Week 3 Upper Gastrointestinal Flashcards
This module covers gastrointestinal assessment along with learning about different upper gastrointestinal disorders such as Nausea and Vomiting, GORD, Gastritis, Peptic Ulcer disease. You will look also learn about oral conditions and assessments, obesity and eating disorders along with nutritional support.
A detailed NURSING ASSESSMENT is essential in determining an appropriate nursing care plan for conditions affecting the digestive system.
Some elements include:
- Vital signs including pain score
- Patient’s medical, surgical and social history - pre-existing conditions, family history, smoking, alcohol, recent travel, occupation
- General appearance
Skin- dehydration, pallor, jaundice, bruising, itching
eyes- sunken, yellow sclera, pale conjunctivae
mouth- halitosis; lips (dry, chapped, pale, sores); tongue (dry and coated, ulcerations); condition of gums and teeth
Weight- fluctuations - Diet- any changes in appetite, altered bowel pattern, food intolerances
- Medication history- usual medications, drug allergies
- SYMPTOMS
Nausea and vomitting- note the onset, duration and triggers of vomitting in addition to characteristic of vomitus eg/haematemesis (blood in vomit)
Dyspepsia (indigestion)
Dysphagia (difficulty swallowing)
Abdominal pain- note site, onset, nature
Bowel sounds- present or absent
Diarrhoea OR Constipation- onset, duration, frequency, characterisitcs of stool eg/melena- black tarry stool resulting from bleeding in upper GI tract
Palpaple lump(s)- site, onset, characteristcs.
A systematic approach to planning and implementing nursing care will ensure that an individual’s needs are comprehensively addressed. Elements include:
COMMUNICATION
OBSERVATIONS
NUTRITION/HYDRATION
ELIMINATION
PAIN RELIEF
MOBILISATION
PSYCHOSOCIAL SUPPORT
A variety of INVESTIGATIONS may be be necessary to make a diagnosis. Specific examples include:
- x-ray, ultrasound, CT
- Gastroscopy/Endoscopy- a procedure where a thin, flexibile tube with a light and camera on one end, called an endoscope, is used to look inside the oesophagus, stomach and small intestine (duodenum).
- Barium Swallow- a test that uses barium swallowed and x-ray to create images of the upper GI tract including throat (pharynx) and oesophagus.
- Colonoscopy- a procedure where a thin, flexible tube with a light and camera attached is used to look inside your large intestine (colon) and rectum.
- Laparoscopy- performed under anaesthetic involving a small incision (keyhole) through the abdominal wall to allow the injection of carbon dioxide into the peritoneal cavity to move organs and structures away from each other to be better visualised. It helps in obtaining tissue and fluid samples as well as detecting inflamattion, masses and other abnormalities.
Nausea is
is a feeling of discomfort in the epigastrium with a conscious desire to vomit
Vomiting is
is the forceful ejection of partially digested food and secretions from the upper GI tract
Nursing assessment for nausea and vomiting:
Vital signs- to help detect fluid volume deficit
General observation- appearance, skin colour and turgor
Collect patient history- Duration, frequency, severity, precipating factors, medications, measures used to alleviate.
Nursing care and interventions for nausea and vomiting:
Emesis bag, postion patient close to a bathroom
Strict fluid balance chart
NBM, or if not prohibited- ice chips to suck on.
Postion patient upright
NGT and suction to decompress the stomach
IVT
Medication thearpy as ordered- antiemetics
Other non-pharmacological therapy- acupuncture, ginger, relaxation, change in body position
Lifespan considerations nausea and vomiting
Older patients are more likely to have cardiac or renal insufficiency that places them at a great risk for life-threatening fluid and electrylite imbalances.
The older adult with a decreased level of consciousness may be at a high risk for aspiration of vomitus.
Gastro-oesophageal reflux disease (GORD) is
a chronic symptom of mucosal damage caused by reflux of stomach acid into the lower oesphagus. In fact, GORD is not a disease, but a syndrome.
GORD is one of the most common gastrointestinal conditions in Australia. It is estimated to occur in
10–15% of the population, with a rising prevalence, most likely due to obesity. In addition to obesity, risk factors include advanced age, male gender, Caucasian ethnicity, diets high in fats, sugars and salt, and smoking
GORD is usually caused by
the ring of muscle at the bottom of the oesophagus becoming weakened.
It is not always clear what causes this but people at risk of developing GORD are:
Obesity- increased pressure on the stomach can weaken muscles in the oesophagus
smoking, alcohol, coffee or chocolate- these may relax the muscles at the bottom of the oesphagus.
pregnancy- temporary changes in hormone levels and increased pressure on stomach
hiatus hernia- when part of your stomach pushes up through the diaphragm
Stress
Gastritis is
inflammation of the stomach lining and is one of the most common problems affecting the stomach. There are two types of gastritis, acute and chronic.
Causes of gastritis
Medications- aspirin, corticosteroids, NSAIDs- these medications inhibit the synthesis of prostaglandins that are protective to the gastric mucosa.
Diet- alcohol, spicy food
Helicobacter pylori infection- prolonged inflammation leads to changes in the stomach and can lead to cancer.
Environmental- radiation, smoking
Pathophysiological conditions- burns, large hiatus hernia, reflux of bile/pancreatic secretions, renal failure, sepsis, shock.
Other factors- endoscopic procedures, NG tube, psychological stress.
GORD Signs and Symptoms- these vary from person to person.
heartburn is the most common symptom. It is a burning, tight sensation felt intermittently beneath the lower sternum and spreading upwards to the throat or Jaw
dyspepsia- pain or discomfort in the upper abdomen
regurgitation- described as hot, bitter or sour liquid coming into the throat or mouth.
respiratory symptoms such as; wheezing, coughing, and dyspnoea
GORD-related chest pain can mimic angina and is described as burning, squeezing or radiating to the back, neck, jaw or arms. Assessment is vital!
GORD Complications
oesophagitis- inflammation of the oesophagus and this can potentially lead to oesophageal ulcers that can bleed, cause pain and make swallowing difficult.
Barrett’s oesphagus- repeated episodes of GORD can damage the cells lining in the lower oesphagus
dental erosion- due to acid reflux into the mouth
Oesophageal cancer
GASTRITIS Signs and Symptoms
Nausea and Vomiting
Abdominal bloating
Abdominal pain
Indigestion
Burning feeling
Loss of appetite
Nursing care and management GORD:
elevate bed to 30 degrees
patient should not lay supine for 2 - 3 hours after a meal
Medication therapy
- Protein pump inhibitors (PPIs) block the acid secretory pathway eg/omeprazole
- PPIs have a short plasma half-life thereofre the TIMING of administration is important with the greatest efficacy seen when given a meal time.
- PPIs should be given approximately 30 minutes before a meal.
- Long term use of PPIs may increase the risk of falls and fractures.
- PPis are associated with increased risk of C.difficile infection in hospitalised patient’s.
education - avoid late night eating and identified activites that causes reflux for them, weight reduction, avoiding alcohol and smoking
Nursing care and management- GASTRITIS
Supportive treatment such as IV fluids and NBM status if vomiting and dehydration accompanies acute gastritis.
Administration of medication therapy- focuses on reducing irritation of the gastric mucosa and providing symptomatic relief eg/ antiemetics, H2 repetor blockers or PPIs to reduce gastric HC1 secretion, antibiotic combinations used to eradicate H.pylori if a cause.
In severe of acute gastritis- NG tube may be used to monitor for bleeding, lavage the precipating agent from the stomach, keep the stomach empty.
Involvement of mulitidisciplanary team- eg/dietician
A peptic ulcer is
a break or ulceration in the mucosal lining of the lower oesophgus, stomach or duodenum.
Peptic ulcer disease (PUD) damages the
lining, usually by increased acid secretion leading to inflammation and ulceration. Helicbacter pylori infection and the use of no-steroidal anti-inflammatory drugs (NSAIDs) are the primary causes of both gastric and duodenal ulcers.
PUD Signs and symptoms
Epigastric pain- Gnawing or burning pain in the middle to upper stomach between meals or at night
Pain that temporarily disappears if you eat something like food milk or antacids
Bloating
Heartburn
Nausea or vomiting
- Bleeding, performation and gastric obstruction are the major complications of PUD
Nursing care and management PUD
Administration of prescribed medication
- PPI’s eg/omeprazole
- H2 blockers eg/rantididine
- Antibiotics eg/amoxicillin, clarithromycin and metroniadole
- Protective medications eg/sucralfate
- Antimetic eg/ Stemetil, ondansetron or metoclopramide to relieve nausea and vomiting.
If complications occur such as haemorrage, performation or pyloric stenosis, intravenous access will need to be established and fluid replacement initiated to correct hypovolemia.
Insertion of a NG tube may be indicated to allow aspiration to decompress and empty the stomach.
Commencement of a fluid balance chart and regular vital signs
A urinary catheter may be required to monitor input/output.
Nutritional therapy- avoid caffeine-containing beverages and foods. Eliminating alcohol as it can delay healing. Avoid foods that cause gastric irritation including hot (spicy) foods, peppper and carbonated beverages.
Gingivitis
The gingiva are the gums, the visible mucosa around teeth. Gingivitis refers to inflammation of the gingiva, and is common. It is a mild form of periodontitis, which means inflammation of all the tissues surrounding the teeth, and is less common
Gingivitis
Signs and symptoms:
Patients with gingivitis present with:
Puffy, dusky red, swollen gums
Gums which are tender and bleed easily
Foul breath
Bleeding when brushing teeth
Development of pus
Formation of abscess with loosening of teeth
Gingivitis
Risk Factors:
Poor oral hygiene, which leads to the build-up of plaque. If teeth are not cared for properly, plaque hardens into tartar and irritates the gingiva
Systemic disorders like diabetes or leukaemia, exposure to heavy metals, pellagra (niacin deficiency) and scurvy (Vitamin C deficiency)
Skin disease, particularly erosive lichen planus
Hereditary factors
Poor or inadequate oral hygiene practices
Tobacco use
Immune compromise
Viral and yeast infections
Dry mouth
Hormonal changes associated with menses and pregnancy
Poor nutrition
Substance abuse
Ill-fitting dental restoration
Type 1 diabetes, leukaemia, Down syndrome, Papillon-Lefevre syndrome and Crohn disease.
Gingivitis
Treatment:
Prevention through health teaching
Dental care
Gingival massage
Regular dental checkups - including professional cleaning of teeth
Treatment of underlying conditions
Candidiasis
is an infection caused by a yeast (a type of fungus) called Candida. Candida normally lives on the skin and inside the body, in places such as the mouth, throat, gut, and vagina, without causing any problems. Sometimes, Candida can multiply and cause an infection if the environment inside the mouth, throat, or esophagus changes in a way that encourages fungal growth. Candidiasis in the mouth and throat is also called thrush or oropharyngeal candidiasis. Candidiasis in the esophagus (the tube that connects the throat to the stomach) is called esophageal candidiasis or Candida esophagitis.
Oral Candidiasis
Signs and Symptoms
White patches on the inner cheeks, tongue, roof of the mouth, and throat
Redness or soreness
Halitosis
Cotton-like feeling in the mouth
Loss of taste
Pain while eating or swallowing
Oral Candidiasis
Risk Factors
Taking antibiotics, including inhaled corticosteroids
Wearing dentures
Having cancer, HIV/AIDS
Smoking
Oral Candidiasis
Treatment
Miconazole oral gel
Good oral hygiene
Rinising mouth after using inhaled corticosteroids
HSV -1
HSV-1 is mainly transmitted by oral-to-oral contact to cause infection in or around the mouth.
HSV-1 affects most people on one or more occasions during their lives and is the herpes simplex virus that will be discussed here.
Both variants of the herpes simplex virus present with localised blistering.
HSV 2
HSV-2 on the other hand is almost exclusively transmitted through genital-to-genital contact during sex.
Both variants of the herpes simplex virus present with localised blistering.
HSV Cold sores
Herpes simplex is commonly referred to as cold sores or fever blisters, as recurrences are often triggered by a febrile illness, such as a cold.
HSV
Signs and Symptoms
Lip lesions
Mouth lesions
Vesicle formation (single or clustered)
Shallow painful ulcers
Blisters
HSV
Risk Factors
Upper respiratory infections
Excessive exposure to sunlight
Food allergies
Emotional tension
Onset of menstruration
HSV Treatment
Topical creams - corticosteroids
Mild antiseptic mouthwash
Viscous lignocaine
Removal or control of predisposing factors
Antiviral agents.
There are two types of oral cancer:
1) oral cavity cancer- which starts in the mouth
2) oropharyngeal cancer- which starts in the part of the throat behind the mouth.
Oral cancer is more common over the age of 40, but is becoming more commonly diagnosied in younger people which is attributed to the human papillomavirus (HPV) which is sexually transmitted.
Oral cancer
Nursing assessment
Subjective data- health history including recurrent oral herpatic lesions, HPV infection or vaccinitation, syphilis, exposure to sunlight, medications (immunosuppressants), past surgery
Functional heatlh patterns- use of alcohol and tobacco, oral hygiene, oral intake, weight loss, mouth or tongue soreness, dysphagia, difficulty speaking.
Objective data- ulcer/s on lip, palpable neck mass, limited movement of tongue, increased salivation, drooling, slurred speech, foul breath odour, smear cytology, biopsy, positive toluidine blue test
Oral Cancer
Nursing management
identify patient’s at risk and education of patients eg/smoking cessation
Pain management- non pharmacological/pharmacological
Provide oral hygiene for patient
reasurrance and anxiety management, especially pre and post op surgery
The World Health Organisation (2016) defines overweight and obesity as
excessive fat accumulation that presents health risks and arises from a sustained energy imbalance.
Nursing care and management
Obesity:
Gathering a health history is vital to determing whether any physical conditions are present that may be causing or contributing to obesity eg/family history, previous attempts of weight loss, any underlying conditions such as hypertension, cardiovascular problems, stroke, cancer, diabetes, any medications, previous surgery (eg/bariatric surgery).
Calculate a BMI and document on admission form
Working within the multidisciplinary team- referal for nutritional therapy, exercise, behaviour modfication, support groups, meciation therapy such as appetite-supressing medications
Nursing care and management
Malnutrition:
Determine contributing factors eg/ socioeconomoic factors, physical illnesses, incomplete diets, history of eating disorders
Calculate a malnutrition score and document on admission
Referral to multidiscioplinary team
For acute intervention- spcialised nutritional support such as oral supplements, enteral nutrition, parenteral nutrition.
Enteral feeding is
a method of supplying nutrients directly into the gastrointestinal tract. Enteral feeding is used for patients who still have a functioning GI tract but for some reason may be unable to take any or enough oral nutrition or it may be unsafe to do so.
Parenteral Nutrition is
intravenous feeding, or feeding into your bloodstream. Parenteral nutrition is used for patient who cannot ingest, digest or absorb nutrients via the GI tract.
Nasogatric tube (NGT)
This is a thin soft, flexible tube that passess through the nostril and down the back of their throat, through the oesophagus and into the stomach. NGT’s can be either fine bore or large bore depending on the need.
Fine bore tubes are usually indicated for patient’s who require short term enteral feeding, removal or replacement of tube should be considered at the 4 week mark, but will depend on local hospital policy.
Large bore tubes, or commonly known as salem sump tubes are double lumen with an air vent, this type of tube is more commonly used in patients who not only require nutritional support but also gastric drainage and aspiration. A salem sump tube should be changes every 10-14 days or as per local hospital policy.
Nasojejunal tube (NJT)
Jejunal feeding is the method of feeding directly into the small bowel. The feeding tube is still inserted via the nose but extends into the small bowel via the stomach and pyloric sphincter into the jejunum. This type of tube is used when gastric feeding is poorly tolerated or contraindicated.
Percutaneous endoscopic gastrostomy (PEG)
This type of tube is inserted surgically or endoscopically through the abdominal wall into the stomach. PEGs are inserted when a patient has difficulty swallowing (dysphagia) or is unable to obtain adequate nutrition via the mouth. Depending on local hospital policy, a PEG tube can be used after insertion in as little as 4 hours or within 24 hours. A PEG tube only requires to be changed every 12 months.
Jejunostomy tube (J-tube)
A jejunostomy tube or J-tube is also a tube that is place through the abdominal wall into the midsection of the small intestine via either a endoscopic or laproscopic procedure. Feeding usually commences within 24-48 hours post placement.
Refeeding syndrome
This is a potentially leathal condition that can occur in acutely ill and severly malnourished patients. It occurs when enteral or parenteral nutrition is given too fast. It is characterised by fluid retention and electrolyte imbalances.
Electrolyte imblances occur and can cause cardiac, respiratory, hepatic or neuromuscular disorders. Whilst the electrolyte imbalance is able to be corrected, if not identifed it can lead to clinical complications and death. To avoid this, nutritional support is introduced slowly and cautiously with the amount provided titrated upward slowly as the patient tolerates the feed
Drug administration
Administering medications via tubes can bring its own complications if the medication is not adminstered properly and following the guidelines.
Some medications are not able to be administered via a tube and this is where it is important to be referring to the “Don’t Rush to Crush” book for guidance. It is also important to ensure that a pre and post flush with water is provided to avoid occlusions.
Aspiration and tube dislodgement are the two most common safety risks when providing nutrition to your patient via a feeding tube. To manage this consider the following
Patient position
Aspiration risk
Tube position
Patient position
correct positions decreases aspiration risk
elevate the head of the bed to a minimum of 30 degrees, preferable is 45 degrees.
if you need to perform a procedure, stop the feed, lower the bed and then return the bed to the position before recommencing the feed.
if patient is on intermittent feeds, remain upright for 30-60 minutes post feed.
Always check local policy and procedure.
Aspiration risk
prior to using the tube for either feeding or medication administration, proper tube positions should always be checked.
aspirate tube to check for position, you should see gastric contents.
Tube position
on insertion, an x-ray needs to be completed to confirm placement. (GOLD STANDARD!)
aspiratate as above, and use a pH strip to confirm placement.
recheck length of tube, at each shift change, pre and post using the tube
Which of the following gastrointestinal organs is in the thoracic cavity?
Mouth
Oesophagus
Stomach
Duodenum
Oesophagus
Which of the following is NOT a region of the small intestine?
Duodenum
Jejunum
IIeum
Plasmodium
Plasmodium
Which of the following organs acidifies food for digestion?
Stomach
Small Intestine
Pancreas
Liver
Stomach
Which of the following does NOT connect with the duodenum
Stomach
Pancreas
Liver
Ileum
Ileum
Which of the following organs produces bile?
Duodenum
Pancreas
gall bladder
liver
liver
The process of moving food from the oesophagus to the stomach is called:
deglutition
peristalsis
bulk movement
churning
peristalsis
Which of the following organs contains and oblique smooth muscle layer, as well as a circular and longitudinal
Oesophagus
Stomach
Small intestine
Colon
Stomach
What is the taenia coli?
A nasty fungal infection
A layer of fat in the colon
A single layer of smooth muscle in the colon
A fat tag hanging from the colon
A single layer of smooth muscle in the colon
Which of the following cell types secretes acid in the stomach
The enteroendocrine cell
The chief cell
The suface mucous cell
the parietal cell
the parietal cell
In which region of the gastrointestinal tract does protein digestion begin?
mouth
stomach
duodenum
pancreas
stomach
In lipid digestion, in which region of the gastrointestinal tract are most micelles formed?
Mouth
Stomach
Small intestine
Colon
Small intestine
Gastric acid breaks proteins into:
Peptides
Amino acids
Proteins
Saccharides
Peptides
Which of the following enzymes DOES NOT digest peptides
Pepsin
Trypsin
Amylase
Carboxypeptidase
Amylase
Which of the following enzymes digests complex polysaccharides such as starch
maltase
lactase
sucrase
amylase
amylase
How is glucose absorbed into epithelial cells in the small intestine
By diffusion
By carrier mediated passive transport
By primary active transport
By secondary active transport
By secondary active transport
To be absorbed into cells, triglycerides must be:
Converted to amino acids
Converted to fatty acids
Transported into cells with glucose
Attached to bananas
Converted to fatty acids
Which of the following macronutrients is transported from the intestines in the lymphatic system?
Carbohydrates
triglycerides
Amino acids
triglycerides
Which of the following defines gastritis?
Ulcer formation in the stomach or duodenum
reflux of gastric content into the oesophagus
inflammation in the lining of the stomach
inflammation in the lining of the stomach
Which of the following is unlikely to lead to gastritis?
smoking
alcohol consumption
sugary food consumption
H pylori infection
sugary food consumption
which of the following is TRUE?
PUD often leads to GORD
Gastritis often causes GORD
Gastritis can cause PUD
GORD very often leads to PUD
Gastritis can cause PUD
Which of the following would provide immediate relief from discomfort in PUD and GORD
antiacids
histamine receptor antagonists
proton pump inhibitors
NSAID’s
antiacids
Which region of the GI tract is PUD least likely to affect?
the oesophagus
the stomach
the small intestines
the oesophagus
Which of the following is not a component of the mucosal protection barrier
Tight junctions between epithelial cells
acid secretion by parietal cells
Alkaline mucus on the gastric surface
Rapid turnover of gastric epuithelial cells
acid secretion by parietal cells
Carbohydrates
For metabolism (and some structures in cells)
Proteins
Structural and functional elements of the body such as excess amino acids used as an energy source
Lipids
Structural components such as myelin sheaths, cell membranes
The mechanism of action of Maxalon (metoclopramide) is:
1st generation antihistamine. Acts on vestibular apparatus and vomiting centre
Serotonin receptor antagonist. Acts on the vagal feedback from intestines and the chemical trigger zone
Dopamine receptor antagonist. Acts on chemical trigger zone to inhibit vomiting
Serotonin receptor antagonist. Acts on vestibular apparatus and vagal feedback
Dopamine receptor antagonist. Acts on chemical trigger zone to inhibit vomiting
Peptic ulcer disease is commonly caused by:
Show answer choices
smoking and alcohol abuse
helicobacter pylori and the use of NSAIDs
excessive intake of acidic foods and alcohol
genetic predisposition
helicobacter pylori and the use of NSAIDs
Pain from Peptic ulcer disease is often located in:
Show answer choices
mucosa in the stomach
X The duodenum X
small intestine
Epigastrium
A patient who has gastroesophageal reflux disease (GORD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GORD is needed?
Show answer choices
“I take antacids between meals and at bedtime each night”
“I sleep with the head of the bed elevated on 4-inch blocks”
“I eat small meals during the day and have a bedtime snack”
“I quite smoking several years ago, but I still chew a lot of gum”
“I eat small meals during the day and have a bedtime snack”
This is scenario 2 from your Tutorial worksheet.
Marissa is a 40-year-old female, recently diagnosed with Peptic Ulcer Disease (PUD) who has been admitted with a potential Upper GI bleed and on the endoscopy list. You observe she is clammy and pale. She presents with melena, concentrated urine and states she has not been able to tolerate food and only small sips of fluid. You conduct an abdominal assessment and she has hyperactive bowel sounds with tenderness in the upper left quadrant. She states prior to this she has had occasions of epigastric pain, reduced appetite and weight loss over the last few weeks. Her vital signs are:
HR- 123, BP 98/61, O2 sats 99%, RR- 24, Pain score 5/10, Weight 51kg, Height 175cm.
Identify 2 (two) appropriate problem statements below:
Show answer choices
Marissa is experiencing deficient fluid volume related to acute loss of blood as evidenced by hypotension, concentrated urine and melena.
Marissa is experiencing moderate pain related to PUD and potential bleed as evidenced by upper abdominal tenderness and pain score of 5/10.
Marissa is experiencing hypervolemia related to acute loss of blood as evidenced by hypertension, concentrated urine and melena.
Marissa is experiencing minimal pain related to PUD and potential bleed as evidenced by lower abdominal tenderness and pain score on 5/10.
Marissa is experiencing deficient fluid volume related to acute loss of blood as evidenced by hypotension, concentrated urine and melena.
Marissa is experiencing moderate pain related to PUD and potential bleed as evidenced by upper abdominal tenderness and pain score of 5/10.
On observing Janice’s mouth, you notice creaming white lesions on the tongue and her inner cheeks. You determine it could be oral thrush. What is the name of the fungus responsible?
Show answer choices
Histoplasmosis
Aspergillosis
Cryptococcus neoformans
Candida albicans
Candida albicans
T/F
Is this statement true or false? A Proton Pump Inhibitor (PPI) blocks the Histamine H2 receptor on the basal surface of the gastric parietal cell and hence prevents sequence of reactions that eventually prevents the phosphorylates of the proton pump to stop pumping H+ into the gastric lumen.
True
