jcmendiola_Achievers2013

Care of Clients with Problems In Oxygenation,

Fluids and Electrolytes, Metabolism and Endocrine
(NCM103)
Patients With Gastrointestinal Alterations II

Alterations of the Esophagus

Gastroesophageal Reflux
Disease (GERD)
Chronic symptoms or mucosal damage
produced by abnormal reflux of gastric
contents into the esophagus which may
result to esophagitis

Causes:
1. Incompetent Lower Esophageal Sphincter (LES)
2. Impaired gastric emptying, partial gastric outlet obstruction
3. Achalasia and impaired expulsion of gastric reflux (Hiatal Hernia)

Signs and Symptoms
1. Heartburn characterized by burning sensation behind the sternum, 30 60 minutes after meals
with reclined position
2. Dysphagia (difficulty swallowing), a less common symptom
3. Chest pain, hoarseness, cough
4. Odynophagia Sharp Substernal pain or swallowing







Pathophysiology















Diagnostic Procedure
1. Endoscopy Most IMPORTANT
2. Esophageal Manometry
a. Measures LES pressure
b. Determines if esophageal peristalsis is adequate (Should be done prior surgery)
3. pH Monitoring
Topics Discussed Here Are:
1. Alterations of the Esophagus
a. Gastroesophageal Reflux Disease (GERD)
b. Hiatal Hernia
c. Achalasia
d. Esophagitis
2. Alterations in Digestion
a. Gastric Bleeding
b. Gastritis
c. Peptic Ulcer Disease
LOOKY
HERE
Chest pain should be ruled out for possible cardiac dysphagia, odynophagia or weight loss (rule out
cancer or esophageal stricture)

Give minimum nitroglycerin; if pain is relieved then it must be a cardiac condition and not a
esophageal disorder
Incompetent (LES), impaired gastric
emptying, partial outlet obstruction,
achalasia and impaired expulsion of
gastric reflux Hiatal Hernia
Drug produced by abnormal reflux of
gastric contents into the esophagus
Hiatal Hernia, characterized by burning
sensation behind the...

Nursing Interventions:
1. Instruct patient to avoid stimulus that increase
stomach pressure and decrease GES pressure
2. Instruct to avoid spices, coffee tobacco
3. Instruct to eat FAT, FIBER
FAT = To DELAY gastric emptying
4. Avoid foods and drinks 2 hours before bedtime
5. Elevate the head of bed with approximately 8
inches
6. Administer prescribed H
2
Blocker, PPI,
Prokinetic medications like Metoclopramide
7. Advise proper weight reduction

jcmendiola_Achievers2013
4. Barium esophagography
5. Acid fast perfusion test

Management
1. Lifestyle Changes
1. Head elevation (6 8 inches, to prevent backflow)
2. Do not Lie DOWN!
3. Bland diet / avoid overeating
i. No spicy food, sweets
ii. Over eating
iii. Chocolates, increased protein, fats
4. Avoid caffeine, alcohol, mint, chocolate, colas
5. Weight Control (As increased food causes pressure to LES)
6. Smoking Cessation (Has effect on pressure of LES)

Hiatal Hernia (HH)
Protrusion of a portion of the stomach through the hiatus of the diaphragm and into the thoracic
cavity
The following are possible causes / contributing factors for having a Hiatal Hernia
o Obesity
o Poor seated posture (Such as slouching)
o Frequent coughing
o Straining with constipation
o Frequent bending over / heavy lifting
o Heredity
o Smoking
2 Types
a. Sliding
90%: The stomach and gastro-esophageal junction Slip up in to the chest
b. Para-Esophageal Hernia / Rolling Hernia
Part of the greater curvature of the stomach Rolls through the diaphragmatic
defect
Pathophysiology


Signs And Symptoms
1. Heart Burn
2. Regurgitation
3. Dysphagia
4. Chest pain / may be
asymptomatic (depends on size of
hernia) [50% without symptoms]

Diagnostic Tests:
1. Barium Study of the esophagus
(Outlines Hernia)
2. Endoscopic Evaluation
visualizes defect

Management:
1. Elevation of head of bead (6-8
inches)
2. Antacid therapy
3. H
2
Receptor antagonist
4. Surgical Repair of hernia if
symptoms are severe


jcmendiola_Achievers2013
Nursing Intervention and Patient Education
Instruct patient on the prevention of reflux of gastric contents into the esophagus by:
a. Eat smaller meals
b. Avoid caffeine, alcohol and smoking
c. Avoid fatty foods
Eating such: Promotes reflux and delays gastric emptying
d. Avoid lying down directly after meals (At least 1 hour)
e. Losing weight if obese
f. Avoid bending from the waist or wearing tight fitting clothes
g. Advise patient to report to the health care immediately for onset of chest pain
which may indicate incarceration of a large para-esophageal hernia

Achalasia
Excessive resting tone of the LES, incomplete relaxation of the LES with swallowing, and failure
of normal peristalsis in the lower thirds of the esophagus
Cause:
o Defective innervations of the mesenteric plexus innervating the involuntary muscles of
the esophagus

Signs and Symptoms
1. Gradual onset of dysphagia with solid and liquids
2. Substernal discomfort or a feeling of fullness
3. Regurgitation of undigested food during a meal / within several hours after a meal
4. Weight loss

Diagnostic Tests:
1. Chest X-Ray To locate the site of
esophagus or with enlargement
2. Barium esophagography
3. Endoscopic ultrasound or a chest CT scan

Management
1. Drug therapy using calcium channel
blockers such as Nifedipine to reduce
LES pressure
2. Esophagomytomy: Esophageal dilation
using a balloon-tipped catheter (preferred
treatment)
3. Surgical therapy for patients who do not
respond to balloon dilation

Complications:
1. Malnutrition Due to lack of absorption of nutrients
2. Lung abscess, pneumonia, Bronchiectasis from nocturnal regurgitation
3. Esophagitis, esophageal diverticula
4. Perforation from dilation procedure
5. Peptic stricture from severe erosive esophagitis

Nursing Assessment:
; Assess for difficulty with swallowing, vomiting, weight loss, chest pain associated with
eating
; Inquire as to what facilitates passage of food, such as position changes

Possible Nursing Diagnoses:
Altered nutrition: less than body requirements related to dysphagia
Implication in reflux
Hemorrhage /
obstruction, strangulation


jcmendiola_Achievers2013
o Improve nutritional status
1. Direct client to eat sitting in an upright position: eat slowly and CHEW
FOOD THOROUGHLY
2. Avoid SPICY, very HOT and very COLD food to minimize symptoms
3. Suggest client to sleep with head of bed ELEVATED to avoid
REFLUX / ASPIRATION
4. Provide BLAND diet and avoid ALCOHOL, ketchup, tomato products,
chocolates, mine and caffeine
Alteration in comfort: pain related to surgical procedure heart burn to regurgitation
o Promoting comfort
1. Assess client for discomfort, chest pain, regurgitation and cough and
incision pain
2. Provide appropriate post-op care
3. Administer analgesics as ordered
4. Assess for effectiveness of pain medications

Patient Education and Health Maintenance
1. Encourage lifestyle and activity changes
2. Advise client to EAT SLOWLY, chew very well, drink plenty of water after meal and
avoid eating near bedtime
3. Advise client to AVOID medications with ANTI-CHOLINERGIC properties (Histamine)
o Which LES pressure and dysphagia
4. Provide information on all diagnostic procedures or surgeries

Esophagitis
a. Is an acute or chronic inflammation of the esophagus
b. Causes:
GERD Most common, reflux esophagitis
Other causes of esophagitis include: Infections (Most commonly candida, herpes simplex,
and cytomegalovirus. These infections are typically seen in Immunocompromised people
such as those with AIDS)
Chemical injury by alkaline/acid solutions may also be seen in children and adults
attempting suicide
Physical injury resulting from radiating therapy or by NGT may also be responsible
Signs and Symptoms and Nursing Interventions is similar WITH GERD!!

Alterations or Disturbances in Digestion (Gastric Bleeding)
Upper GI Bleeding:
o Bleeding in the:
Esophagus (Ex: Esophageal varices [rupture may occur] due to portal HTN)
Stomach
Duodenum Due to ulcer, gastritis
Lower GI Bleeding:
o Bleeding from:
Jejunum
Ileum
Colon
Rectum

Acute Blood LOSS is (150 300 mL of blood, SEVERE is 1 LITER!!)
a. Characterized by HEMATEMESIS
b. HEMATOCHECIA Frank bleeding from the rectum
c. MELENA Dark, tarry stools
d. OCCULT BLEEDING
e. Guaiac Test

jcmendiola_Achievers2013
Laboratory Tests:
a. CBC If RBCs are depleted
b. ABGs For F&E imbalance

Pathophysiology










































Gastritis
Diffuse or localized inflammation of the gastric mucosa
It is the common pathologic condition of the stomach
Two Types:
o Acute Gastritis Short Term INFLAMMATORY PROCESS
o Chronic Gastritis LONG Term / Chronic form of ACUTE
Type A = Autoimmune (Least common, 10%)
Type B = Helicobacter Pylori (More common, 90%)


jcmendiola_Achievers2013
Assessment
Acute Chronic
Abdominal Distention
Headache
Anorexia
Nausea and Vomiting
Pyrosis
Singultus (Hiccup)
Sour taste in the mouth
Dyspepsia
Nausea and Vomiting / Anorexia
Pernicious Anemia

Acute Gastritis is related to:
Ingestion of chemical agents and food products that IRRITATE and ERODE gastric mucosa
o (Food seasonings and spices, alcohol, drugs (NSAIDS), aspirin)
Corrosive Agents
o Cleaning fluids or kerosene insecticides, pesticides
Or some bacteria that can also produce acute gastritis if they contaminate food
o (Salmonella, Staphylococci, Clostridium botulinum)

Pathophysiology



























jcmendiola_Achievers2013
Chronic Gastritis
Chronic Gastritis Type A
Basically AUTOIMMUNE
In nature and involves all of the
ACID SECRETING GASTRIC TISSUE,
particularly the tissue in the fundus.
Circulating antibodies are produced that
attack the gastric parietal cells and
eventually may cause pernicious anemia
from loss of intrinsic factor (IF)













Chronic Gastritis Type B
Associated with infection by Helicobacter Pylori, which is currently believed to be a direct cause
of the gastritis. It involves the fundus and the antrum of the stomach. the infection damages the
mucosal protective mechanism and leaves the mucosa vulnerable to the side effects of alcohol,
smoking, gastric acid and alkaline reflux from the duodenum
Some of these symptoms may accompany gastritis:
o Abdominal pain / discomfort
o Gastric hemorrhage
o Appetite loss
o Belching
o Nausea / Vomiting
o Fatigue

NURSING INTERVENTION
(FOR BOTH Type A & B)
1. Provide information to reduce anxiety
especially on emergency cases
2. Promote nutrition It will be on NPO
Give ice chips then clear liquids then
solids as soon as possible or symptoms
have subsided
3. Maintain fluid balance Hydration either
orally or IV
4. Lifestyle modification Discouragement
of alcohol, caffeine, smoking
5. Administer medications as ordered to
relieve pain, to gastric acidity and treat
infection
6. Teach the effects of medications that
irritate the gastric mucosa


Gastric Irritant Infection of H. Pylori
Impairment of the HCl
and IF secretion
Atrophy of the gastric
gland and thinning of
the mucosa
Damaged mucosa
(Inflammation)
General Signs
and Symptoms
Gastritis Type B Pathophysiology

MEDICATIONS for Type B
- Erythromycin
- Ranitidine
- Prostaglandin inhibitors
- Antacid-regenerate cells
** Treat effects of meds that irritates

jcmendiola_Achievers2013
Diagnostic Procedures
EGD To visualize the gastric mucosa for inflammation
Absent (Achlorhydria) or LOW levels of HCl (Hypochlorhydria) or INCREASED levels
of HCl (Hyperchlorhydria)
Biopsy to establish correct diagnosis whether acute or chronic

Nursing Intervention (Additional)
1. Give BLAND diet
2. Monitor for signs of complications like: Bleeding, obstruction and pernicious anemia
3. Instruct to avoid spicy foods, irritating foods, alcohol and caffeine, NSAIDS
4. Administer prescribed medications H
2
Blocker, antibiotics, mucosal protectants
5. Inform the need for Vitamin B
12
injection if deficiency is present

Peptic Ulcer Disease (PUD)
Refers to ulceration in the mucosa of the lower esophagus, stomach to duodenum
Duodenal ulcers are more common!
Causes:
a. H. pylori infection present in most clients with PUD
b. Ulcergenic drugs like NSAIDS
c. Zollinger-Ellison syndrome and other hypersecretory syndromes
Rare islet tumor cells: GASTRIN = GASTRIC ACID Secretion!! XD
Theres presence of FAT MALABSORPTION

RISK FACTORS
a. Prolonged NSAIDS / Corticosteroids
b. Stress, low socio-economic status
c. Alcohol, caffeine, family history (Type O are more prone)

Clinical Manifestations (Assessment Findings)
Gnawing / Burning Epigastric pain 1 3 hours after meal (can be nocturnal)
Gastric Aggravation of pain with food: 1 cm pyloric sphincter
Duodenal Right Upper Epigastria, pain with empty stomach (2 3 hours after meal);
1.5 cm of pyloric area
Early satiety, anorexia, weight loss, heart burn, belching (may indicate reflux)
Dizziness, syncope, hematemesis, or melena (Hemorrhage)
Anemia

ALERT!!!
Sudden intense mid-epigastric pain radiating to the right shoulder may indicate ULCER
PERFORATION
A PEPTIC ULCER may arise at various locations
Stomach Called Gastric Ulcer
Duodenum Called Duodenal Ulcer
Esophagus Called Esophageal Ulcer

Signs and Symptoms
Gastric Ulcer
Weight loss
Burning left (epigastric pain)
Food frequently aggravate pain
Pain at bedtime
Duodenal Ulcer
Epigastric pain at bedtime
Burning / Cramping, mid epigastric pain
Abdominal pain, classically epigastric with
severity related to meal times
Duodenal Ulcers are classically
relieved by food,
Gastric Ulcers are exacerbated by it
A Gastric Ulcer could give epigastric pain
during the meal as gastric acid is secreted
or after the meal as the alkaline duodenal
contents reflux in to the stomach
Symptoms of Duodenal Ulcers would
manifest mostly BEFORE the meal, when
acid (produced stimulated by ____) is
passed into the duodenum


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Pain 2 4 hours, pressure meal, eating pain
Weight gain
Nausea / Vomiting

Pathophysiology





























Diagnostic Examination
Upper GI Endoscopy with possible biopsy and cytology (More accurate to detect Ca on ulcer)
Upper GI Radiologic Exam (Barium)
Serial Stool Exam to detect occult blood (Fecal Occult Blood Test)
Gastric Secretion Test
Serology Test for H. pylori Antibodies

Management
General Measures
1. Eliminate use of NSAIDS / other causative drugs
2. Eliminate cigarette smoking
3. Well-balanced diet with regular meal intervals
Drug Therapy
4 Ex. Proton Pump Inhibitors (PPI) + Metronidazole (Antibiotics), Ranitidine,
Clarithromycin
Surgery
4 Vagotomy
Cutting (Removal) of the vagus
Tunical Acid reduction ; removal of entire connection of vagus nerve
Highly selective
Selective Removal of vagus nerve connection in stomach


jcmendiola_Achievers2013
4 Highly selective parietal vagotomy
4 Gastrectomy
Removal of some parts of the stomach
Gastroduodenostomy (Billroth I)
Gastrojejunostomy (Billroth II) Stomach straight to jejunum
Total Gastrectomy (Esophagojejunostomy) Esophagus straight to Jejunum
Gastric resection (Antrectomy)

Complications
1. GI Bleeding
2. Ulcer Perforation Leads to peritonitis, perforation is an EMERGENCY CASE
3. Gastric outlet obstruction (Pyloric sphincter)

Nursing Assessment (PQRST)
Assess for pain
Eating pattern: Type of food/current medications
History of illness (Previous GI Bleeding)
Obtain psychosocial physical examination STRESS
VS Especially BP (Orthostatic HTN Possible BLEEDING)!

Possible Nursing Diagnoses
Fluid volume deficit related to active bleeding
Pain related to epigastric distress secondary to hypersecretion of acid, mucosal erosion /
perforation
Altered nutrition: less then body requirements related to mucosal erosion
Knowledge deficit related to physical, dietary and pharmacological treatment















Medical Management
Pharmacologic: Combination of antibodies, PPI and Bismuth salt to eradicate H. pylori for 10 14
days, H
2
receptor antagonist and PPI are used to treat NSAID induced ulcer
Stress reduction



Nursing Interventions
Prevention
1. Monitor I&O, stools
2. Monitor: H/H and electrolytes
3. Administer IV fluids / blood as ordered
4. Insert NGT as ordered and to monitor drainage for signs and symptoms of blood
5. Administer meds via NGT to neutralize acid as ordered
Cushings Ulcer
- Common in clients with
head injury and brain
trauma, more penetrating
and deeper than stress ulcer,
involves esophagus,
stomach and duodenum
- Observed about 72 hours
after ********* , involves
stomach and duodenum
Duodenal Ulcer
Age: 30 60 years old
M/F = 3:1
80% of peptic ulcer are duodenal
Weight gain
Hypersecretion of HCl Acid
Pain occurs 2 3 hours after meal
Ingestion of food relieved pain
Vomiting is uncommon

Gastric Ulcer
Usually 50 and over
M/F = 1:1
Weight loss
Pain occurs to 1 hour after meal
Hemorrhage is Less likely
Melena is more common than
Hematemesis
- Most likely to perforate
- Possibility of malignancy is
rare

RISK FACTOR: Alcohol, smoking, stress

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6. Prepare client for lavage
7. Observe client for PR, BP (SHOCK)
8. Prepare client for diagnostic procedure / surgery to determine / stop source of bleeding
Pain Relief
1. Administer prescribed pain medications
2. Provide small frequent meals to prevent gastric distention if not on NPO
3. Advise client about the irritating effects of some foods / medications
Education About Treatment Regimen
1. Explain all tests and procedures to increase knowledge and cooperation to decrease
anxiety
2. Allow client to ask questions and clarify misunderstandings: Review diet, activities,
medication and treatment
3. Give client listing / medications, dosage, line of administration and desired effects to
promote compliance
4. Teach client the signs and symptoms of bleeding and when to notify health care provider
Post-Gastric Surgery Education
To prevent signs and symptoms of dumping syndrome following Billroth surgeries
1. Advise client to chew food and eat slowly
2. Instruct client to drink ample amount of fluid after meals and not during
3. Instruct client to eat several small meals a day; in CHO to prevent diarrhea

Pharmacotherapy
H
2
Receptor Antagonist (PO/IV)
Antibiotics: To eradicate H. pylori
Mucosal Barrier
Antacids
4 Gastric acidity
4 Taken 1 hour after medications
Maalox Diarrhea
Calcium Carbonate Uric Acid
4 Aluminum Hydroxide Constipation
PPI
4 Acid secretion of the PC
4 4 8 week medication

Mga nacopy ko na KULANG KULANG XD
Vagotomy
Severing of the Vagus Nerve
GA
Diminish cholinergic stimulation to the PC - Response to gastric
Billroth I
Removal of the lower portion of the antrum
Antrum contains the cells that secrete juices
Small portion of the duodenum and pylorus
Remaining portion is anastomosed to the duodenum
Billroth II
Remaining portion is anastomosed to the jejunum

Complications
Billroth I
Feeling of fullness
Dumping syndrome
Diarrhea / anemia
Recurrence rate is < 1 %
Billroth II
Dumping syndrome
Anemia
Malabsorption
Weight loss
Recurrence rate of ulcer is 10 15%
Surgical WALA XD
- Total Gastrectomy
-
-
-

- Vagotomy
- Pyloroplasty
- Billroth I (Gastroduodenostomy)
- Billroth II (Gastrojejunostomy)

jcmendiola_Achievers2013
Nursing Intervention
1. Give BLAND diet
2. H
2
Blocker
3. Monitor complications of bleeding
4. Provide teaching

Bleeding
1. NPO
2. Hematocrit and hemoglobin
3.
4. Assist in saline lavage
5. Insert NGT for decompression
6. Prepare to administer blood transfusion
7. Prepare to give vasopressin

Surgical Procedure for PUD
1. Monitor VS
2. Fowler: Post Op! Position
3. NPO until peristalsis returns!
4. Monitor bowel sounds (BOWEL SOUNDS 1
st
BEFORE FLATUS!)
5. Monitor for complication of surgery
6. Monitor I&O, IVF
7. Maintain NGT
8. Diet progressive: Clear liquid Full Liquid Bland
9. Manage Dumping Syndrome!