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Assessment of the Gastrointestinal System

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Dry, painful mouth, open ulcerations, predisposing the client to infection ... Frequent rinsing of the mouth with solution, not commercial mouthwash ... – PowerPoint PPT presentation

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Title: 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
(No Transcript)
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
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