Management of Patients With Gastric and Duodenal Disorders

Gastritis
Inflammation of the stomach:
A common GI problem
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.
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.
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
Chronic:
`Modify diet, promote rest, reduce stress, avoid alcohol and NSAIDs
`Pharmacologic therapy (See Table 37-1)
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:
`excessive secretion of stomach acid, dietary factors, chronic use of NSAIDs, alcohol, smoking, and familial tendency.
Manifestations:
`dull gnawing pain or burning in the mid-epigastrium; heartburn and vomiting may occurTreatment includes medications, lifestyle changes, and occasionally surgery (See Tables 37-1 and 37-3)

Is the following statement True or False?

The most common site for peptic ulcer formation is the pylorus.

False

The most common site for peptic ulcer formation is not the pylorus. The most common site for peptic ulcer formation is the duodenum.

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
Nursing Process: The Care of the Patient with Gastritis—Diagnoses
Anxiety
Imbalanced nutrition
Risk for fluid volume imbalance
Deficient knowledge
Acute pain
Nursing Process: The Care of the Patient with Gastritis—Planning
Major goals:
reduce anxiety
avoidance of irritating foods
adequate intake of nutrients
maintenance of fluid balance
increased awareness of dietary management
relief of pain
Interventions
Reduce anxiety:
use calm approach and explain all procedures and treatments.
Promote optimal nutrition:
for acute gastritisPromote fluid balance; monitor I&O, for signs of dehydration, electrolyte imbalance, and hemorrhage.

Measures to relieve pain: diet and medications.
See Chart 37-1.

Nursing Process: The Care of the Patient with Peptic Ulcer—Assessment
Assess pain and methods used to relieve pain
Dietary intake and 72 hour diet diary
Lifestyle and habits such as cigarette and alcohol use
Medications; include use of NSAIDs
Sign and symptoms of anemia or bleeding
Abdominal assessment
Nursing Process: The Care of the Patient with Peptic Ulcer—Diagnoses
Acute pain
Anxiety
Imbalanced nutrition
Deficient knowledge
Collaborative Problems/Potential Complications
Hemorrhage
Perforation
Penetration
Pyloric obstruction (gastric outlet obstruction)
Nursing Process: The Care of the Patient with Peptic Ulcer—Planning
Major goals:
relief of pain
reduced anxiety
maintenance of nutritional requirements
knowledge about the management and prevention of ulcer recurrence
absence of complications
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
Patient Teaching
Medication teaching
Dietary restrictions
Lifestyle changes
See Chart 37-2
What is the best time to teach a client to take proton pump inhibitors?
A. 30 minutes before a meal
B. With a meal
C. Immediately after the meal
D. One to three hours after the meal

A

The best time for a client to take a proton pump inhibitor is before a meal. It is a delayed-release medication that is to be swallowed whole and taken before a meal.

Management of Potential Complications
Management of hemorrhage:
`Assess for evidence of bleeding, hematemesis or melena, and symptoms of shock and anemia.
`Treatment
“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.Pyloric obstruction:
`Symptoms include nausea and vomiting, constipation, epigastric fullness, anorexia, and (later) weight loss.
`Treatment
“Insert NG tube to decompress the stomach, provide IV fluids and electrolytes. Balloon dilation or surgery may be required.

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/impending shock.
`Treatment:
Bariatric Surgery
`Morbid obesity:
“persons more than two times IBW or more than 100 pounds greater than IBW.
`Surgery is preformed only after nonsurgical methods have failed.
`Selection factors
“body weight, patient history, and failure to lose weight using other means, absence of endocrine disorders, and psychological stability See Chart 37-3
Nursing Care of the Patient Undergoing Bariatric Surgery
`Preoperative care; evaluation and counseling
`Postoperative care is similar to gastric resection but the patient is at greater risk for complications due to obesity
`Postoperative diet
`Patients require psychosocial interventions to modify their eating behaviors.
`Follow-up care
`Education regarding long-term effects

Is the following statement True or False?

The average weight loss after bariatric surgery is 60% of previous body weight.

True

The average weight loss after bariatric surgery is 60% of previous body weight.

Gastric Cancer
`Incidence is deceasing, but accounts for 12,000 deaths in U.S. annually.
I`ncreased incidence in men, Native Americans, Hispanic Americans, and African Americans, typically ages 40-70.
`Risk factors
“diet, chronic inflammation of the stomach, H. pylori infection, pernicious anemia, smoking, achlorhydria, gastric ulcers, previous subtotal gastrectomy, and genetics.
`Manifestations
“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 unresectable or metastasized.
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
Nursing Process: The Care of the Patient with Gastric Cancer—Diagnoses
Anxiety
Imbalanced nutrition
Pain
Anticipatory grieving
Deficient knowledge
Nursing Process: The Care of the Patient with Gastric Cancer—Planning
Major goals:
reduced anxiety
optimal nutrition
relief of pain
adjustment to the diagnosis
anticipated lifestyle changes
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.
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 teaching for potential dumping syndrome after gastric resection.
Six small feedings low in carbohydrates and sugar, with fluids between, not with, meals.
Assessment
Other Interventions
Pain:
`Administer analgesic as prescribed
`Nonpharmacologic pain relief measures
Psychosocial support:
`Allow patient to express fears concern and grief
`Allow patient to participate in decisions
`Include family members and significant others
`Referral/involvement of other support persons as needed.
Patient teaching (see Chart 37-5)
Nursing Process: The Care of the Patient with Gastric Surgery—Assessment
Patient and family knowledge
Nutritional status
Abdominal assessment
Postoperatively assess for potential complications
Nursing Process: The Care of the Patient with Gastric Surgery—Diagnoses
Anxiety
Pain
Deficient knowledge
Imbalanced nutrition
Collaborative Problems/Potential Complications
Hemorrhage
Dietary deficiencies
Bile reflux
Dumping syndrome
Nursing Process: The Care of the Patient with Gastric Surgery—Planning
Major goals:
reduced anxiety
increased knowledge
optimal nutrition
management of complications that can interfere with nutrition
relief of pain
avoidance of hemorrhage
enhanced self-care skills at home
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
Patient teaching (see Chart 37-6).
Individualized nutritional care and support.
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
Malabsorption of vitamins and minerals:
`Supplementation of iron and other nutrients
`Parenteral administration of vitamin B12 due to lack of intrinsic factor
Care and Prevention of Complications
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
`Treatment
“Avoid fluid with meals
“Avoid high carbohydrate/sugar intake
Steatorrhea:
`Treatment
“Reduce fat intake and administer loperamide
Dietary Self-Management
To delay stomach emptying and dumping syndrome assume low Fowler’s position after meals; lie down for 20-30 minutes.
Take antispasmodics as prescribed.
Avoid fluid with meals.
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.

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