INFLAMMATION CONCEPT: GERD, HIATAL HERNIA, APPENDICITISBrunner ch. 35 & 38

Gastroesophageal Reflux Disease (GERD) (1014)

Backflow of gastric contents into esophagus.

Incidence increases with age Affects infants as well but is referred to

as GER

Etiology Motility problems Incompetent esophageal sphincter Pyloric stenosis (more common in

infants)

Assessment Pyrosis Dyspepsia Odynophagia Dysphagia Acid regurgitation Eructation Hypersalivation

(brash) Globus sensation

Nocturnal cough Wheezing Hoarseness Lying down or

straining exacerbates symptoms

Diagnosed by barium swallow or endoscopy

Complications Mucosal inflammation and breakdown Sphincter incompetence Chronic esophagitis, ulceration, and

changes in the mucosa (Barrett’s epithelium).

Barrett’s is associated stricture and a 30% risk of cancer. Endoscopy shows red mucosa. Bx reveals dysplasia of the epithelium (looks more like intestinal than esophageal tissue)

Dietary Management Small frequent meals Fluids between meals Low fat diet Lose weight if indicated Avoid spicy or acid foods, caffeine,

carbonated drinks , chocolate, beer, mint, very hot or cold drinks

Other Suggestions Sit up 1-2h after meals Don’t eat 2h before bed Reverse Trendelenberg with 6-8” blocks Upper body elevated on pillows Don’t strain or bend or wear tight

clothing Stop smoking

Pharmacologic Management Antacids H2 blockers (Pepcid, Zantac) Proton pump inhibitors (Prilosec,

Nexium). Increases incidence of stomach infection.

GI stimulants (Urecholine, Reglan). Watch for extrapyramidal side effects.

Hiatal Hernia (1012) Herniation of stomach thru an enlarged

esophageal opening in the diaphragm (1013).

Type 1 (sliding): upper stomach slides thru the opening into the chest cavity (90% ).

Type 2 (paraesophageal or rolling): upper stomach pushes up against diaphragm.

Contributing Factors Age Obesity Congenital weakness Trauma Surgery Pregnancy Ascites Heavy lifting

Assessment

50% have dysphagia, dyspepsia, reflux

50% asymptomatic Dx by x-ray,

barium swallow, fluoroscopy

Most complain of fullness or chest pain after eating

May be asymptomatic

Dx by x-ray, barium swallow, fluoroscopy

Type 1 Type 2

Complications Hemorrhage Obstruction Strangulation

Management Similar to GERD Small frequent meals and may need

dietary restrictions if reflux is present No reclining for at least 1 hr after eating

to prevent upward movement of the stomach

HOB up on 4-8” blocks H2 blockers or proton pump inhibitors If needed, Nissen fundoplication

Surgical ManagementIf all else fails, Nissen fundoplication can be done by laparoscopic or open method.

Repair of the hernia is done first then part of fundus is wrapped around distal esophagus and sutured.

Postop Care for Nissen Fundoplication

Physical assessment HOB up 30 degrees TCDB, IS Analgesics IVF I&O NPO with possible NGT (suction) unless laparoscopic May have po after peristalsis returns (HCP decides) No gassy foods, carbonated drinks, gum, straws Ambulate!!

Appendicitis (1075) Inflammation and infection of appendix Appendix is attached to the cecum

immediately past the ileocecal valve.

Etiology Easily obstructed due to small lumen

and inefficient emptying. Caused by kinking, fecalith, tumor, or

foreign body.

Assessment Periumbilical pain moving to McBurney’s

point (halfway between iliac crest and umbilicus)

+Rovsing’s sign (pressing on LLQ causes RLQ pain)

+Blumberg’s sign (rebound) +Obturator muscle test (internal rotation

of hip causes RLQ pain) +Ileopsoas muscle test (hip flexion or

hip abduction causes RLQ pain)

Assessment con’t Guarding Pain with digital rectal examination (DRE) Low grade fever Anorexia NVD or constipation (NO LAXATIVES for

anyone with RLQ pain) Elevated WBC (usually 11-16,000) +Abd x-ray or CT (shows RLQ density or

bowel distention)

Complications Ruptured appendix—pain becomes

diffuse and generalized; WBC elevates from 16-40,000

Peritonitis (inflammation of peritoneum) Sepsis Paralytic ileus

Plan of Care: Expected Outcomes

Patient will receive proper management of appendicitis

Patient’s pain will be controlled Infectious and inflammatory processes

will subside Patient will experience full recovery

without complications (wound infection, DVT, respiratory infection, etc.)

Patient will receive and understand all instructions

Surgical Management Appendectomy:

-Open or laparoscopic-Usually 24h stay -If perforated, several days with NG, IV, drains, possible open wound, IV meds-Pre and postop antibiotics

Nursing Management Depends on whether OP or inpatient Preoperatively, pt is assessed, IV with antibiotics,

site is marked, laxatives & enemas are contraindicated

Postop VS per protocol Pain control—IV to po IVF and meds Wound assessment and changes (if inpatient) Advance DAT and activity Pt education re: wound care, S&S infection, pain

mgmt, activity restrictions, RTC time, when to call MD.

Plan of Care: Evaluation Appendicitis has been resolved:

Appendectomy performed successfully Infection and inflammation has subsided as

evidenced by VS and WBC returned to normal levels

Patient’s pain is controlled Patient had no complications Patient received and understood all

instructions