Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Chapter 29...

Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Chapter 29

Care of Patients with Disorders of the Upper Gastrointestinal System

Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.

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).

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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.

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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.

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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.

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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.

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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

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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

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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

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Obesity

Etiology and pathophysiology Signs and symptoms Diagnosis

Height and weight chart Waist and hip circumference Body mass index (BMI)

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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

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Bariatric Surgery

Preoperative care There is greater risk of pulmonary and thrombus

formation, as well as death, for the obese patient

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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

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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

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Gastric Bypass

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Vertical Banded Gastroplasty

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Circumgastric Banding

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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

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Complications

Leakage of stomach contents Gastric stretching Dumping syndrome Nutritional deficiencies—iron, vitamin B12,

calcium, and folate

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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

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Assessment

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

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Expected Outcomes

Patient will make positive statements about decreasing body size

Patient will verbalize feelings of self-worth

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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

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Upper GI Disorders

Stomatitis Dysphagia

Causes Diagnosis Treatment Nursing management

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Implementation

Aspiration Suctioning Nutrition and gastrostomy

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Cancer of the Oral Cavity

Etiology Pathophysiology Signs and symptoms Diagnosis—physical examination and biopsy Treatment—radiation, chemotherapy, and

surgery Nursing management

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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

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Cancer of the Esophagus (cont.)

Gastroesophageal reflux disease (GERD) is a cause of Barrett’s esophagus, which is a precancerous condition

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Cancer of the Esophagus (cont.)

Signs, symptoms, and diagnosis Treatment

Esophagectomy Nursing management

Postoperative care Nutrition

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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.)

1.“How much alcohol do you consume?”

2.“Have you had any oral lesions?”

3.“Do you have family members who have cancer?”

4.“What do you smoke?”

5.“Have you been exposed to hepatitis virus?”

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Hiatal Hernia (Diaphragmatic Hernia)

Etiology and pathophysiology Signs and symptoms Treatment

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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

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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

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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

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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

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Gastroesophageal Reflux Disease (GERD)

Etiology and pathophysiology Signs and symptoms Diagnosis and treatment Nursing management

Diet therapy, lifestyle changes, drug therapy, and education

Complications

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Gastroenteritis

Caused by food or water contaminated with a virus, a pathogenic bacteria, or parasites

Signs and symptoms Management

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Gastritis

Etiology Pathophysiology Signs and symptoms Diagnosis Treatment

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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

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Peptic Ulcers

Etiology Helicobacter pylori Duodenal ulcers and some pre-pyloric ulcers Gastric ulcers Tension, anxiety, and prolonged stress Drug-induced ulcers

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Peptic Ulcers (cont.)

Pathophysiology Signs and symptoms

Daily pattern of pain Gastrointestinal bleeding

Diagnosis Endoscopy Gastric acid analysis

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Peptic Ulcers (cont.)

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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

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Nursing Management

Complications Hemorrhage Perforation Obstruction

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Surgical Treatment of Peptic Ulcer

Pyloroplasty with truncal or proximal gastric vagotomy

Subtotal gastrectomy (gastric resection) Total gastrectomy

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Nursing Care of the Patient Undergoing Gastric Surgery

Preoperative care Postoperative care

Specific patient teaching Diet restrictions  

Dumping syndrome

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Gastric Cancer

Etiology Signs and symptoms Pathophysiology Diagnosis Treatment Nursing management

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Gastric Cancer (cont.)

Treatment Surgical intervention Radiation therapy Chemotherapy Adjuvant therapy

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Common Therapies for Disorders of the Gastrointestinal System

Gastrointestinal decompression Enteral nutrition Total parenteral nutrition

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Small-Bore Feeding Tube Placement

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Audience Response Question 2Regarding the care of enteral feeding tubes, which nursing behavior(s) demonstrate(s) appropriate nursing care? (Select all that apply.)1.Aspirating contents of jejunostomy tube

2.Gentle flushing of a clogged enteral tube with 30 mL of water

3.Checking for 1-inch play on a gastrostomy tube

4.Monitoring BUN, prealbumin, hematocrit, electrolytes, and glucose

5.Rotating a jejunostomy tube 360 degrees each day

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