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Anorexia. Lack of appetiteAppetite center is located in the hypothalamusInfluenced by unpleasant or noxious food odors, effect of drugs, emotional stress, fear, psychological problems and illness. Anorexia S/S . Eventually will show vitamin deficiency, especially of water soluable as not stored in the body. Dry skin, brittle hair, sore mouth, bleeding gums, and easy bruisingWound healing is poor and mental state may deteriorateBones soften and taste and smell diminishWeak, tired, reduced s14
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1. Medical Surgical I Chpt 51: Disorders of Upper GI
3. Anorexia S/S Eventually will show vitamin deficiency, especially of water soluable as not stored in the body.
Dry skin, brittle hair, sore mouth, bleeding gums, and easy bruising
Wound healing is poor and mental state may deteriorate
Bones soften and taste and smell diminish
Weak, tired, reduced stool, bowel irregularity and constipation
4. Medical Management High calorie diet, high calorie supplemental feedings, tube feedings, total parenteral nutrition and psychiatric care may all be used to treat.
5. Nursing Management Obtain complete medical and allergy history
Find out eating patterns and preferences
Keep a record of BMs, may have either diarrhea or constipation
May need to dilute formula until he is regulated, increasing dietary fiber and giving stool softener
6. Anorexia Box 51-1 pg. 822 Provide foods he likes
Offer between snacks, milk shakes, ensure
Do daily calorie counts
Keep serving sizes and containers small
Serve and keep hot foods hot and cold foods cold
Encourage eating with others
7. Anorexia formulate a nutritional plan with dietitian to promote wt gain (600 calories per meal
Prevent unpleasant odors
do not do painful or unsightly procedures before meals
8. Nausea and Vomiting If prolonged, weakness, weight loss, nutritional deficiency, dehydration, and electrolyte and acid-base balance may occur
common causes are drugs, infection of GI tract, intestinal obstruction, systemic infections, lesions of the CNS, food poisoning, emotional stress, early pregnancy and uremia
9. Nausea Vomiting usually produced by distention of duodenum.
Nausea is accompanied by increased salivation and peripheral vasoconstriction causing cold, clammy skin and tachycardia.
Vomiting center located in the medulla is sensitive to parasympathetic neurotransmitters released in response to gastric irritation.
10. Nausea Valsalva maneuver which accompanies the forceful expulsion of stomach contents causes dizziness, hypotension and bradycardia
Fluid loss causes dehydration and leads to excessive thirst and decreased urine
Eyes and oral mucus membranes will be dry or dull and fluid loss causes poor skin turgor
11. Nausea and vomiting Ingestion of large amounts of alcohol, consuming contaminated food or drugs that cause GI side effects, bacterial or viral infection are common causes
If caused by intestinal obstruction the abdomen is distended, tender, and firm to touch. Bowel sounds are hypoactive or absent.
12. Nursing Care Get good history
Find out symptoms that occur prior to N/V
Frequency,color ,amount are all important assessments
List of foods eaten last 24 hours and where he has eaten
Assess general appearance, weight, vitals, I&O, and fluid volume deficit
Review Nsg care in fundamentals book
13. Cancer of Oral Cavity Smoking, chewing tobacco, drinking alcohol in excess can cause oral cancer.
Lip Ca caused by pipe smoking and prolonged exposure to wind and sun
May distort appearance and make it hard to masticate and cause local pain
may have dysphagia
May invade surrounding tissue including carotid and cause hemorrhage and death
14. Oral Cancer
15. Oral Cancer Early stage of oral cancer is symptom free. becomes concerned about lump, lesion or abnormality of lip or mouth.
Pain, soreness and bleeding occur late
If on tongue may have trouble tasting food or difficulty in eating. Pain, numbness and loss of feeling also occur
Leukoplakia , a white patch on tongue or inner cheek may become cancerous
16. Nursing Care Same as any other patient with Ca
focus is on maintaining patent airway, promoting adequate fluid and food intake, and communication--repeat or clarify what he has said and substitute written, give a magic slate, alphabet board or paper & pencil
17. Nursing for Oral Cancer After surg, place on side or abdomen with head turned to the side to facilitate drainage
After fully awake, elevate HOB so can breathe easier and cough up secretions and control edema of site
Keep suction, O2, trach set available
Do not irrigate mouth until awake and alert, then turn head to side and gently irrigate into an emesis basin. Instill small amt only
18. Nursing Care Must have order before giving anything by mouth.
Observe as he swallows small amount. If coughing then suction out of mouth stat. suction mouth PRN to remove secretions, blood, or irrigating fluids
Give antiemetics for nausea and maintain patency of gastric tube. No straws as distention of abdomen from air
19. Oral Cancer Nurse needs to promote effective coping and therapeutic grieving. May cry, refuse to talk and extreme sadness
Allow time to adjust to loss and change in appearance
Let him ventilate feelings
some may be suicidal
Avoid hot and cold or spicy foods
20. Gastointestinal Intubation NG tube or gastric decompression may be needed. Review fundamentals
Should have adequate nutrition, appropriate stooling patterns (amount, consistency, and frequency) and preservation of intact skin and nasal mucosa. Keep membranes moist
discomfort from dryness and unpleasant taste may be relieved with frequent mouth care
21. Nursing Care Ice chips and analgesic throat lozenges, gargles, or sprays may help if mouth and throat become sore
always give mouth care after removing tube...may have sore throat for several days
At risk for fluid volume deficit. Observe for dehydration
Protect from infections that stem from micros within formula or tube
22. Nursing Care for NG feedings Signs of infection include diarrhea, fever or abnormal WBC count.
Keep feeding formula refrigerated and unopened until ready to use. Warm to room temp before giving
Hang volume for 4 to 6 hours at a time
Flush with water before adding more formula. Discard after 24 hrs. Wash equipment after each use
23. Care Plan Prevent vomiting by checking tube position and gastric residual before instilling more
Place in semi-fowlers during feeding and for 30 min after. Never get below 30 degrees
clamp feeding after bolus or intermittent feeding
24. Prevent aspiration of any draining liquid during tube removal by instilling a small amt. of air to clear secretions and formula from tube, pinch the tube closed and have him hold his breath while removing
Always refeed gastric contents as has electrolytes
Monitor weight
25. Percutaneous Endoscopic Gastrostomy Before a PEG tube is inserted, the nurse should weigh him, assess vitals, auscultate bowel sounds and let him void.
After should continue to monitor vitals, observe breathing, inspect skin and dressing. Examine appearance and volume of secretions during first 24 hours when attached to gravity drainage. Auscultate bowel sounds and palpate for distention
26. PEG Tube
27. PEG Note tolerance for formula. report abd. distention, vomiting, fever, and severe pain.
Monitor the characteristics and pattern of bowel elimination and trends in daily wt.
If tube falls out, insert a foley cath and inflate balloon and clamp it to keep stoma from sealing. Notify Dr.
feedings can be given thru foley cath inserted into abdomen until replaced.
28. Gastroesophageal Reflux Disease (GERD) Develops when gastric contents flow in an upward direction into esophagus. Everyone has some but if excessive, or causes pain or resp distress then considered a disease
Cardiac sphincter does not close completely allowing contents of stomach to go into esophagua. Obesity, preg can increase it.
29. GERD S/S Epigastric pain or discomfort (dyspepsia) and regurgitation. May have difficulty in swallowing (dysphagia), painful swallowing (odynophagia), inflammation of the lining of esophagus (esophagitis), aspiration pneumonia, and respiratory distress.
May bleed and vomit blood or have tarry stools (melena). May lead to anemia. can cause chest pain and be mistaken for MI
30. GERD Evaluate lifestyle changes needed to reduce GERD
Avoid alcohol, peppermint, licorice, and caffeine.
Weight loss helps and avoid tight fitting clothing
elevate HOB, stop smoking and avoid eating or drinking for several hours before bedtime
31. Esophageal Diverticulum Weakness of esophageal wall. The diverticula trap food and secretions which then narrows the lumen, interferes with the passage of food and exerts pressure on trachea.
Trapped food decomposes within the esophagus causing esophagitis or ulceration in the mucosa
32. Signs and Symptoms Has foul breath and has difficulty or pain when swallowing, belching, regurgitation, or coughing
Gurgling sounds may be heard when auscultating the mid-upper chest
Bland, soft, or semisoft or liquid diet given. Small meals eaten 4 to 6 times a day
Oral hygeine will not alter the foul breath...review care of hiatal hernia
33. Hiatal Hernia Hiatal or diaphragmatic hernia is a protrusion of part of the stomach into esophagus. A portion of the stomach protrudes thru diaphragm into chest cavity
Caused by defect in the diaphragm where esophagus passes thru
Factors which increase intra-abdominal pressure (multiple preg or obesity) contributes to development
34. Hiatal Hernia Can cause GERD
Will have heartburn, belching and a feeling of substernal or epigastric pressure or pain after eating and when lying down.
If scars form, swallowing becomes difficult. as food distends the esophagus, vomiting may occur
Review care page 838 and 839
35. Cancer of Esophagus Correlation between alcohol abuse and cigarette smoking
Signs and symptoms usually develop slowly
Beginning symptoms are mild, vague feelings of discomfort and difficulty in swallowing some foods.
Weight loss accompanies progressive dysphagia. solid foods may become impossible to swallow so drinks liquids
36. Cancer of Esophagus By the time swallowing difficulty is pronounced it has usually invaded surounding tissues and lymphatics. May have back pain and respiratory distress
Pain is a late symptom
Major nursing goal is improved nutrition and weight gain.Consult with dietitian. Avoid foods or drinks with lots of gas, such as souffles or carbonated beverages. No straws or narrow necked bottles to avoid air
37. Cancer of Esophagus May need NG tube, Gastrotomy tube, or TPN
Must care for skin around tube insertion site, prevent infection, maintain patency of tube and teaching how to manage tube after discharge.
If surgery done, teach how to support surgical incision for coughing and deep breathing
38. Gastritis pg. 840 Inflammation of stomach lining
Submucosal layers of stomach can become inflamed when mucous layer is reduced or penetrated by irritating substances. May have epigastric discomfort or heartburn. The mucous producing cells heal and regenerate in 3 to 5 days so gets better
chronic irritation leads to ulceration
39. Gastritis s/s Complains of epigastric fullness, pressure, pain, anorexia, N/V
When gastritis is caused by bacterial or viral infection may have vomiting, diarrhea, fever and abdominal pain.
Drugs, poisons, toxic substances and corrosives can cause gastric bleeding
40. Medical Management avoid irritating substances such as spicy foods, alcohol and caffeine
Observe color and characteristics of any vomitus or stools
Teach about diet, drug therapy and need for continued medical follow-up
41. Peptic Ulcer Disease Circumscribed loss of tissue in an area of the GI tract that is in contact with HCL and pepsin. Most occur in the duodenum but may also occur at lower end of esophagus, in the stomach or in jejunum
Gastric ulcers are more likely to recur and become cancerous. 80-90% are caused by Helicobacter pylori. Smoking and chronic use of Asa or NSAIDS also cause
42. Helicobacter pylori
43. H. Pylori A gram-negative microorganism, is present in the gastric or duodenal mucosa of 80% or 90% of clients with peptic ulcers.
This bacteria, which shelters itself in the bicarbonate-rich mucus, is a factor in chronic gastritis and peptic ulcer disease.
Secretes an enzyme that theoretically depletes gastric mucus, making it more vulnerable to injury.
44. Peptic Ulcer S/S Location of pain is in mid-epigastrium, does not radiate
Pain most often occurs when stomach is empty
should monitor for hemorrhage, obstruction and perforation
signs of bleeding: Coffee-ground appearing emesis and black tarry stools (melena)
45. Peptic Ulcer Most often described as having a burning quality. Complains of pain that disturbs sleep and occurs one to several hours after eating. Pain may be releived by eating
Back pain may be irritation of pancreas by ulcer.
Protracted vomiting may occur if symptoms ignored as causes obstruction
46. Dumping syndrome If a total gastrectomy done, must receive vitamin B12 injections for life to prevent pernicious anemia
Clients with gastrojejunostomy are at risk for dumping syndrome when eating solid food. Will have weakness, dizziness, sweating, palpitations, abdominal cramps and diarrhea due to rapid emptying or dumping of large amounts of partly digested food into jejunium
47. Dumping Syndrome The presence of this concentrated solution in the gut draws fluid from the circulating blood into intestine, causing hypovolemia. The drop in BP can produce syncope. Sudden appearance of CHO in jejunum stimulates pancreas to secrete excessive insulin and hypoglycemia. To help dumping syndrome, eat carbohydrates, especially simple sugars in moderation
48. Nursing Management Determine type of pain, onset in relation to eating, location and duration
Get dietary Hx and foods that cause distress. Does eating relieve pain?
If receiving tube feedings, re-instill gastric residual because it has enzymes, electrolytes and partially digested nutrients.
If surgery, follow guidelines same as gastric surgery page 835
49. Cancer of Stomach Heredity and chronic inflammation of the stomach appear to contribute.
Foods preserved with nitrates may predispose
Early symptoms are vague. As tumor enlarges symptoms include a prolonged feeling of fullness after eating, anorexia, weight loss, and anemia and melena. Pain is late sign
50. Cancer of Stomach Surgery and chemotherapy done.
Nursing should teach prevention...how to change dietary habits to reduce causes.
Teach early warning signs
51. Post-op Care Inspect surgical dressing for drainage and tubes or catheters for placement, patency, and type of drainage.
Carefully observe NG tube drainage for bleeding. May contain small amount of dark blood when first returns from OR the drainage should promptly return to yellow-green
52. Complications to Observe For Change in vitals, especially low BP, rapid pulse, and elevated temp
Extreme restlessness
Difficulty breathing, increased resp rate, cyanosis
Severe pain, especially after pain med given; pain in another site and not operative site (leg, head, chest)
53. Complications Abdominal distention or rigidity
Urinary output less than 35 ml per hour if cath or failure to void within 8 hours of surgery
Failure to pass flatus or stool more than 48 hours postop
Profuse diaphoresis
54. Complications Excessive bloody drainage from NG tube, surgical drains, or surgical dressing
Separation of surgical wound edges
Unusual color or odor of drainage