Chapter 37 Management of Patients With Gastric and Duodenal Disorders

1. Chapter 37Management of Patients With Gastric and Duodenal Disorders

2. Gastritis • Acute/Chronic Inflammation of the stomach; • Dietary indiscretion • Coffee, aspirin, alcohol • Smoking • Physiologic stress (esp. in ICU not receive enteral feedings) • Medications • Aspirin, corticosteroids, chemotherapy • Bile reflux, Pancreatic secretion reflux and radiation therapy • Microorganisms • helicobacter pylori • Contaminated foods (salmonella or staphylococcus)

3. Erosive Gastritis

4. Manifestations of Gastritis • Epigastric tenderness, anorexia,, nausea and vomiting, • May have vitamin deficiency due to malabsorption of B12 • Associated with PUD and Helicobacter pylori • Diagnosis is usually by UGI X-ray or endoscopy and biopsy r/o CA • Gastric analysis for decreased acid production (achlorhydria) Serum, stool and biopsy for H. pylori

5. Complications Gastritis • Ulceration and Hemorrhage • Cancer of the stomach

6. Medical Management of Gastritis • Eliminate cause • Surgery if hemorrhage • Pharmacological Antiemetics Antacids (neutralize acid) • Amphojel (ammonium hydroxide) • 1-2 hr between other meds • Cardiac patients should watch for signs of MI PPI (Inhibit enzyme that produces gastric acid) • Prevacid, Prilosec • Give 30 “ before meals • Do not crush or chew (can sprinkle on food) • Prilosec with Biaxin will treat h. pylori in duodenal ulcers H2R blockers (reduce volume and concentration of gastric acid secretion) • Zantac • Use caution in liver/renal patients

7. Nursing Interventions • Goal decrease gastric irritation • NPO with IV fluid and electrolyte replacement • Plan for nausea and vomiting • Oral rehydrating solutions progressive fluids and diet as tolerated

8. Peptic Ulcer • Erosion of GI mucosa by HCL and pepsin • Histamine release occurs with the erosion of mucosa in duodenal and gastric ulcers vasodilation and capillary permeability which further stimulates HCL and pepsin release • Duodenum is most common site of peptic ulcer

9. Peptic Ulcer • Risk factors same as gastritis • Hot spicy food is NOT a factor • Associated with infection of H. pylori • Manifestations include a dull gnawing pain or burning in the mid-epigastrium; heartburn and vomiting may occur • Treatment includes medications, lifestyle changes, and occasionally surgery (See Tables 37-1 p 1046 and 37-3 pg 1050 )

10. Peptic Ulcer • Treatment includes medications • H. Pylori • Flagyl • Prilosec (PPI) • Biaxin • Same as gastritis • Pain relief • Life style modification (bland diets) • Quit smoking/drinking alcohol • No NSAIDS and Anti-inflammatory medications

11. WARNING • Do not administer antacids to cardiac clients c/o mid epigastric distress or “heartburn”

12. Deep Peptic Ulcer

13. Surgical Procedures for Peptic Ulcers Vagotomy is the surgical cutting of the vagus nerve to reduce acid secretion in the stomach. Pyloroplasty is a surgical procedure to widen the opening in the lower part of the stomach (pylorus) so that the stomach contents can empty into the small intestine. The indications for urgent surgery include failure to achieve hemostasis endoscopically, recurrent bleeding despite endoscopic attempts at achieving hemostasis.

14. Question Is the following statement True or False? The most common site for peptic ulcer formation is the pylorus.

15. Answer False The most common site for peptic ulcer formation is not the pylorus. The most common site for peptic ulcer formation is the duodenum.

16. Complications PUD • Hemorrhage: ulcer erodes thru vessel • Assessment • Pain n/v • Hematemsis, melena or both • VS show hypovolemic shock • Treatment • Fluids: blood, NS, LR • Medication to decrease acid • NPO, NGT, saline lavage • Surgery if unresponsive

17. Complications PUD • Perforation • Assessment • Sudden severe unrelenting pain • Rigid Board like abdomen • Hyperactive to absent bowel sounds • Peritonitis severity depends on size of perforation and amount of gastric leakage • Treatment • Antibiotics • Self healing or immediate laparoscopic surgical closure • Fluid volume replacement

18. Complications of PUD • Gastric outlet obstruction (duodenal ulcers near pyloric valve • Assessment • Gradual onset • Hx PUD • Swelling, dilation of stomach • Foul, projectile, vomit • Relief with vomiting • Treatment • Decompression with NGT(continuous) • Fluid Volume Replacement • Antiulcer medication • Pyloroplasty to enlarge valve opening

19. Question What is the best time to teach a client to take proton pump inhibitors? • 30 minutes before a meal • With a meal • Immediately after the meal • One to three hours after the meal

20. Answer A The best time for a client to take a proton pump inhibitor is before a meal. It is a delayed-release medication that is to be swallowed whole and taken before a meal.

21. The nurse is caring for a client who has been diagnosed with a bleeding duodenal ulcer. What data identified on a nursing assessment would indicate an intestinal perforation and require immediate nursing action? • Increasing abdominal distention with pain and vomiting • Decreasing Hgb/Hct with bloody stools • Diarrhea with increased bowel sounds and hypovolemia • Decreasing BP with tachycardia and disorientation

22. The nurse is caring for a client who has been diagnosed with a bleeding duodenal ulcer. What data identified on a nursing assessment would indicate an intestinal perforation and require immediate nursing action? • Increasing abdominal distention with pain and vomiting Perforation is characterized by increasing distention and board like abdomen. There are frequently increased pain with fever and guarding, peritonitis can occur rapidly. The nurse should maintain NPO, BR and immediately notify the Dr. Decreased HGB/HCT occur with hemorrhage. Remember to select the answer which reflects what the question is specifically asking.

23. Bariatric Surgery • Morbid obesity: persons more than two times IBW, BMI exceeds 30 kg/m2, or more than 100 pounds greater than IBW. • Surgery is preformed only after nonsurgical methods have failed. Selection factors include • body weight, • patient history, • absence of endocrine disorders • psychological stabilitySee Chart 37-3 (1056)

24. Surgical Procedures for Morbid Obesity—Roux-en-Y Gastric Bypass (REG) Combined restrictive/malabsorptive

25. Surgical Procedures for Morbid ObesityGastric Banding

26. Surgical Procedures for Morbid Obesity—Vertical-banded Gastroplasty

27. Surgical Procedures for Morbid Obesity—Biliopancreatic Diversion with Duodenal Switch

28. Nursing Care of the Patient Undergoing Bariatric Surgery • Preoperative care; evaluation and counseling • Postoperative care is similar to gastric resection but the patient is at greater risk for complications due to obesity • Postoperative diet: six small feedings totaling 600-800 calories per day (see Chart 37-4) • Patients require psychosocial interventions to modify their eating behaviors. • Follow-up care • Education regarding long-term effects

29. The average weight loss after bariatric surgery is 60% of previous body weight over 5 years

30. Interventions (bariatric) • Maintain post-op homeostasis • Airway management • Increased risk for thrombosis • Compression hose • Lovenox • Early ambulation • Do not adjust or insert NG tube even if protocol to do so for N/V • Anastomotic leaks (shoulder , back and abdominal pain, tachycardia, U.O.) • Abdominal binder protects incision • Monitor blood sugar in diabetics • Dumping may occur in bypass of small intestine

31. Dumping Syndrome • Assessment • Weakness, dizziness, tachycardia • Epigastric fullness, cramping and hyperactive bowel sounds • 15-20 mins. After eating • Diaphoresis • Resolves in 6-12 months • Prevention • Smaller meals >3hr apart • proteins/fiber simple carbohydrates • no fluids with meals (15 min. a.c /60mins p.c) • Add peaches, plums, apples • Lay on left side after meals20minues to delay stomach emptying

32. An obese client has had a combination restrictive malabsorptive bariatric surgery. What will be important for the nurse to include in discharge teaching for this client • Increase intake of food high in iron, Ca, and B12 to prevent malnutrition • Do not take any fluids with meals or immediately after • Elevate the head of the bed to prevent development of reflux during sleep • Plan intake of three balanced meals a day with increased fluids between meals

33. An obese client has had a combination restrictive malabsorptive bariatric surgery. What will be important for the nurse to include in discharge teaching for this client • Increase intake of food high in iron, Ca, and B12 to prevent malnutrition • Do not take any fluids with meals or immediately after • Elevate the head of the bed to prevent development of reflux during sleep • Plan intake of three balanced meals a day with increased fluids between meals

34. Gastric Cancer • Incidence is deceasing, but accounts for 12,000 deaths in U.S. annually. • Increased incidence in men, Native Americans, Hispanic Americans, and African Americans, typically ages 40-70. • Risk factors include diet, chronic inflammation of the stomach, H. pylori infection, pernicious anemia, smoking, achlorhydria, gastric ulcers, previous subtotal gastrectomy, and genetics. • Manifestations include pain relieved by antacids, dyspepsia, early satiety, weight loss, abdominal pain, loss or decrease in appetite, bloating after meals, nausea, and vomiting. Diagnosis of the disease is often late. • Treatment is surgical removal of the tumor if possible, and palliative care if the tumor is unresectable or metastasized.(which is common due to being asymptomatic until late stages)

35. Nursing Diagnosis :Anxiety • Provide a relaxed, nonthreatening atmosphere. • Allow patient to express fears and concerns. • Provide support and encourage family support. (Preparing for dying process) • Promote positive coping measures. • Explain treatments and procedures. • Referral to support persons such as social worker or clergy.

36. Promote Optimal Nutrition • Encourage small, frequent meals of non-irritating foods. • Provide foods high in calories and vitamins A and C and iron. • Provide diet and teaching for potential dumping syndrome after gastric resection. • Six small feedings low in carbohydrates and sugar, with fluids between, not with, meals. • Assessment includes I&O, daily weights, assessment for signs of dehydration, and nutritional status.

37. Collaborative Problems/Potential Complications • Hemorrhage • Dietary deficiencies • Take supplements vitamins, medium-chain triglycerides, and B12 injections • Bile reflux (rx: Questran) • Dumping syndrome

38. Care and Prevention of Complications • Gastric retention • May require reinstatement of NPO and Ng suction. Use low-pressure suction • Bile reflux • Agents that bind with bile acid: cholestyramine • Malabsorption of vitamins and minerals • Supplementation of iron and other nutrients • Parenteral administration of vitamin B12 due to lack of intrinsic factor

39. In planning discharge teaching for the client who has undergone a gastrectomy, the nurse includes what information regarding dumping syndrome? • The syndrome will be a permanent problem and the client should eat 5-6 small meals a day • The client should decrease the amount of fluid consumed with each meal and for 1 hour after each meal • The client should increase the amount of complex carbohydrates and fiber in the diet • Activity will decrease the problem; it should be scheduled about 1 hour after meals

40. In planning discharge teaching for the client who has undergone a gastrectomy, the nurse includes what information regarding dumping syndrome? • The syndrome will be a permanent problem and the client should eat 5-6 small meals a day • The client should decrease the amount of fluid consumed with each meal and for 1 hour after each meal • The client should increase the amount of complex carbohydrates and fiber in the diet • Activity will decrease the problem; it should be scheduled about 1 hour after meals

41. On the second day post-op the client’s nasogastric tube is draining bile colored liquid containing coffee ground material. What is the best nursing action? • Reposition the NG tube and irrigate with NS • Call the physician and discuss the possibility of the client bleeding • Continue to monitor the amount of drainage and correlate it with any change in VS • Irrigate the NG tube with iced saline and attach it to gravity.

42. On the second day post-op the client’s nasogastric tube is draining bile colored liquid containing coffee ground material. What is the best nursing action? • Reposition the NG tube and irrigate with NS • Call the physician and discuss the possibility of the client bleeding • Continue to monitor the amount of drainage and correlate it with any change in VS • Irrigate the NG tube with iced saline and attach it to gravity.