GI problems Flashcards
What is the most common manifestation of GI diseases?
N/V
Nausea - subjective
Vomiting - objective
Vomiting can lead to:
- dehydration
- loss of Water and essential electrolytes
- Metabolic alkalosis – loss of HCl from stomach
- Metabolic acidosis – when contents of small intestine are lost (less common)
What are common S/S of vomiting (dehydration)?
- Lethargy
- Sunken eyeballs
- Pallor
- Dry mucus membranes
- Poor skin turgor
- Decreased urinary output
- S/S of electrolyte disturbances
- Hypokalemia – Important bc leads to cardiac issues
- Metabolic alkalosis
What should the nurse assess emesis for?
Amount/frequency/character/color of emesis
Emesis contains partially digested food several hours after meal = gastric outlet obstruction or delayed gastric emptying
Color helps determine presence and source of bleeding (if present)
Blood in emesis could be from a
- Mallory-Weiss tear
- esophageal varices
- gastric/duodenal ulcers or cancer
What is a Mallory-Weiss tear?
a tear of the tissue the lower esophagus often caused by violent coughing or vomiting, and if left untreated can lead to anemia, fatigue, shortness of breath, and shock
What does blood in emesis look like?
Coffee-ground” appearance
blood turns dark brown when interacting with HCl acid
If there is blood in emesis, don’t assume ___.
it’s the only place they are loosing blood!
Check H&H, BP
Regurgitation
effortless process where partially digested food slowly comes up from the stomach
Projectile vomiting
forceful expulsion of stomach contents w/o nausea (usually a neuro issue)
What is cyclic vomiting syndrome?
Disorder that causes recurrent episodes of nausea, vomiting, and lethargy
Episodes of nausea, vomiting, and lethargy last anywhere from an hour to 10 days
Can have 4-12 cycles per year, if left untreated
Between attacks N/V absent
Common triggers: emotional excitement and infection
Often considered to be a variant of migraines
What is care for someone with Cyclic vomiting syndrome?
- When in hospital, NPO and IV fluids until diagnosis is confirmed
- May need NG tube (persistent vomiting or bowel obstruction)
- Address dehydration, acid-base and electrolyte imbalances
- Monitor I/O, VS
- Quiet/odor-free environment
- Monitor mental status and risk for aspiration
- If decreased mental status and risk for vomiting is present, then place side-lying
- Older/unconscious/altered gag reflex all at increased risk (semi-Fowler’s or side lying) - When PO started:
- Clear liquids when PO is started
a. Liquids at room temp
b. progress slowly
- Advance slowly from clear liquids to dry toast, crackers
- Next advance to high carbohydrate / low fat
- Eat slowly & small amounts
- Fluids between meals (not with meals)
For patients who are at higher risk of aspiration with vomiting (Older/unconscious/altered gag reflex), what position do they go in?
Semi-Fowler’s or Side-Lying Position
What are the two types of oral cancer?
Oral cavity – starts in the mouth
Oropharyngeal – develops in the throat
-Broadly called HNSCC (Head and Neck Squamous cell carcinoma) - Broad term for oral, pharynx, larynx
What are the clinical manifestations of oral cancer?
- Leukoplakia: “smoker’s patch” – white patch on mouth mucosa or tongue (precancerous lesion)
- Erythroplasia (or plakia): red, velvety patch on mouth or tongue (precancerous lesion)
- Ulcer: lip or tongue
- Soreness of tongue
- Chronic sore throat
- Later: dysphagia, increased salivation, jaw movement, slurred speech, tooth/earache
What is treatment for oral cancer?
- SURGERY
- May be extensive and deforming
- Mandibulectomy – removal of part of the mandible
- Radical neck dissection with tracheostomy- Will do a biopsy to check for cancer 1st
- Glossectomy – removal of the tongue
- RADIATION THERAPY
- may be used alone if Cancer small or can’t be removed
- Also used after surgery (6 weeks)
- CHEMOTHERAPY
- can shrink tumors before surgery
- used after surgery in case of metastasis (a secondary malignant growth)
What is post surgery care for a patient who had oral cancer?
Airway maintenance Communication Nutrition: may require a PEG tube Pain relief Body image
What is Gastroesophageal Reflux Disease (GERD)?
Chronic symptoms of mucosal damage caused by reflux of stomach acid into the lower esophagus
Most common UGI problem in adults
What are the clinical manifestations of GERD?
Heartburn (pyrosis) Dyspepsia (pain) Regurgitations (baby barf) Hypersalivation Noncardiac chest pain May also report 1. Wheezing 2. Coughing 3. Dyspnea 4. Hoarseness 5. Sore throat 6. Lump in throat 7. Choking 8. Regurgitation 9. So pt may not know they have GERD and think its Respiratory
Diagnosis:
- Mild symptoms 2X/wk or moderate to severe symptoms 1x/wk
- Response to therapy
What are common GERD complications?
- esophagitis
- Barrett’s esophagus
- Respiratory (Cough, Bronchospasm, Laryngospasm, Aspiration leading to pneumonia)
- Dental erosion
What is Barrett’s esophagus? Why is it dangerous?
Precancerous lesion that can lead to esophageal cancer
Can be a complication of GERD and esophagitis
So pay attention to this!!
Monitoring! (endoscopy q2-3 years or ablation)
GERD drugs include these classes:
Antacids Histamine (H2) receptor blockers Proton Pump Inhibitors (PPI) Cholinergic Prokinetics Prostaglandins (Antiulcer) Al and Mg
Antacids
neutralize HCL acid
Histamine (H2) Receptor blockers
decrease HCL secretion
Proton Pump Inhibitors (PPI)
decrease HCL secretion
Cholinergic
increase LES (lower esophageal sphincter) pressure
Prokinetics
increase gastric motility and emptying
Prostoglandins (antiulcers)
form a protective layer in the stomach
What is patient teaching for GERD patients?
- Low-fat diet
- Small, frequent meals, avoid late evening meals and avoid milk (an irritant)
- Avoid alcohol, smoking, caffeine
- Tell the patient not to lie down for 2-3 hours after eating, wear tight clothing around the waist, or bend over (esp after eating)
- Avoid eating within 3 hours of bedtime
- Sleep with HOB on 4-6-inch blocks
- Provide information of drugs, including reasons for use and common side effects.
- Weight reduction
- Avoid Foods / Drinks that lower LES pressure (chocolate, peppermint, fatty foods coffee, tea) or irritate the esophagus (tomato-based foods, orange juice, cola, red wine)
- Drink fluid between meals (prevents over distention of the stomach)
Surgeries for GERD include:
Nissan fundoplication - wrap the stomach around the esophagus
LINX Reflux Management System - A series of titanium beads, each with a magnetic core, connected together to form a ring shape
-Pts will no longer be able to undergo Magnetic Resonance Imaging (MRI) procedures
Postoperative Care for GERD:
Goals:
- Prevent respiratory complications
- Maintain fluid/electrolyte balance
- Prevent infections
Respiratory assessment
- Respiratory rate / rhythm
- Pulse rate / rhythm
- Signs of pneumothorax (dyspnea, chest pain, cyanosis)
Deep breathing techniques / Incentive spirometer
Accurate I&O
Pain medication
Medications to prevent nausea/vomiting
When peristalsis returns
- start with fluids only
- Gradually add solids
- Normal diet gradually resumed
Patient should
- Avoid gas-forming foods
- Chew food thoroughly
What are the two types of hiatal hernias?
Sliding and Paraseophageal/Rolling
S/S: Can be asymptomatic Heartburn Dyspepsia (pain midline, upper abdomen) Regurgitation Dysphagia
Complications GERD Esophagitis Hemorrhage from erosion Stenosis of esophagus Ulceration in herniated portion of stomach Strangulation of herniated portion stomach Regurgitation with tracheal aspiration
What is the teaching/nursing care of a hiatal hernia?
SAME AS GERD
- Low-fat diet
- Small, frequent meals, avoid late evening meals and avoid milk (an irritant)
- Avoid alcohol, smoking, caffeine
- Tell the patient not to lie down for 2-3 hours after eating, wear tight clothing around the waist, or bend over (esp after eating)
- Avoid eating within 3 hours of bedtime
- Sleep with HOB on 4-6-inch blocks
- Provide information of drugs, including reasons for use and common side effects.
- Weight reduction
- Avoid Foods / Drinks that lower LES pressure (chocolate, peppermint, fatty foods coffee, tea) or irritate the esophagus (tomato-based foods, orange juice, cola, red wine)
- Drink fluid between meals (prevents over distention of the stomach)
What is common management of hiatal hernias?
Conservative therapy
- Eliminate restrictive / tight garments
- Avoid lifting / straining
- Eliminate smoking / alcohol
- Antacids / antisecretory medications
- Elevate HOB
- Weight loss
Surgery - Can be done laparoscopically
- Herniotomy (cut the sack off)
- Herniorrhaphy (close the defect)
- Gastropexy (attach the stomach under the diaphragm to prevent reherniation)
Esophageal cancer is usually a late diagnosis. Risk factors include:
- Age (older; 70-84)
- Race (White, Alaskan Native)
- Male
- Barrett’s esophagus - Precancerous lesion so pay attention to this!!
- Lifestyle (smoking)
- Exposure - asbestos, cement dust
- Achalasia - delayed emptying of the lower esophagus
What are S/S of esophageal cancer?
- Progressive dysphagia (swallowing difficulty)
- Weight Loss
- Pain (late symptom)
- Regurgitation
- Hemorrhage
- Perforation
- Fistula w/ trachea or lung
- If tumor is in upper 1/3rd esophagus then will have Sore throat, Choking, and Hoarseness
Treatment for esophageal cancer includes:
- SURGERY
esophagesctomy, esophagogastostomy, esophagoenterostomy - ENDOSCOPIC THERAPY
dilation, stent therapy, radiofrequency ablation, and a few others - RADIATION AND CHEMOTHERAPY
- TARGETED THERAPY (targets specific cells)
- NUTRITION
nutrition is important throughout the course of treatment as it can get difficult to eat/drink
-tube feeding when needed
Nursing Care for esophageal cancer:
Surgery – post op = ICU 1-2 days
Complications:
- anastomotic leaks,
- fistula formation,
- interstitial pulmonary edema,
- respiratory distress
Priorities:
1. NG Tube: Drainage – bloody 8 – 12 hours; NEVER REPOSITION or irrigate without consulting surgeon
2. Emphasis on respiratory care (T,C, DB)
3. VTE prophylaxis and pain management
4. Nutrition- Jejunostomy or Gastrostomy tube
note: Monitor for anastomotic leakage into mediastinum
s/s: Pain, fever, dyspnea upon resumption of feeding
5. FOWLER’S OR SEMI-FOWLER’S POSITION
- prevents reflux
- Once drinking or eating, maintain upright 2-3 hours
What is gastritis?
Inflammation of gastric mucosa
One of most common stomach problems
- May be acute or chronic
- Diffuse or localized
Causes:
- Breakdown of gastric mucosal barrier
- HCL & Pepsin into – mucosa
- Causing tissue edema and disruption of capillary walls
What are risk factors for gastritis?
Drugs (ASA, steroids, iron supplements, NSAIDs)
-Even though NSAIDS are anti-inflammatory, they irritate the stomach
Diet
- Alcohol
- spicy food
Microorgamisms
esp Helicobacter pylori (H. pylori)
Environmental
- Radiation
- smoking
Pathophysiologic conditions
1. Burns, large hiatal hernia, physiologic stress, sepsis, more…
Other- endoscopic procedures, NG tube, psychologic stress
What are S/S of gastritis?
Acute and Chronic Gastritis:
- Anorexia
- Nausea
- Vomiting
- Epigastric tenderness
- Feeling of fullness
- Hemorrhage
- Associated with alcohol
Chronic Gastritis:
Atrophy/loss of parietal cells causes the loss of intrinsic factor (IF) as well which is essential for the absorption of cobalamin (B12).
The loss of cobalamin absorption will cause:
1. anemia - IF needed for growth and maturation of RBCs
2. neurologic complications
- paresthesias of the feet and hands
- reduced vibratory and position senses
- ataxia
- muscle weakness
- impaired thought processes ranging from confusion to dementia
What are common diagnostic studies for gastritis?
Patient symptoms and history of alcohol or drug use
Endoscopic examination with biopsy
- H. pylori infection: breath, urine, serum, stool, and gastric tissue biopsy
CBC (anemia due to lack of intrinsic factor)
Stool (occult blood)
Serum tests for antibodies to parietal cells & intrinsic factor
What is care for chronic gastritis?
Eliminate & avoid cause
Drug therapy
- PPI
- Antibiotic (likely 2 different ones OR PPI, Bismuth [coats and protects], antibiotic, antifungal)
Non-irritating diet (six small meals/day)
NO smoking
What does smoking do?
it causes an almost immediate, marked decrease in lower esophageal sphincter pressure
