Assessment of the Gastrointestinal System

1

• Assessment of the Gastrointestinal System

2
Overview of the Gastrointestinal Tract

• Structure
• Function
• Nerve supply
• Blood supply
• Oral cavity
• Esophagus
• Stomach
• (Continued)

3
Overview of the Gastrointestinal Tract (Continued)

• Pancreas
• Liver and gallbladder
• Intestines

4
Assessment Techniques

• History
• Demographic data
• Family history and genetic risk
• Personal history
• Diet history
• Anorexia
• Dyspepsia

5
Current Health Problems

• Pattern of bowel movements
• Color and consistency of the feces
• Occurrence of diarrhea or constipation
• Effective action taken to relieve diarrhea or
  constipation
  
• Presence of frank blood or tarry stools
• Presence of abdominal distention or gas

6
Skin Changes Related to Gastrointestinal Disorders

• Skin discolorations or rashes
• Itching
• Jaundice
• Increased susceptibility to bruising
• Increased tendency to bleed

7
Physical Assessment

• Mouth and pharynx
• Abdomen and extremities
• Inspection (Cullens sign)
• Auscultation, look for borborygmus
• Percussion
• Palpation

8
Laboratory Tests

• Complete blood count
• Clotting factors
• Electrolytes
• Assays of liver enzymesaspartate and alanine
  aminotransferase
  
• Serum amylase and lipase
• Bilirubin the primary pigment in bile
• (Continued)

9
Laboratory Tests (Continued)

• Evaluation of oncofetal antigens CA 19-9 and CEA
• Urine testsamylase, urine urobilinogen
• Stool testsfecal occult blood test, ova
  parasites, Clostridium difficile infection
  
• Radiographic examinations

10
Upper Gastrointestinal Series and Small Bowel
Series

• Before test
• Maintain NPO for 8 hr.
• Withhold analgesics and anticholinergics for 24
  hr.
  
• Client drinks 16 ounces of barium.
• Rotate examination table.
• (Continued)

11
Barium Enema

• Barium enema enhances radiographic visualization
  of the large intestine.
  
• Only clear liquids are given 12 to 24 hr before
  the test NPO the night before bowel cleansing
  is done.
  
• After the test, expel the barium drink plenty of
  fluids stool is chalky white for 24 to 72 hr.

12
Upper Gastrointestinal Series and Small Bowel
Series (Continued)

• After the test
• Give plenty of fluids.
• Administer mild laxative or stool softener
  stools may be chalky white for 24 to 72 hr.

13
Percutaneous Transhepatic Cholangiography

• X-ray study of the biliary duct system
• Laxative before the procedure
• NPO for 12 hr before test
• Coagulation tests, intravenous infusion
• Bedrest for several hours after procedure
• Assessment of vital signs
• (Continued)

14
Percutaneous Transhepatic Cholangiography
(Continued)

• Client positioned on right side with a firm
  pillow or sandbag placed against the lower ribs
  and abdomen
  

15
Other Tests

• Computed tomography
• Endoscopy direct visualization of the
  gastrointestinal tract by means of a flexible
  fiberoptic endoscope

16
Esophagogastroduodenoscopy

• Visual examination of the esophagus, stomach, and
  duodenum
  
• NPO for 6 to 8 hr before the procedure
• Conscious sedation
• After the test, assessment of vital signs every
  30 min
  
• NPO until gag reflex returns
• Throat discomfort possible for several days

17
Endoscopic Retrograde Cholangiopancreatography

• Visual and radiographic examination of the liver,
  gallbladder, bile ducts, and pancreas
  
• NPO for 6 to 8 hr before test
• Access for intravenous sedation
• After the test, assessment of vital signs every
  15 min
  
• (Continued)

18
Endoscopic Retrograde Cholangiopancreatography
(Continued)

• Return of gag reflex checked
• Assessment for pain
• Colicky abdominal pain

19
Small Bowel Capsule Enteroscopy

• Visualization of the small intestine
• Only water for 8 to 10 hr before test
• NPO for first 2 hr of the testing
• Application of belt with sensors

20
Colonoscopy

• Endoscopic examination of the entire large bowel
• Liquid diet for 12 to 24 hr before procedure, NPO
  for 6 to 8 hr before procedure
  
• Bowel cleansing routine
• Assessment of vital signs every 15 min
• If polypectomy or tissue biopsy, blood possible
  in stool

21
Proctosigmoidoscopy

• Endoscopic examination of the rectum and sigmoid
  colon
  
• Liquid diet 24 hr before procedure
• Cleansing enema, laxative
• Position client on left side in the knee-chest
  posture.
  
• (Continued)

22
Proctosigmoidoscopy (Continued)

• Mild gas pain and flatulence from air instilled
  into the rectum during the examination
  
• If biopsy was done, a small amount of bleeding
  possible
  

23
Gastric Analysis

• Measurement of the hydrochloric acid and pepsin
  content for evaluation of aggressive gastric and
  duodenal disorders (Zollinger-Ellison syndrome)
  
• Basal gastric secretion and gastric acid
  stimulation test
  
• NPO for 12 hr before test
• Nasogastric tube insertion

24
Other Tests

• Ultrasonography
• Endoscopic ultrasonography
• Liver-spleen scan

25
Gasrointestinal Intubation

• To remove gas and fluids from the stomach or
  intestines (decompression).
  
• To diagnose GI motility and to obtain gastric
  secretions for analysis.
  
• To relieve and treat obstructions or bleeding
  within the GI tract.

26
Gastrointestinal Intubation cont

• To provide a means for nutrition ( gavage
  feeding), hydration, and medication when the oral
  route is not possible or is contraindicated.
  
• To promote healing after esophageal, gastric, or
  intestinal surgery by preventing distension of
  the GI tract and strain on the suture lines.
  

27
Gastrointestinal Intubation cont.

• To remove toxic toxic substances (lavage) that
  have been ingested either accidentally or
  intentionally and to provide for irrigation.

28
General Nursing Care

• Assessing tube placement must be assessed after
  insertion and maintenance. Assessing tube
  placement is essential to prevent complications
  or death from incorrect tube placement.
• Nasogastric tube placement must be assessed after
  insertion and then intermittently to ensure that
  it is in the correct position and not in the
  lungs (most common), esophagus, pleural space, or
  brain.

29

• Interventions for Clients with Oral Cavity
  Problems

30
Stomatitis

• Painful, single or multiple ulcerations of the
  oral mucosa that appear as inflammation and
  denudation of the oral mucosa, impairing the
  protective lining of the mouth
• Primary stomatitis
• Secondry stomatitis
• Candidiasis

31
Clinical Manifestations

• Dry, painful mouth, open ulcerations,
  predisposing the client to infection
  
• Commonly found on the buccal mucosa, soft palate,
  oropharyngeal mucosa, and lateral and ventral
  areas of the tongue
  
• If candidiasis, white plaquelike lesions on the
  tongue when wiped away, red sore tissue appears

32
Oral Hygiene

• Soft-bristled toothbrush or disposable foam swabs
  to stimulate gums and clean the oral cavity are
  recommended.
  
• Frequent rinsing of the mouth with solution, not
  commercial mouthwash
  
• Mouth care every 2 hr and twice during the night,
  if stomatitis is not controlled

33
Drug Therapy

• Antibiotics such as tetracycline syrup and
  minocycline (swish and swallow)
  
• Antifungals such as nystatin oral suspension
  (swish and swallow)
  
• Intravenous acyclovir for immunocompromised
  clients with herpes simplex stomatitis
  
• (Continued)

34
Drug Therapy (Continued)

• Anti-inflammatory agents and immune modulators
• Symptomatic topical agents such as gargle or
  mouthwash
  

35
Leukoplakia

• Slowly developing changes in the oral mucous
  membranes characterized by thickened, white,
  firmly attached patches that are slightly raised
  and sharply circumscribed.
• Most common oral lesion among adults
• (Continued)

36
Leukoplakia (Continued)

• Oral hairy leukoplakia is an early manifestation
  of HIV infection and is highly correlated with
  the progression from HIV to AIDS.
  

37
Erythroplakia

• Red, velvety mucosal lesions on the surface of
  the oral mucosa
  
• Higher degree of malignant transformation in
  erythroplakia than in leukoplakia
  
• Commonly found on the floor of the mouth, tongue,
  palate, and mandibular mucosa

38
Squamous Cell Carcinoma

• Most common oral malignancy can be found on the
  lips, tongue, buccal mucosa, and oropharynx
  
• Highly associated with aging, tobacco use, and
  alcohol ingestion
  
• Tumor, node, metastasis classification system for
  tumors of the lips and oral cavity

39
Basal Cell Carcinoma

• Occurs primarily on the lips
• Lesion is asymptomatic and resembles a raised
  scab evolves into ulcer with a raised pearly
  border
  
• Aggressively involves the skin of the face, but
  does not metastasize
  
• Major etiologic factor is exposure to sunlight

40
Kaposis Sarcoma

• Malignant lesion arising in blood vessels
• Usually painless
• Raised purple nodule or plaque
• Found on the hard palate, gums, tongue, or
  tonsils
  
• Most often associated with AIDS

41
Risk for Ineffective Airway Clearance

• Interventions include
• Excessive tumor involvement and tenacious
  secretions can inhibit airway patency.
  
• Nursing measures for maintaining airway patency
  is primary focus.
  
• Assessment should focus on clients dyspnea,
  inability to cough effectively, or inability to
  swallow.

42
Nonsurgical Management

• Airway management
• Cough management
• Aspiration precautions

43
Surgical Management

• Tracheostomy
• Decannulation accomplished after postoperative
  edema resolves

44
Impaired Oral Mucous Membrane

• Oral cavity lesions can be treated by surgical
  excision, by nonsurgical treatments such as
  radiation or chemotherapy, or by a combination of
  treatments (multimodal therapy)

45
Nonsurgical Management

• Oral care
• Radiation therapy
• Chemotherapy

46
Surgical Management

• Preoperative care
• Operative procedure
• Postoperative care
• Maintaining airway patency
• Protecting the operative area
• Relieving pain
• Promoting nutrition

47
Acute Sialadenitis

• Inflammation of a salivary gland, caused by
  infectious agents, irradiation, or immunologic
  disorders
  
• Interventions
• Hydration
• Application of warm compresses
• Massage of the gland
• Use of saliva substitute
• Use of sialagogues

48
Postirradiation Sialadenitis

• Xerostomia results in very dry mouth caused by
  severe reduction in the flow of saliva.
  
• Little can be done during the course of
  radiation, but frequent sips of water and
  frequent mouth care, especially before meals, are
  the most effective interventions.
• (Continued)

49
Postirradiation Sialadenitis (Continued)

• Saliva substitutes can be used after the course
  of radiation therapy is complete.
  

50
Salivary Gland Tumors

• Relatively rare among oral tumors
• Often associated with radiation of the head and
  neck areas
  
• Assessment ability to wrinkle brow, raise
  eyebrows, squeeze eyes shut, wrinkle nose, pucker
  lips, puff out cheeks, and grimace or smile
  
• Treatment of choice surgical excision of the
  parotid gland

51

• Interventions for Clients with Esophageal Problems

52
Gastroesophageal Reflux Disease

• Occurs as a result of the backward flow (reflux)
  of gastrointestinal contents into the esophagus
  
• Reflux esophagitis characterized by acute
  symptoms of inflammation
  
• (Continued)

53
Gastroesophageal Reflux Disease (Continued)

• Esophageal reflux occurs when gastric volume or
  intra-abdominal pressure is elevated, the
  sphincter tone of the lower esophageal sphincter
  is decreased, or it is inappropriately relaxed.

54
Clinical Manifestations

• Dyspepsia
• Regurgitation
• Hypersalivation or water brash
• Dysphagia and odynophagia
• Others manifestations chronic cough, asthma,
  atypical chest pain, eructation (belching),
  flatulence, bloating, after eating, nausea and
  vomiting

55
Diagnostic Assessment

• 24-hr ambulatory pH monitoring
• Endoscopy
• Esophageal manometry

56
Nonsurgical Management

• Diet therapy
• Client education
• Lifestyle changes elevate head of bed 6 in. for
  sleep, sleep in left lateral decubitus position
  stop smoking and alcohol consumption reduce
  weight wear nonbinding clothing refrain from
  lifting heavy objects, straining, or working in a
  bent-over posture

57
Drug Therapy

• Antacids elevate the level of the gastric
  contents.
  
• Histamine receptor antagonists decrease acid
  production.
  
• Proton pump inhibitors provide effective,
  long-acting inhibition of gastric acid
  secretion.
  
• Prokinetic drugs increase gastric emptying and
  improve lower esophageal sphincter pressure and
  esophageal peristalsis.

58
Other Treatments

• Endoscopic therapies
• Surgical therapies

59
Hiatal Hernia

• Protrusion of the stomach through the esophageal
  hiatus of the diaphragm into the thorax
  
• Sliding hernia most common, occurring when
  esophagogastric junction and a portion of the
  fundus of the stomach slide upward through the
  esophageal hiatus into the thorax
• Rolling hernia fundus rolls into the thorax
  beside the esophagus

60
Assessment

• Heartburn
• Regurgitation
• Pain
• Dysphagia
• Belching
• Worsening symptoms after eating or when in
  recumbent position
  

61
Nonsurgical Management

• Drug therapy antacids, histamine receptor
  antagonists
  
• Diet therapy avoid eating in the late evening
  and avoid foods associated with reflux
  
• Weight reduction
• (Continued)

62
Nonsurgical Management (Continued)

• Elevate head of bed 6 -12 in. for sleep, remain
  upright for several hours after eating, avoid
  straining and vigorous exercise, avoid nonbinding
  clothing.

63
Surgical Management

• Laparoscopic Nissen Fundoplication (LNF) is the
  most common surg proc. the stomach fundus is
  wrapped around the lower part of the esophagus
  and then sutured onto itself to hold it in place.

64
Surgical Management

• Preoperative care
• Operative procedures
• Postoperative care
• Respiratory care
• Nasogastric tube management
• Nutritional care for complications of surgery
  including gas bloat syndrome and aerophagia (air
  swallowing)

65
Achalasia

• Esophageal motility disorder believed to result
  from esophageal denervation characterized by
  chronic and progressive dysphagia
  
• Primary symptoms dysphagia and regurgitation of
  solids, liquids, or both

66
Drug and Diet Therapy

• Calcium channel blockers
• Nitrates
• Direct injection of botulinum toxin into the
  lower esophageal muscle
  
• Semisoft foods
• Arching the back while swallowing
• Avoidance of restrictive clothing

67
Esophageal Dilation

• Passage of progressively larger sizes of
  esophageal bougies using polyurethane balloons on
  a catheter
  
• Metal stents used to keep the esophagus open for
  longer durations
  
• Complications bleeding, signs of perforation,
  chest and shoulder pain, elevated temperature,
  subcutaneous emphysema, hemoptysis

68
Esophagomyotomy

• Surgical procedure for achalasia is done to
  facilitate the passage of food.
  
• Laparoscopic approach is most common.
• For long-term refractory achalasia, the surgeon
  may attempt excising the affected portion of the
  esophagus with or without replacement of a
  segment of colon or jejunum.

69
Esophageal Tumors

• Esophageal tumors can be benign or malignant.
• Barretts esophagus is ultimately malignant.
• Clinical manifestations include dysphagia,
  odynophagia, regurgitation, vomiting, foul
  breath, chronic hiccups, pulmonary complications,
  chronic cough, and hoarseness.

70
Imbalanced Nutrition Less Than Body Requirements

• Interventions include
• Nonsurgical management
• Nutrition therapy
• Swallowing therapy
• Chemotherapy
• Radiation therapy
• (Continued)

71
Imbalanced Nutrition Less Than Body Requirements
(Continued)

• Photodynamic therapy
• Esophageal dilation
• Endoscopic therapies
• Surgical removal of the tumor

72
Surgical Management

• Esophagectomy the removal of all or part of the
  esophagus
  
• Esophagogastrostomy the removal of part of the
  esophagus and proximal stomach
  
• Minimally invasive esophagectomy
• Extensive preoperative care
• Operative procedures

73
Postoperative Care

• Highest postoperative priority respiratory care
• Cardiovascular care
• Wound management
• Nasogastric tube management
• Nutritional care
• Discharge planning

74
Diverticula

• Sacs resulting from the herniation of esophageal
  mucosa and submucosa into surrounding tissue
  
• Zenkers diverticulum most common
• Diet therapy for size and frequency of meals
• Surgical management

75
Esophageal Trauma

• Trauma to the esophagus can result from blunt
  injuries, chemical burns, surgery or endoscopy,
  or stress of protracted vomiting.
  
• Nothing is administered by mouth broad-spectrum
  antibiotics are given.
  
• Surgical management requires resection of part of
  the esophagus with a gastric pull-through and
  repositioning or replacement by a bowel segment.

76

• Interventions for Clients with Stomach Disorders

77
Gastritis

• Gastritis is defined as inflammation of the
  gastric mucosa two types
  
• Acute gastritis
• Chronic gastritis
• Type A gastritis
• Type B gastritis
• Atrophic gastritis
• Helicobacter pylori, Escherichia coli can cause
  gastritis.

78
Clinical Manifestations

• Abdominal tenderness
• Bloating
• Hematemesis
• Melena
• Intravascular depletion and shock

79
Nonsurgical Management

• Primary treatment identification and elimination
  of causative factors
  
• Drug therapy
• H2-receptor antagonists
• Antacids
• Antisecretory agents
• Vitamin B12
• Triple therapy for H. pylori infection

80
Other Therapies

• Diet therapy
• Limit intake of foods and spices that cause
  distress (tea, coffee, cola, chocolate, mustard,
  paprika, cloves, pepper, and hot spices), as well
  as tobacco and alcohol.
• Stress reduction

81
Surgical Management

• Partial gastrectomy
• Pyloroplasty
• Vagotomy
• Total gastrectomy

82
Peptic Ulcer Disease

• PUD is a mucosal lesion of the stomach or
  duodenum as a result of gastric mucosal defenses
  impaired and no longer able to protect the
  epithelium from the effects of acid and pepsin.
• Acid, pepsin, and Helicobacter pylori infection
  play an important role in the development of
  gastric ulcers.
  

83
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84
Duodenal Ulcers

• Most duodenal ulcers occur in the first portion
  of the duodenum.
  
• Duodenal ulcers present as deep, sharply
  demarcated lesions that penetrate through the
  mucosa and submucosa into the muscularis propria.

85
Stress Ulcers

• Acute gastric mucosa lesions occurring after an
  acute medical crisis or trauma
  
• Associated with head injury, major surgery,
  burns, respiratory failure, shock, and sepsis.
  
• Principal manifestation bleeding caused by
  gastric erosion
  

86
Complications of Ulcers

• Hemorrhagehematemesis
• Perforationa surgical emergency
• Pyloric obstructionmanifested by vomiting caused
  by stasis and gastric dilation
  
• Intractable diseasethe client no longer responds
  to conservative management, or recurrences of
  symptoms interfere with ADLs
  

87
Clinical Manifestations

• Epigastric tenderness usually located at the
  midline between the umbilicus and the xiphoid
  process
  
• Dyspepsia
• Typically described as sharp, burning, or gnawing
  pain
  
• Sensation of abdominal pressure or of fullness or
  hunger

88
Acute or Chronic Pain

• One of the primary purposes for employing drug
  therapy is to eliminate or reduce pain.
  
• Analgesics are not the mainstay of pain relief
  for PUD.
  
• Ulcer drug regimen itself promotes relief of pain
  by eradicating H. pylori infection and promoting
  healing of the gastric mucosa.

89
Drug Therapy

• Four primary goals for drug therapy
• Provide pain relief
• Eradicate H. pylori infection
• Heal ulcerations
• Prevent recurrence

90
Hyposecretory Drugs

• Hyposecretory drugs produce a reduction in
  gastric acid secretion.
  
• Antisecretory agents
• H2-receptor antagonists
• Prostaglandin analogues

91
Antisecretory Agents

• Antisecretory agents, also called proton pump
  inhibitors, include
  
• Prilosec
• Prevacid
• Aciphex
• Protonix
• Nexium

92
H2-Receptor Antagonists

• Drugs that block histamine-stimulated gastric
  secretion
  
• May be used for indigestion and heartburn
• Block the action of the H2-receptors of the
  parietal cells, thus inhibiting gastric acid
  secretion
  
• The most common Zantac, Pepcid, and Axid

93
Prostaglandin Analogues

• These agents reduce gastric acid secretion and
  enhance gastric mucosal resistance to tissue
  injury.
  
• Misoprostol (Cytotec) helps prevent NSAID-induced
  ulcers.
  
• Uterine contraction is a significant adverse
  effect of misoprostol.

94
Antacids

• Antacids buffer gastric acid and prevent the
  formation of pepsin they are effective in
  accelerating the healing of duodenal ulcers.
  
• The most widely used preparations are mixtures of
  aluminum hydroxide and magnesium hydroxide, such
  as Mylanta or Maalox.
  
• (Continued)

95
Antacids (Continued)

• For optimal effect, take about 2 hr after meals.
• Antacids can interact with certain drugs and
  interfere with their effectiveness.
  

96
Mucosal Barrier Fortifiers

• Sucralfate (Carafate) is a sulfonated
  disaccharide that forms complexes with proteins
  at the base of a peptic ulcer this protective
  coat prevents further digestive action of both
  acid and pepsin.
• (Continued)

97
Mucosal Barrier Fortifiers (Continued)

• Sucralfate binds bile acids and pepsins, reducing
  injury from these substances.
  
• The main side effect of sucralfate is
  constipation.

98
Diet Therapy

• Diet therapy may be directed toward neutralizing
  acid and reducing hypermotility.
  
• A bland, nonirritating diet is recommended during
  the acute symptomatic phase.
  
• Avoid bedtime snacks.
• Avoid alcohol and tobacco.

99
Complementary and Alternative Therapies

• Kundalini yoga techniques are being studied to
  see how they can help manage gastrointestinal
  disorders.
  
• Certain herbs are thought to heal inflamed tissue
  and increase blood flow to the gastric mucosa.
  
• Other substances include zinc, vitamin C,
  essential fatty acids, acidophilus, vitamins E
  and A, and glutamine.

100
Potential for Gastrointestinal Bleeding

• Interventions include
• Monitoring and early recognition of complications
  (critical to the successful management of PUD).
  
• Preventing and/or managing bleeding, perforation,
  and gastric outlet obstruction.
  
• Possible surgical treatment.

101
Hypovolemia Management

• Monitor vital signs and observe for fluid loss
  from bleeding and vomiting.
  
• Monitor serum electrolytes.
• Insert two large-bore peripheral IV catheters to
  replace both fluids and blood lost.
  
• (Continued)

102
Hypovolemia Management (Continued)

• Volume replacement with isotonic crystalloid
  solutions should be started immediately.
  
• Blood products may be ordered to expand volume
  and correct abnormalities in the CBC.
  
• Orthostatic hypotension is common in clients with
  decreased fluid volume.

103
Bleeding Reduction Gastrointestinal

• Endoscopic therapy can assist in achieving
  hemostasis.
  
• Acid-suppressive agents are used to stabilize the
  clot by raising the pH level of gastric
  contents.
  
• Upper gastrointestinal bleeding may require the
  health care provider to insert nasogastric tube.
  
• Saline lavage requires the insertion of a
  large-bore nasogastric tube.

104
Nonsurgical Management

• Perforation is managed by immediately replacing
  fluid, blood, and electrolytes.
  
• Administering antibiotics
• Keeping the client NPO
• Pyloric obstruction related to edema, and spasm
  generally responds to medical therapy.

105
Surgical Management

• Preoperative care insertion of a nasogastric
  tube.
  
• Operative procedure
• A simple gastroenterostomy permits neutralization
  of gastric acid.
  
• (Continued)

106
Surgical Management (Continued)

• Vagotomy eliminates the acid-secreting stimulus
  to gastric cells and decreases the response of
  parietal cells.
  
• Pyloroplasty facilitates emptying of stomach
  contents.
  

107
Postoperative Care

• Monitor the nasogastric tube.
• Monitor for postoperative complications
• Dumping syndrome (constellation of vasomotor
  symptoms after eating)
  
• Reflux gastropathy
• (Continued)

108
Postoperative Care (Continued)

• Delayed gastric emptying (usually resolved within
  1 week)
  
• Afferent loop syndrome may occur after a Billroth
  II resection.
  
• Recurrent ulceration occurs in about 5 of
  clients.
  

109
Nutritional Management

• Deficiencies of vitamin B12, folic acid, and
  iron impaired calcium metabolism and reduced
  absorption of calcium and vitamin D develop as a
  result of partial removal of the stomach.
• These problems are caused by a shortage of
  intrinsic factor.
  
• Monitor CBC for signs of megaloblastic anemia and
  leukopenia.

110
Zollinger-Ellison Syndrome

• Zollinger-Ellison syndrome is manifested by upper
  gastrointestinal tract ulceration, increased
  gastric acid secretion, and the presence of a
  nonbeta cell islet tumor of the pancreas, called
  a gastrinoma.
• Clients may complain of peptic ulcer disease
  symptoms and may have diarrhea and/or steatorrhea.

111
Interventions

• The aim of therapy is to suppress acid secretion
  to control the clients symptoms.
  
• Drugs of choice are
• Prevacid
• Prilosec
• Zantac
• (Continued)

112
Interventions (Continued)

• If medical therapy fails, a vagotomy and
  pyloroplasty to supplement pharmacologic means of
  controlling hypersecretion may be performed.
  

113
Gastric Carcinoma

• Gastric carcinoma refers to malignant neoplasms
  in the stomach.
  
• Clinical manifestations early gastric cancer may
  be asymptomatic, but indigestion and abdominal
  discomfort are the most common symptoms.
  
• (Continued)

114
Gastric Carcinoma (Continued)

• Signs of distant metastasis include
• Virchow's nodes
• Sister Mary Joseph nodes
• Blumer's shelf
• Krukenberg's tumor

115
Nonsurgical Management

• Drug therapy
• The role of chemotherapy in gastric cancer
  remains uncertain.
  
• Radiation therapy
• The use of this treatment is limited because the
  disease is often widely disseminated.

116
Surgical Management

• Preoperative care is similar to that provided for
  general anesthesia and abdominal surgery.
  
• Operative procedures include subtotal and total
  gastrectomy.
  
• Postoperative complications
• Pneumonia
• Anastomotic leak
• (Continued)

117
Surgical Management (Continued)

• Hemorrhage
• Reflux aspiration
• Wound infection
• Sepsis
• Reflux gastritis
• Paralytic Ileus
• Bowel obstruction
• Dumping syndrome

118

• Interventions for Clients with Malnutrition and
  Obesity

119
Nutritional Standards to Promote Health

• Dietary recommendations, food guide pyramids for
  adequate nutrition
  
• Nutritional assessment includes
• Diet history
• Anthropometric measurements
• Measurement of height and weight
• Assessment of body fat (body mass index)

120
Malnutrition

• Protein-calorie malnutrition
• Marasmus calorie malnutrition, in which body fat
  and protein are wasted, serum proteins are often
  preserved
  
• Kwashiorkor
• Marasmic-kwashiorkor

121
Laboratory Assessment

• Hematology
• Protein studies
• Serum cholesterol
• Other laboratory tests

122
Imbalanced Nutrition Less Than Body Requirements

• Interventions include
• Drug therapy
• Partial enteral nutrition
• Total enteral nutrition
• Candidates for total enteral nutrition

123
Enteral Nutrition

• Types of enteral products for nutrients
• Methods of administration of total enteral
  nutrition
  
• Types of tubes
• Types of feedings
• Complications of total enteral nutrition
• Aspiration, fluid excess, increased osmolarity,
  dehydration, electrolyte imbalances

124
Parenteral Nutrition

• Partial parenteral nutrition
• Total parenteral nutrition
• Complications include
• Fluid imbalances
• Electrolyte imbalances
• Glucose imbalances
• Infection

125
Obesity

• Overweight increase in body weight for height
  compared to standard
  
• Obesity at least 20 above upper limit of normal
  range for ideal body weight
  
• Morbid obesity severe negative effect on health

126
Obesity Complications

• Diabetes mellitus
• Hypertension
• Hyperlipidemia
• CAD
• Obstructive sleep apnea
• Obesity hypoventilation syndrome
• Depression and other mental health/behavioral
  health problems
  
• (Continued)

127
Obesity Complications (Continued)

• Urinary incontinence
• Cholelithiasis
• Chronic back pain
• Early osteoarthritis
• Decreased wound healing
• Increased susceptibility to infection

128
Obesity and Health Promotion

• Health promotion/illness prevention
• Teach the potential consequences and
  complications.
  
• Teach the importance of eating a healthy diet.
• Teach that foods eaten away from home tend to be
  higher in fat, cholesterol, and salt, and lower
  in calcium.
  
• (Continued)

129
Obesity and Health Promotion (Continued)

• Reinforce need for regular moderate activity for
  at least 30 min per day.
  
• Educate regarding diet and activity for children
  and adolescents, and continuing throughout
  adulthood.
  

130
Nonsurgical Management

• Fasting
• Very low-calorie diets of 200 to 800 calories per
  day
  
• Balanced and unbalanced low-energy diets
• Novelty diets
• Diet therapy
• Exercise program
• (Continued)

131
Nonsurgical Management (Continued)

• Drug therapy
• Complementary and alternative therapies and
  treatments
  

132
Surgical Management

• Liposuction
• Panniculectomy
• Bariatric surgery
• Preoperative care
• Operative procedures
• Vertical banded gastroplasty
• Circumgastric banding
• Gastric bypass
• Roux-en-Y gastric bypass

133
Postoperative Care

• Analgesia
• Skin care
• Nasogastric tube placement
• Diet
• Prevention of postoperative complications
• Observe dumping syndrome signs such as
  tachycardia, nausea, diarrhea, and abdominal
  cramping

134
Gastrointestinal Intubation

• To remove gas and fluids from the stomach or
  intestines (decompression).
  
• To diagnose GI motility and to obtain gastric
  secretions for anaysis