Transcript Chapter 58

NUR240
Stressors of the
Gastrointestinal System
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Overview of the Gastrointestinal Tract
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Structure
Function
Nerve supply
Blood supply
Oral cavity
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Stomach
Pancreas
Liver and gallbladder
Intestines
Esophagus
Assessment Techniques
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History
Demographic data
Family history and genetic risk
Personal history
Diet history
– Anorexia
– Dyspepsia
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Current Health Problems
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Pattern of bowel movements
Color and consistency of the feces
Occurrence of diarrhea or constipation
Effective action taken to relieve diarrhea or
constipation
• Presence of frank blood or tarry stools
• Presence of abdominal distention or gas
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Skin Changes Related to Gastrointestinal
Disorders
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Skin discolorations or rashes
Itching
Jaundice
Increased susceptibility to bruising
Increased tendency to bleed
Physical Assessment
• Mouth and pharynx
• Abdomen and extremities
– Inspection (Cullen’s sign)
– Auscultation, look for borborygmus
– Percussion
– Palpation
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Laboratory Tests
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Complete blood count
Clotting factors
Electrolytes
Assays of liver enzymes—aspartate and
alanine aminotransferase
• Serum amylase and lipase
• Bilirubin: the primary pigment in bile
(Continued)
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Laboratory Tests (Continued)
• Evaluation of oncofetal antigens CA 19-9 and
CEA
• Urine tests—amylase, urine urobilinogen
• Stool tests—fecal occult blood test, ova
parasites, Clostridium difficile infection
• Radiographic examinations
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Upper Gastrointestinal Series and Small
Bowel Series
• Before test:
– Maintain NPO for 8 hr.
– Withhold analgesics and anticholinergics for 24 hr.
• Client drinks 16 ounces of barium.
• Rotate examination table.
• After the test:
– Give plenty of fluids.
– Administer mild laxative or stool softener; stools
may be chalky white for 24 to 72 hr.
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Barium Enema
• Barium enema enhances radiographic
visualization of the large intestine.
• Only clear liquids are given 12 to 24 hr before
the test; NPO the night before; bowel
cleansing is done.
• After the test, expel the barium: drink plenty
of fluids; stool is chalky white for 24 to 72 hr.
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Percutaneous Transhepatic
Cholangiography
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X-ray study of the biliary duct system
Laxative before the procedure
NPO for 12 hr before test
Coagulation tests, intravenous infusion
Bedrest for several hours after procedure
Assessment of vital signs
Client positioned on right side with a firm pillow
or sandbag placed against the lower ribs and
abdomen
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Other Tests
• Computed tomography
• Endoscopy: direct visualization of the
gastrointestinal tract by means of a flexible
fiberoptic endoscope
• Ultrasonography
• Endoscopic ultrasonography
• Liver-spleen scan
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Esophagogastroduodenoscopy
• Visual examination of the esophagus,
stomach, and duodenum
• NPO for 6 to 8 hr before the procedure
• Conscious sedation
• After the test, assessment of vital signs every
30 min
• NPO until gag reflex returns
• Throat discomfort possible for several days
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Endoscopic Retrograde
Cholangiopancreatography (ERCP)
• Visual and radiographic examination of the
liver, gallbladder, bile ducts, and pancreas
• NPO for 6 to 8 hr before test
• Access for intravenous sedation
• Return of gag reflex checked
• Assessment for pain, colicky abd pain
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Small Bowel Capsule Enteroscopy
• Visualization of the small intestine (camera
pill)
• Only water for 8 to 10 hr before test
• NPO for first 2 hr of the testing
• Application of belt with sensors
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Colonoscopy
• Endoscopic examination of the entire large
bowel
• Liquid diet for 12 to 24 hr before procedure,
NPO for 6 to 8 hr before procedure
• Bowel cleansing routine
• Assessment of vital signs every 15 min
• If polypectomy or tissue biopsy, blood
possible in stool
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Gastric Analysis
• Measurement of the hydrochloric acid and
pepsin content for evaluation of aggressive
gastric and duodenal disorders (ZollingerEllison syndrome)
• Basal gastric secretion and gastric acid
stimulation test
• NPO for 12 hr before test
• Nasogastric tube insertion
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Gastroesophageal Reflux Disease
AKA GERD
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• Occurs as a result of the backward flow
(reflux) of gastrointestinal contents into the
esophagus
• Reflux esophagitis characterized by acute
symptoms of inflammation
• Esophageal reflux occurs when gastric
volume or intra-abdominal pressure is
elevated, the sphincter tone of the lower
esophageal sphincter (LES) is decreased, or
it is inappropriately relaxed.
Gastroesophageal Reflux Disease
• Etiology: smoking, caffeine, alcohol
• Increased abdominal pressure from obesity,
ascites, pregnancy, tight clothing
• Contributing factors: fatty foods, Ca channel
blockers, nitrate, theophylline, peppermint,
chocolate, anticholinergics
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Clinical Manifestations
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Dyspepsia
Regurgitation
Hypersalivation
Dysphagia
Others manifestations: chronic cough,
asthma, atypical chest pain, eructation
(belching), flatulence, bloating, after eating,
nausea and vomiting
Diagnostic Assessment
• 24-hr ambulatory pH monitoring
• Endoscopy
• Esophageal manometry
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Nonsurgical Management
• Diet therapy- 4-6 small meals/day. Limit
caffeine, tea, cola and chocolate
• Remain upright 1-2 hrs after meals
• Client education
• 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 bentover posture
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Drug Therapy
• Antacids neutralize excess acids, give 1-3hr pc
and at hs
• Histamine receptor antagonists decrease acid
production. Ex. Zantac, Pepcid, Axid, Tagamet
• Proton pump inhibitors provide effective,
long-acting inhibition of gastric acid secretion.
Ex. Protonix, Prilosec, Nexium, Prevacid
• Prokinetic drugs increase gastric emptying
and improve LES pressure and esophageal
peristalsis. Ex. Reglan
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Other Treatments
• Endoscopic therapies
• Surgical therapies
For more info , check out these websites:
www.ddnc.org
www.gastro.org
www.heartburnalliance.org
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Hiatal Hernia
• Protrusion of the stomach through the
esophageal hiatus of the diaphragm into the
thorax
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Assessment
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Heartburn
Regurgitation
Pain
Dysphagia
Belching
Worsening symptoms after eating or when in
recumbent position
Nonsurgical Management
• Drug therapy: antacids, histamine receptor
antagonists
• Diet therapy: avoid eating in the late evening
and avoid foods associated with reflux
• Weight reduction
• Elevate head of bed 6 in. for sleep, remain
upright for several hours after eating, avoid
straining and vigorous exercise, avoid
nonbinding clothing.
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Nursing Considerations
• Imbalanced nutrition
• Risk for aspiration
• Acute pain
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Surgical Management
Hiatal Hernia Repair
• Preoperative care
• Operative procedures
• Postoperative care
– Respiratory care
– Nasogastric tube management
– Nutritional care for complications of surgery
including gas bloat syndrome and aerophagia (air
swallowing)
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Diverticula
• A pouchlike herniation through the muscular
wall of a tubular organ.
• May occur in the stomach, SI, or most
commonly, the colon.
• Zenker’s diverticulum most common
• Diet therapy : size and frequency of meals
• Surgical management
• Both sexes are equally affected
• Incidence increases with age
• Diet high in refined sugars
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Diverticulosis
• Indicates the presence of diverticula
• Symptoms: cramping, narrow stools,
constipation, weakness and fatigue
• Complications: hemorrhage, diverticulitis
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Diverticulitis
• Inflammation around the divericular sac
• Undigested food and bacteria collect in the
sacs
• Primarily in individuals older than 50
• S&S: localized pain (LLQ), fever, elevated WBCs
• Dx: colonscopy, BE, CT Scan
• Complications: perforation, hemorrhage,
obstruction, abscess
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Treatment
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Broad spectrum antibiotics
Pain relief
Diet- hi fiber
Avoid seeds, popcorn, figs, berries, seeds, etc.
Sx: if peritonitis or abscess, segment is
resected with temp colostomy
• Anti-anxiety measures
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Inflammatory Bowel Disease
• Etiology: uncertain, may be a genetic
predisposition, may be autoimmune
• Umbrella term for ulcerative colitis and
Crohn’s disease
• Manifestations:
diarrhea- up to 20/day with exacerbations
crampy abdominal pain
exacerbations/ remissions
Definitive dx by colonoscopy
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Ulcerative Colitis
• Edematous, inflamed mucosa with multiple
abscesses beginning in the rectum and moving
up through the LI
• Inflammation, microscopic hemorrhages and
abscesses develop- becomes ulcerated
• Primarily affects large bowel distal to proximal,
mucosal to submucosal involvement
• Affects younger people (age 15-25)
• More common in females
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Crohn’s Disease
• Any part of the intestine, most commonly in
terminal ileum and ascending colon
• Patchy lesions (shallow ulcers), inflammation,
edema and formation of fistulastransmural
(entire bowel wall)
• Etiology:
• Dx:
• Manifestations:
• Complications:
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Acute tx for all disorders
• Fluids and bowel rest
• Medications
• Potential surgery: Colectomy
Colostomy
Long Term- low-fiber, low, residue diet
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Assessments
• WBC, Hgb, Electrolytes, ESR
• Ulcerative Colitis: Bloody diarrhea with mucus
and cramping, abd pain
• Crohn’s Disease: Non-bloody diarrhea, crampy
abd pain, insidious weight loss, fatigue, LGT
• Bowel sounds
• F&E balance
• S&S infection
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Acute exacerbation
• Keep pt NPO with an IV and promote bowel
rest
• Correct malnutrition
• Pain control
• Administer prescribed meds
• Provide high calorie, high protein, low fat, low
fiber diet with instructions
• Provide nutritional supplements
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Complications and Nursing
Implications
• Fluid and electrolyte imbalance, malnutrition
• Bowel obstruction or perforation
Ulcerative Colitis
• Toxic megacolon
• Increased risk for colon Ca
Crohn’s Disease
• Fistulas
• Massive or repeated bowel resections
• Risk for cholelithiasis and pancreatitis
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Medications
• 5-aminosalicylic acid drugs- anti-inflammatory
effects
sulfasalazine (Azulfidine)
mesalamine (Asacol)
• Corticosteroids
• Immunosuppressive agents
azathioprine (Imuran)
• Antibiotics and antidiarrheal drugs if
applicable
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Irritable Bowel Syndrome (IBS)
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AKA spastic bowel or functional colitis
Motility disorder of GI tract
Intermittent constipation/diarrhea patterns
No inflammation
IBS Manifestations
• Abdominal pain, may be relieved by
defecation
• Intermittent colicky abdominal pain
• Altered bowel elimination
• Abdominal bloating, flatulence
• Possible nausea and vomiting
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IBS Dx
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Stool- occult blood, O& P
CBC and ESR
Sigmoidoscopy or colonoscopy
Upper GI or small bowel series
IBS Tx
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Bulk forming laxatives
Anticholinergics- Antispas, Bentyl
Immodium, lomotil for diarrhea
Antidepressants and SSRIs may relieve abd pain
High fiber diet
Avoid gas forming foods-if excess gas is problem
Avoid caffeine
Stress and anxiety reduction
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Peptic Ulcer Disease (PUD)
• Mucosal lesion of the gastric mucosa or
duodenum
• Gastric ulcers, duodenal ulcers, stress ulcers
• Mucosal defenses are impaired, edema,
degenerative changes of superficial epithelium
• Causes: Helicobacter pylori infection – up to 90%,
infection is cause
NSAID use
Severe stress
Hypersecretory states
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PUD S&S
• Dyspepsia
Gastric Ulcer
Pain
• Pain
• Orthostatic changes 30-60 min pc
Duodenal
Ulcer Pain
1.5-3hr pc
Rarely occurs Often occurs
at night
at night
Pain worse
with eating
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Pain relieved
by eating
PUD: Dx Procedures
• Helicobacter pylori testing
• Gastric sampling
• Urea breath test, IgG testing
• EGD-Esophagogastroduodenoscopy-definitive
test for PUD
• Stool samples for occult blood
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Treatment
• Triple Therapy:
Bismuth or Proton Pump Inhibitors
2 Antibiotics- Flagyl + tetracycline,
clarithromycin, amoxicillin
Antacids
Sucralfate (Carafate)
• Avoid substances that increase gastric secretion
• Avoid foods that cause discomfort
• Smaller meals
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Complications and Nsg
Implications
• Assess for perforation/peritonitis
• Assess for GI Bleeding
What to look for??
What to do?
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Intestinal Obstruction
• May be from mechanical (90% of all) or
nonmechanical causes (paralytic ileus)
• Symptoms vary according to location
• Bowel sounds hyperactive above obstruction
and hypoactive below
• Tx focuses on F&E balance, decompressing the
bowel and relief/removal of obstruction
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Dx Procedures
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CBC
Acid-base balance assessment
Electrolytes- hypokalemia
Xray- F&U abd xrays look for free air and gas
Endoscopy and BE
Cat Scan
Nursing Interventions
NPO with bowel rest
NGT
IVF and electerolytes
Pain management
Ambulation
Possible preop the patient
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Complications and Nsg
Implications
Dehydration
Electrolyte Imbalance
Perforation
Ischemic or Strangulated Bowel
Peritonitis
Shock
Metabolic Alkalosis- UGI Obstruction
Metabolic Acidosis- LGI Obstruction
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Gastric and Colorectal Cancer
• Early gastric (malignant neoplasms in
stomach) Ca- manifestations:
• Indigestion, loss appetite, bloating
• Weight loss, fatigue, abdominal discomfort
• Many clients have no clinical manifestations.
• Advanced Ca- Vomiting, occult blood in stool,
Iron deficiency anemia, palpable mass,
enlarged lymph nodes, pallor
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Gastric Ca
• Gastric Ca- Interventions :
• Relieve pain- analgesics, position for comfort,
NG tube initially.
• Monitor for complications- hemorrhage.
• To maintain nutrition- may need TPN
• Patient and family education regarding diet,
supplements, medication.
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Gastric Ca- Tx
• Drug – 5FU Fluorouracil, FAM protocol
Adriamycin and mitomycin C combined.
• Surgical management- In early Ca- surgery is
usually curative, palliative resection for
Advanced Ca.
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• Standard
post op care
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Colorectal Ca
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Diagnostic tests- CBC, fecal occult blood, CEA, colonoscopy, CT, CXray, biopsy.
ACS Recommendation for Early Colorectal Ca Detection:
FOBT every year
Flexible sigmoidoscopy every 5 years
FOBT every year plus flexible sigmoidoscopy every 5 years
Double contrast BE every 5 years
Colonoscopy every 10 years
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Staging of CA, 0-4. 0= CA in situ, 4=distant mets.
Ostomy surgery
Radiation
Chemo
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Colorectal Ca
• Ileostomy- stoma formed from ileum
• Colostomy- stoma formed from colon
• Reasons-colorectal CA, colitis, Crohn’s,
diverticulitits
• Temporary or permanent colostomy.
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Colorectal Ca
• Most tumors in rectum or sigmoid colon
• Manifestations- Bleeding, change in bowel
habits, pain, anorexia and weight loss with
advanced disease.
• Complications- Obstruction, perforation and
extension (metastasis) of disease.
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Colorectal Surgery
• NPO- until peristalsis returns, clears to
advance, low residue, high calorie diet.
Cough and deep breathe
• PCA for pain
• Inspect stoma- color- pink, red.
• Patient teaching- stoma will shrink over 3
months, appliance fitted
• IV, I and O, Foley
• Monitor electrolytes
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Colorectal Surgery
Life style- sexuality, self esteem, body image,
enterostomal therapy nurse, support groups.
• Assess educational needs of client, learning
disabilities, hand dexterity, vision.
• Educate patient and family- regarding care.
• Teach assessment of stoma, clean skin and
stoma gently, assess for irritation.
• Skin barriers to protect skin.
http://www.colorectal-cancer.net/
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The nurse should explain that a diet for a
peptic ulcer will most likely consist of
which of the following?
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1. Bland foods
2. High protein foods
3. Any foods that are tolerated.
4. Large amounts of milk.
Interventions for Clients
with Morbid Obesity
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Nutritional Standards to Promote
Health
• Dietary recommendations, food guide
pyramids for adequate nutrition
• Nutritional assessment includes:
– Diet history
– Anthropometric measurements
– Measurement of height and weight
– Assessment of body fat (body mass index)
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Laboratory Assessment
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Hematology
Protein studies
Serum cholesterol
Other laboratory tests
Obesity
• Overweight: increase in body weight for
height compared to standard
• Obesity: at least 20% above upper limit of
normal range for ideal body weight
• Morbid obesity: severe negative effect on
health
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Obesity Complications
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Diabetes mellitus
Hypertension
Hyperlipidemia
CAD
Obstructive sleep apnea
Obesity hypoventilation syndrome
Depression and other mental
health/behavioral health problems
(
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Obesity Complications
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Urinary incontinence
Cholelithiasis
Chronic back pain
Early osteoarthritis
Decreased wound healing
Increased susceptibility to infection
Obesity and Health Promotion
• Health promotion/illness prevention
– Teach the potential consequences and
complications.
– Teach the importance of eating a healthy diet.
– Teach that foods eaten away from home tend to
be higher in fat, cholesterol, and salt, and lower
in calcium.
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Obesity and Health Promotion
– Reinforce need for regular moderate activity for
at least 30 min per day.
– Educate regarding diet and activity for children
and adolescents, and continuing throughout
adulthood.
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Nonsurgical Management
• Very low-calorie diets of 200 to 800 calories per
day
• Balanced and unbalanced low-energy diets
• Novelty diets
• Diet therapy
• Exercise program
• Drug therapy
• Complementary and alternative therapies and
treatments
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Surgical Management
Indications-Morbid obesity with co-morbidities and
weight control measures that have failed.
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Liposuction
Panniculectomy
Bariatric surgery
Preoperative care
Operative Procedures
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Vertical banded gastroplasty
Circumgastric banding
Gastric bypass
Roux-en-Y gastric bypass
Gastric bypass- create a small stomach which
empties directly into jejunum.
Gastric banding- laparoscopic- adjustable band
around upper part of stomach.
Vertical banded Gastroplasty- “stomach
stapling”.
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Postoperative Care
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Analgesia
Skin care
Nasogastric tube placement
Diet
Prevention of postoperative complications –
Upper GI with gastrograffin
• Observe dumping syndrome signs such as
tachycardia, nausea, diarrhea, and abdominal
cramping
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Summary of Bariatric Sx
• Multidisciplinary team should evaluate and
educate potential surgical candidates
• Life altering way of eating, surgery will limit
amt of food one is able to eat
• Teach how to prevent dumping syndrome
• Prevent postop complications, infections,
monitor wound healing, nutrition, body image
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