- Group of ulcerative disorders in the upper GI tract caused by resistance of mucosa to acid-pepsin injury
- Common site: 1 st part of duodenum
- Risk factors:
- Helicobacter pylori (H. pylori) –
- gastric ulcers
- Cigarrete smoking
- Alcohol & caffeine intake
- Stress
- NSAIDs
- Curling’s ulcer – 72hrs in clients with severe burns
- Cushing’s ulcers – resulting from head injury
- Gastric Ulcer Duodenal Ulcer
- Site - antrum of stomach - duodenum (proximal)
- Problem - weakened mucosa - ↑in HCl
- Pain - gnawing epigastric pain - gnawing epigastric pain
- - occurs 1hr after eating - occurs 2hrs after eating
- - aggravated by eating - relieved by food (closure
- (increase acid secretion) of pyloric sphincter)
- - relieved by vomiting
- (acid is expelled)
- - no pain at hours of sleep - pain at hours of sleep
- ( decreased HCl production) (continuous gastric emptying)
- Bleeding - commonly hematemesis - commonly melena
- (anemia, weight loss)
- Demographics
- - common in older people - middle-age people
- - females with familial history - males with no significant familial history (stress- related)
- History taking – include use of NSAIDs & ASA
- Lab findings: occult blood
- Barium contrast / Barium Swallow – radiologic visualization of upper GI
- NPO 6-8hrs prior
- 250mL Barium every hour 4hrs prior
- After procedure: instruct client to increase oral fluids
- Stool should return to normal brown color within 72hrs
- Endoscopy (gastroscopy or duodenoscopy) – direct visualization of the GI system by means of lighted flexible tube
- Secure consent
- NPO 8hrs prior
- Local anesthesia is used although sedative s may
- be prescribed to help the client relax
- NPO 1-2hrs after or until gag reflex returns
- Primary objective: provide stomach rest
- Small frequent meals
- Avoid foods that increases acidity (eg. caffeine, alcohol, milk)
- Bland diet
- Lifestyle changes: stop smoking
- Stress management
- Mental & physical rest
- Bismuth subsalicylate (Pepto-Bismol) for H.pylori
- Promotes ulcer healing through mucosal bicarbonate production
- Harmless darkening of stool
- Sucralfate (Caralfate) & prostaglandin analogs; Misoprostol (Cytotec)
- Provides local protective coat lining the stomach
- Should not be administered with antacids
- SE: diarrhea & pruritus
- Antacids: - given 1-3hrs after meals & at bedtime (empty stomach; ↓ pain
- administer separately at least 1-2hrs apart (interferes with other drug absorption)
- Magnesium hydroxide (Maalox, Mylanta) – neutralize HCl ; SE: constipation
- H 2 antagonists: Cimetidine (Tagamet), Ranitidine (Zantac), Famotidine – histamine antagonist – inhibits HCl production; tx lasts for 4-6wks ; SE: diarrhea & reversible impotence
- Calcium carbonate – cause constipation; may cause hypercalcemia
- Aluminum hydroxide (Amphojel)
- Proton-pump inhibitors: Omeprazole, pantoprazole – inhibits H+ secretion
- Gastrectomy
- Total – resection of the stomach with anastomosis of the esophagus & jejunum
- Subtotal – partial resection of the stomach
- Billroth I – gastroduodenostomy
- Billroth II – gastrojejunostomy
- Complications: pernicious anemia
- perforation – (+) abdominal rigidity, tarry stool
- dumping syndrome – rapid emptying of stomach due to stimulation of gastrocolic reflex (triggered by high-CHO food/concentrated CHO)
- S/Sx: D iarrhea Mgt: lie down after meals
- D iaphoresis fluid in between meals
- D izziness eat dry foods high in CHON & fat (delays emptying) & low in CHO
- Antrectomy – removal of lower portion of stomach (entire antrum)
- Vagotomy – interruption of vagus nerve to decrease gastric secretion
- Backward movement of gastric contents into the esophagus (causes heartburn)
- Causes:
- Weak or incompetent lower esophageal sphincter
- Delayed gastric emptying – increases gastric volume & pressure
- Esophageal mucosal injury – related to the destructive nature of the refluxate & amount of time it is in contact with the mucosa (acidic gastric fluids)
- Hiatal hernia - protrusion of the diaphragm taking place through the opening where the esophagus passes
- Hernia may retard esophageal acid clearance
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- Heartburn (pyrosis) – occurs 30-60mins after eating; usually at night
- Made worse by bending at the waist (relieved by sitting upright)
- Belching (water brash)
- Pain – epigastric or retrosternal area (pain may be confused with angina)
- Burning sensation that moves up & down
- Occurs after meals
- Relieved with antacids, by standing, or by walking
- Precipitated by straining or lifting
- Dysphagia – resulting from edema
- wheezing
- Chronic cough
- hoarseness
- Esopha goscopy – passage of flexible fiber optic endoscope into the esophagus
- To visualize the lumen of the upper GI tract
- Permits biopsy
- 24-hour pH Monitoring – small tube with pH electrode is passed through the nose into the esophagus
- Data in the electrode are recorded in a small lightweight box attached to the waist
- Button can be pressed when heartburn or pain occurs
- Instruct client to:
- Have small frequent feedings (4-6x/day) but NPO 3h rs before sleep
- Avoid caffeine, fats, chocolates in the diet (reduces esophageal sphincter tone)
- Avoid alcohol & smoking
- Eat meals sitting up rather (avoid recumbent position for several hours after eating)
- Avoid bending for long periods – increases intra-abdominal pressure
- Sleep with head elevated
- Weight loss for overweight / obese clients
- Meds:
- Antacids
- H 2 blockers: Cimetidine, Ranitidine, Famotidine
- Proton-pump inhibitors: Omeprazole, pantoprazole
- Motility agents: Meteclopramide – increases lower esophageal pressure & enhance esophageal clearance
- Nissen fundoplication – most frequently used & involves gastric wraparound (fundus around lower esophagus)
- Hill’s operation – narrows the esophageal opening
- Esophageal diverticulum – out-pouching of the esophageal wall due to weakness of mucularis layer
- Causes: congenital defect, esophageal trauma, scar tissue
- Tends to retain food; gurgling, belching, coughing, foul-smelling breath
- Small frequent feedings of semisoft foods
- Progressive disease; therefore surgical intervention
- Achalasia – failure of lower esophageal sphincter to relax & swallowed food has difficulty passing into the stomach (“something stuck in the throat”)
- Cause: idiopathic
- Enlarged esophagus
- Small frequent meals (semisoft & warm)
- Eat slowly & allow time to chew food thoroughly
- Strict aspiration precaution
- Dx: endoscopy, barium contrast – determine the site & extent of swallowing disorder
- Hiatal hernia – barium swallow (confirmatory)
- Cause: muscle weakening due to aging, congenital, trauma
- Esophageal cancer – more common among 50 years of age
- Squamous cell tumors – associated with dietary & environmental influences (alcohol & tobacco use)
- Adenocarcinoma – located in the distal esophagus & may invade the adjacent upper part of the stomach
- Dysphagia – more frequent complain
- Weight loss, anorexia, fatigue, & pain on swallowing
- Tx: surgical resection, chemotherapy, irradiation (palliative)
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- Presence of gallstones
- Possible causes: gallbladder stasis, infection, genetics
- Risk factors:
- DM
- Vagotomy
- Long-term TPN
- Liver cirrhosis
- Pancreatitis
- obesity
- Manifestations: colicky pain, jaundice, nausea & vomiting
- inflammation of the gallbladder
- inflammation believed to be caused by chemical irritation from the concentrated bile, mucosal swelling, ischemia from venous congestion & lymphatic stasis, gallstones
- Risk factors: sedentary lifestyle & obesity
- Types:
- Acute – complete or partial obstruction
- Chronic – from repeated episodes of acute cholecystitis or irritation of gallbladder by stones
- Pain often precipitated by a fatty meal commonly at RUQ
- Does not spontaneously subside
- Not responsive to analgesics
- Tenderness on RUQ
- Vomiting – bilious in character
- Fever
- High WBC count
- Elevated total serum bilirubin, AST / ALT
- Intolerance to fatty food
- belching
- Ultrasound – can detect wall thickening (inflammation)
- - can detect small (1-2cm) gallstones
- Cholescintigraphy – gallbladder scan
- - relies on the ability of the liver to extract rapidly injected radionuclide (technetium-99) that is excreted into the bile ducts
- - reading every 10-15mins of the hour
- - highly accurate
- Oral cholecystography – radiologic technique that uses oral tablets containing radiopaque contrast medium
- - fat-free diet 1-2days prior
- - dye is taken 10-14hrs prior
- -may produce nausea & vomiting or diarrhea
- Low-cholesterol diet
- Laparoscopic cholecystectomy – treatment of choice for symptomatic gallbladder disease
- - longer duration of operation shorter hospital stay (1 day after OR)
- - client can resume work 1-2wks after
- ESWL (Extracorporeal Shock-wave Lithotripsy) – uses soundwaves to pulverize gallstones (30-40mins)
- - suitable only for radiolucent stones
- TPN contents:
- Calories - 25 kCal/kg/day
- Protein - 1.5g/kg/day
- Carbohydrate & Fat
- Electrolytes and water
- Minerals, Vitamins, Micronutrients - trace elements and water-soluble vitamins, vitamin C, thiamine and zinc
- monitoring of the following is vital:
- Metabolic indicators
- Evidence of complications, notably infection but also line-related thrombosis, and other line complications.
- Adverse drug interactions
- Condition characterized by excess body fat (BMI ≥ 30)
- May be seen as a sign of lack of self-control
- Causes:
- Basic energy imbalance – more energy intake (food) than energy expanded for basal metabolic needs & exercise = weight gain
- Genetic & family factor – genetic control regulates differences in body fat & sex differences in weight; family food patterns add to genetic factor = social pressure, habits & attitudes toward food
- Physiological factor – amount of body fat is related to the number & size of fat cells in the body
- Psychosocial factor – eating under emotional stress; using food for comfort
- Hypertension
- Cardiovascular & pulmonary diseases
- Gallbladder diseases
- Glucose intolerance / insulin resistance
- Stroke
- Arthritis
- Infertility
- Cancer (prostate, colon, breast)
- Focused on lifestyle modification
- Determine client’s motivation & goal/s to lose weight (organizations: eg. TOPS, Weight Watchers, Overeater anonymous)
- Physical activity – prevention of weight gain
- Exercise must be started slowly with the duration & intensity increased independent of each other
- Dietary therapy – individually prescribed based on client’s weight status & risk profile (usually calorie-restricted)
- Risky practices for weight loss
- Fad diets
- Fasting
- Clothing & body wraps
- Drugs
- Surgery
- Criteria for Evaluating Weight-reduction Diet
- Realistic goals – promote 1-2lbs/wk weight loss; easily adapted to lifestyle; based on individual’s calorie requirement
- Reduce caloric intake (Food consumption)
- - use food to meet nutritional requirements rather than vitamins & minerals supplement
- - encourage food from major food groups
- - decrease fat consumption
- - increase fruits, vegetables, grains, & fiber
- Behavior Modification – control of eating behaviors & promotes physical activity
- Exercise – encourage exercise plan that is acceptable & enjoyable to the client
- Culturally acceptable – offer a maintenance plan after achievement of weight loss; re-educating of eating habits
- Sibutramine – inhibits serotonin, dopamine, norepinephrine re-uptake; decreasing appetite
- Orlistat – lipase inhibitor; decreases fat absorption in the intestine
- Surgery: Bariatric Surgery
- Gastroplasty / Gastric Stapling – staples the top part of the stomach with the creation of a small pouch to receive ingested food
- Psychiatric evaluation prior to procedure & participation in support groups
- Comprehensive & extensive pre-op assessment
- Post op: client can eat only 30mL / 5mins until satisfied via NGT then weaned
- Bariatric Surgery – also known as Gastric banding, O besity surgery (group of various procedures)
- usually for men who are at least 100 pounds overweight and women who are at least 80 pounds overweight
- limits the amount of food you can take in
- reduce the size of the stomach
- stomach is divided into two sections reducing the size of the new pouch from approximately two quarts to two ounces
- drastic reduction in the size limits its capacity to hold food causing client to feel full after eating only a small amount;
- also causes the food to bypass part of the digestive system, reducing the amount of calories the body absorbs
- after surgery, client will find it hard to eat foods high in sugars and fats
- emphasize that procedure is in no way to be considered cosmetic surgery
Nursing Lecture about Altered Nutrition:Gastrointestinal System
Altered Nutrition: Gastrointestinal System and Biliary Disorders
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