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Caring for Clients with Disorders of the Upper Gastrointestinal Tract Disorders that Affect Eating Anorexia Lack of appetite; Malnutrition Pathophysiology and Etiology The appetite center Stimulates or suppresses appetite Location and function; Gluconeogenesis Assessment Findings: Signs and Symptoms Absence of hunger; Nausea; Hypovitaminosis Assessment Findings: Diagnostic Findings Reduced hemoglobin level and blood cell counts Anorexia nervosa Is an eating disorder characterized by unrealistic fear of weight gain, selfstarvation, and conspicuous distortion of body image. Two subtypes of anorexia nervosa —a restricting type, characterized by strict dieting and exercise without binge eating —binge-eating/purging type, marked by episodes of compulsive eating with or without self-induced vomiting and the use of laxatives or enemas. Causes & Symptoms Anorexia is a disorder that results from the interaction of cultural and interpersonal as well as biological factors. While the precise cause of the disease is not known, it has been linked to the following: Social Influences Occupational Goals Genetic and Biological Influences Psychological Factors - Inability to interpret the body's hunger signals accurately due to early experiences of inappropriate feeding. Diagnosis Anorexics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea (failure to menstruate) in females, abdominal pain Constipation lack of energy The patient may feel chilly or have developed lanugo, a growth of downy body hair. If the patient has been vomiting, she may have eroded tooth enamel Weight loss - 15% below normal Treatment Nutritional Therapy Alternative treatments should serve as complementary to a conventional treatment program. Alternative therapies for anorexia nervosa include: Herbal therapy - may help reduce anxiety and depression which are often associated with this disorder: chamomile (Matricaria recutita) lemon balm (Melissa officinalis) hydrotherapy AromatherapyMedications Medications, including antidepressants, anti-anxiety drugs, selective serotonin reuptake inhibitors, and lithium carbonate. One study of Prozac showed it helped the patient maintain weight gained while in the hospital. Bulimia nervosa Is an eating disorder and psychological condition in which the subject engages in recurrent binge eating followed by feelings of guilt, depression, and self-condemnation and intentional purging to compensate for the excessive eating. Purging can take the form of vomiting, fasting, inappropriate use of laxatives, enemas, diuretics or other medication, or excessive physical exercise. The cycle damages bodily organs. Bulimia is common especially among young women of normal or nearly normal weight. Diagnosis Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: Eating, in a fixed period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). Self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months. Types of Bulimia Purging Type is the more common type of bulimia, and involves any of self-induced vomiting, laxatives, diuretics, enemas, or ipecac, to rapidly extricate the contents from their body. Non-Purging Type occurs in only approximately 6%8% of bulimia cases, as it is a less effective means of ridding the body of such a large number of calories. It involves doing excessive exercise or fasting after a binge, to counteract the large amount of calories previously ingested. Causes of Bulimia Bulimia is related to deep psychological issues and feelings of lack of control. Sufferers often use the destructive eating pattern to feel in control over their lives. They may hide or hoard food and overeat when stressed or upset. They may feel a loss of control during a binge, and consume great quantities of food (over 20,000 calories. There are higher rates of eating disorders in groups involved in activities that emphasize thinness and body type, such as gymnastics, dance and cheerleading, figure skating. Treatment Several residential treatment centers offer long term support, counseling, and symptom interruption. The most popular form of treatment involves therapy, often group psychotherapy or cognitive behavioral therapy. Anorexics and bulimics typically go through the same types of treatment and are members of these same treatment groups. Anti-depressants or anti-psychotics. Disorders that Affect Eating: Anorexia Medical and Surgical Management Short-term: No medical intervention Various approaches for persistent anorexia Psychological and psychiatric treatment Nursing Management Monitoring weight daily Obtaining medical and allergy history Additional nursing measures for altered bowel patterns Disorders that Affect Eating: Nausea and vomiting Pathophysiology and Etiology Common causes and symptoms Assessment Findings: Signs and Symptoms Loss of appetite and dehydration Assessment Findings: Diagnostic Findings Low levels of serum sodium and chloride Medical and Surgical Management IV fluids, electrolytes, and drug therapy Nursing Management Assessing medical, allergy, and dietary history, and bowel patterns Nursing Process: The Client with Nausea and Vomiting Assessment Obtain medical, dietary, drug, and allergy history- details of food intake Monitoring signs of fluid volume deficit Diagnosis, Planning, and Interventions Deficient fluid volume Imbalanced nutrition Evaluation of Expected Outcomes Oral intake and output; Maintained weight, serum electrolyte levels and other laboratory test results Obesity Is an abnormal accumulation of body fat, usually 20% or more over an individual's ideal body weight. Obesity is associated with increased risk of illness, disability, and death Causes of Obesity Results from an excess of energy (caloric) intake over expenditure, but this statement does not explain why some individuals can eat as much as they like without gaining weight while others remain overweight despite constant dieting. Studies of genetically obese animals and those with damage to the part of the brain called the hypothalamus suggest that individuals may balance body weight around a “setpoint” that is maintained—without conscious control—by variations in metabolic rate in response to caloric intake. Variations in the prevalence of obesity among population groups suggest a genetic basis for the condition. Treatment Involve keeping a food diary and developing a better understanding of the nutritional value and fat content of foods. It may also involve changing grocery shopping habits (e.g. buying only what is on a prepared list and going only on a certain day), timing of meals (to prevent feelings of hunger, a person may plan frequent small meals), and actually slowing down the rate at which a person eats. Understanding what psychological issues underlie a person's eating habits. For example, one person may binge eat when under stress, while another may always use food as a reward. In recognizing these psychological triggers, an individual can develop alternate coping mechanisms that do not focus on food. How people spend their time. Making activity and exercise an integral part of everyday life is a key to achieving and maintaining weight loss. Starting slowly and building endurance keeps individuals from becoming discouraged. Varying routines and trying new activities also keeps interest high. Other weight-loss medications available with a doctor's prescription include: Sibutramine (Meridia) Diethylpropion (Tenuate, Tenuate Dospan) Mazindol (Mazanor, Sanorex) Phendimetrazine (Bontril, Prelu-2) Phentermine (Adipex-P, Fastin, Ionamin, Oby-Cap) Surgical Treatment Lipectomy – liposuction Jaw wiring Gastric Stapling ( Gastric Partitioning, Gastroplasty) Bypass Procedure Disorders that Affect Eating Cancer of the Oral Cavity Cancer cells; Effects on oral cavity Pathophysiology and Etiology Causes for oral and lip cancer Consequences Squamous cell carcinoma Assessment Findings: Signs and Symptoms Early symptoms: Lesion; Lump; Changes; Pain; Soreness; Bleeding; Leukoplakia; Biopsy of the lesion DISORDERS OF THE MOUTH CARIES - Decay of a bone or tooth, especially dental caries. Candidiasis is an infection caused by a species of the yeast Candida, usually Candida albicans. Candida may cause mouth infections in people with reduced immune function, or in patients taking certain antibiotics. Candidiasis Treatment Treatment of candidiasis is primarily accomplished through the use of antifungal drugs. Oral candidiasis is usually treated with prescription lozenges or mouthwashes. Some of the most-used prescriptions are nystatin mouthwashes (Nilstat or Nitrostat) and clotrimazole lozenges. Disorders that Affect Eating: Cancer of the Oral Cavity Medical and Surgical Management Transfusions and antianxiety agents Tumor excision Radiation therapy and chemotherapy Tracheostomy and tube feedings Nursing Management Addressing communication problems Post-operative care after oral surgery Promoting effective coping skills Nutritional management Disorders that Affect Eating: Cancer of the Oral Cavity Nursing Management (Cont’d) Gastrointestinal Intubation for Feedings or Medications Reason Types of GI intubation Procedure Route of administration Selecting type of tube Nursing Process: The Client Receiving Tube Feedings Assessment Reason for tube feedings Evaluating renal function and digestive issues Diagnosis, Planning, and Interventions Client receiving tube feedings and medications; Objectives; Fluid volume deficit – hydration; Infection Imbalanced nutrition: Dietary intake Aspiration and risk for Diarrhea Nursing Process: The Client Receiving Tube Feedings Evaluation of Expected Outcomes Maintains weight, clear lungs and normal bowel patterns Gastrointestinal Intubation for decompression Larger GI tube Gastric sump tube Gastrostomy Tubes for Long-Term Feeding Gastrostomy; Endoscopically Nursing Process: The Client Receiving Tube Feedings Fig. 51-1 Measuring length of nasogastric tube for placement into stomach Nursing Process: The Client Receiving Tube Feedings Gastrostomy Tubes for Long-Term Feeding: General considerations Surgical placement; Gastrostomy; Laparotomy; PEG – Procedure Gastric feedings; Passage of food into the small intestine Gastrostomy feeding devices Gastrostomy Tubes for Long-Term Feeding: Nursing Management Precautions before and during PEG Preparation of client’s skin Monitor: Vital signs and client’s tolerance of the procedure Disorders of the Esophagus Gastroesophageal Reflux Disease Gastric contents flow upward Pathophysiology and Etiology Inability of lower esophageal sphincter to close Assessment Findings: Signs and Symptoms Epigastric pain, burning sensation, and regurgitation Disorders of the Esophagus: Gastroesophageal Reflux Disease Assessment Findings: Diagnostic Findings Barium swallow findings; Upper endoscopy with biopsy; Capsule; Bronchoscopy Medical and Surgical Management Conservative measures and medications Fundoplication (tucking of fundus) and Stretta procedure Nursing Management Dietary management; Lifestyle changes Patient education What is the Stretta Procedure? Delivers precise radiofrequency (RF) waves to the gastro esophageal (GE) junction to restore lower esophageal sphincter function. Once the lower esophageal sphincter function is restored it will act as a barrier to prevent the upward flow of gastric contents into your esophagus. Disorders of the Esophagus: Esophageal Diverticulum Pathophysiology and Etiology Zenker’s diverticulum ( pharynx) Congenital or acquired weakness of esophageal wall Assessment Findings: Signs and Symptoms Foul breath and difficulty in swallowing Barium swallow and esophagoscopy Disorders of the Esophagus: Esophageal Diverticulum Medical and Surgical Management Diet therapy: Bland; Soft; Semisoft; Liquid Surgical excision of the diverticulum Nursing Management Educate about diet and lifestyle changes Advise pregnant clients that symptoms of GERD usually resolve after delivery Disorders of the Esophagus Hiatal Hernia Axial or sliding and paraesophageal (A protrusion of a portion of the stomach) Pathophysiology and Etiology Defect in diaphragm Congenital muscle weakness Assessment Findings Heartburn, belching or pain after eating Barium swallow and esophagoscopy Medical and Surgical Management Narrowed esophagus stretched endoscopically Nursing Process: The Client with an Esophageal Disorder Assessment Evaluate appetite, pain, weight and use of medications Diagnosis, Planning, and Interventions Postoperative care Imbalanced nutrition Pain related to pressure or reflux of gastric secretions Evaluation of Expected Outcomes Consumes adequate nutrients Relief from epigastric pain Disorders of the Esophagus: Cancer of the Esophagus Pathophysiology and Etiology Affects men more often than women Tumor usually is squamous cell carcinoma Correlation with esophageal cancer, alcohol abuse, and cigarette smoking Assessment Findings Beginning and progressive symptoms Barium swallow, biopsy, EGD, bronchoscopy and endoscopic ultrasound or mediastinoscopy Disorders of the Esophagus: Cancer of the Esophagus Medical and Surgical Management Palliative measures, endoscopic laser surgery or esophageal dilatation Surgery Nursing Management Focusing on nutritional needs Caring for client with tube feedings Postoperative care after surgery Patient education Gastric Disorders: Gastritis Pathophysiology and Etiology Causes; Helicobacter pylori (Bacterium commonly infecting the gastric mucosa in patients with ulcers. Result of acid production Assessment Findings Common symptoms Symptoms with bacterial or viral infection Complete blood count, stool test and gastroscopy Gastric Disorders: Gastritis Medical and Surgical Management Restricted eating and IV fluids Avoidance of irritating substances Various drugs: Antiemetics; antibiotics Nursing Management Evaluate response to dietary modifications and prescribed medications Observe color and characteristics of vomitus or stool Patient education Gastric Disorders: Peptic Ulcer Disease Pathophysiology and Etiology Infection with Helicobacter pylori Family history and other risk factors Development of ulcers Chronic gastric inflammation Assessment Findings Abdominal pain and back pain Bleeding- hematemesis and melena FIG 51-4 Gastric ulcer Gastric Disorders: Peptic Ulcer Disease Assessment Findings: Diagnostic Findings Esophagogastroduodenoscopy Gastric washing Low Hemoglobin and RBC Medical and Surgical Management Eradication therapy,Gastrectomy Nursing Management Assessment of pain and dietary history Nutritional management; Bowel patterns Nursing Process: The Client with a Gastric Disorder Assessment Information on current symptoms, past gastric problems and treatments or surgery Signs of abdominal pain, malnutrition, and dehydration Diagnosis, Planning, and Interventions Risk for deficient fluid volume Deficient knowledge Evaluation of Expected Outcomes Fluid intake and output; Nutritional intake Gastric Disorders: Cancer of the Stomach Pathophysiology and Etiology Stomach malignancies Heredity and chronic inflammation Achlorhydria and chronic ingestion of toxins Assessment Findings Early symptoms: Stool contains occult blood Barium swallow, CT scan, tissue biopsy, gastric analysis and ultrasonography Gastric Disorders: Cancer of the Stomach Medical and Surgical Management Subtotal or total gastrectomy Chemotherapy Palliative radiation Nursing Management Client and family teaching Instructing high risk groups Surgery for gastric cancer Nursing Management General Nutritional Considerations Limiting high fat foods and liquid Intermittent cyclic and bolus tube feedings Use of medium-chain triglycerides (MCT) General Pharmacologic Considerations H2 antagonists, antacids and sucralfate Patient education Avoiding sodium bicarbonate Nursing Management General Gerontologic Considerations Factors leading to anorexia Oropharyngeal dysphagia Modification of diet Greater risk for: Aspiration Superficial gastritis and gastric ulcers Hiatal hernia Pernicious anemia (inability to absorb vitamin B12) End of Presentation