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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 – – – – – – – 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 • • • • • 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 • • • • • • 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 • • • • CBC Chemistry Occult Blood Amylase Other Tests and Diagnostics • • • • Gastric analysis Urease (CLO test) X-rays Endoscopy with biopsy Other Tests and Diagnostics • • • • Esophagoscopy Gastroscopy Gastroduodenoscopy Esophagogastroduodenoscopy (EGD) Nursing Care – Ulcers • • • • • • 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 • • • • Cytoprotective Anticholinergics Prostaglandin Analogs Antibiotics Antibiotics • Most effective treatment against Helicobacter Pylori – – – – 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. – – – – – 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 • • • • 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 – – – – – – 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 • • • • 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) • • • • Middle-lower abdominal pain Gradual onset, cramp-like pain, less intense Late vomiting—fecal smelling emesis Marked abdominal distension What to look for: LBO • • • • Diminished or absent bowel sounds Lethargy, oliguria, dehydration Stool shape alteration (“ribbons”) Hemoconcentration, hypokalemia, hyponatremia Diagnostics: LBO • • • • 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 • • • • Bleeding Infection Pain Thrombophlebitis Complications of surgical intervention • • • • 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 • • • • • Flushing Palpitation Diarrhea/nausea Abdominal cramping Urge to defecate Early S/S of dumping syndrome • • • • • Epigastric fullness Distention Anxiety Shame Embarrassessment Late Manifestations of dumping • • • • • Occurs 2-3 hours after eating Rapid entry of high CHO food Hyperglycemia Excessive insulin production Hypoglycemic symptoms Management of dumping • • • • 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? 1. 2. 3. 4. 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? 1. 2. 3. 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