Care of Client with GI and liver alterations

• Care of Clients with Gastrointestinal (GI) and Liver Alterations
• Overview of the GI

  • Oral Cavity
  • Oral Health
• Prevention of dental carries and plaques

  1. Practicing effective mouth care

  2. Reducing the intake of starches and sugars (refined carbohydrates)

  3. Applying fluoride to the teeth

  4. Refraining from smoking

  5. Controlling diabetes

  6. Visiting dentist regularly
• Medications that cause dry mouth

  • Diuretic agents
  • Antihypertensive medications
  • Anti-inflammatory agents
  • Antidepressant medications
• Problems of aging exacerbated by poor dentition

  • Decreased food intake
  • Loss of appetite
  • Social isolation
  • Increased susceptibility to systemic infection (from periodontal disease)
  • Trauma to the oral cavity secondary to thinner, less vascular oral mucous membranes
• Hiatal Hernia


  Characterized by: opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach tends to move up into the lower portion of the thorax

  
• Hiatal Hernia occurs more often in women than in men
• Signs and symptoms of Hiatal Hernia

  • Mostly asymptomatic
  • Heartburn, regurgitation, dysphagia

  
• Management of Hiatal Hernia

  • Small, frequent meals
  • Do NOT lay flat for 1 hour after meals
  • Elevate head of bed
  • Surgery (such as fundoplication)
• Gastroesophageal Reflux Disease (GERD)


  Characterized by: excessive backflow of gastric or duodenal contents into the esophagus
• Causes of GERD


  • Incompetent lower esophageal sphincter
  • Pyloric stenosis
  • Hiatal hernia
  • Motility disorder
• Increased risk of GERD with older adults
• Clinical manifestations of GERD

  • Burning in the esophagus
  • Indigestion
  • Regurgitation
  • Dysphagia
  • Painful swallowing
  • Hypersalivation
  • Esophagitis
• Assessment and Diagnostics for GERD

  • Endoscopy or barium
  • Ambulatory 12- to 36-hour esophageal pH monitoring
• Prevention of GERD


  • Low-fat diet
  • Decreased caffeine, tobacco, beer, milk, peppermint/spearmint, carbonated beverages
  • Do NOT eat 2 hours before BT
  • Weight management
  • Avoid tight clothes
  • Elevate head of bed
• Management of GERD


  • Antacids or histamine-2 (H2) receptor antagonists (Famotidine [Pepcid], nizatidine [Axid], or ranitidine [Zantac])
  • Proton pump inhibitors (lansoprazole [Prevacid], rabeprazole [AcipHex], esomeprazole [Nexium], omeprazole [Prilosec], orpantoprazole [Protonix])
  • Prokinetic agents (bethanechol [Urecholine], domperidone [Motilium], or metoclopramide [Reglan])
  • Surgery: Nissen fundoplication (if meds don't work)
• Nissen Fundoplication


  The upper curve of the stomach (the fundus) is wrapped around the esophagus and sewn into place so that the lower portion of the esophagus passes through a small tunnel of stomach muscle

  
• Goals of Nissen Fundoplication surgery

  • Strengthen the valve between the esophagus and stomach, which stops acid from backing up into the esophagus as easily
  • Allows the esophagus to heal
  • Can treat GERD and Hiatal hernia that are not controlled by medications

  
• Complications of Nissen Fundoplication surgery

  • Difficulty swallowing because the stomach is wrapped too high or tight on the esophagus
  • The esophagus sliding out of the wrapped portion of the stomach
  • Heartburn
  • Bloating and gas buildup

  
• Post-op dietary instructions for Nissen Fundoplication (avoid stretching of stomach and gas)

  • Eat very slowly, small bites, and chew well
  • Eat small, frequent meals (six to eight per day)
  • Avoid drinking large amounts of fluids with meals (limit fluids to 1/2 cup with meals and one cup with snacks)
  • Sit upright while eating and stay upright for 30 minutes after each meal. Sit upright for 2 hours after your last meal or snack of the day
  • Avoid crusty breads and sticky, gummy foods, such as bananas, fresh doughy breads, rolls and doughnuts
  • Avoid sweets to prevent dumping syndrome
  • Avoid drinking through a straw. Do not chew gum or tobacco. Chew with mouth closed
  • Avoid any foods that cause stomach gas and distention such as corn, dried beans, peas, lentils, onions, broccoli, cauliflower and any food from the cabbage family
  • Avoid carbonated drinks, alcohol, citrus and tomato products
• Heartburn (GERD)


  Usually occurs after eating or while lying down or bending over. Burning sensation in your chest that may start in your upper abdomen and radiate all the way to your neck. Odynophagia or painful swallowing. Can be brief or continue for a few hours
• Myocardial Infarction (MI)


  Sudden pressure, tightening, squeezing or crushing chest pain. Pain spreading to the back, neck, jaw, shoulders or arms — especially the left arm. Chest discomfort accompanied by shortness of breath, sweating, dizziness or nausea. Pressure or tightness in the chest during physical activity or when you're under emotional stress. Feels like heartburn - but different and accompanied by SOB, dizziness or chest tightness
• Gastritis


  Characterized by inflammation of the gastric mucosa
• Gastritis is common in older adults
• Types of Gastritis


  • Acute – lasting several hours to few days
  • Chronic – as a result of repeated gastritis or irritation
• Causes of Gastritis


  • H.pylori (non-erosive)
  • Long term intake of NSAIDs, alcohol, or radiation (erosive)
• Clinical manifestations of Gastritis

  • Rapid onset of abdominal discomfort, headache, exhaustion, nausea, anorexia, vomiting, hiccups, sour taste
  • Pain can be relieved by eating
  • Erosive gastritis may lead to bleeding (vomiting blood or black tarry stools)
• Assessment and Diagnostics for Gastritis


  • History and physical assessment
  • Endoscopy
  • Assessment for presence of H.pylori
• Management of Gastritis


  • May heal on its own in 1-3 days
  • Non-irritating diet as tolerated
  • Avoid food until relief of symptoms
  • IV fluids
  • In case of bleeding, control it
  • NG tube
  • Medications: antacids, H2 blockers, proton pump inhibitors
  • Teach patient to modify diet, rest, stress management, avoid alcohol, avoid NSAIDs
  • Treat H.pylori
• Peptic Ulcer Disease (PUD)

  Can be gastric, duodenal, or esophageal ulcer
• Causes of PUD


  • GERD or chronic gastritis
  • H.pylori
  • NSAIDs
  • Excessive secretion of HCl
• Family history and chronic illnesses/ stress (i.e., hospitalization, COPD, CKD, burns…) play a role in PUD
• Clinical manifestations of PUD

  • Many people are asymptomatic
  • Dull gnawing pain, burning sensation in min-epigastric area or back, epigastric tenderness, abdominal distention
  • Heartburn, vomiting, constipation or diarrhea, bleeding
  • Gastric ulcer: pain after eating
  • Duodenal ulcer: pain 2-3 hours after eating, relief of pain after eating. awakened by pain at night more
• Assessment and Diagnostics for PUD


  • Detailed assessment and history
  • Endoscopy, biopsy to test for H.pylori
• Medical management of PUD

  • Medications (antibiotics [for H.pylori], proton pump inhibitors, bismuth salts [Pepto-Bismol] [treat H.pylori])
  • H2blockers (in absence of H.pyori)
  • Avoid NSAIDs
  • Compliance with medical management is essential!
  • Smoking cessation
  • Dietary modification: avoid too hot or too cold food, no alcohol, no coffee, no caffeinated beverages, small frequent meals
• Surgical management of PUD


  • When treatment fails
• Obesity


  Characterized as a metabolic disease due to accumulation of fat in a manner that impairs health
• Classifications of Obesity


  • Overweight: body mass index (BMI) of 25 to 29.9 kg/m2
  • Obese: BMI exceeds 30 kg/m2
• Effects of Obesity


  • Affects mortality and morbidity; it is a health risk
  • May also lead to low self esteem, impaired body image, depression, decreased QOL
• Diseases associated with Obesity


  • See Table 42-1