Download Upper GI Key Points Assessment ANATOMY AND PHYSIOLOGY

Upper GI Key Points
Assessment
ANATOMY AND PHYSIOLOGY REVIEW
 The gastrointestinal system includes the GI tract or alimentary canal, consisting of the mouth,
esophagus, stomach, small and large intestines, and rectum.
 The salivary glands, liver, gallbladder, and pancreas secrete substances into this tract to form
the GI system.
 The main function of the GI tract, with the aid of organs such as the pancreas and the liver, is
the digestion of food to meet the body’s nutritional needs, and the elimination of waste
resulting from digestion.
 The GI tract is susceptible to many health problems, including structural or mechanical
alterations, impaired motility, infection, and cancer.
 Although the GI tract is continuous from the mouth to the anus, it is divided into specialized
regions, each of which has a specific function.
 The functions of the GI tract include secretion, digestion, absorption, motility, and
elimination.
 The oral cavity includes the buccal mucosa, lips, tongue, hard palate, soft palate, teeth, and
salivary glands, and is involved with speech, taste, and mastication.
 Saliva contains mucin and an enzyme called salivary amylase, also known as ptyalin, which
begins the breakdown of carbohydrates.
 The esophagus is a muscular canal that extends from the pharynx to the stomach functioning
to move food and fluids from the pharynx to the stomach.
 The stomach functions as a food reservoir where the digestive process begins, using
mechanical movements and chemical secretions.
 The intestinal phase begins as the chyme passes from the stomach into the duodenum, causing
distention.
 The exocrine function of the pancreas secretes enzymes needed for digestion of
carbohydrates, fats, and proteins.
 The endocrine part of the pancreas is made up of the islets of Langerhans, with alpha cells
producing glucagon and beta cells producing insulin, essential in the regulation of
metabolism.
 The liver performs more than 400 functions in three major categories: storage, protection, and
metabolism.
 The small intestine has three main functions: movement (mixing and peristalsis), digestion,
and absorption.
 The large intestine’s functions are movement, absorption, and elimination.
ASSESSMENT TECHNIQUES
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One tool for assessing GI function is the nutritional-metabolic and elimination pattern
assessment found in Gordon’s Functional Health Patterns.
 Ask questions about changes in appetite, weight, and stool to determine the events related to
the current health problem.
 Collect data about the patient’s age, gender, and culture.
 Question the patient about previous GI disorders or abdominal surgeries, prescription
medications, over-the-counter drugs, smoking, chewing tobacco, and travel history, which
may provide clues about the cause of symptoms like diarrhea.
 The goal of a nutritional assessment is to gather information about how well the patient’s
nutritional needs are being met, special diets, and food allergies.
 Inquire about family history, since some GI disorders have genetic predisposition.
 Obtain a chronologic account of the current problem and treatments and explore the
characteristics associated with each symptom, including the location, quality, quantity,
timing, and aggravating or alleviating factors.
 Physical assessment involves a comprehensive examination of the patient’s nutritional status,
mouth, and abdomen.
 The abdominal examination begins at the patient’s right side and proceeds in a systematic
fashion through the right upper quadrant, left upper quadrant, left lower quadrant, and right
lower quadrant.
 The abdomen is assessed in a sequence different from that used for other body systems:
inspection, auscultation, percussion, and then palpation, so that palpation and percussion do
not increase intestinal activity and bowel sounds.
 Inspect the skin and note overall contour and symmetry of the abdomen, scarring or
discolorations, abdominal distention, bulging flanks, and taut, glistening skin.
 Auscultation of the abdomen is performed with the diaphragm of the stethoscope because
bowel sounds are usually high pitched.
 Bowel sounds are normally heard as relatively high-pitched irregular gurgles every 5 to 15
seconds, characterized as normal, hypoactive, or hyperactive.
 Bowel sounds are diminished or absent after abdominal surgery or in the patient with
peritonitis or paralytic ileus.
 Percussion is used to determine the size of solid organs; to detect the presence of masses,
fluid, and air; and to estimate the size of the liver and spleen.
 The purpose of palpation, used by advanced practitioners, is to determine the size and location
of abdominal organs and to assess for masses or tenderness.
 Do not palpate or auscultate any abdominal pulsating mass as it could be a life-threatening
aortic aneurysm.
 Psychosocial assessment focuses on how the GI health problem affects the patient’s life and
lifestyle.
 Emotional stress has been associated with the development or exacerbation of irritable bowel
syndrome and other GI disorders.
 Laboratory tests may include a complete blood count for diagnosis of anemia and infection;
coagulation studies, electrolytes, assays of serum enzymes for the evaluation of the liver and
pancreas, bilirubin, ammonia, and oncofetal antigens to diagnose and monitor for GI cancer.
 Stool studies evaluate the function and integrity of the GI tract and detect the presence of
infections, protozoa, parasites, and blood in the stool.
 Radiographic examinations detect structural and functional disorders.
 The nurse’s role is to properly prepare the patient for the examination, to provide an
explanation of the procedure, and to provide the necessary post-procedure care.
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An upper GI radiographic series is an x-ray visualization from the oral part of the
pharynx to the duodenojejunal junction to detect disorders of structure or function of the
esophagus, stomach, or duodenum.
 Instruct the patient to drink plenty of fluids and take a laxative as prescribed to eliminate
barium if used during diagnostic testing.
 Endoscopy is direct visualization of the GI tract using a flexible fiberoptic endoscope to
evaluate bleeding, ulceration, inflammation, tumors, and cancer of the esophagus,
stomach, biliary system, or bowel.
 EGD-Esophagogastroduodenoscopy is a visual examination of the esophagus, stomach,
and duodenum, during which a physician can inject a sclerotherapy agent into an affected
area to stop bleeding.
 ERCP-Endoscopic retrograde cholangiopancreatography includes visual and radiographic
examination of the liver, gallbladder, bile ducts, and pancreas to identify the cause and
location of obstruction
 The priority for care is to check for the return of the gag reflex after an upper endoscopic
procedure before offering fluids or food, to avoid aspiration.
 Assess patients who have endoscopies for bleeding, fever, and severe pain.
 Monitor vital signs carefully for the patient having any endoscopic procedure and
moderate sedation.
 If an endoscopic procedure on an ambulatory basis is scheduled, remind the patient to
have someone available to drive him or her home because of the effects of moderate
sedation.
 Colonoscopy is an endoscopic examination of the entire large bowel, during which tissue
biopsy specimens or polyps may be removed through the colonoscope.
 Proctosigmoidoscopy, often referred to as a sigmoidoscopy, is an endoscopic
examination of the rectum and sigmoid colon using a flexible scope to screen for colon
cancer, investigate the source of GI bleeding, or diagnose or monitor inflammatory bowel
disease.
 For patients having a colonoscopy, check for passage of flatus before allowing fluids or
food.
 Teach patients to limit caffeine and alcohol in their diets to reduce risk of gastrointestinal
health problems.
 Teach patients having invasive colon diagnostic procedures to follow instructions
carefully for the bowel preparation to ensure that the bowel is clear.
 The 2010 American Cancer Society Screening Guidelines recommend yearly fecal occult
blood test, yearly fecal immunochemical test, or stool DNA (sDNA) at unspecified
intervals to detect colorectal cancer early when it can be treated.
 The newest test for detection of colorectal cancer is stool DNA (ColoSure®). This test
examines stool DNA to detect changes in the vimetin gene. Most patients with colorectal
cancer have genetic changes, that can be detected by this simple test.
 The 2010 American Cancer Society Screening Guidelines include options to determine the
presence of colorectal cancer or polyps for people over 50 years of age:
o Double-contrast barium enema every 5 years
o Flexible sigmoidoscopy every 5 years
o CT colonography (virtual colonoscopy) every 5 years
o Colonoscopy every 10 years
Chapter 57: Care of Patients with Esophageal Problems
Key Points - Print
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The esophagus moves partially digested food from the mouth to the stomach.
Common problems of the esophagus that can interfere with digestion and nutrition are caused
by inflammation, structural defects or obstruction, and cancer.
Collaborative management requires dietary and lifestyle changes, as well as medical and
surgical therapies.
GASTROESOPHAGEAL REFLUX DISEASE
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Gastroesophageal reflux disease (GERD) is the most common upper GI disorder in the
United States, occurring most often in middle-aged and older adults. The incidence of GERD
is increasing throughout the world.
GERD occurs as a result of reflux, or backward flow, of gastrointestinal contents into the
esophagus.
Reflux produces symptoms by exposing the esophageal mucosa to the irritating effects of
gastric or duodenal contents, resulting in inflammation, which may be mild to severe.
During the process of healing, the body may substitute Barrett’s epithelium for the normal
squamous cell epithelium of the lower esophagus.
This new tissue is more resistant to acid and therefore supports esophageal healing, but it is
associated with an increased risk of cancer in patients with prolonged GERD.
The fibrosis and scarring that accompany the healing process can produce esophageal
stricture, which is narrowing of the esophageal opening.
The stricture leads to progressive difficulty in swallowing.
Dyspepsia, also known as heartburn, is the main symptom of GERD and is described as a
substernal burning sensation that tends to move up and down the chest in a wavelike fashion.
Other symptoms include eructation or belching, flatulence, and difficult or painful
swallowing.
For most patients, GERD can be controlled by nutrition therapy, lifestyle changes, and drug
therapy.
The most important role of the nurse is patient and family education.
In the past decade, several noninvasive endoscopic procedures have been approved for the
diagnosis and treatment of severe GERD. This nonsurgical procedure has also been approved
for patients with Barrett’s esophagus.
A very small percentage of patients with GERD require antireflux surgery.
A newer drug, omeprazole/sodium bicarbonate (Zegerid), is the first immediate-release drug
and is designed for short-term use.
Another newer drug, dexlansoprazole (Kapidex), is a dual-release (delayed release) drug that
is available in several dosages, but tends to be associated with more side and adverse effects
than some of the other drugs.
HIATAL HERNIA
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Hiatal hernias, also called diaphragmatic hernias, involve the protrusion of a portion of the
stomach through the esophageal hiatus of the diaphragm into the chest.
Most patients with hiatal hernias are asymptomatic, but some may have daily symptoms
similar to those with GERD.
Patients with hiatal hernias may be managed either medically or surgically based on the
severity of symptoms and the risk of serious complications.
The primary focus of care after conventional surgery is the prevention of respiratory
complications.
Remember the following key points when caring for patients with esophageal disorders.
 Collaborate with the health care team for the patient with impaired swallowing and/or limited
nutrition.
 Remain with the dysphasic patient during meals to prevent or assist with choking episodes.
 Teach the patient oral exercises and correct positioning aimed at improving swallowing.
 Stress the importance of recognizing and controlling reflux through dietary management and
medications to avoid further esophageal damage.
 Teach the patient to elevate the head of the bed by 6 inches when sleeping to prevent
nighttime reflux.
 Instruct the patient to sleep in the right side-lying position to minimize the effects of nighttime
episodes of reflux.
 Be sure to frequently monitor the nutritional status of the patient with esophageal cancer.
 Teach the patient with esophageal cancer to monitor his or her body weight and to notify the
health care provider of a loss of 5 pounds or greater.
 Teach the patient to avoid alcoholic beverages, smoking, and other substances that lead to
increased gastroesophageal reflux.
 Teach the patient to prevent gas bloat syndrome by avoiding drinking carbonated beverages,
eating gas-producing foods, chewing gum, and drinking with a straw.
Chapter 58: Care of Patients with Stomach Disorders
Key Points - Print
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The most common stomach disorders include gastritis, peptic ulcer disease, and gastric
cancer, all of which result in impaired or altered digestion and nutrition.
The stomach is part of the upper GI system which is responsible for a large part of the
digestive process.
Diseases that affect the stomach can be very serious and in some cases life threatening.
GASTRITIS
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Gastritis is defined as inflammation of the gastric mucosa.
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It can be scattered or localized and can be classified according to cause, cellular changes, or
distribution of the lesions.
Gastritis can be designated as erosive, causing ulcers, or nonerosive.
Prostaglandins provide a protective mucosal barrier that prevents the stomach from digesting
itself by a process called acid autodigestion.
With a break in the protective barrier, mucosal injury occurs.
Inflammation of the gastric mucosa or submucosa after exposure to local irritants or other
cause can result in acute gastritis.
Chronic gastritis appears as a patchy, diffuse inflammation of the mucosal lining of the
stomach, resulting in thinning and atrophy of the walls and lining of the stomach.
Helicobacter pylori infection and penetration of the mucosal gel layer of the gastric
epithelium is often responsible, although other forms of bacterial gastritis occur less often.
Type A gastritis has been associated with the presence of antibodies to parietal cells and
intrinsic factor, therefore, most likely related to autoimmune disease.
H. pylori infection causes type B gastritis, which is more common.
A balanced diet, regular exercise, avoidance of excessive use of aspirin and other NSAIDs,
and stress reduction techniques can help prevent gastritis.
Symptoms of acute gastritis include mild to severe epigastric discomfort, anorexia, cramping,
nausea and vomiting, abdominal tenderness and bloating, hematemesis, or melena.
Chronic gastritis causes few symptoms unless ulceration occurs.
Methods to detect H. pylori include a blood test to detect IgG or IgM anti-H. pylori
antibodies, immune testing using an enzyme-linked immunosorbent assay and immune
chromatomography, and breath and stool analyses.
Esophagogastroduodenoscopy via an endoscope with biopsy is the gold standard for
diagnosing gastritis.
Collaborative management is directed toward supportive care for relieving the symptoms and
removing the cause of discomfort.
Acute gastritis healing is spontaneous, usually occurring within a few days.
Surgery, such as partial gastrectomy, pyloroplasty, and/or vagotomy, may be needed for
patients with major bleeding or ulceration.
Treatment of chronic gastritis varies with the cause.
PEPTIC ULCER DISEASE
 A peptic ulcer is a mucosal lesion of the stomach or duodenum.
 Three types of ulcers may occur: gastric ulcers, duodenal ulcers, and stress ulcers, which are
less common.
 Most gastric and duodenal ulcers are caused by H. pylori infection, which is transmitted via
the fecal-oral route and thought to be acquired in childhood.
 Peptic ulcer disease results when mucosal defenses become impaired and no longer protect
the epithelium from the effects of acid and pepsin.
 Acid, pepsin, and H. pylori infection play an important role in the development of gastric
ulcers.
 The most common complications are hemorrhage, perforation, pyloric obstruction, and
intractable disease, with hemorrhage as the most serious.
 If perforation into the peritoneal cavity is present, the patient has a rigid, boardlike abdomen
accompanied by rebound tenderness.
 Serologic testing for IgG anti-H. pylori antibody is the most common noninvasive method to
confirm H. pylori infection. IgA and IgM anti-H. pylori antibody testing may also be
performed.
 Hemoglobin and hematocrit values may be low, indicating bleeding.
 A stool specimen may be positive for occult blood if bleeding is present.
 GI bleeding may be tested using a Nuclear Medicine GI bleeding study. No special
preparation is required for this scan. The patient is injected with a contrast medium (usually
Tc99m) and the GI system is scanned for the presence of bleeding after a waiting period.
 The major diagnostic test is esophagogastroduodenoscopy.
 The primary goals of drug therapy are to (1) provide pain relief, (2) eliminate H. pylori
infection, (3) heal ulcerations, and (4) prevent recurrence.
 Teach patients about complementary and alternative therapies that can reduce stress,
including hypnosis and imagery.
 Teach patients the importance of adhering to H. pylori treatment to prevent the risk for
gastric cancer.
 A new faster-acting form of omeprazole combined with sodium bicarbonate (Zegerid) can be
purchased OTC and is prescribed most often for active duodenal ulcers for a 4 to 8 week
period.
 The patient who is actively bleeding has a life-threatening emergency and requires supportive
therapy to prevent hypovolemic shock and possible death.
 Endoscopic therapy via an esophagogastroduodenoscopy (EGD) can assist in achieving
homeostasis during an acute hemorrhage by isolating the bleeding artery to embolize (clot) it.
o Octreotide (Sandostatin) or terlipressin (Novapressin) may be given IV as adjuvant
therapy.
o These drugs are synthetic GI hormones (somatostatin analogues) that suppress gastric
acid secretion.
 For patients with persistent, massive upper GI bleeding or those who are not surgical
candidates, catheter-directed embolization may be performed.
 The primary methods of endoscopic therapy are (1) thermal contact using a heater probe or
multielectrocoagulation, (2) injection of the bleeding site with diluted epinephrine, and (3)
clipping the bleeding vessel with a mechanical clip.
 Surgical intervention is rare but may be used to treat patients who do not respond to medical
therapy or to treat a surgical emergency that develops as a complication.
 Dumping syndrome is a term that refers to a group of vasomotor symptoms that occur after
eating as a result of the rapid emptying of food contents into the small intestine, which shifts
fluid into the gut causing abdominal distention.
 Observe the patient for signs and symptoms of dumping syndrome after gastric surgery and
teach them the manifestations and management of this syndrome.
 Interventions to minimize dumping syndrome include small, frequent meals, avoiding liquids
with meals, avoiding foods that cause discomfort, eliminating caffeine, alcohol, and tobacco
consumption, receiving B12 injections as appropriate, and lying flat after eating for a short
time.
Keep these general guidelines in mind when caring for these patients.
 Refer patients and families to organizations focused on digestive disorders where they can
obtain information and support.
 Identify patients at risk for gastritis and peptic ulcer disease, especially older adults who take
large amounts of NSAIDs and those with H. pylori.
 Teach patients the importance of complying with H. pylori treatment to prevent the risk of
gastric cancer.
 Teach patients with abnormal symptoms, such as abdominal tenderness, abdominal pain that
is relieved by food or pain or that becomes worse 3 hours after eating, dyspepsia, melena,
and/or distention to consult with their physician immediately for prompt diagnosis and
treatment.
 Teach patients that hematemesis is a medical emergency and that they should go to the
emergency department for prompt treatment.
 Teach patients about various complementary and alternative therapies that are currently used
for gastritis and peptic ulcer disease.
 For patients who have undergone a gastrectomy, collaborate with the dietitian and instruct the
patient regarding diet changes to avoid distention and dumping syndrome.
 Teach the proper administration of antacids and provide the information that antacids can
interfere with the effectiveness of certain drugs.
 Teach the proper administration of H2 antagonists on an empty stomach.
 Teach the proper administration of antisecretory agents, noting that most cannot be crushed
because they are sustained-release or enteric-coated tablets.
Chapter 62: Care of Patients with Problems of the Biliary System and Pancreas
Key Points - Print
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The liver, gallbladder, and pancreas secrete enzymes and substances that promote food
digestion in the stomach and small intestine.
 When these organs do not work properly, the person has impaired digestion which may result
in inadequate nutrition.
 Patients with biliary and pancreatic disorders are at high risk for biliary obstruction, a serious
and painful complication.
 Interdisciplinary management of patients with problems of the biliary system and pancreas
includes the need to promote nutrition for normal cellular function.
GALLBLADDER DISORDERS
CHOLECYSTITIS
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Cholecystitis is an inflammation of the gallbladder that affects many people in affluent
countries.
 It may be either acute or chronic, although most patients have the acute type.
 Two types of acute cholecystitis are calculous and acalculous cholecystitis.
 The most common type is calculous cholecystitis, in which chemical irritation and
inflammation results from gallstones that obstruct the cystic duct most commonly, gallbladder
neck, or common bile duct.
 Acalculous cholecystitis, inflammation occurring without gallstones, is associated with biliary
stasis caused by changes in the regular filling or emptying of the gallbladder.
 Chronic cholecystitis results when repeated episodes of cystic duct obstruction result in
chronic inflammation, most often with calculi.
 Jaundice, seen as yellow discoloration of the skin and mucous membranes, and icterus, which
is yellow discoloration of the sclera, can occur in patients with acute cholecystitis, but is most
commonly observed with the chronic form of the disease.
 Women from 20 to 60 years of age are twice as likely to develop gallstones as men.
 Obesity, pregnancy, estrogen, birth control pills, and combinations of those factors are major
risk factor for gallstone formation, especially in women.
 Teach patients to avoid losing weight too quickly and keep weight under control to help
prevent gallbladder disease.
 Patients with acute cholecystitis present with abdominal pain, although clinical manifestations
vary in intensity and frequency.
 There are no laboratory tests specific for gallbladder disease, so differential diagnosis rules
out diseases causing similar symptoms, such pancreatitis.
 When the cause of cholecystitis or cholelithiasis is not known or the patient has
manifestations of biliary obstruction, such as jaundice, an endoscopic retrograde
cholangiopancreatography may be performed.
o Some patients have the less invasive and safer magnetic resonance
cholangiopancreatography which can be performed by an interventional radiologist.
 Most patients do not respond to nonsurgical interventions during the acute phase of
cholecystitis, therefore, surgery is the treatment of choice.
 Cholecystectomy is a surgical removal of the gallbladder via laparoscopic cholecystectomy
or, far less often, cholecystectomy.
 A new procedure is natural orifice transluminal endoscopic surgery (NOTES) for removal of
or repair of organs. Surgery can be performed on many body organs through the mouth,
vagina, and rectum. For removal of the gallbladder, the vagina is used most often because it
can be easily decontaminated with Betadine or other antiseptic, and allows easy access into
the peritoneal cavity.
CANCER OF THE GALLBLADDER
 Primary cancer of the gallbladder is rare, more common in women than in men, and usually
is an adenocarcinoma or squamous cell cancer.
 The diagnosis of gallbladder cancer is typically made by ultrasonography but computed
tomography scan, endoscopic retrograde cholangiopancreatography (ERCP), or magnetic
resonance cholangiopancreatography are also used.
 The prognosis for the patient with cancer of the gallbladder is poor because it is usually
diagnosed in late disease.
 Treatments used include surgery, radiation therapy, and chemotherapy.
 Surgical intervention is either potentially curative for an early resectable tumor or palliative
for advanced disease with metastasis.