NCM 116 Lec

• Disturbances in Ingestion:

  • Gastroesophageal Reflux (GERD)
  • Hiatal Hernia
  • Achalasia
• Gastroesophageal Reflux (GERD):

  • Backflow of gastric or duodenal contents into the esophagus causing troublesome symptoms and/or mucosal injury
  • Causes include incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, and motility disorder
  • Predisposing factors: pyloric surgery, long-term NG tube, agents decreasing LES pressure, conditions increasing intraabdominal pressure
  • Associated factors: tobacco use, coffee drinking, alcohol consumption, H. pylori infection
• • Clinical manifestations: pyrosis (heartburn), dyspepsia, regurgitation, dysphagia, hypersalivation, esophagitis
  • Assessment and Diagnostic Findings: endoscopy, barium swallow, esophageal pH monitoring
  • Management: low-fat, high-fiber diet, avoid certain foods and drinks, maintain normal body weight, elevate head of the bed, administer prescribed medications, consider surgery
• Hiatal Hernia:

  • Opening in the diaphragm allowing part of the stomach to move up into the thorax
  • Types: sliding (Type 1) and paraesophageal hernia
  • Clinical manifestations: pyrosis, regurgitation, dysphagia, vague symptoms
  • Complications: hemorrhage, obstruction, strangulation
  • Assessment and Diagnostic Findings: X-ray studies, esophagogastroduodenoscopy, chest CT scan
  • Management: frequent small feeding, avoid reclining after eating, elevate head of the bed, consider surgical hernia repair
• Achalasia:

  • Absent or ineffective peristalsis of the distal esophagus with failure of the esophageal sphincter to relax
  • Clinical manifestations: dysphagia, heartburn, non-cardiac chest or epigastric pain
  • Assessment and Diagnostic Findings: X-ray, barium swallow, CT scan, endoscopy
  • Management: eat slowly, drink fluids with meals, use medications to decrease esophageal pressure, consider procedures like botulinum toxin injection or pneumatic dilation
• Disturbances in Digestion:

  • Nausea and Vomiting
  • Gastrointestinal bleeding
• Nausea and Vomiting:

  • Nausea is uneasiness in the stomach, vomiting is forcible emptying of stomach contents
  • Management of Nausea: drink clear or ice-cold drinks, eat light bland foods, avoid certain foods, eat and drink slowly
  • Management of Vomiting: drink gradual large amounts of clear liquids, avoid solid food until vomiting episode passes, rest
  • Complications: dehydration
• Gastrointestinal bleeding:

  • Gastritis is inflammation of the gastric mucosa
  • Types: acute (stress-related) and chronic
  • Etiology includes bacteria, irritating foods, NSAIDs, alcohol, bile, and radiation
  • Pathophysiology involves disruption of the mucosal barrier leading to inflammation, erosion, and ulceration
  • Clinical manifestations: epigastric pain, dyspepsia, headache, anorexia, hiccups, nausea, vomiting, bleeding
  • Assessment and Diagnostic Findings: endoscopy, biopsy, CBC, detection of H. pylori
• • Medical Management: refrain from alcohol and food until symptoms subside, follow a non-irritating diet
• Medical Management:

  • Refrain from alcohol and food until symptoms subside
  • Non-irritating diet/bland diet
  • Drugs (antacids, histamine-2 receptor antagonists – Famotidine, proton pump inhibitors-omeprazole)
  • IVF
  • Surgery – gastrojejunostomy (anastomosis of jejunum to stomach to detour around the pylorus)
• Nursing Management:

  • Reduce anxiety
  • Promoting optimal nutrition
  • IVF
  • No intake of caffeinated beverages – stimulant that increases gastric activity and pepsin secretion
  • Stop smoking – nicotine reduces the secretion of pancreatic bicarbonate, which inhibits the neutralization of gastric acid in duodenum
  • Promoting fluid balance
  • Relieve pain
  • Monitor for signs of complications like bleeding, obstruction and pernicious anemia
• • Pathophysiology of PUD: disturbance in acid secretion and mucosal protection
• Peptic Ulcer Disease:

  • Excavation that forms in the mucosa of the stomach in the pylorus, duodenum or esophagus
  • Ulceration of the gastric and duodenal lining
  • Most common peptic ulceration: anterior part of the upper duodenum
  • Risk factors: NSAIDs, H. pylori, smoking and alcohol, familial tendency (Type O), ZES (Zollinger-Ellison syndrome)
  • Clinical manifestations: dull, gnawing pain or burning sensation-mid epigastrium or back, pyrosis vomiting, constipation/diarrhea, bleeding (hematemesis, melena), peptic ulcer perforation
• Pathophysiology:

  • Erosion → (due to increased concentration/activity of acid-pepsin or decreased resistance of normal protective mucosal barrier) → damaged mucosa can't secrete enough mucus to act as a barrier against normal digestive juices
  • NSAIDs – inhibits prostaglandin synthesis → disruption of protective mucosal barrier → decreased resistance to bacteria → infection from H. pylori occur
• Medical Management:

  • Pharmacologic therapy: Proton pump inhibitor, H2 blockers, antibiotics, bismuth salt – suppress H. pylori
  • Triple therapy – 2 antibiotics and proton pump inhibitors (10-14 days)
  • Avoid use of Aspirin and other NSAIDs
  • Smoking Cessation – decreases the secretion of bicarbonate from pancreas into the duodenum resulting in increased acidity of duodenum
  • Dietary Modification: avoid over secretion of acid and hypermobility in the GIT
• Surgical Management:

  • Indicated for life-threatening hemorrhage, perforation or obstruction
  • Pyloroplasty – transecting nerves that stimulate acid secretion and opening the pylorus
  • Antrectomy – removal of pyloric (antrum) portion of the stomach with anastomosis to either duodenum (gastroduodenostomy or Billroth 1) or jejunum (gastrojejunostomy or Billroth 11)
• Nursing Process:

  • Nursing Diagnosis: Acute pain related to the effect of gastric acid secretion on damaged tissue
  • Collaborative Problems/Potential Complications: Hemorrhage, Perforation, Penetration
  • Goal: Relieve pain
  • Nursing Interventions: Relieve pain, reduce anxiety, maintain optimal nutritional status, monitoring and managing potential complications: Hemorrhage, Perforation and Penetration
• Signs and symptoms of perforation:

  • Sudden, severe upper abdominal pain
  • Vomiting
  • Fainting
  • Boardlike abdomen
  • Hypotension and tachycardia - shock
• Post-operative Nursing Management:

  • Monitor VS
  • Post-op position: FOWLER'S
  • NPO until peristalsis returns
  • Monitor for bowel sound
  • Monitor for complications of surgery
  • Monitor I and O, IVF
  • Maintain NGT
  • Diet progress: clear liquid, full liquid, six bland meals
  • Manage DUMPING SYNDROME
• Gastric Ulcer:

  • Epigastric pain
  • Characteristic: Gnawing, sharp pain in the mid-epigastrium 1-2 hours AFTER eating, often NOT RELIEVED by food intake, sometimes AGGRAVATING the pain!
  • Assessment: Nausea, Vomiting, Hematemesis, Weight loss
  • Nursing Interventions: Give BLAND diet, small frequent meals during the active phase of the disease, administer prescribed medications - H2 blockers, PPI, mucosal barrier protectants and antacids, monitor for complications of bleeding, perforation and intractable pain, provide teaching about stress reduction and relaxation techniques
• Nursing Interventions for BLEEDING:

  • Maintain on NPO
  • Administer IVF and medications
  • Monitor hydration status, hematocrit and hemoglobin
  • Assist with SALINE lavage
  • Insert NGT for decompression and lavage
  • Prepare to give VASOPRESSIN to induce vasoconstriction to reduce bleeding
  • Prepare patient for SURGERY if warranted
• Duodenal Ulcer:

  • Ulceration of duodenal mucosa and submucosa
  • Usually due to increased gastric acidity
  • Assessment: Burning pain in the mid-epigastrium 2-4 HOURS after eating or during the night, RELIEVED by food intake
• Disturbances in Absorption and Elimination:

  • Disorders of Intestinal Motility
  • Constipation: fewer than three bowel movements weekly or bowel movements that are hard, dry, small or difficult to pass
  • Risk factors: Pregnant women, Post-op patient, Older client
  • Causes: Drugs (anti-cholinergic, anti-depressants, opioids, iron preparation), Immobility, Diet – low fiber and fluid intake, Inability to increase intra-abdominal pressure to facilitate passage of stool, Lack of exe
• Factors contributing to constipation:

  • Low fiber and fluid intake
  • Inability to increase intra-abdominal pressure to facilitate passage of stool (e.g. spinal cord injury)
  • Lack of exercise
  • Stress-filled life
• Pathophysiology of constipation:

  • Interference with major functions of the colon such as mucosal transport, myo electric activity, and the process of defecation
  • Ignoring the urge to defecate leads to insensitivity of rectal mucous membrane and musculature, requiring a stronger stimulus for peristaltic rush
  • Fecal retention causes irritability of the colon, leading to colicky midabdominal or low abdominal pains
  • Loss of muscular tone in the colon, making it unresponsive to normal stimuli
• Clinical manifestations of constipation:

  • Three bowel movements per week
  • Abdominal distention
  • Pain and bloating
  • Sensation of incomplete evacuation
  • Straining
  • Elimination of small-volume, lumpy, hard dry stools
• Assessment and diagnostic findings for constipation:

  • Patient's history
  • Physical examination
  • Barium enema
  • Sigmoidoscopy
  • Stool testing for occult blood
• Complications of constipation:

  • Straining resulting in valsalva maneuver
  • Fecal impaction leading to fecal incontinence
  • Hemorrhoids
  • Fissures
• Medical management of constipation:

  • Education
  • Exercise
  • Bowel habit training
  • Increased fiber and fluid intake
• Classification of diarrhea:

  • Acute (self-limiting 1-2 days)
  • Persistent (2-4 weeks)
  • Chronic (more than 4 weeks and return sporadically)
• Causes of chronic diarrhea:

  • Adverse effect of chemotherapy
  • Anti-arrhythmic drugs, antihypertensive drugs, endocrine problems
  • Malabsorption disorders (lactose intolerance)
• Pathophysiology of chronic diarrhea:

  • Pathogens (Salmonella) invade the intestinal mucosa, leading to inflammatory changes and smaller volume of bloody stools
• Clinical manifestations of chronic diarrhea:

  • Increased frequency and fluid content of stools
  • Abdominal cramps, distention
  • Borborygmus (rumbling noise caused by movement of gas through intestines)
  • Anorexia, thirst
  • Tenesmus (painful straining with a strong urge)
  • Voluminous, greasy stools indicating intestinal malabsorption
  • Presence of blood, mucus, and pus in stools suggesting colitis
  • Nocturnal diarrhea associated with diabetic neuropathy
• Assessment and diagnostic findings for chronic diarrhea:

  • Stool exam
  • CBC
  • Serum electrolytes
  • Endoscopy/barium enema
• Complications of chronic diarrhea:

  • Dehydration with electrolyte loss (K+)
  • Cardiac dysrhythmias (bicarbonate)
  • Metabolic acidosis presenting with low urine output, muscle weakness, paresthesia, hypotension, anorexia, and drowsiness
• Medical management of chronic diarrhea:

  • Antibiotics
  • Anti-inflammatory drugs
  • Anti-diarrheal medications (loperamide, Lomotil)
• Nursing management of chronic diarrhea:

  • Assess and monitor the characteristics and pattern of diarrhea
  • Encourage increased fluid intake and foods low in bulk
  • Advise avoiding caffeine, alcohol, dairy products, and fatty foods
• Risk factors for irritable bowel syndrome:

  • Women
  • Age below 45 years old
  • Genetic factors
  • Environmental factors
  • Psychosocial factors
• Pathophysiology of irritable bowel syndrome:

  • Functional disorder of intestinal motility due to neuroendocrine dysregulation, changes in serotonin signals, infection, and irritation
  • Affects peristaltic waves and intensity, leading to altered bowel movements
• Clinical manifestations of irritable bowel syndrome:

  • Constipation, diarrhea, or both
  • Abdominal pain precipitated by eating and relieved by defecation
  • Bloating and abdominal distention