agents <ul><li>Antisecretory agents, also called proton pump inhibitors, include: </li></ul><ul><ul><li>Prilosec </li></ul></ul><ul><ul><li>Prevacid </li></ul></ul><ul><ul><li>Aciphex </li></ul></ul><ul><ul><li>Protonix </li></ul></ul><ul><ul><li>Nexium </li></ul></ul>
    91. 92. H 2 -Receptor Antagonists <ul><li>Drugs that block histamine-stimulated gastric secretion </li></ul><ul><li>May be used for indigestion and heartburn </li></ul><ul><li>Block the action of the H 2- receptors of the parietal cells, thus inhibiting gastric acid secretion </li></ul><ul><li>The most common: Zantac, Pepcid, and Axid </li></ul>
    92. 93. Prostaglandin Analogues <ul><li>These agents reduce gastric acid secretion and enhance gastric mucosal resistance to tissue injury. </li></ul><ul><li>Misoprostol (Cytotec) helps prevent NSAID-induced ulcers. </li></ul><ul><li>Uterine contraction is a significant adverse effect of misoprostol. </li></ul>
    93. 94. Antacids <ul><li>Antacids buffer gastric acid and prevent the formation of pepsin; they are effective in accelerating the healing of duodenal ulcers. </li></ul><ul><li>The most widely used preparations are mixtures of aluminum hydroxide and magnesium hydroxide, such as Mylanta or Maalox. </li></ul><ul><li>(Continued) </li></ul>
    94. 95. Antacids (Continued) <ul><li>For optimal effect, take about 2 hr after meals. </li></ul><ul><li>Antacids can interact with certain drugs and interfere with their effectiveness. </li></ul>
    95. 96. Mucosal Barrier Fortifiers <ul><li>Sucralfate (Carafate) is a sulfonated disaccharide that forms complexes with proteins at the base of a peptic ulcer; this protective coat prevents further digestive action of both acid and pepsin. </li></ul><ul><li>(Continued) </li></ul>
    96. 97. Mucosal Barrier Fortifiers (Continued) <ul><li>Sucralfate binds bile acids and pepsins, reducing injury from these substances. </li></ul><ul><li>The main side effect of sucralfate is constipation. </li></ul>
    97. 98. Diet Therapy <ul><li>Diet therapy may be directed toward neutralizing acid and reducing hypermotility. </li></ul><ul><li>A bland, nonirritating diet is recommended during the acute symptomatic phase. </li></ul><ul><li>Avoid bedtime snacks. </li></ul><ul><li>Avoid alcohol and tobacco. </li></ul>
    98. 99. Complementary and Alternative Therapies <ul><li>Kundalini yoga techniques are being studied to see how they can help manage gastrointestinal disorders. </li></ul><ul><li>Certain herbs are thought to heal inflamed tissue and increase blood flow to the gastric mucosa. </li></ul><ul><li>Other substances include zinc, vitamin C, essential fatty acids, acidophilus, vitamins E and A, and glutamine. </li></ul>
    99. 100. Potential for Gastrointestinal Bleeding <ul><li>Interventions include: </li></ul><ul><ul><li>Monitoring and early recognition of complications (critical to the successful management of PUD). </li></ul></ul><ul><ul><li>Preventing and/or managing bleeding, perforation, and gastric outlet obstruction. </li></ul></ul><ul><ul><li>Possible surgical treatment. </li></ul></ul>
    100. 101. Hypovolemia Management <ul><li>Monitor vital signs and observe for fluid loss from bleeding and vomiting. </li></ul><ul><li>Monitor serum electrolytes. </li></ul><ul><li>Insert two large-bore peripheral IV catheters to replace both fluids and blood lost. </li></ul><ul><li>(Continued) </li></ul>
    101. 102. Hypovolemia Management (Continued) <ul><li>Volume replacement with isotonic crystalloid solutions should be started immediately. </li></ul><ul><li>Blood products may be ordered to expand volume and correct abnormalities in the CBC. </li></ul><ul><li>Orthostatic hypotension is common in clients with decreased fluid volume. </li></ul>
    102. 103. Bleeding Reduction: Gastrointestinal <ul><li>Endoscopic therapy can assist in achieving hemostasis. </li></ul><ul><li>Acid-suppressive agents are used to stabilize the clot by raising the pH level of gastric contents. </li></ul><ul><li>Upper gastrointestinal bleeding may require the health care provider to insert nasogastric tube. </li></ul><ul><li>Saline lavage requires the insertion of a large-bore nasogastric tube. </li></ul>
    103. 104. Nonsurgical Management <ul><li>Perforation is managed by immediately replacing fluid, blood, and electrolytes. </li></ul><ul><ul><li>Administering antibiotics </li></ul></ul><ul><ul><li>Keeping the client NPO </li></ul></ul><ul><li>Pyloric obstruction related to edema, and spasm generally responds to medical therapy. </li></ul>
    104. 105. Surgical Management <ul><li>Preoperative care: insertion of a nasogastric tube. </li></ul><ul><li>Operative procedure </li></ul><ul><ul><li>A simple gastroenterostomy permits neutralization of gastric acid. </li></ul></ul><ul><li>(Continued) </li></ul>
    105. 106. Surgical Management (Continued) <ul><ul><li>Vagotomy eliminates the acid-secreting stimulus to gastric cells and decreases the response of parietal cells. </li></ul></ul><ul><ul><li>Pyloroplasty facilitates emptying of stomach contents. </li></ul></ul>
    106. 107. Postoperative Care <ul><li>Monitor the nasogastric tube. </li></ul><ul><li>Monitor for postoperative complications: </li></ul><ul><ul><li>Dumping syndrome (constellation of vasomotor symptoms after eating) </li></ul></ul><ul><ul><li>Reflux gastropathy </li></ul></ul><ul><ul><li>(Continued) </li></ul></ul>
    107. 108. Postoperative Care (Continued) <ul><ul><li>Delayed gastric emptying (usually resolved within 1 week) </li></ul></ul><ul><ul><li>Afferent loop syndrome may occur after a Billroth II resection. </li></ul></ul><ul><ul><li>Recurrent ulceration occurs in about 5% of clients. </li></ul></ul>
    108. 109. Nutritional Management <ul><li>Deficiencies of vitamin B 12 , folic acid, and iron; impaired calcium metabolism; and reduced absorption of calcium and vitamin D develop as a result of partial removal of the stomach. </li></ul><ul><li>These problems are caused by a shortage of intrinsic factor. </li></ul><ul><li>Monitor CBC for signs of megaloblastic anemia and leukopenia. </li></ul>
    109. 110. Zollinger-Ellison Syndrome <ul><li>Zollinger-Ellison syndrome is manifested by upper gastrointestinal tract ulceration, increased gastric acid secretion, and the presence of a non–beta cell islet tumor of the pancreas, called a gastrinoma. </li></ul><ul><li>Clients may complain of peptic ulcer disease symptoms and may have diarrhea and/or steatorrhea. </li></ul>
    110. 111. Interventions <ul><li>The aim of therapy is to suppress acid secretion to control the client’s symptoms. </li></ul><ul><li>Drugs of choice are: </li></ul><ul><ul><li>Prevacid </li></ul></ul><ul><ul><li>Prilosec </li></ul></ul><ul><ul><li>Zantac </li></ul></ul><ul><ul><li>(Continued) </li></ul></ul>
    111. 112. Interventions (Continued) <ul><li>If medical therapy fails, a vagotomy and pyloroplasty to supplement pharmacologic means of controlling hypersecretion may be performed. </li></ul>
    112. 113. Gastric Carcinoma <ul><li>Gastric carcinoma refers to malignant neoplasms in the stomach. </li></ul><ul><li>Clinical manifestations: early gastric cancer may be asymptomatic, but indigestion and abdominal discomfort are the most common symptoms. </li></ul><ul><li>(Continued) </li></ul>
    113. 114. Gastric Carcinoma (Continued) <ul><li>Signs of distant metastasis include: </li></ul><ul><ul><li>Virchow's nodes </li></ul></ul><ul><ul><li>Sister Mary Joseph nodes </li></ul></ul><ul><ul><li>Blumer's shelf </li></ul></ul><ul><ul><li>Krukenberg's tumor </li></ul></ul>
    114. 115. Nonsurgical Management <ul><li>Drug therapy </li></ul><ul><ul><li>The role of chemotherapy in gastric cancer remains uncertain. </li></ul></ul><ul><li>Radiation therapy </li></ul><ul><ul><li>The use of this treatment is limited because the disease is often widely disseminated. </li></ul></ul>
    115. 116. Surgical Management <ul><li>Preoperative care is similar to that provided for general anesthesia and abdominal surgery. </li></ul><ul><li>Operative procedures include subtotal and total gastrectomy. </li></ul><ul><li>Postoperative complications: </li></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Anastomotic leak </li></ul></ul><ul><li>(Continued) </li></ul>
    116. 117. Surgical Management (Continued) <ul><ul><li>Hemorrhage </li></ul></ul><ul><ul><li>Reflux aspiration </li></ul></ul><ul><ul><li>Wound infection </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Reflux gastritis </li></ul></ul><ul><ul><li>Paralytic Ileus </li></ul></ul><ul><ul><li>Bowel obstruction </li></ul></ul><ul><ul><li>Dumping syndrome </li></ul></ul>
    117. 118. Interventions for Clients with Malnutrition and Obesity
    118. 119. Nutritional Standards to Promote Health <ul><li>Dietary recommendations, food guide pyramids for adequate nutrition </li></ul><ul><li>Nutritional assessment includes: </li></ul><ul><ul><li>Diet history </li></ul></ul><ul><ul><li>Anthropometric measurements </li></ul></ul><ul><ul><li>Measurement of height and weight </li></ul></ul><ul><ul><li>Assessment of body fat (body mass index) </li></ul></ul>
    119. 120. Malnutrition <ul><li>Protein-calorie malnutrition </li></ul><ul><li>Marasmus calorie malnutrition, in which body fat and protein are wasted, serum proteins are often preserved </li></ul><ul><li>Kwashiorkor </li></ul><ul><li>Marasmic-kwashiorkor </li></ul>
    120. 121. Laboratory Assessment <ul><li>Hematology </li></ul><ul><li>Protein studies </li></ul><ul><li>Serum cholesterol </li></ul><ul><li>Other laboratory tests </li></ul>
    121. 122. Imbalanced Nutrition: Less Than Body Requirements <ul><li>Interventions include: </li></ul><ul><ul><li>Drug therapy </li></ul></ul><ul><ul><li>Partial enteral nutrition </li></ul></ul><ul><ul><li>Total enteral nutrition </li></ul></ul><ul><ul><li>Candidates for total enteral nutrition </li></ul></ul>
    122. 123. Enteral Nutrition <ul><li>Types of enteral products for nutrients </li></ul><ul><li>Methods of administration of total enteral nutrition </li></ul><ul><li>Types of tubes </li></ul><ul><li>Types of feedings </li></ul><ul><li>Complications of total enteral nutrition: </li></ul><ul><ul><li>Aspiration, fluid excess, increased osmolarity, dehydration, electrolyte imbalances </li></ul></ul>
    123. 124. Parenteral Nutrition <ul><li>Partial parenteral nutrition </li></ul><ul><li>Total parenteral nutrition </li></ul><ul><li>Complications include: </li></ul><ul><ul><li>Fluid imbalances </li></ul></ul><ul><ul><li>Electrolyte imbalances </li></ul></ul><ul><ul><li>Glucose imbalances </li></ul></ul><ul><ul><li>Infection </li></ul></ul>
    124. 125. Obesity <ul><li>Overweight: increase in body weight for height compared to standard </li></ul><ul><li>Obesity: at least 20% above upper limit of normal range for ideal body weight </li></ul><ul><li>Morbid obesity: severe negative effect on health </li></ul>
    125. 126. Obesity Complications <ul><li>Diabetes mellitus </li></ul><ul><li>Hypertension </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>CAD </li></ul><ul><li>Obstructive sleep apnea </li></ul><ul><li>Obesity hypoventilation syndrome </li></ul><ul><li>Depression and other mental health/behavioral health problems </li></ul><ul><li>(Continued) </li></ul>
    126. 127. Obesity Complications (Continued) <ul><li>Urinary incontinence </li></ul><ul><li>Cholelithiasis </li></ul><ul><li>Chronic back pain </li></ul><ul><li>Early osteoarthritis </li></ul><ul><li>Decreased wound healing </li></ul><ul><li>Increased susceptibility to infection </li></ul>
    127. 128. Obesity and Health Promotion <ul><li>Health promotion/illness prevention </li></ul><ul><ul><li>Teach the potential consequences and complications. </li></ul></ul><ul><ul><li>Teach the importance of eating a healthy diet. </li></ul></ul><ul><ul><li>Teach that foods eaten away from home tend to be higher in fat, cholesterol, and salt, and lower in calcium. </li></ul></ul><ul><ul><li>(Continued) </li></ul></ul>
    128. 129. Obesity and Health Promotion (Continued) <ul><ul><li>Reinforce need for regular moderate activity for at least 30 min per day. </li></ul></ul><ul><ul><li>Educate regarding diet and activity for children and adolescents, and continuing throughout adulthood. </li></ul></ul>
    129. 130. Nonsurgical Management <ul><li>Fasting </li></ul><ul><li>Very low-calorie diets of 200 to 800 calories per day </li></ul><ul><li>Balanced and unbalanced low-energy diets </li></ul><ul><li>Novelty diets </li></ul><ul><li>Diet therapy </li></ul><ul><li>Exercise program </li></ul><ul><li>(Continued) </li></ul>
    130. 131. Nonsurgical Management (Continued) <ul><li>Drug therapy </li></ul><ul><li>Complementary and alternative therapies and treatments </li></ul>
    131. 132. Surgical Management <ul><li>Liposuction </li></ul><ul><li>Panniculectomy </li></ul><ul><li>Bariatric surgery </li></ul><ul><li>Preoperative care </li></ul><ul><li>Operative procedures </li></ul><ul><ul><li>Vertical banded gastroplasty </li></ul></ul><ul><ul><li>Circumgastric banding </li></ul></ul><ul><ul><li>Gastric bypass </li></ul></ul><ul><ul><li>Roux-en-Y gastric bypass </li></ul></ul>
    132. 133. Postoperative Care <ul><li>Analgesia </li></ul><ul><li>Skin care </li></ul><ul><li>Nasogastric tube placement </li></ul><ul><li>Diet </li></ul><ul><li>Prevention of postoperative complications </li></ul><ul><li>Observe dumping syndrome signs such as tachycardia, nausea, diarrhea, and abdominal cramping </li></ul>
    133. 134. Gastrointestinal Intubation <ul><li>To remove gas and fluids from the stomach or intestines (decompression). </li></ul><ul><li>To diagnose GI motility and to obtain gastric secretions for anaysis </li></ul>