1. Gastrointestinal System: Part IV – Stomach Disorders
Chapter 55
Mrs. April Page MSN ARNP FNPC
Gulf Coast State College
NUR1213c Intermediate Adult Care

2. Lesson Objectives
Compare the etiology, clinical manifestations, and management of acute gastritis, chronic gastritis, and peptic ulcer disease (PUD).
Utilize the nursing process in providing care of patients with peptic ulcer disease, who undergo bariatric surgical procedures.
Describe the pharmacologic, dietary, and surgical treatment of peptic ulcer and gastric cancer.
Discuss the etiology, clinical manifestations, and management of tumors of the small intestine.

3. LESSON OBJECTIVE ONE
Compare the etiology, clinical manifestations, and management of acute gastritis, chronic gastritis, and peptic ulcer disease (PUD).

4. Gastritis
Inflammation of the stomach
A common GI problem

5. Gastritis (Cont.)
Acute: rapid onset of symptoms usually caused by dietary indiscretion. Other causes include medications, alcohol, bile reflux, and radiation therapy. Ingestion of strong acid or alkali may cause serious complications.

6. Gastritis (Cont.)
Chronic: prolonged inflammation due to benign or malignant ulcers of the stomach or by Helicobacter pylori. May also be associated with some autoimmune diseases, dietary factors, medications, alcohol, smoking, or chronic reflux of pancreatic secretions or bile.

7. Erosive Gastritis

8. Nursing Process: The Care of the Patient With Gastritis—Assessment
History including presenting signs and symptoms
Dietary history and dietary associations with symptoms
72 hour diet; diary may be helpful
Abdominal assessment

9. Manifestations of Gastritis
Acute: abdominal discomfort, headache, lassitude, nausea, vomiting, hiccupping
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

10. Manifestations of Gastritis (Cont.)
May be associated with achlorhydria, hypochlorhydria, or hyperchlorhydria
Diagnosis is usually by UGI X-ray or endoscopy and biopsy

11. Nursing Process: The Care of the Patient With Gastritis—Diagnoses
Anxiety
Imbalanced nutrition
Risk for fluid volume imbalance
Deficient knowledge
Acute pain

12. Nursing Process: The Care of the Patient With Gastritis—Planning
Major goals may include reduced anxiety, avoidance of irritating foods, adequate intake of nutrients, maintenance of fluid balance, increased awareness of dietary management, and relief of pain

13. Medical Management of Gastritis
Acute
Refrain form alcohol and food until symptoms subside
If due to strong acid or alkali treatment to neutralize the agent, avoid emetics and lavage due to danger of perforation and damage to esophagus
Supportive therapy

14. Medical Management of Gastritis (Cont.)
Chronic
Modify diet, promote rest, reduce stress, avoid alcohol and NSAIDs
Pharmacologic therapy

15. Interventions
Reduce anxiety; use calm approach and explain all procedures and treatments
Promote optimal nutrition; for acute gastritis, the patient should take no food or fluids by mouth.
Introduce clear liquids and solid foods as prescribed.
Evaluate and report symptoms.

16. Interventions (Cont.)
Discourage caffeinated beverages, alcohol, cigarette smoking.
Refer for alcohol counseling and smoking cessation

17. Interventions (Cont.) Promote fluid balance;
monitor I&O,
for signs of dehydration,
electrolyte imbalance,
and hemorrhage
Measures to relieve pain: diet and medications

18. Peptic Ulcer
Erosion of a mucous membrane forms an excavation in the stomach, pylorus, duodenum, or esophagus
Associated with infection of H. pylori
Risk factors include excessive secretion of stomach acid, dietary factors, chronic use of NSAIDs, alcohol, smoking, and familial tendency

19. Peptic Ulcer (Cont.)
Manifestations include a dull gnawing pain or burning in the mid- epigastrium; heartburn and vomiting may occur
Treatment includes medications, lifestyle changes, and occasionally surgery

20. Deep Peptic Ulcer

21. LESSON OBJECTIVE TWO
Utilize the nursing process in providing care of patients with peptic ulcer disease, who undergo bariatric surgical procedures.

22. LESSON OBJECTIVE TWO, Part A
Utilize the nursing process in providing care of patients with peptic ulcer disease.

23. Nursing Process: The Care of the Patient With Peptic Ulcer—Assessment (CONT.)
Assess pain and methods used to relieve pain
Dietary intake and 72 hour diet diary
Lifestyle and habits such as cigarette and alcohol use

24. Nursing Process: The Care of the Patient With Peptic Ulcer—Assessment
Medications; include use of NSAIDs
Sign and symptoms of anemia or bleeding
Abdominal assessment

25. Nursing Process: The Care of the Patient With Peptic Ulcer—Diagnoses
Acute pain
Anxiety
Imbalanced nutrition
Deficient knowledge

26. Collaborative Problems and Potential Complications
Hemorrhage
Perforation
Penetration
Pyloric obstruction (gastric outlet obstruction)

27. Nursing Process: The Care of the Patient With Peptic Ulcer—Planning
Major goals for the patient may include relief of pain, reduced anxiety, maintenance of nutritional requirements, knowledge about the management and prevention of ulcer recurrence, and absence of complications

28. Relieve Pain Treat with prescription medications
Avoid aspirin, NSAIDs, and alcohol

29. Anxiety Assess anxiety Calm manner
Explain all procedures and treatments
Help identify stressors
Explain various coping and relaxation methods such as biofeedback, hypnosis, and behavior modification

30. Patient Education Medication education Dietary restrictions
Lifestyle changes

31. Management of Potential Complications
Management of hemorrhage
Assess for evidence of bleeding, hematemesis or melena, and symptoms of shock/impending shock and anemia
Treatment includes IV fluids, NG, and saline or water lavage; oxygen, treatment of potential shock including monitoring of VS and UO; may require endoscopic coagulation or surgical intervention

32. Management of Potential Complications
Pyloric obstruction
Symptoms include nausea and vomiting, constipation, epigastric fullness, anorexia, and (later) weight loss
Insert NG tube to decompress the stomach, provide IV fluids and electrolytes. Balloon dilation or surgery may be required

33. Management of Potential Complications
Management of perforation or penetration
Signs include severe upper abdominal pain that may be referred to the shoulder, vomiting and collapse, tender board-like abdomen, and symptoms of shock or impending shock
Patient requires immediate surgery

34. LESSON OBJECTIVE TWO, PART B
Utilize the nursing process in providing care of patients who undergo bariatric surgical procedures.

35. Obesity Obesity is body mass indices (BMI) above 30 mg/m2
66% of all adults are overweight or obese

36. Obesity (Cont.)
Obesity-related mortality rates are 30% greater for every gain of 5 kg/m2 of body mass beyond a BMI of 25 kg/m2
Increased risk for disease, disorders, low self-esteem, impaired body image, depression, and diminished quality of life

37. Obesity Management Lifestyle modifications Pharmacotherapy
Bariatric surgery

38. Bariatric Surgery
Morbid obesity: persons more than two times IBW, BMI exceeds 30 kg/m2, or more than 100 pounds greater than IBW; high risk for health complications

39. Bariatric Surgery (Cont.)
Surgery is preformed only after nonsurgical methods have failed
Selection factors include body weight, patient history, failure to lose weight using other means, absence of endocrine disorders, and psychological stability

40. Surgical Procedures for Morbid Obesity—Roux-en-Y Gastric Bypass

41. Surgical Procedures for Morbid Obesity— Gastric Banding

42. Surgical Procedures for Morbid Obesity— Vertical-Banded Gastroplasty

43. Sleeve Gastrectomy

44. Surgical Procedures for Morbid Obesity—Biliopancreatic Diversion With Duodenal Switch

45. Nursing Care of the Patient Undergoing Bariatric Surgery (Cont.)
Preoperative care; evaluation and counseling
Postoperative care is similar to gastric resection, but the patient is at greater risk for complications because of obesity
Postoperative diet: six small feedings totaling 600 to 800 calories per day

46. Nursing Care of the Patient Undergoing Bariatric Surgery
Patients require psychosocial interventions to modify their eating behaviors
Follow-up care
Education regarding long-term effects

47. Collaborative Problems and Potential Complications
Hemorrhage
Bile reflux
Dumping syndrome
Dysphagia
Bowel or gastric outlet obstruction

48. Nursing Process: The Care of the Patient With Gastric Surgery—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

49. Interventions Provide interventions to reduce anxiety Pain
Administer analgesics as prescribed so patient may perform pulmonary care, leg exercises, and ambulation activities
Position in Fowler’s position
Maintain function of NG tube

50. Interventions (Cont.) Patient education
Individualized nutritional care and support

51. Care and Prevention of Complications
Gastric retention
May require reinstatement of NPO and Ng suction; use low- pressure suction
Bile reflux
Agents that bind with bile acid: cholestyramine

52. Care and Prevention of Complications (Cont.)
Malabsorption of vitamins and minerals
Supplementation of iron and other nutrients
Parenteral administration of vitamin B12 because of a lack of intrinsic factor

53. Care and Prevention of Complications
Dumping syndrome
Caused by rapid passage of food into the jejunum and drawing of fluid into the jejunum caused by hypertonic intestinal contents
Causes vasomotor and GI symptoms with reactive hypoglycemia

54. Care and Prevention of Complications (Cont.)
Avoid fluid with meals
Avoid high carbohydrate and sugar intake
Steatorrhea
Reduce fat intake and administer loperamide

55. Dietary Self-Management
To delay stomach emptying and dumping syndrome, assume low Fowler’s position after meals; lie down for 20 to 30 minutes
Take antispasmodics as prescribed
Avoid fluid with meals

56. Dietary Self-Management
Meals should contain more dry items than liquid items
Eat fat as tolerated but keep carbohydrate intake low and avoid concentrated carbohydrates
Eat small, frequent meals
Take dietary supplements as prescribed; vitamins, medium-chain triglycerides, and B12 injections

57. LESSON OBJECTIVE THREE
Describe the pharmacologic, dietary, and surgical treatment of peptic ulcer and gastric cancer.

58. Gastric Cancer (Cont.)
Incidence is deceasing, but accounts for more than 10,000 deaths in U.S. annually
Increased incidence in men, Native Americans, Hispanic Americans, and African Americans

59. Gastric Cancer (Cont.)
Risk factors include diet, chronic inflammation of the stomach, H. pylori infection, pernicious anemia, smoking, achlorhydria, gastric ulcers, previous subtotal gastrectomy, and genetics

60. Gastric Cancer (Cont.)
Manifestations include pain relieved by antacids, dyspepsia, early satiety, weight loss, abdominal pain, loss or decrease in appetite, bloating after meals, nausea, and vomiting. Diagnosis of the disease is often late
Treatment is surgical removal of the tumor if possible, and palliative care if the tumor is un-resectable or metastasized

61. Nursing Process: The Care of the Patient With Gastric Cancer—Assessment
Dietary history and nutritional status
Risk factors and smoking and alcohol history
Social support, individual and family coping
Resources
Physical assessment, including assessment of the abdomen

62. Nursing Process: The Care of the Patient With Gastric Cancer—Diagnoses
Anxiety
Imbalanced nutrition
Pain
Anticipatory grieving
Deficient knowledge

63. Nursing Process: The Care of the Patient With Gastric Cancer—Planning
Major goals include reduced anxiety, optimal nutrition, relief of pain, adjustment to the diagnosis, and anticipated lifestyle changes

64. Anxiety Provide a relaxed, nonthreatening atmosphere
Allow patient to express fears and concerns
Provide support and encourage family support
Promote positive coping measures
Explain treatments and procedures
Referral to support persons such as social worker or clergy

65. Promote Optimal Nutrition
Encourage small, frequent meals of non-irritating foods
Provide foods high in calories and vitamins A and C and iron
Provide diet and education for potential dumping syndrome after gastric resection

66. Promote Optimal Nutrition (Cont.)
Six small feedings low in carbohydrates and sugar, with fluids between, not with, meals
Assessment includes I&O, daily weights, assessment for signs of dehydration, and nutritional status

67. Other Interventions Pain Psychosocial support
Administer analgesic as prescribed
Nonpharmacologic pain relief measures
Psychosocial support
Allow patient to express fears concern and grief

68. Other Interventions (Cont.)
Allow patient to participate in decisions
Include family members and significant others
Referral or involvement of other support persons as needed
Patient education

69. LESSON OBJECTIVE FOUR
Discuss the etiology, clinical manifestations, and management of tumors of the small intestine.

70. Tumors of the Small Intestine
64% malignant
Higher rates of cancer among older adults, African Americans, and men
May be asymptomatic or present with pain, occult bleeding, weight loss, nausea, vomiting, and intestinal obstruction

71. Tumors of the Small Intestine
Assessment includes CBC, bilirubin, carcinoembryonic antigen (CEA)
Diagnose by upper GI radiograph or abdominal CT
Treat with surgery and chemotherapy