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Adult Health I Test IV > Esophageal Disorders > Flashcards

Esophageal Disorders Flashcards

1
Q

what is GERD?

A
  • Common condition characterized by gastric content and enzyme backflow into the esophagus
  • Some backflow of stomach contents is normal, but when the reflux is excessive, the corrosive fluids irritate the esophageal tissue–>causes a delay in their clearance–>exposes esophageal tissue to the acidic fluids–>irritation
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2
Q

what causes there to be excessive reflux?

A
  • Incompetent LES
  • Pyloric stenosis
  • Hiatal hernia
  • Excessive intra-abdominal or intragastric pressure
  • Motility problems
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3
Q

primary tx for GERD

A
  • Diet and lifestyle changes
  • Medication: antacids, H2 receptor antagonists, PPIs
  • Surgery
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4
Q

GERD: health promotion and dz prevention

A
  • Maintain a BMI <30
  • Stop smoking
  • Limit or avoid alcohol and tobacco
  • Eat a low fat diet
  • Avoid foods that lower the LES pressure
  • Avoid eating/drinking 2 hr before bed
  • Avoid tight fitting clothes
  • Elevate the HOB 6-8 in
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5
Q

GERD: risk factors

A
  • Obesity
  • Older age: delayed gastric emptying and weakened LES tone
  • Sleep apnea
  • NG tube
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6
Q

GERD: contributing factors

A
  • Excessive ingestion of foods that relax the LES include fatty & fried foods, chocolate, caffeinated beverages, peppermint, spicy foods, tomatoes, citrus fruits, alcohol
  • Prolonged or frequent abdominal distention from overeating or delayed emptying
  • Inc abdominal pressure from obesity, pregnancy, bending at the waist, ascites, tight clothing at the waist
  • Meds that relax the LES: theophylline, nitrates, CCBs, anticholinergics, diazepam
  • Inc gastric acids from meds (NSAIDs) or stress
  • Debilitation resulting in weakened LES tone
  • Hiatal hernia (LES displacement into the thorax w/ delayed esophageal clearance)
  • Lying flat
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7
Q

GERD: expected findings

A
  • Classic report of dyspepsia after eating an offending food/fluid and regurgitation
  • Radiating pain (neck, jaw, back)
  • Report of a feeling of having a heart attack
  • Pyrosis
  • Dyspepsia (indigestion)
  • Dysphagia or odynophagia (pain on swallowing)
  • Pain that worsens w/ position (bending, straining, laying down)
  • Pain that occurs after eating and lasts 20 min to 2 hours
  • Throat irritation (chronic cough, laryngitis), hypersalivation, bitter taste in mouth (from regurg)
    • Chronic GERD can lead to dysphagia
  • Inc flatus and eructation (burping)
  • Pain is relieved (almost immediately) by drinking water, sitting upright, or taking antacids
  • Manifestations occurring 4-5 times/week on consistent basis
  • Tooth erosion
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8
Q

what are the diagnostic procedures for GERD?

A
  • EGD
  • esophageal pH monitoring
  • esophageal manometry
  • barium swallow
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9
Q

GERD: EGD

A
  • Done under moderate sedation
  • Looks for tissue damage and to dilate strictures in the esophagus
    • Esophageal lining should be pink, but usually red w/ persistent GERD
  • Biopsies will be done to determine if high grade dysplasia (HGD) is present
    • HGD is evidenced by squamous mucosa of the esophagus replaced by columnar epithelium (which are the cells seen in stomach/intestines)
      • When HGD is found, 30% inc in developing cancer
  • Allows for visualization of esophagus revealing esophagitis or Barrett’s epithelium (premalignant cells)
  • Nursing Actions:
    • Verify gag response has returned prior to providing fluids or food
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10
Q

GERD: esophageal pH monitoring

A
  • Small catheter is placed thru the nose and into the distal esophagus, or a small capsule is attached to the esophageal wall during endoscopy
    • pH readings are taken in relation to food, position, activity for 24-48 hours
  • Most accurate way to diagnose GERD
  • Helpful for clients with atypical manifestations
  • Nursing Actions:
    • Instruct the client to keep a journal of foods, beverages consumed, symptoms, and activity during the test period
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11
Q

GERD: esophageal manometry

A
  • Records LES pressure and peristaltic activity of the esophagus
  • Client swallows 3 small tubes, and pressure readings and pH levels are tested
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12
Q

GERD: barium swallow

A
  • Identifies a hiatal hernia, strictures, or structural abnormalities which would contribute to or cause GERD
  • Nursing Actions:
    • Instruct the client to use cathartics to evacuate the barium from the GI tract following the procedure
      • Failure to eliminate the barium places client at risk for fecal impaction
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13
Q

list classes of meds for GERD

A
  • PPIs
  • Antacids
  • H2 Receptor Antagonists
  • Prokinetics
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14
Q

GERD: PPIs

A
  • PPIs: pantoprazole, omeprazole, esomeprazole, rabeprazole, lansoprazole
  • Reduce gastric acid by inhibiting the cellular pump of the gastric parietal cells necessary for gastric acid secretion
  • Nursing Considerations:
    • Monitor for electrolyte imbalances and hypoglycemia in clients who have DM
    • Long term use has been related to the development of community acquired pneumonia and c. diff infections
  • Client education:
    • Long term use of PPIs places the client at risk for frxs, especially in older adults
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15
Q

GERD: Antacids

A
  • aluminum hydroxide, magnesium hydroxide, calcium carbonate, sodium bicarb
  • Neutralize excess acid and increase LES pressure
  • Nursing Considerations:
    • Ensure there are no contraindications w/ other meds (levothyroxine)
    • Evaluate kidney function in clients taking magnesium hydroxide
  • Client Edu:
    • Instruct client to take when acid secretion is the highest (1-3 hours after eating and at bedtime), and to separate other meds by at least 1 hour
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16
Q

GERD: H2 Receptor Antagonistis

A
  • ranitidine, famotidine, nizatidine
  • Reduce the secretion of acid
  • Onset is longer than antacids, but effect has a longer duration
  • Nursing Considerations:
    • Use cautiously in clients w/ kidney dz
  • Client Edu:
    • Take w/ meals & at bedtime
    • Separate dosages from antacids (1 hour before or after taking antacid)
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17
Q

GERD: Prokinetics

A
  • metoclopramide
  • Inc motility of esophagus and stomach
  • Nursing Considerations:
    • Monitor the client taking metoclopramide for extrapyramidal SEs
  • Client Edu:
    • Instruct client to report abnormal, involuntary movemen
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18
Q

GERD: Stretta

A
  • type of therapeutic procedure
  • procedure uses radiofrequency energy, applied by an endoscope, to decrease vagus nerve activity
  • Causes LES muscle tissue to contract & tighten
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19
Q

GERD: fundoplication

A
  • therapeutic procedure for GERD
  • can be indicated for clients who fail to respond to other treatments
  • Fundus of the stomach is wrapped around and behind the esophagus thru a laparoscope to create a physical barrier
  • Nursing Considerations:
    • Complications:
      • temporary dysphagia: monitor for aspiration
      • Gas bloat syndrome: difficulty belching to relieve distention
      • atelectasis/pneumonia: monitor respiratory function
  • Client Edu:
    • Diet:
      • Avoid offending foods
      • Avoid large meals
      • Remain upright after eating
      • Avoid eating before bedtime
      • Consume 4-6 small meals throughout the day
    • Lifestyle:
      • Avoid clothing that is tight fitting around the abdomen
      • Lose weight
      • Elevate HOB 6-8 in
      • Sleep on right side
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20
Q

list complications of GERD

A
  • aspiration of gastric secretion
  • Barrett’s epithelium or esophageal carcinoma
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21
Q

GERD: aspiration of gastric secretion

A
  • Causes: reflux of gastric fluids into esophagus can be aspirated into trachea
  • Risks assoc with aspiration:
    • Asthma exacerbation from inhaled aerosolization of acid
    • Frequent URI, sinus/ear infections
    • Aspiration pneumonia
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22
Q

GERD: Barrett’s epithelium (premalignant) or esophageal adenocarcinoma

A
  • Cause: reflux of gastric fluids leads to esophagitis
    • In chronic esophagitis, the body continuously heals inflamed tissue, eventually replacing normal esophageal epithelium w/ premalignant tissue or malignant adenocarcinoma
  • Nursing actions:
    • Determine cause of GERD w/ client
    • Review lifestyle changes that can decrease gastric reflux
    • Monitor nutritional status
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23
Q

Hiatal Hernia

A
  • AKA diaphragmatic hernia
  • Protrusion of the stomach (in part or total) above the diaphragm into the thoracic cavity thru the hiatus/opening of the diaphragm
24
Q

2 types of hiatal hernia

A
  • Sliding: more common
    • Portion of the stomach and gastroesophageal junction move above the diaphragm
    • Generally occurs w/ increases in intra-abdominal pressure or while the client is in supine
  • Paraesophageal (rolling):
    • part of the fundus of the stomach moves above the diaphragm although the gastroesophageal junction remains below the diaphragm
25
Q

Hiatal Hernia: health promotion and dz prevention

A
  • Avoid eating immediately prior to going to bed
  • Avoid foods/drinks that dec LES pressure
  • Exercise regularly
  • Maintain healthy weight
  • Elevate HOB at least 6 in
  • Avoid straining or excessive vigorous exercise
  • Avoid wearing clothing that is tight around abdomen
26
Q

hiatal hernia: expected findings

A
  • Presenting manifestations depend on type and are typically worse after a meal
  • Sliding: heartburn, reflux, chest pain, dysphagia, belching
  • Paraesophageal: fullness after eating, sense of breathlessness/suffocation, chest pain, worsening of symptoms when reclining
  • Physical assessment:
    • Pharyngitis
    • inspiratory/expiratory wheezes
27
Q

hiatal hernia: list diagnostic procedures

A
  • barium swallow w/ fluoroscopy
  • EGD
  • CT scan of chest w/ contrast
28
Q

hiatal hernia: barium swallow w/ fluoroscopy

A
  • Allows visualization of esophagus
  • Nursing Actions:
    • Instruct client to use cathartics to evacuate the barium from the GI tract after procedure
    • Failure to eliminate barium places client at risk for fecal impaction
29
Q

hiatal hernia: EGD

A
  • Allows visualization of esophagus and gastric lining
  • Nursing Actions
    • Verify gag response has returned prior to giving fluids/food following procedure
30
Q

hiatal hernia: CT scan w/ contrast

A
  • Allows visualization of the esophagus and stomach
  • Nursing Actions:
    • Assess for iodine allergies
    • Encourage fluids following procedures to promote dye excretion and minimize risk of renal injury
    • Monitor BUN/creatinine
31
Q

hiatal hernia: 2 classes of meds

A
  • PPIs
  • antacids
32
Q

hiatal hernia: PPIs

A
  • pantoprazole, omeprazole, esomeprazole, rabeprazole, lansoprazole
  • Reduce gastric acid by inhibiting the cellular pump of the gastric parietal cells necessary for gastric acid secretion
  • Nursing Considerations:
    • Monitor for electrolyte imbalances and hypoglycemia in clients who have DM
    • Long term use has been related to the development of community acquired pneumonia and c. diff infections
  • Client education:
    • Long term use of PPIs places the client at risk for frxs, especially in older adults
33
Q

hiatal hernia: antacids

A
  • aluminum hydroxide, magnesium hydroxide, calcium carbonate, sodium bicarb
  • Neutralize excess acid and increase LES pressure
  • Nursing Considerations:
    • Ensure there are no contraindications w/ other meds (levothyroxine)
    • Evaluate kidney function in clients taking magnesium hydroxide
  • Client Edu:
    • Instruct client to take when acid secretion is the highest (1-3 hours after eating and at bedtime), and to separate other meds by at least 1 hour
34
Q

what are the therapeutic procedures for hiatal hernia?

A
  • Fundoplication: reinforcement of LES by wrapping portion of fundus of stomach around distal esophagus
  • Laparoscopic Nissen fundoplication: minimally invasive w/ fewer complications
35
Q

nursing considerations/client edu for hiatal hernia w/ the therapeutic procedures

A
  • Nursing Considerations:
    • Elevate HOB to promote lung expansion
    • Instruct client to support incision during movement and coughing to minimize strain on suture lines
  • Client Edu:
    • Consume a soft diet for first week postop
    • Avoid carbonated beverages
    • Ambulate, but avoid heavy lifting
36
Q

complications of the therapeutic procedures for hiatal hernia

A
  • Temporary dysphagia
  • Gas bloat syndrome (difficulty burping and distention)
  • atelectasis/pneumonia
37
Q

hiatal hernia: complications

A
  • Volvulus: twisting of esophagus and stomach
  • Obstruction (paraesophageal hernia): blockage of food in herniated portion of stomach
  • Strangulation (paraesophageal hernia): compression of blood vessels to the herniated portion of the stomach
  • Iron Deficiency Anemia (paraesophageal hernia): resulting from bleeding into gastric mucosa due to obstruction
38
Q

esophageal varices

A
  • Swollen, fragile blood vessels that are generally found in the submucosa of the lower esophagus, but varices can develop higher in the esophagus or extend ot the stomach
  • Occurs as a result of portal HTN, usually due to cirrhosis of the liver
  • When they hemorrhage, it is a medical emergency w/ high mortality
    • Recurrence of esophageal bleeding is common
39
Q

esophageal varices: health promotion and dz prevention

A
  • Avoid alcohol
  • Avoid heavy lifting
  • Avoid straining w/ bowel movements
  • Chew food completely, as poorly chewed foods can irritate the area
  • Avoid salicylates and other meds that irritate the esophagus
40
Q

esophageal varices: risk factors

A
  • Portal HTN: elevated blood pressure in veins that carry blood from the intestines to the liver
  • Alcoholic cirrhosis
  • Viral hepatitis
  • Older adults: frequently have depressed immune function, dec liver function, and cardiac disorders that make them vulnerable to bleeding
41
Q

portal HTN

A
  • Caused by impaired circulation of blood thru the liver–>collateral circulation develops, creating varices in the upper stomach and esophagus
    • Varices are fragile and can bleed easily
  • Primary risk factor for development of esophageal varices
42
Q

esophageal varices: expected findings

A
  • May experience no manifestations until the varices bleed
    • Hematemesis, melena, and general deterioration of physical and mental status
  • Activities that precipitate bleeding→Valsalva maneuver, lifting heavy objects, coughing, sneezing, alcohol consumption
  • Physical Assessment Findings w/ bleeding varices:
    • Shock
    • hypoTN
    • Tachycardia
    • Cool, clammy skin
43
Q

esophageal varices: lab tests

A
  • Liver fcn tests: indicate liver disorder
  • H&H: can indicate anemia secondary to occult bleeding or overt bleeding
  • Elevated serum ammonia level: indicates an inc nitrogen load from bleeding varices
44
Q

esophageal varices: diagnostic procedures

A
  • Endoscopy: therapeutic interventions can be performed during the endoscopy
  • Nursing Actions:
    • Administer preprocedure sedation
    • After the procedure, monitor V/S and take measures to prevent aspiration
45
Q

esophageal varices: nursing care

A
  • If bleeding is suspected, establish IV access w/ a large bore needle, monitor V/S and HCT, type and cross match for possible transfusions, and monitor for overt and occult bleeding
46
Q

esophageal varices: meds

A
  • nonselective beta blockers
  • vasoconstrictors
47
Q

esophageal varices: nonselective beta blockers

A
  • Propranolol: prescribed to decreased HR and consequently reduce hepatic venous pressure
  • Used prophylactically (not for emergency hemorrhage)
48
Q

esophageal varices: vasoconstrictors

A
  • Octreotide: synthetic form of hormone somatostatin decreases the bleeding from the varices but does not affect BP
  • Vasopressin causes constriction of esophageal and proximal gastric veins and reduces portal pressure
  • Nursing Considerations:
    • Vasopressin should not be given to clients who have coronary artery dz due to resultant coronary constriction
      • Potent vasoconstriction can cause problems with peripheral and cerebral circulation
      • If vasopressin is used with nitroglycerin IV in this client population, it can decrease or prevent the vasoconstriction of the coronary arteries
    • Monitor for fluid retention and hyponatremia, as vasopressin has an antidiuretic effect
49
Q

esophageal varices: list the therapeutic procedures used

A
  • endoscopic variceal ligation (EVL)
  • endoscopic sclerotherapy
  • transjugular intrahepatic portal systemic shunt (TIPS)
  • esophagogastric balloon tamponade
  • surgical intervention
50
Q

esophageal varices: endoscopic variceal ligation (EVL)

A
  • Can be used w/ acute bleeding
  • During endoscopy, the varices are rubber banded to cut off the circulation to the varices
    • Necrosis of the tissue occurs w/ eventual sloughing off of the varix
  • There is a significant decrease in rebleeding as well as decreased mortality postprocedure
  • Complications:
    • Superficial ulceration
    • Dysphagia
    • Temporary chest discomfort
    • Esophageal strictures (rare)
  • Nursing Actions:
    • Administer preprocedure sedation
    • After procedure, monitor V/S and prevent aspiration
51
Q

esophageal varices: endoscopic sclerotherapy

A
  • During endoscopy, a sclerosing agent is injected into the varices resulting in thrombosis of the varicosity
  • Complications:
    • Bleeding
    • Perforation of the esophagus
    • Aspiration pneumonia
    • Esophageal stricture
  • Nursing actions:
    • Administer preprocedure sedation
    • After procedure: monitor V/S and prevent aspiration
    • Antacids, H2 receptor blockers, or PPIs may be administered after the procedure to protect the esophagus and prevent acid reflux which is often caused by sclerotherapy
52
Q

esophageal varices: Transjugular intrahepatic portal-systemic shunt (TIPS)

A
  • Used to tx an acute episode of bleeding when EVL and medications are not controlling the bleeding
    • It rapidly lowers portal pressure
    • Procedure is costly and is only used when other measures do not work
  • While the client is under sedation or general anesthesia, a catheter is passed into the liver via the jugular vein in the neck
    • A stent is then placed b/w the portal and hepatic veins bypassing the liver
    • Portal HTN is subsequently relieved
  • Complications:
    • Bleeding
    • Sepsis
    • Heart failure
    • Organ perforation
    • Liver failure
  • Nursing Actions:
    • Monitor V/S
    • Keep HOB elevated
53
Q

esophageal varices: esophagogatric balloon tamponade

A
  • Rarely used but can be used to temporarily control bleeding until another measure can be implemented
  • Risks:
    • Tube migration: which can lead to airway obstruction
    • Aspiration of gastric contents into lungs
  • Clients are often intubated to protect the airway
  • Can cause necrosis of tissue if left in place for extended period of time
    • Balloon should be in place no longer than 12 hours
  • Nursing Actions:
    • Check balloons for leak prior to insertion
    • Monitor placement of the tube and observe for possible airway obstruction
    • Monitor for aspiration into lungs and secretions or blood from esophagus
    • Provide oral suction
    • Maintain balloon pressure at prescribed pressure for prescribed time to dec risk of esophageal or gastric necrosis from ischemia
    • Monitor the client who has dec mentation or confusion and who might pull on tube
54
Q

esophageal varices: surgical intervention

A
  • Last resort
    • TIPS has replaced many surgical options
    • High morbidity and mortality with surgery
  • Bypass procedures establish a venous shunt that pypasses the liver and dec portal HTN
    • Common shunts include:
      • Splenorenal: splenic, left renal veins
      • Mesocaval: mesenteric vein, vena cava
      • Portacaval: portal vein, IVC
    • Clients commonly have NG tube inserted to monitor for hemorrhage
  • Nursing actions:
    • Monitor for inc in liver dysfunction or encephalopathy
    • Monitor NG tube secretions for bleeding
    • Monitor PT, PTT, platelets, INR
55
Q

esophageal varices: hypovolemic shock

A
  • complication of esophageal varices
  • due to hemorrhage from varices
  • Nursing actions:
    • Observe for manifestations of hemorrhage and shock (tachycardia, hypoTN)
    • Monitor V/S, Hgb, Hct, and coagulation studies
    • Replace losses and support therapeutic procedures to stop and control bleeding

Adult Health I Test IV (10 decks)

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