Transcript GastricStressors.

Nursing Care of the patient with
Gastric Mucosal Stressors
By: Joanna Shedd, MS, CNS, RN
Functions of the G.I. Tract
• Ingestion – mouth and oral
cavity
• Digestion – begins in the
stomach
• Absorption – commences in
small intestine
• Elimination – via large
colon and anus
Normal Gastric Mucosa
• Pink
• Ruggae
• No break in mucosa
Gastritis
• Inflammation of the
gastric or stomach
mucosa
• Acute or chronic
Causes of Gastritis
• Acute Gastritis
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Dietary
Drugs
Alcohol
Bile reflux
Radiation therapy
Acid ingestion
May develop acute
illness
• Chronic Gastritis
– Ulcers
– H. Pylori
– Autoimmune disorders
Pathophysiology
• Gastric mucous
membrane becomes
edematous
• Hyperemia occurs
• Mucosa undergoes
superficial erosion
• Potential for hemorrhage
Clinical Manifestations
• Abdominal discomfort
• Headache
• Intolerance to spicy or
fatty foods
• Nausea/vomiting
• Hiccupping
• Anorexia
• Belching
• Heartburn
• Pain relieved by eating
Assessment
• Upper GI
• Endoscopy
• Histological exam
Treatment
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Avoid causative agents
IV fluid management
NG tube
Analgesics/antacids
Removal of gangrenous
tissue
• Antibiotics for H. Pylori
Peptic Ulcer Disease: Scope of the Problem
• Common occurrence
• 1 in 10 people will be
affected at some point
during their lifetime.
Classification of Peptic Ulcers
• Duodenal
• Gastric
• Stress
What Causes of Peptic Ulcers?
• Helicobactor pylori
• NSAID use
• Alterations of acid
secretions/mucosal
lining
What Causes of Peptic Ulcers?
• Smoking
(associated)
• Alcohol
(aggravates)
• Gastrinoma
Signs & Symptoms
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Epigastric Burning
Dyspepsia
Bloating
Burping
Nausea
Poor appetite
Gastric Ulcer
• 20-25% incidence
• 70% caused by H. pylori
• Normal – hyposecretion
of gastric acid
• Pain ½ - 1hr after meal
Gastric Ulcer
• Pain relieved by vomiting
• Weight loss
• Food ingestion does not
alleviate pain
• Hematemesis
• Hemorrhage more likely
Duodenal Ulcers
• Pyloric region common
• More frequent - 75-80%
• Hypersecretion of
stomach acid
• Weight gain
• Pain 2-3 hours after meal
Duodenal Ulcers
• Wake at night (1-2am)
• Food ingestion relieves
pain
• Vomiting uncommon
• Melena
• Perforation risk
Helicobacter Pylori - 1982
• May be contracted
via food/water.
• Not all people will
develop ulcers.
• Has been isolated in
saliva.
H. Pylori is a survivor
• Helicobacter pylori
produces urease
• Neutralizes stomach acid –
ammonia
• Bacteria penetrates
stomach lining
• Weaken defenses, stomach
produces more acid
Diagnostic Tests for H. Pylori
• Blood
– H. pylori antibodies
• Breath
– Urea breath test
• Stool
– HPSA
• Endoscopy
– Gastric tissue biopsy &
examination
Treatment Goals
• Kill Bacteria
– Metronidazole, tetracycline,
clarithromycin, amoxicillin
Treatment Goals
• Decrease Stomach Acid
– H2 blockers, Proton pump inhibitors,
antacids
• Protect Stomach Lining
– Bismuth, subsalicylate,
Zollinger-Ellison Syndrome
• Gastrin-producing tumor in pancreas or duodenum
• Extreme gastric hyperacidity
• Severe peptic ulcers
Stress Ulcers
• Physiological stressful
events, i.e, shock, burns,
multiple organ trauma
• Vent dependent pts.
• Preceded by shock
• Decreased mucosal blood
flow
• Reflux duodenal contents to
stomach
Other Tests and Diagnostics
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CBC
Chemistry
Occult Blood
Amylase
Other Tests and Diagnostics
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Gastric analysis
Urease (CLO test)
X-rays
Endoscopy with biopsy
Other Tests and Diagnostics
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Esophagoscopy
Gastroscopy
Gastroduodenoscopy
Esophagogastroduodenoscopy (EGD)
Nursing Care – Ulcers
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Medications
Stress reduction and rest
Smoking cessation
Dietary modifications
Surgical management
Prevent recurrence!
General care for GI examinations
• NPO 8-12 hours (or more) before exam
• Explain necessity of having to ingest contrast
media
• Explain anesthetic methods
General care for GI Examinations
• Remove dentures
• Keep NPO until gag reflex
fully returns
• VS as per protocols
General care for GI examinations
• Explain changes in stool color
• Warn against constipation
• Observe for s/s bleeding
Perforation
• Surgical emergency.
• Ulcer erodes all the way
through stomach or
duodenum.
• Partially digested food
contaminates peritoneal
cavity.
Emergency Symptoms
• Sharp, sudden, persistent stomach pain
– Could be a perforation
• Bloody or black stools
– Acid, or erosion breaks through blood vessel
• Bloody emesis, “coffee-ground” emesis
– Could be obstruction
Nursing Care of patient with GI Bleed
• Frequent vital signs, 02
therapy
• Check skin color
• Guiac emesis and stools
• Maintain fluid and electrolyte
balance
Nursing Care of patient with GI Bleed
• Gastric lavage
• May need MD to do cauterization
• Emotional support and reassurance
Drug Therapy
• Antacids
• Pump inhibitors
• Histamine receptor
antagonists
Drug Therapy
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Cytoprotective
Anticholinergics
Prostaglandin Analogs
Antibiotics
Antibiotics
• Most effective
treatment against
Helicobacter Pylori
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Amoxicillin
Tetracycline
Clarithromycin
Metronidazole
Antacids
• Neutralizes gastric acid thus ↑ PH
– Calcium carbonate/ TUMS
– Magnesium hydroxide/ Milk of Magnesia
– Aluminum hydroxide/ AlternaJel
Pump Inhibitors
• Reduce stomach’s
production of acid.
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omeprazole;Prilosec
lansoprazole; Prevacid
rabeprazole; Aciphex
pantoprozole; Protonix
Esomeprazole; Nexium
• Ulcer healing
Histamine2 receptor antagonists
• Block histamine2 receptors.
• Inhibition of gastric acid
secretion.
– Cimetidine/Tagamet
– Ranitidine/Zantac
– Famotidine/Pepcid
• Ulcer healing
Cytoprotective Drugs
• Protect gastric mucosa
– Sucralfate (carafate)
– PeptoBismol
Anticholinergics
• Blocks vagal
stimulation of
acetylcholine.
– Dicyclomine HCL
– Propantheline
Prostaglandin Analogs
• Enhances the mucus/bicarbonate
layer
• Improves mucosal blood flow
• Side effects: diarrhea
– Misoprostol/cytotec
Appendicitis
• Incomplete emptying
• Causes inflammation/
infection
• Most common 10-30
y/o
• Most common surgical
emergency
What to Look For: Appendicitis
• Wave-like abdominal pain
(starting out)
• Pain intensifies and
becomes steady
• Localization of pain at
McBurney’s Point
Appendicitis
• Rebound tenderness
• Temperature elevation
• WBC elevation
What to Do: Appendicitis
• Keep the patient NPO
• No pain medication
• No heat to abdomen
What to Do: Appendicitis
• Prepare for surgery
• I.V. and antibiotic
therapy as ordered
• Manage anxiety
• “Hot” vs. “Perf”ed
appy
What to look for: Diverticulitis
• Crampy abdominal pain in lower LEFT
quadrant is a classic sign (sigmoid colon)
• Hx of constipation, bloating
• Fever
• Nausea
• WBC’s elevated
What to Do:Diverticulitis
• Bowel Rest (NPO or clear
liquids only)
• I.V. fluid management
• Administer medications
– Antibiotics
– Analgesics
– Anticholinergics
What to Do:Diverticulitis
• Teaching
• Prevent constipation
– Fiber to sweep colon
– Liberal intake fluids
• Assess for developing
complications
– Sudden ↑ in pain
What to look for: Peritonitis
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Sudden sharp pain
Rigid, board-like abd.
No bowel sounds
Rebound tenderness
What to look for: Peritonitis
• Fluid shift to abdominal
cavity
• Tachycardia,
hypovolemic shock
• Air in abd.on x-ray
What to Do: Peritonitis
• Fluid and electrolyte
replacement
• Naso-gastric suction
• Antibiotic therapy
• Prepare for surgery
• Pain management
• Manage anxiety
Bowel Obstruction:
Clinical Manifestations
• Small bowel
– Crampy wave-like pain
– Passing of blood and
mucous in stool and
emesis
– Dehydration
– Distention of abdomen
– Fecal vomiting
• Large bowel
– Symptoms are slower
to develop
– Shape of stool
– Blood in stool
– Distention of abdomen
– Fecal vomiting
Pathophysiology
• Accumulation of intestinal fluids and gas
proximal to the obstruction
Treatment of Intestinal Obstructions
• Decompression
of the bowel
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NG tube
NPO
IV fluids
Surgery
Rectal tube
Colonoscopy
Small Bowel Obstruction (SBO)
• Severe umbilical or
epigastric pain
• Pain is colicky or
crampy
• Reverse peristalsis
• Profuse vomiting-bile
tinged color
What to look for: SBO
• Lethargy, oliguria, dehydration
• High pitched hyperactive bowel sounds
proximal to obstruction
• Hemoconcentration, hypokalemia,
hyponatremia
Diagnostics: SBO
• Abd x-ray/ CT scans
• CBC
– s/s dehydration, anemia
• Chemistries
– s/s dehydration
– Electrolyte imbalance
Management: SBO
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NG tube to low intermittant suction as ordered
Maintain patency of NG tube
Manage I.V. fluids
Surgical tx will depend on severity of obstruction
Large Bowel Obstruction (LBO)
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Middle-lower abdominal pain
Gradual onset, cramp-like pain, less intense
Late vomiting—fecal smelling emesis
Marked abdominal distension
What to look for: LBO
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Diminished or absent bowel sounds
Lethargy, oliguria, dehydration
Stool shape alteration (“ribbons”)
Hemoconcentration, hypokalemia, hyponatremia
Diagnostics: LBO
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Abdominal x-ray
CT or MRI abd
CBC - dehydration
Chemistries - dehydration
Management: LBO
• Measure abdominal girth
• Assess pain at regular
intervals
• Keep strict intake and
output records
• Describe emesis
• NGT
Nursing: LBO
• IV hydration
• Monitor urine output
(30cc/hr or >)
• Daily weight
• Vital signs
• Prepare for either surgery
or palliation
Vagotomy
• Surgical management
of duodenal ulcers
• Removal of vagal
nerves
• See p. 1213
Bilroth I and II Procedures
• Bilroth I
• Tx for gastric cancer
• Remove lower stomach
and part of duodenum
and pylorus
• Remaining anastamosed
to duodenum
Bilroth I and II Procedures
• Removal of lower stomach attached to jejunum
• See p. 1214
• Can lead to dumping syndrome, anemia,
malabsorption and weight loss
Surgical Interventions
• Colectomy with anastamosis
• Temporary colostomy
• Permanent colostomy
Surgical: Ostomy
• Surgical management if
obstruction is too great or
involved
• Surgical creation of
opening to ileum of small
bowel through sigmoid
• Output is can be formed to
liquid
• Maintain skin, monitor
output
Complications of surgical intervention
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Bleeding
Infection
Pain
Thrombophlebitis
Complications of surgical intervention
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Atelectasis/Pneumonia
Gastrectomy Anemia
Nutritional Problems
Dumping syndrome
Nutritional Problems
• Folic acid deficiency
• Vit B12 deficiency
• ↓ absorption of
Calcium and Vit. D
• ↓ caloric intake
• Weight loss
Early S/S of dumping syndrome
• Occurs 5-30 minutes
after eating
• Vertigo
• Tachycardia
• Syncope
• Sweating
Early S/S of dumping syndrome
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Flushing
Palpitation
Diarrhea/nausea
Abdominal cramping
Urge to defecate
Early S/S of dumping syndrome
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Epigastric fullness
Distention
Anxiety
Shame
Embarrassessment
Late Manifestations of dumping
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Occurs 2-3 hours after eating
Rapid entry of high CHO food
Hyperglycemia
Excessive insulin production
Hypoglycemic symptoms
Management of dumping
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Small frequent meals (6 vs. 3)
High fat and protein
Low carbohydrate
No fluids 1 hour prior to eating
or 2 hrs after
• Lie down after eating for 30-60
minutes
• Drug therapy
A client asks you why he needs to take amoxicillin
for his gastric ulcer. Your best response is it will:
1. Eradicate the infection causing the ulcer
2. Prevent a nosocomial infection
3. Reduce acid production that causes an
ulcer
4. Treat the underlying viral agent associated
with gastric ulcers.
Hemorrhage is a common complication
of gastric ulcers. What assessment
finding would best support the
complication of bleeding due to PUD?
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Dyspepsia
Hematemesis
Hypoglycemia
Steatorrhea
Your client has s/s of peptic ulcer disease. They receive
medication to decrease gastric acidity. Which medication
reduces hydrochloric acid secretion?
1.
2.
3.
4.
Aspirin
Aluminum hydroxide
Cimetidine
Sucralfate
The following admission orders are on your
client’s chart that is diagnosed with PUD. Which
order should the nurse question?
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2.
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4.
NG tube to low intermittant suction
Guiac all stools
Monitor vital signs q4 hr
Mylanta 30 cc PO QID
Which of the following s/s would be your highest
priority when anticipating the complications of
PUD?
1. A board-like abdomen with no bowel
sounds
2. Epigastric pain during the night
3. Nausea with projectile vomiting
4. Pain that radiates through the back
Which of the following would the nurse teach a
client about his diet to prevent dumping
syndrome?
1. After eating, ambulate to promote
digestion
2. Eat food high in carbohydrates for calories
3. Eat slowly and drink fluids during meals
4. Eat six small ↑PRO, ↓CHO meals a day