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Objectives
Compare the etiology, clinical manifestations,
and management of acute gastritis, chronic
gastritis, and peptic ulcer.
Describe the management of the patient with
gastritis.
Describe the dietary, pharmacologic, and
surgical treatment of peptic ulcer.
Describe the nursing management of patients
who undergo surgical procedures to treat
obesity.
Use the nursing process as a framework for care
of patients undergoing gastric surgery.
Educate patient regarding an acute or chronic
gastric or duodenal condition.
Objectives
Gastritis
Inflammation of gastric mucosa
Irritants
Aspirin, NSAIDS, Excessive alcohol use, caffeine
Manifestations of Gastritis
Acute: abdominal discomfort, headache, lassitude, nausea,
vomiting, hiccuping.
Chronic: epigastric discomfort, anorexia, heartburn after
eating, belching, sour taste in the mouth, nausea and
vomiting, intolerance of some foods. May have vitamin
deficiency due to malabsorption of B12.
May be associated with achlorhydria, hypochlorhydria, or
hyperchloryhydria.
Diagnosis is usually by UGI X-ray or endoscopy and
biopsy.
If acute
Education
Treatment
If r/t ingestion of strong acids or alkalis
Neutralize
Supportive therapy
Fiberoptic Endoscopy
Gastrojejunostomy
NG, analgesics, sedatives, antacids, IV fluids
Drug therapy
Pharmacologic therapy (See Table 23-1)
H2 Receptor Antagonists
PPIs
Antacids
Mucosal protectant
We discussed
these in Part 1.
GI Protectant
Sucralfate (Carafate)
Coats injured area in the stomach to prevent
further injury from acid
PO
Tx of duodenal ulcers, maintenance of duodenal
ulcers after healing, tx of oral and esophageal
ulcers due other factors such as chemo, under
investigation for tx of gastric ulcers and gastric
damage r/t NSAIDS, and stress ulcers in acutely ill
GI Protectant
Prostaglandin
Misoprostol (Cytotec)
Inhibits gastric acid secretion and increases
bicarb and mucous production in the stomach
PO
Prevention of NSAID induced ulcers in adults at
high risk for developing gastric ulcers, under
investigation for tx of duodenal ulcers in pts who
are not responsive to other treatment
Prostaglandins
Question
The nurse is teaching a patient about health
promotion and maintenance to prevent chronic
gastritis. Which information should the nurse
include? (Select all that apply)
A. A balanced diet can help prevent gastritis.
B. To prevent gastritis, you should limit you calcium
intake.
C. If you stop smoking, there is less of a chance you will
develop gastritis.
D. Yoga has been found to be effective.
E. Drink alcohol only 5 days a week.
Peptic Ulcer
Erosion of a mucous membrane forms an excavation in
the stomach, pylorus, duodenum, or esophagus
Associated with infection of H. pylori
Manifestations include a dull gnawing pain or burning in
the mid-epigastrium; heartburn and vomiting may occur
Comparison of duodenal and gastric ulcer (Table 23-2 p 636)
Risk Factors
Clinical Manifestations
May have no symptoms or may last days, weeks,
months and then disappear and reappear
Complains of dull, gnawing pain or burning
sensation in the midepigastrium or in the back
Other symptoms
Pyrosis, vomiting, constipation, or diarrhea, and
bleeding
Ulcer Comparison
Duodenal Ulcer
Most common
Hypersecretion of stomach
acid
May have wt gain
Pain 2-3 hours after a meal
Often pain will awaken 1-2am
Gastric Ulcer
Less common
Normal to hyposecretion of
stomach acid
Weight loss may occur
Pain -1hr after a meal
Pain rare at night
Pain may be relieved by
vomiting
Ingestion of food does not help
sometimes increases pain
Vomiting common
Hemorrhage more common
Hematemesis more common
than melena
Question
Which assessment data supports to the nurse the clients
diagnosis of gastric ulcer.
A. Presence of blood in the clients stool for the past
month.
B. Reports of a burning sensation moving like a wave.
C. Sharp pain in the upper abdomen after eating a heavy
meal.
D. Complaints of epigastic pain 30-60 minutes after
ingesting food..
Diagnostics
Barium study of upper GI
Endoscopy preferred
Biopsy
Nursing Management
Treatment of peptic ulcers with antibiotics to
eradicate H. pylori
Lower reoccurrence rate
Treatment includes
Lifestyle changes
Medications (See Table 23-3)
Ulcer healing- H2 receptor antagonists (dine) and
PPIs along with bismuth salts to suppress or
eradicate H pylori
Prophylactic therapy for NSAID ulcers PPIs and
Prostaglandin analog misoprostol
H-pylori tx
Gastric Surgery
Gastrectomy- removal of all or part of stomach
Antrectomy- removal of antrum portion of
stomach
Vagotomy- severe branches of the vagus nerve
Pyloroplasty- enlargement of the opening
between the stomach and small intestine
Complications
Hemorrhage (Most common)[GI bleed]
Hematemesis
Melena
Management of hemorrhage
Complications
Management of perforation
Management of penetration
Back and epigastic pain not relieved by meds that were effective
before
Patient requires immediate surgery.
Pyloric obstruction
Question
You are providing discharge teaching to you client
regarding taking a proton pump inhibitors.
Which information would you want to stress to
the client?
a. Before meals
b. With a meal
c. Immediately after the meal
d. One to three hours after the meal
Morbid Obesity
People who are > 2x their ideal body weight
(IBW)
More than 100 pounds greater than IBW
Body mass index (BMI) exceeds 30
Risk factors
Diabetes
Cardiovascular disease
Cancer
Osteoarthritis
Asthma
Sleep apnea
Depression
Medical Management
Bariatric Surgery
Average wt loss after sx is 61%
Improvement seen in comorbid conditions
6-12 months of counseling and education prior to sx
After sx will require lifelong monitoring of wt loss
Risk of malnutrition and wt gain
Surgery is preformed only after nonsurgical methods
have failed.
Selection factors include body weight, patient history,
and failure to lose weight using other means, absence of
endocrine disorders, and psychological stability
Table 23-5 Selection criteria
Procedures
Figure 23-3 pg 644
Combined restrictive and malabsorptive procedure
Roux-en-Y gastric bypass
Restrictive procedures
Gastric banding
Vertical banded gastroplasty
May be performed
Laparoscopy
Open surgical technique
Complications
Most common
Bleeding, blood clots, bowel obstruction,
incisional or ventral hernias, and infection.
Other symptoms
Nausea
Dumping syndrome
Diarrhea
Constipation
Nutritional deficiencies
Table 23-6
Gastric Cancer
Diet
Chronic inflammation of stomach
Pernicious anemia
Achlorhydria
Gastric ulcers
H. pylori infection
Hx of subtotal gastrectomy
Gastric Cancer
Patho
Clinical Manifestations
Assessment
EGD test of choice
Barium x-ray of upper GI tract
CT to detect mets
Ascites and hepatomegaly may be present if liver
involvement
May be able to palpate nodules around the
umbilicus (Sister Mary Josephs nodules)
Surgical management
Treatment
radiation therapy- palliative
Chemotherapy- 5FU, cisplatin, doxorubicin,
etoposide, and mitomycin-C
Improved response
Combination therapy 5FU and other agents
After surgery
Hemorrhage, infection, abdominal distention,
atelectasis or impaired nutritional status
Planning
Major goals include reduced anxiety, increased
knowledge, optimal nutrition, management of
complications that can interfere with nutrition,
relief of pain, avoidance of hemorrhage and
steatorrhea, and enhanced self-care skills at
home.
Interventions
Reduce anxiety
Pain
Maintain NG tube
Prevent distention
Teaching
Interventions
Resuming enteral intake
May already be malnourished
Enteral/Parenteral
After return of bowel sounds and NG
removal
May give fluids and small amount of food
Foods gradually added until pt can
tolerate six small meals a day and drink
120mL between meals
Interventions
Recognizing obstacles to adequate nutrition
Dysphagia
Gastric retention-nausea, vomiting, abdominal distention
May require reinstatement of NPO and Ng suction. Use lowpressure suction
Bile reflux
May occur with removal of pylorus
Burning epigastric pain and vomiting
TX with cholestyramine (Questran), antacid, metoclopramide
hydrochloride (Reglan)
Dumping Syndrome
Due to rapid passage of food into the jejunum and drawing of fluid
into the jejunum due to hypertonic intestinal contents.
Causes vasomotor and GI symptoms with reactive hypoglycemia
Avoid fluid with meals
Avoid high carbohydrate/sugar intake
Question
Which statement about general principles of diet therapy
for patients with dumping syndrome is true?
A. Patients with dumping syndrome should have liquids
between meals only.
B. Patients with dumping syndrome should be
encouraged to eat a diet high in roughage.
C. Patients with dumping syndrome should eat a high
carbohydrate diet.
D. The diet for a patient with dumping syndrome must
be low in fat and protein.
Interventions
Obstacles to adequate nutrition
Steatorrhea
Reduce fat intake and administer loperamide
Malabsorption of vitamins and minerals
Supplementation of iron and other nutrients
Parenteral administration of vitamin B12 due to lack
of intrinsic factor
May require Fe and Vitamin B12 supplements
IM B12 1xmo in pts with total gastrectomy
Interventions
Monitoring for s/sx of potential complications
Hemorrhage
Monitor for s/s of shock
Monitor NGT output and abd drsg
Duodenal Tumors
Usually benign
Uncommon
Asymptomatic most of the time
If symptomatic
Intermittent pain or occult blood
May place at higher risk for malignancy
Malignant
Cause signs and symptoms
Many times not discovered until metastasized to distant sites
Clinical manifestations
Weight loss
Malnutrition
Bleeding
Pain
Duodenal Tumors
Diagnosis
Upper GI
Entercolysis
Abdominal CT
Nursing management
Benign tumors
If symptomatic
Excision/resection or electrocautery
Duodenal tumors
Malignant tumor
Most common-adenocarcinoma
Second and third portion of the duodenum involved
Symptoms
Bleeding or duodenal obstruction
Nursing care
Objectives
Describe the health care needs of patients with
constipation, diarrhea, or fecal incontinence.
Compare the conditions of malabsorption with regard to
their pathophysiology, clinical manifestations, and
management.
Describe diverticular disease and the care of patients
with diverticulitis.
Compare and contrast regional enteritis and ulcerative
colitis regarding their pathophysiology, and medical,
surgical, and nursing management.
Identify the care needs of the patient with inflammatory
bowel disease.
Objectives
Describe the responsibilities of the nurse in meeting the
needs of the patient with an ileostomy.
Describe the various types of intestinal obstructions, as
well as their medical and nursing management.
Describe the pathophysiology, assessment, and
management in regards to cancer of the colon or rectum.
Describe anorectal conditions including fissures, fistulas,
hemorrhoids, and sexually transmitted anorectal
diseases.
Identify the complications of gastric surgery and their
prevention and management.
Educate patient regarding an acute or chronic intestinal
or rectal condition.
Objectives
Describe the therapeutic actions, indications, pharmacokinetics
contraindications, most common adverse reactions, and important
drug- drug interactions associated with the following types of
gastrointestinal medications:
Laxatives and antidiarrheals
Antiemetic agents.
Compare and contrast the prototype drugs with the other drugs in that
class for the following types of gastrointestinal medications:
Laxatives and antidiarrheals
Antiemetic agents.
Heredity
High fat diet or stimulating or irritating foods
Alcohol
Smoking
Stress
Depression
Anxiety
Antidepressants
Tegaserod (Zelnorm)
Removed from market
Question
The nurse is teaching a patient with IBS about
ways to help manage the IBS. Which patient
statements indicate that teaching has been
effective?
A. I should eat a low-fiber diet.
B. Fish oil can be used to ease constipation.
C. I should exercise regularly to help manage
the disease.
D. I should drink with my meals.
Malabsorption
Inability to absorb one or more of the major
vitamins, minerals, and nutrients.
Patho
Risk factors
Abdominal diseases or deformities, surgery,
radiation, and certain meds that inhibit bacterial
growth such as antibiotics. Use of mineral oil or
laxatives increase peristalsis.
Malabsorption
Clinical manifestations (Table 24-2)
Diarrhea, or frequent, loose, bulky, foul-smelling, stools
increased fat and gray in color. Abdominal distention, pain,
increased flatus, weakness, weight loss, decreased sense of
well-being. Malnutrition and weight loss.
Diagnostic test
Endoscopy with biopsy of the mucosa
Malabsorption
Complications
Using corticosteroids
Hypertension
Hypokalemia
insomnia
Euphoria
Using antibiotics
Reduce vit K producing intestinal flora
Prolonged PT and INR with pts taking Warfarin
Using anticholinergics
Urinary retention
Altered mental status
Glaucoma
Appendicitis
Acute inflammation of the vermiform appendix
the blind pouch attached to the cecum of the colon
S/S: vague, dull or poorly localized epigastric or
periumbilical pain progresses to RLQ pain that is
sharp, well localized, loss of appetite, local
tenderness at McBurneys point, poss rebound
tenderness, Rovsings sign, fever of 100F or greater,
nausea
If appendix has ruptured, the pain becomes more
diffuse, abdominal distention, pt condition worsens.
Appendicitis
Constipation- Do not administer laxatives or
cathartics to a pt who has fever, nausea and
abdominal pain.
Cause perforation
Diagnostic testing
Physical exam and imaging studies, CBC (elevated WBC with
elevated neutrophils), abdominal x-ray, ultrasound, CT, or
laparoscopy
Appendicitis
Nursing management
Appendicitis
Complications (Table 24-3 p 663)
Peritonitis
Pelvic abscess
Subphrenic abscess
Illeus
Diverticular disease
Patho
Diverticula, Diverticulitis, Diverticulosis
Risk factors
Hx of diverticulitis
Congenital predisposition in those under 40
Repeated inflammation
Large bowel can narrow-cramps, narrow stools, and increased
constipation or obstruction.
Weakness, anorexia, and fatigue
Diverticular disease
Diagnostic
Gerontologic considerations
Diverticular disease
Nursing management
Diverticulitis
Diet
Medication
Acute diverticulitis
Hospitalization
Rest bowel
Broad spectrum antibiotics 7-10 days
Opoid
Avoid NSAIDS-increased risk of perforation
Antispasmodics
Supplement dietary fiber for normal stools
Metamucil
Stool softeners
Warm oil in rectum
Suppository
Diverticular disease
If medical management does not work
Surgery for complications
CT guided percutaneous abscess drainage and
antibiotics if no complications
Types of surgery
One staged resection
Multiple stage (Figure 24-3p 664)
Complications
Peritonitis
Abscess formation
Bleeding
Question
The nurse is working in an outpatient clinic.
Which client is most likely to have a diagnosis of
diverticulosis?
A. A 60 year old male with a sedentary lifestyle.
B. A 72 year old female with multiple
childbirths.
C. A 63 year old female with hemorrhoids.
D. A 40 year old male with a family history of
diverticulosis.
Peritonitis
Inflammation of the peritoneum, the serous membrane
lining the abdominal cavity and covering the viscera.
Life threatening
Peritonitis
Life-threatening
Primary or secondary
Diffuse abdominal pain
Constant localized and more intense
Peritonitis
Diminished perception of pain
Taking corticosteroids, analgesics, diabetics with
neuropathy, and pts with cirrhosis who have ascites
Peritonitis
Nursing management
Peritonitis
Monitor BP via arterial line if shock
I & O, CVP, PAP, monitor IV response
Ongoing assessment
Pain, GI function, fluid and lytes balance, and position
Watch for signs subsiding
Observe drainage
Drains from being dislodged
Incision care
Discharge teaching
Home care
Complications
Sepsis
Shock
Pulmonary emboli
es
Question
The client diagnosed with diverticulitis is
complainant of severe pain in the left lower
quadrant and has an oral temp of 100.6 F.
Which intervention should the nurse implement
first?
A. Notify the health care provider
B. Document the finding in the chart
C. Administer an oral antipyretic
D. Assess the clients abdomen
Diagnosis
Barium enema-cobblestone
CT scan bowel wall thickening and fistula formation
CBC decreased hgb and hct, elevated WBC, ESR elevated, albumin and
protein decreased
Ulcerative colitis
Ulcerative colitis-recurrent ulcerative and inflammatory
disease of the mucosal and submucosal layers of the colon
and rectum.
Affects the superficial mucosa of the colon
Characterized by multiple ulcerations, diffuse
inflammations, and desquamation or shedding of the colonic
epithelium
Bleeding
Mucosa edematous and inflamed
Lesions one after another touching
Abscesses
Begins in the rectum spreads to the entire colon
Bowel narrows, shortens, thickens
Ulcerative colitis
Abdominal pain LLQ
Cramping
Usually characterized by diarrhea
Up to 15-20 stools per day
Ulcerative colitis
Assessment
Diagnostics
Complications
Toxic megacolon
Perforation
Bleeding vascular engorgement
Highly vascular granulation tissue
Osteoporotic fracture
5-aminosalicyllic acid
5 ASA sulfa free
Antibiotics
Corticosteroids
Immunosuppressants
Antidiarrheals
Immunomodulators
Question
Which signs symptoms would the nurse expect
to find in a client diagnosed with ulcerative
colitis?
A. 10-20 bloody stools per day
B. Steatorrhea
C. Hard, rigid abdomen
D. Urinary stress incontinence.
Non-neoplastic polyps
Benign epithelial growth occur mostly in large intestine and
small intestine
More common in men and increase with age (50)
Clinical manifestations
Depends on size
Symptoms-rectal bleeding, lower abd pain, obstruction
Nursing management
Removal of polyp and repair as needed
Colorectal Cancer
The third most common cause of cancer deaths
in the United States.
Importance of screening procedures.
Patho
Colorectal Cancer
Risk factors
Clinical Manifestations
Colorectal Cancer
Right-Sided Lesions
Dull abdominal pain
Melena
Rectal lesions
Tenesmus
Rectal pain
Feeling of incomplete evacuation after BM
Constipation alternating with diarrhea
Bloody stool
Nursing management
If intestinal obstruction
IV fluids, NG with suction, blood if needed
Colostomies
Complications of elderly
If colostomy indicated:
Decreased vision
Impaired hearing
Difficulty with fine motor movements
Increased potential for skin breakdown
Watch for s/s of decreased blood flow to stoma
Delayed elimination after irrigation
R/t decreased peristalsis and mucus production
Question
The nurse is admitting a client to a medical floor with a
diagnosis of adenocarcinoma of the colon. Which
assessment data support this diagnosis?
A. The client reports up to 20 bloody stools per day.
B. The client has a feeling of fullness after a heavy meal
C. The client has diarrhea alternating with constipation .
D. The client complains of right lower quadrant pain.
Intestinal obstruction
Mechanical: caused by occlusion of the lumen of
the intestinal tract (Figure 24-9 p 678)(Table 24-5 p 679)
Examples: adhesions, hernias, intussusception,
polypoid tumors or neoplasms, stenosis,
strictures, and abscesses
Bowel OBS
Adhesions
Followed by:
Hernias
Neoplasms
Intrussusception
Volvulus
Carcinoma
Diverticulitis
IBD
SBO Patho
Fluid, intestinal contents, gas accumulate above
the obstruction
Increased pressure in bowel
Decreased venous and arteriolar pressure
Causes edema and necrosis
Eventually rupture or perforation causing
peritonitis
Question
A 75-year-old male patient presents at the emergency
department with symptoms of a small bowel obstruction.
An emergency room nurse is obtaining assessment data
from this patient. What assessment finding is
characteristic of a small bowel obstruction?
A. Vomiting
B. Increased urine output
C. Moist mucous membranes
C. Mucus in stool
SBO Diagnostics
Clinical manifestations
Abdominal x-rays
CT scan
Lab- s/s of dehydration
NGT to suction
IV therapy (fluid and electrolyte replacement)
Surgery to remove or treat obs
May remove portion of bowel
Maintain NGT
Monitoring fluid and electrolyte balance
Assessment of bowel function
Monitor nutritional status
Post-op surgical care
Clinical manifestations
Abd X-rays
CT scan
MRI
BE is contraindicated
Monitor s/s
IV fluids and electrolytes
Emotional support
Comfort
If condition does not respond
Surgery
Preop teaching
Post-op care
Anal fistula
Tiny, tubular, fibrous tract that extends into the anal
canal from an opening located beside the anus (Figure
24-10A p 680)
Usually related to infection
Can be from trauma, fissures, or regional enteritis
Symptoms
Pus or stool leaking
May pass flatus or feces from vagina or bladder
Depending on where it is
Anal fissure
Longitudinal tear or ulceration in the anal canal lining (Figure 2410B p680)
Trauma
Passing a large firm stool
Persistent tightening of the anal canal because of stress or anxiety
Childbirth
Trauma
Overuse of laxatives
Symptoms
Hemorrhoids
Dilated portion of veins in the anal canal (Figure
24-10C p680)
Treatment
Good personal hygiene and avoid excess straining
Non-surgical
Surgical
Question
Which information does the nurse include when
teaching a patient with new onset hemorrhoids about
prevention and flare ups? Select all that apply.
A. Increase the fiber in your diet to prevent
constipation.
B. Do not participate in any physical exercise.
C. Maintain a healthy weight.
D. Increase your fluid intake.
E. Prolonged sitting or standing will not affect the
development of hemorrhoids.
Sigmoidoscopy
Treatment
Treatment
Antibiotics
If abscess
Surgery-Abscess incised and drained then further surgery to excise
cyst and secondary sinus tracts
Anorectal disorders
Nursing Management of Patients with Anorectal
conditions (Box 24-3 p 681).
Relieving constipation
Reducing anxiety
Relieving pain
Promoting urinary elimination
Treating patients self-care
Continuing care