Download Chapter 7 Body Systems

Medical-Surgical Nursing:
Concepts & Practice
3rd edition
Chapter 28
Care of Patients with Disorders of the Upper
Gastrointestinal System
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Dumping syndrome
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Theory Objectives
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Discuss eating disorders and their management,
including bariatric surgery.
Compare the signs and symptoms of oral,
esophageal, and stomach cancer.
Illustrate the cause of gastroesophageal reflux
disease (GERD).
Explain the etiology and prognosis for Barrett’s
esophagus.
Describe the pathophysiology, means of medical
diagnosis, and treatment for gastritis.
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Theory Objectives (Cont.)
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
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Compare and contrast the treatment and
nursing care of the patient with GERD and a
patient with peptic ulcer.
Review the difference in the care of the
patient with a nasogastric tube for
decompression and care of the patient with a
feeding tube.
Compare the care for a patient receiving total
parenteral nutrition with care of the patient
receiving enteral feedings.
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Clinical Practice Objectives
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Implement a teaching plan for a patient who
has GERD.
Plan postoperative care for a patient having
gastric surgery.
Demonstrate proper care of the patient with a
Salem sump tube for gastric decompression.
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Clinical Practice Objectives (Cont.)
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Manage a tube feeding for the patient
receiving formula via a feeding pump.
Review a nursing care plan for the patient
with a gastrointestinal disorder.
Write a nursing care plan for the patient with
an upper gastrointestinal disorder.
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Anorexia Nervosa
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Patients with anorexia nervosa refuse to eat
adequate quantities of food and are in danger
of literally starving to death.
Diagnosis requires extensive interviewing and
treatment, including behavior modification
and nutrition support, which may take months
to years.
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Bulimia Nervosa
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Patients with bulimia consume large
quantities of food and then induce vomiting to
get rid of it so that weight is not gained.
Laxatives
Some patients with anorexia nervosa also
have bulimia.
Some individuals practice bulimia
occasionally without harm.
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Bulimia Nervosa (Cont.)

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Bulimia can lead to severe fluid and
electrolyte imbalances, starvation, and death.
Treatment of bulimia includes psychotherapy,
antidepressant medication, and behavior
modification.
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Obesity
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Etiology and pathophysiology
Signs and symptoms
Diagnosis
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Height and weight chart
Waist and hip circumference
Body mass index (BMI)
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Obesity Treatment

Bariatric surgery
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Extensive counseling and assessment
Modify lifestyle and stringent regimen required to
lose weight and keep weight off
Types
• Gastric restrictive
• Malabsorptive
• Gastric restrictive combined with malabsorptive surgery
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Bariatric Surgery

Preoperative care

There is greater risk of pulmonary embolism and
thrombus formation, as well as death, for obese
patients.
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Restrictive Procedures
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Laparoscopic adjustable gastric banding is
performed by placing an inflatable band around
the fundus of the stomach.
The band is inflated and deflated via a
subcutaneous port to change the size of the
stomach as the patient loses weight.
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Restrictive Procedures (Cont.)


For vertical banded gastroplasty, the surgeon
creates a small stomach pouch by placing a
vertical line of staples.
A band is placed to provide an outlet to the
small intestine.
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Gastric Bypass
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Vertical Banded Gastroplasty
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Circumgastric Banding
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Malabsorptive and Combination
Procedures
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The total gastric bypass procedure causes severe
nutritional deficiencies and is no longer
recommended.
The roux-en-Y gastric bypass (RYGB) limits the
stomach size, and the duodenum and part of the
jejunum are bypassed. This limits the absorption of
calories.
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Complications
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Leakage of
stomach contents
Gastric stretching
Dumping
syndrome
Nutritional
deficiencies—
iron, vitamin B12,
calcium, and
folate
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Healthy People 2020 Goals Related to
Losing Weight and Obesity
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Increase the proportion of
adults who are at a healthy
weight.
Reduce the proportion of
adults who are obese.
Reduce the proportion of
children and adolescents
who are overweight or
obese.
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Assessment
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Family history
Contributing factors
Record of eating patterns for a 7-day period
Weight and height
BMI
Skinfold thickness measurement
General health assessment
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Expected Outcomes
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Patient will make positive statements about
decreasing body size.
Patient will verbalize feelings of self-worth.
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Implementation
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Diet and exercise plan
Lifestyle and preferences
Eating and exercise diary
Guidance and support
Discourage fad diets and emphasize the
importance of a well-balanced, nutritious, lowcalorie diet.
Commercial programs on weight reduction
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Upper GI Disorders

Stomatitis – inflammation of the mucous
membranes of the mouth – poor oral hygiene, nutrition,
radiation therapy, drugs, pathogenic microorganisms

Dysphagia – difficulty swallowing
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Causes
Diagnosis
Treatment
Nursing management
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Dysphagia
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Causes – tumors, inflammation, esophageal
diverticula, motility disorders from neurologic
disorders
Diagnosis- speech therapy eval, modified
barium swallow
Treatment – semi-soft, pureed foods,
thickened liquids
Nursing Mgt – “Altered nutrition: less than
body requirements”, “Potential for aspiration”
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Cancer of the Oral Cavity
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Cause unknown – genetics, smoking, chew
tobacco, heavy alcohol use increase risk,
vape use not known
Signs and symptoms – leukoplakia may
occur on tongue or mucosa
Diagnosis—physical examination and biopsy
Treatment—radiation, chemotherapy, and
surgery
Nursing management – monitor respiratory
status, aseptic wound care, trach care
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Cancer of the Esophagus
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Cigarette smoking is a major cause of
esophageal cancer in the United States.
When combined with heavy alcohol
consumption, the risk for esophageal cancer
greatly increases.
Esophageal cancer is the second most
common cancer in China but is seen less in
North America.
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Cancer of the Esophagus (Cont.)

GERD is a cause of Barrett’s esophagus,
which is a precancerous condition.
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Barretts esophagus
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Cancer of the Esophagus (Cont.)
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Signs, symptoms, and diagnosis
Treatment
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Esophagectomy – removal of sections of the
esophagus with reconstruction with part of the
stomach (high complication risk)
Photodynamic therapy - laser destroys damaged
cells
Nursing management
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Postoperative care – patent airway
Nutrition – parental fluids
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Audience Response Question 1
When screening for the presence of risk factors
for oral and pharyngeal cancers, the nurse
would ask which question(s)? (Select all that
apply.)
1.
2.
3.
4.
5.
“How much alcohol do you consume?”
“Have you had any oral lesions?”
“Do you have family members who have cancer?”
“What do you smoke?”
“Have you been exposed to hepatitis virus?”
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Hiatal Hernia (Diaphragmatic Hernia)
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Etiology and pathophysiology – defect in the
wall of the diaphragm where esophagus
passes through. Portion of the stomach
/lower part of esophagus up into the thoracic
cavity
Signs and symptoms – reflux, epigastric pain
Diagnosed by UGI series
Treatment – weight reduction, antacids,
histamine H2 receptors, keep HOB elevated
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Treatment of Hiatal Hernia
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Reduce weight.
Avoid tight-fitting clothes around the
abdomen.
Take antacids and histamine (H2)-receptor
antagonists.
Elevate head of the bed on 6- to 8-inch
blocks.
Take proton pump inhibitors (PPIs).
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Treatment of Hiatal Hernia (Cont.)
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Instruct not to eat within several hours before
going to bed.
Limit intake of alcohol, chocolate, caffeine,
and fatty foods.
Avoid smoking.
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Nursing Management
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Teach ways to prevent pain and reflux.
Encourage weight reduction.
Remind the patient to stay upright for 2 hours
after eating and not to eat for 3 hours before
bedtime.
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Nursing Management (Cont.)
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If the head of the bed cannot be raised, a
wedge pillow should be used to elevate the
upper body; this position helps prevent reflux
and assists gravity in maintaining the
stomach in the abdominal cavity.
H2 (Tagamet, Pepcid, Zantac) or PPIs
(Prilosec, Prevacid)
Avoid foods that cause bloating.
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Gastroesophageal Reflux Disease
GERD – Syndrome not a disease

Etiology and pathophysiology – transient
relaxation of the lower esophageal sphincter.
90% of patients with GERD have a hiatal
hernia, delayed stomach emptying. 75%
patients with asthma have GERD (irritation of
upper airways)
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Gastroesophageal Reflux Disease
GERD – Syndrome not a disease
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Signs and symptoms – EGD barium
esophagram, ambulatory PH monitoring
Diagnosis and treatment – diet therapy, drugs
(antacids, H2 receptor antagonists, PPI,
prokinetic drugs), education.
Nursing management


Diet therapy, lifestyle changes, drug therapy, and
education
Complications
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Gastroenteritis
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Inflammation of the stomach and small
intestine
Caused by food or water contaminated with a
virus, a pathogenic bacteria, or parasites
Signs and symptoms – V & D, abdominal
cramping, distention, fever, blood/mucus in
stool
Management – keep NPO till vomiting stops,
fluids then given with electrolytes
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Gastritis – inflammation of mucous
membrane lining the stomach
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Etiology – Helicobacter pylori bacteria, excessive
alcohol, contaminated food, cocaine use, ingestion of
medications
Pathophysiology – acute or chronic inflammation
Signs and symptoms – N&V, anorexia, pain &
tenderness in the stomach region
Diagnosis – history, physical, endoscopic exam
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Gastritis – inflammation of mucous
membrane lining the stomach

Treatment – Acute – no food by mouth,
antispasmodics, antacids, H2 receptor
antagonist, PPI. Chronic – diet therapy and
change in drinking habits, avoid spicy or acidic
foods
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Peptic ulcer
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Peptic Ulcers
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Etiology
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H. pylori
Duodenal ulcers and some pre-pyloric ulcers
Gastric ulcers
Tension, anxiety, and prolonged stress
Drug-induced ulcers
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Peptic Ulcers (Cont.)
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Pathophysiology – ulceration with loss of
tissue in the upper GI tract (duodenal &
gastric)
Signs and symptoms
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Daily pattern of pain
Gastrointestinal bleeding
Diagnosis
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Endoscopy
Gastric acid analysis
WBC – elevated in response to injury or
hypovolemia
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Peptic Ulcers (Cont.)
Gastric
Duodenal
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Treatment
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Antacids
Gastric bleeding and normal saline lavage
H2-receptor antagonist
PPIs
Presence of H. pylori—administration of
clarithromycin (Biaxin) plus another antibiotic,
an H2 inhibitor, and a PPI
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Nursing Management
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Complications
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Hemorrhage – ulcer erodes vessels causing
bleeding in the stomach
Perforation – erosion of the ulcer through all walls
of the stomach or intestine. Sudden, severe pain
in upper abdomen that persists and increases in
intensity (may refer to shoulders)
Obstruction – result of scarring, loss of
musculature at the pylorus – persistent vomiting
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Surgical Treatment of Peptic Ulcer
Pyloroplasty with truncal or proximal gastric
vagotomy
 Subtotal gastrectomy (gastric resection)
 Total gastrectomy
 See Figure 28-4
Page 657

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Nursing Care of the Patient Undergoing
Gastric Surgery
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Preoperative care – liquid diet, NPO, NG tube
inserted in OR- stomach contents are
suctioned out
Postoperative care
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Specific patient teaching – NG tube till removed
Diet restrictions – small amount liquids to small,
frequent meals – if total gastrectomy – diet is
restricted
Dumping syndrome – rapid passage of food
and liquid into the jejunum
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Gastric Cancer
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Etiology – pernicious anemia and absence of
hydrochloric acid, diet high in smoked, highly
salted or spiced foods. H. pylori, genetics,
type A blood
Signs and symptoms – indigestion, loss of
appetite, N&V, weight loss, blood in stool
Pathophysiology – grows from mucous
glands, antrum or pyloric area
Diagnosis – upper GI series, endoscopic
exam
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Gastric Cancer

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Treatment – surgical – debulk tumor, removal
40% 5 year cure rate
Radiation and/or chemotherapy – cancer may
spread to lymph nodes, the liver and ovaries
in women
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Common Therapies for Disorders of the
Gastrointestinal System
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Gastrointestinal decompression – insert NG
tube to remove fluids and gas from the
stomach
Enteral nutrition – nasoduodenal tube
placement confirmed by xray
Total parenteral nutrition – IV feeding – larger
central vein like superior vena cava. – PICC
line
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Small-Bore Feeding Tube Placement
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Audience Response Question 2
Regarding the care of enteral feeding tubes,
which nursing behavior(s) demonstrate(s)
appropriate nursing care? (Select all that apply.)
1.
2.
3.
4.
5.
Aspirating contents of jejunostomy tube
Gentle flushing of a clogged enteral tube with 30 mL
of water
Checking for 1-inch play on a gastrostomy tube
Monitoring blood urea nitrogen, prealbumin,
hematocrit, electrolytes, and glucose
Rotating a jejunostomy tube 360 degrees each day
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