Medical Surgical I

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Chpt 51 Disorders of Upper GI

• Medical Surgical I

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Anorexia

• Lack of appetite
• Appetite center is located in the hypothalamus
• Influenced by unpleasant or noxious food odors,
  effect of drugs, emotional stress, fear,
  psychological problems and illness

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Anorexia S/S

• Eventually will show vitamin deficiency,
  especially of water soluable as not stored in the
  body.
• Dry skin, brittle hair, sore mouth, bleeding
  gums, and easy bruising
• Wound healing is poor and mental state may
  deteriorate
• Bones soften and taste and smell diminish
• Weak, tired, reduced stool, bowel irregularity
  and constipation

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Medical Management

• High calorie diet, high calorie supplemental
  feedings, tube feedings, total parenteral
  nutrition and psychiatric care may all be used to
  treat.

5
Nursing Management

• Obtain complete medical and allergy history
• Find out eating patterns and preferences
• Keep a record of BMs, may have either diarrhea or
  constipation
• May need to dilute formula until he is regulated,
  increasing dietary fiber and giving stool softener

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Anorexia Box 51-1 pg. 822

• Provide foods he likes
• Offer between snacks, milk shakes, ensure
• Do daily calorie counts
• Keep serving sizes and containers small
• Serve and keep hot foods hot and cold foods cold
• Encourage eating with others

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Anorexia

• formulate a nutritional plan with dietitian to
  promote wt gain (600 calories per meal
• Prevent unpleasant odors
• do not do painful or unsightly procedures before
  meals

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Nausea and Vomiting

• If prolonged, weakness, weight loss, nutritional
  deficiency, dehydration, and electrolyte and
  acid-base balance may occur
• common causes are drugs, infection of GI tract,
  intestinal obstruction, systemic infections,
  lesions of the CNS, food poisoning, emotional
  stress, early pregnancy and uremia

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Nausea

• Vomiting usually produced by distention of
  duodenum.
• Nausea is accompanied by increased salivation and
  peripheral vasoconstriction causing cold, clammy
  skin and tachycardia.
• Vomiting center located in the medulla is
  sensitive to parasympathetic neurotransmitters
  released in response to gastric irritation.

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Nausea

• Valsalva maneuver which accompanies the forceful
  expulsion of stomach contents causes dizziness,
  hypotension and bradycardia
• Fluid loss causes dehydration and leads to
  excessive thirst and decreased urine
• Eyes and oral mucus membranes will be dry or dull
  and fluid loss causes poor skin turgor

11
Nausea and vomiting

• Ingestion of large amounts of alcohol, consuming
  contaminated food or drugs that cause GI side
  effects, bacterial or viral infection are common
  causes
• If caused by intestinal obstruction the abdomen
  is distended, tender, and firm to touch. Bowel
  sounds are hypoactive or absent.

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Nursing Care

• Get good history
• Find out symptoms that occur prior to N/V
• Frequency,color ,amount are all important
  assessments
• List of foods eaten last 24 hours and where he
  has eaten
• Assess general appearance, weight, vitals, IO,
  and fluid volume deficit
• Review Nsg care in fundamentals book

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Cancer of Oral Cavity

• Smoking, chewing tobacco, drinking alcohol in
  excess can cause oral cancer.
• Lip Ca caused by pipe smoking and prolonged
  exposure to wind and sun
• May distort appearance and make it hard to
  masticate and cause local pain
• may have dysphagia
• May invade surrounding tissue including carotid
  and cause hemorrhage and death

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Oral Cancer
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Oral Cancer

• Early stage of oral cancer is symptom free.
  becomes concerned about lump, lesion or
  abnormality of lip or mouth.
• Pain, soreness and bleeding occur late
• If on tongue may have trouble tasting food or
  difficulty in eating. Pain, numbness and loss of
  feeling also occur
• Leukoplakia , a white patch on tongue or inner
  cheek may become cancerous

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Nursing Care

• Same as any other patient with Ca
• focus is on maintaining patent airway, promoting
  adequate fluid and food intake, and
  communication--repeat or clarify what he has said
  and substitute written, give a magic slate,
  alphabet board or paper pencil

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Nursing for Oral Cancer

• After surg, place on side or abdomen with head
  turned to the side to facilitate drainage
• After fully awake, elevate HOB so can breathe
  easier and cough up secretions and control edema
  of site
• Keep suction, O2, trach set available
• Do not irrigate mouth until awake and alert, then
  turn head to side and gently irrigate into an
  emesis basin. Instill small amt only

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Nursing Care

• Must have order before giving anything by mouth.
• Observe as he swallows small amount. If coughing
  then suction out of mouth stat. suction mouth PRN
  to remove secretions, blood, or irrigating fluids
• Give antiemetics for nausea and maintain patency
  of gastric tube. No straws as distention of
  abdomen from air

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Oral Cancer

• Nurse needs to promote effective coping and
  therapeutic grieving. May cry, refuse to talk and
  extreme sadness
• Allow time to adjust to loss and change in
  appearance
• Let him ventilate feelings
• some may be suicidal
• Avoid hot and cold or spicy foods

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Gastointestinal Intubation

• NG tube or gastric decompression may be needed.
  Review fundamentals
• Should have adequate nutrition, appropriate
  stooling patterns (amount, consistency, and
  frequency) and preservation of intact skin and
  nasal mucosa. Keep membranes moist
• discomfort from dryness and unpleasant taste may
  be relieved with frequent mouth care

21
Nursing Care

• Ice chips and analgesic throat lozenges, gargles,
  or sprays may help if mouth and throat become
  sore
• always give mouth care after removing tube...may
  have sore throat for several days
• At risk for fluid volume deficit. Observe for
  dehydration
• Protect from infections that stem from micros
  within formula or tube

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Nursing Care for NG feedings

• Signs of infection include diarrhea, fever or
  abnormal WBC count.
• Keep feeding formula refrigerated and unopened
  until ready to use. Warm to room temp before
  giving
• Hang volume for 4 to 6 hours at a time
• Flush with water before adding more formula.
  Discard after 24 hrs. Wash equipment after each
  use

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Care Plan

• Prevent vomiting by checking tube position and
  gastric residual before instilling more
• Place in semi-fowlers during feeding and for 30
  min after. Never get below 30 degrees
• clamp feeding after bolus or intermittent feeding

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• Prevent aspiration of any draining liquid during
  tube removal by instilling a small amt. of air to
  clear secretions and formula from tube, pinch the
  tube closed and have him hold his breath while
  removing
• Always refeed gastric contents as has
  electrolytes
• Monitor weight

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Percutaneous Endoscopic Gastrostomy

• Before a PEG tube is inserted, the nurse should
  weigh him, assess vitals, auscultate bowel sounds
  and let him void.
• After should continue to monitor vitals, observe
  breathing, inspect skin and dressing. Examine
  appearance and volume of secretions during first
  24 hours when attached to gravity drainage.
  Auscultate bowel sounds and palpate for distention

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PEG Tube
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PEG

• Note tolerance for formula. report abd.
  distention, vomiting, fever, and severe pain.
• Monitor the characteristics and pattern of bowel
  elimination and trends in daily wt.
• If tube falls out, insert a foley cath and
  inflate balloon and clamp it to keep stoma from
  sealing. Notify Dr.
• feedings can be given thru foley cath inserted
  into abdomen until replaced.

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Gastroesophageal Reflux Disease (GERD)

• Develops when gastric contents flow in an upward
  direction into esophagus. Everyone has some but
  if excessive, or causes pain or resp distress
  then considered a disease
• Cardiac sphincter does not close completely
  allowing contents of stomach to go into
  esophagua. Obesity, preg can increase it.

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GERD S/S

• Epigastric pain or discomfort (dyspepsia) and
  regurgitation. May have difficulty in swallowing
  (dysphagia), painful swallowing (odynophagia),
  inflammation of the lining of esophagus
  (esophagitis), aspiration pneumonia, and
  respiratory distress.
• May bleed and vomit blood or have tarry stools
  (melena). May lead to anemia. can cause chest
  pain and be mistaken for MI

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GERD

• Evaluate lifestyle changes needed to reduce GERD
• Avoid alcohol, peppermint, licorice, and
  caffeine.
• Weight loss helps and avoid tight fitting
  clothing
• elevate HOB, stop smoking and avoid eating or
  drinking for several hours before bedtime

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Esophageal Diverticulum

• Weakness of esophageal wall. The diverticula trap
  food and secretions which then narrows the lumen,
  interferes with the passage of food and exerts
  pressure on trachea.
• Trapped food decomposes within the esophagus
  causing esophagitis or ulceration in the mucosa

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Signs and Symptoms

• Has foul breath and has difficulty or pain when
  swallowing, belching, regurgitation, or coughing
• Gurgling sounds may be heard when auscultating
  the mid-upper chest
• Bland, soft, or semisoft or liquid diet given.
  Small meals eaten 4 to 6 times a day
• Oral hygeine will not alter the foul
  breath...review care of hiatal hernia

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Hiatal Hernia

• Hiatal or diaphragmatic hernia is a protrusion of
  part of the stomach into esophagus. A portion of
  the stomach protrudes thru diaphragm into chest
  cavity
• Caused by defect in the diaphragm where esophagus
  passes thru
• Factors which increase intra-abdominal pressure
  (multiple preg or obesity) contributes to
  development

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Hiatal Hernia

• Can cause GERD
• Will have heartburn, belching and a feeling of
  substernal or epigastric pressure or pain after
  eating and when lying down.
• If scars form, swallowing becomes difficult. as
  food distends the esophagus, vomiting may occur
• Review care page 838 and 839

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Cancer of Esophagus

• Correlation between alcohol abuse and cigarette
  smoking
• Signs and symptoms usually develop slowly
• Beginning symptoms are mild, vague feelings of
  discomfort and difficulty in swallowing some
  foods.
• Weight loss accompanies progressive dysphagia.
  solid foods may become impossible to swallow so
  drinks liquids

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Cancer of Esophagus

• By the time swallowing difficulty is pronounced
  it has usually invaded surounding tissues and
  lymphatics. May have back pain and respiratory
  distress
• Pain is a late symptom
• Major nursing goal is improved nutrition and
  weight gain.Consult with dietitian. Avoid foods
  or drinks with lots of gas, such as souffles or
  carbonated beverages. No straws or narrow necked
  bottles to avoid air

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Cancer of Esophagus

• May need NG tube, Gastrotomy tube, or TPN
• Must care for skin around tube insertion site,
  prevent infection, maintain patency of tube and
  teaching how to manage tube after discharge.
• If surgery done, teach how to support surgical
  incision for coughing and deep breathing

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Gastritis pg. 840

• Inflammation of stomach lining
• Submucosal layers of stomach can become inflamed
  when mucous layer is reduced or penetrated by
  irritating substances. May have epigastric
  discomfort or heartburn. The mucous producing
  cells heal and regenerate in 3 to 5 days so gets
  better
• chronic irritation leads to ulceration

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Gastritis s/s

• Complains of epigastric fullness, pressure, pain,
  anorexia, N/V
• When gastritis is caused by bacterial or viral
  infection may have vomiting, diarrhea, fever and
  abdominal pain.
• Drugs, poisons, toxic substances and corrosives
  can cause gastric bleeding

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Medical Management

• avoid irritating substances such as spicy foods,
  alcohol and caffeine
• Observe color and characteristics of any vomitus
  or stools
• Teach about diet, drug therapy and need for
  continued medical follow-up

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Peptic Ulcer Disease

• Circumscribed loss of tissue in an area of the GI
  tract that is in contact with HCL and pepsin.
  Most occur in the duodenum but may also occur at
  lower end of esophagus, in the stomach or in
  jejunum
• Gastric ulcers are more likely to recur and
  become cancerous. 80-90 are caused by
  Helicobacter pylori. Smoking and chronic use of
  Asa or NSAIDS also cause

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Helicobacter pylori
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H. Pylori

• A gram-negative microorganism, is present in the
  gastric or duodenal mucosa of 80 or 90 of
  clients with peptic ulcers.
• This bacteria, which shelters itself in the
  bicarbonate-rich mucus, is a factor in chronic
  gastritis and peptic ulcer disease.
• Secretes an enzyme that theoretically depletes
  gastric mucus, making it more vulnerable to
  injury.

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Peptic Ulcer S/S

• Location of pain is in mid-epigastrium, does not
  radiate
• Pain most often occurs when stomach is empty
• should monitor for hemorrhage, obstruction and
  perforation
• signs of bleeding Coffee-ground appearing emesis
  and black tarry stools (melena)

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Peptic Ulcer

• Most often described as having a burning quality.
  Complains of pain that disturbs sleep and occurs
  one to several hours after eating. Pain may be
  releived by eating
• Back pain may be irritation of pancreas by ulcer.
  
• Protracted vomiting may occur if symptoms ignored
  as causes obstruction

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Dumping syndrome

• If a total gastrectomy done, must receive vitamin
  B12 injections for life to prevent pernicious
  anemia
• Clients with gastrojejunostomy are at risk for
  dumping syndrome when eating solid food. Will
  have weakness, dizziness, sweating, palpitations,
  abdominal cramps and diarrhea due to rapid
  emptying or dumping of large amounts of partly
  digested food into jejunium

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Dumping Syndrome

• The presence of this concentrated solution in the
  gut draws fluid from the circulating blood into
  intestine, causing hypovolemia. The drop in BP
  can produce syncope. Sudden appearance of CHO in
  jejunum stimulates pancreas to secrete excessive
  insulin and hypoglycemia. To help dumping
  syndrome, eat carbohydrates, especially simple
  sugars in moderation

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Nursing Management

• Determine type of pain, onset in relation to
  eating, location and duration
• Get dietary Hx and foods that cause distress.
  Does eating relieve pain?
• If receiving tube feedings, re-instill gastric
  residual because it has enzymes, electrolytes and
  partially digested nutrients.
• If surgery, follow guidelines same as gastric
  surgery page 835

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Cancer of Stomach

• Heredity and chronic inflammation of the stomach
  appear to contribute.
• Foods preserved with nitrates may predispose
• Early symptoms are vague. As tumor enlarges
  symptoms include a prolonged feeling of fullness
  after eating, anorexia, weight loss, and anemia
  and melena. Pain is late sign

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Cancer of Stomach

• Surgery and chemotherapy done.
• Nursing should teach prevention...how to change
  dietary habits to reduce causes.
• Teach early warning signs

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Post-op Care

• Inspect surgical dressing for drainage and tubes
  or catheters for placement, patency, and type of
  drainage.
• Carefully observe NG tube drainage for bleeding.
  May contain small amount of dark blood when first
  returns from OR the drainage should promptly
  return to yellow-green

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Complications to Observe For

• Change in vitals, especially low BP, rapid pulse,
  and elevated temp
• Extreme restlessness
• Difficulty breathing, increased resp rate,
  cyanosis
• Severe pain, especially after pain med given
  pain in another site and not operative site (leg,
  head, chest)

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Complications

• Abdominal distention or rigidity
• Urinary output less than 35 ml per hour if cath
  or failure to void within 8 hours of surgery
• Failure to pass flatus or stool more than 48
  hours postop
• Profuse diaphoresis

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Complications

• Excessive bloody drainage from NG tube, surgical
  drains, or surgical dressing
• Separation of surgical wound edges
• Unusual color or odor of drainage