NCMB 316 Gastrointestinal Disorders PDF

OUR LADY OF FATIMA UNIVERSITY - COLLEGE OF NURSING NCMB 316: Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception & Coordination Transcribed By: Tirados, Lagrimas, & Victorino...

OUR LADY OF FATIMA UNIVERSITY - COLLEGE OF NURSING NCMB 316: Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception & Coordination Transcribed By: Tirados, Lagrimas, & Victorino Section: BSN 3 - Y2 - 6 Week 2: Gastrointestinal Disorders heartburn wherein the patient Disturbances in Ingestion has a feeling of burning Gastroesophageal Reflux Disease sensation of the esophagus characterized by backflow/ reflux of which is non cardiac in nature) stomach or duodenal contents into the ○ Regurgitation is the hallmark of esophagus resulting to esophageal symptom mucosal injury ○ Dyspepsia or the feeling of Causes: indigestion ○ incompetent lower esophageal ○ Dysphagia (difficulty); or sphincter wherein the junction odynophagia (painful) between esophagus and the ○ Hypersalivation or excessive stomach are open and allows production of saliva the reflux ○ Esophagitis (inflammation of ○ pyloric stenosis there is a the esophageal lining) narrowing in the junction ○ May mimic heart attack (take between the stomach and note of manifestation for us to duodenum which prevents deliver a appropriate stomach contents to move management) towards the intestine ○ Dental erosions, ulcerations in ○ hiatal hernia part of stomach the pharynx and esophagus, that protrudes into the laryngeal damage, esophageal diaphragm strictures, adenocarcinoma, ○ motility disorder there is an pulmonary complications abnormality in peristaltic (aspiration) movement Diagnosis: Other Risk Factors: ○ Patient's history (for accurate ○ increased in aging diagnosis) ○ irritable bowel syndrome ○ Ambulatory pH monitoring ○ obstructive airway disorders Gold standard (COPD and asthma and the Involves the placement possible cause is hyperinflation of transnasal catheter it of lungs) uses ○ Barrett Esophagus lining of Endoscopy (wireless esophageal mucosa is altered. It capsule and it is looks like stomach rugal kasi inserted until stomach) diba dapat smooth lang yung Device is inserted inside esophagus natin but with GERD, the stomach for it looks like stomach rugal approximately 24 hours ○ PUD (Peptic Ulcer Disease) It quantify, measures ○ Angina (related to chest pain the reflux which may contribute to gastric ○ Endoscopy or Barium swallow is stimulation which result to used to evaluate damage to the GERD ) esophageal mucosa which rule ○ Associated with irritants which out esophageal strictures and are: tobacco use,coffee drinking, hiatal hernia alcohol consumption, H. Pylori Management: infection (stomach is exposed ○ Patient education (tell the client to h.pylori infection) ro avoid situation that can cause Clinical Manifestations: esophageal irritation for ○ Pyrosis (also known as decreases lower esophageal Page 10  OUR LADY OF FATIMA UNIVERSITY - COLLEGE OF NURSING NCMB 316: Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception & Coordination Transcribed By: Tirados, Lagrimas, & Victorino Section: BSN 3 - Y2 - 6 sphincter) Upper—pharyngoesopha ○ Stop smoking geal ○ Limit alcohol intake Middle—midesophageal ○ Weight loss (obesity can Lower—epiphrenic contribute to GERD wherein fats puts pressure into the stomach) Zenker Diverticulum ○ Maintain N body weight (based Most common type of diverticulum on BMI) Located in pharyngoesophageal (upper) ○ Low-fat diet, avoid caffeine, area of the esophagus Caused by foods containing peppermint, dysfunctional sphincter that fails to open carbonated beverages (Gastric (pulsion diverticulum) which leads to irritants) increase in pressure that forces the ○ Elevate head of bed (prevent mucosa and submucosa to protrude or aspiration and reflux) herniate into the muscle of the ○ Avoid eating or drinking 2 hrs esophagus which is called as pulsion prior bedtime diverticulum ○ Avoid tight-fitting clothes ○ Posterior to the pharynx and Antacid (neutralizes gastric acid middle of the neck and the SE: loss of normal Common in people older than 60 year gastric flora which may lead to old in infection clostridium difficile) , Clinical Manifestations H2 blockers (it can contribute in ○ Dysphagia managing GERD by decreasing ○ Fullness in the neck (presence gastric acid of food or liquid in the pouch or production—cimetidine) , PP diverticula) (decreasing gastric ○ Pouch becomes full with food or production—zole I, prokinetic liquid agents (metoclopramide or ○ Belching, regurgitation of flacil—accelerate gastric undigested food (particularly of emptying which promotes the patient in recumbent or lying passage of gastric contents into position) the intestine) ○ Coughing (cause by irritation or Open Laparoscopic Nissen aspiration) Fundoplication: ○ Gurgling noises after eating ○ (involves gastric portion of the (occur when air passes the fundus around the sphincter diverticulum) area of the esophagus ○ Halitosis (foul odor of the mouth ○ Fundus of the stomach is which is caused by decomposed wrapped around the sphincter food that are retained in the so that it will tighten the junction diverticulum) between the esophagus and ○ Sour taste in the mouth stomach to prevent the reflux (retained food in the diverticulum which is also Esophageal Diverticulum decomposed) An out-pouching of mucosa and Diagnosis submucosa that protrudes through a ○ Barium swallow (it can weak portion of the muscles of the determine the exact measure esophagus and location if diverticulum and ○ May occur in one of three areas esophagus) of the esophagus ○ Esophagoscopy is Page 11  OUR LADY OF FATIMA UNIVERSITY - COLLEGE OF NURSING NCMB 316: Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception & Coordination Transcribed By: Tirados, Lagrimas, & Victorino Section: BSN 3 - Y2 - 6 Contraindicated (because there and part of the stomach herniates is a possibility of perforation of (moves up in 5he upper portion of the the diverticulum and when it thorax) into the lower portion of the perforate it can lead to thorax mediastinitis wherein in ○ Occurs more often in women mediastinitis, there is an than in men because during inflammation of tissues and pregnancy the uterus pushes the organs in the stomach upward mediastinum—organ that 2 Types: separates the lungs ○ Sliding — Endoscopy Type I Hiatal H ○ Endoscopic septotomy Upper portion of the (dissection of the pouch) stomach and the ○ Peroral endoscopic myotomy gastroesophageal (POEM) (involves dissecting junction are displaced only of cricopharyngeal muscle upward wherein the leaving the pouch sack hernia slides in and out unchanged) of the thorax Open Surgery: Diverticulectomy (done to 90-95% of patients with remove the pouch itself) HH has this type thus Intra Op: makes it the most ○ Avoid trauma to the carotid common type artery and internal Jugular veins ○ Paraesophageal — (surgical sight in diverticulotomy Classified into II, III, IV is just adjacent to these major All or part of the arteries) stomach pushes ○ NGT may be inserted w/ through the diaphragm imaging Type IV has the greatest (prevent post op ileus, herniation use with imaging Other technique) abdominal Blunt insertion of NGT is structures avoided to prevent moves up perforation through the Post Op: diaphragm ○ Observe for the incision for (colon, bowel evidence of leakage and along with development and fistula stomach ○ Request for post op xray to Clinical Manifestations: determine any leakage from the ○ Pyrosis(heartburn) surgical site ○ Regurgitation and dysphagia ○ Food and fluids are withheld Intermittent epigastric pain until evidence of no leakage ○ Take note that Most patient are (NPO until xray shows no asymptomatic and have a vague leakage at the surgical site) symptom of intermittent ○ Diet begins with liquid then DAT epigastric pain ○ Fullness after eating Hiatal Hernia ○ Intolerance to food N&V The opening in the diaphragm which Complication may occur if not properly esophagus passes becomes enlarged managed such as: Hemorrhage, Page 12  OUR LADY OF FATIMA UNIVERSITY - COLLEGE OF NURSING NCMB 316: Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception & Coordination Transcribed By: Tirados, Lagrimas, & Victorino Section: BSN 3 - Y2 - 6 Obstruction, Volvulus (obstruction of response to swallowing bowel caused by twisting of intestine Rare condition, progresses slowly which and supporting mesentery which may occurs in people between 20 to 40 and lead to » strangulation) 60 to 70 yo Diagnosis Clinical Manifestations: ○ X Ray studies is the ○ Dysphagia is the main symptom confirmatory ○ Difficulty in swallowing solid ○ Barium swallow food is the hallmark of ○ Esophagogastroduodenoscopy symptoms ○ Esophageal manometry ○ Sensation of food sticking In the measures the pressure and lower portion of the esophagus constriction of the esophagus ○ Intentional regurgitation, they do during swallowing this to relieve the discomfort ○ CT scan produced by prolonged Management: distention of the esophagus ○ Frequent, small feeding so food ○ Noncardiac epigastric pain (this can pass easily through the may mimic myocardial infarction) esophagus ○ Pyrosis - Mirrors GERD ○ Recline for 1 hour after eating to Diagnosis: prevent reflux ○ X Ray studies ○ Elevate head of bed 4 to 8 Bird's beak deformity inches or 10 to 20 cm which suggest ○ Toupet (involves creating a esophageal dilation the barrier between the esophagus location is above the and stomach) or Nissen narrowing at the lower (wrapping the portion of the gastroesophageal gastric fundus around the sphincter sphincter of the esophagus) ○ Barium swallow Fundoplication (laparoscopic ○ CT scan of the chest procedure and considered as ○ Endoscopy the current guideline and that ○ High-resolution manometry are indicated for patients with (Confirmatory diagnosis) complications) determines peristalsis ○ Post Op: contraction amplitude, and Progressive liquid to esophageal pressure. solid diet Management: Manage N&V, nutritional ○ Eat slowly and drink fluids w/ intake, weight meals monitoring ○ Botulinum toxin injection via WOF belching, endoscopy. this inhibits the abdominal distention, contraction of the smooth epigastric pain because muscle that is used to px who this manifestation may cannot receive other definitive indicate a need for treatment surgical revision ○ Pneumatic dilation is used to stretch the narrowed area of the Achalasia esophagus (air filled cylinder Absent or ineffective peristalsis of the shaped balloon is placed in the distal esophagus accompanied by narrowed area of the esophagus failure of the sphincter to relax in to provide the dilation) Page 13  OUR LADY OF FATIMA UNIVERSITY - COLLEGE OF NURSING NCMB 316: Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception & Coordination Transcribed By: Tirados, Lagrimas, & Victorino Section: BSN 3 - Y2 - 6 Nursing consideration: lymphoid tissue lymphoma. moderate sedation is ○ Other possible causes — administered since Long-term drug therapy painful tong procedure (aspirin & NSAIDS which na toh may lead to chemical ○ Esophagomyotomy (Heller gastric injury or Myotomy) is performed gastropathy) , reflux of laparoscopically duodenal contents into Cutting the esophageal the stomach (often muscle fibers occurs after surgery e.g. ○ POEM involves mucosal and Billroth 1 & II) , submucosal resection of the autoimmune disorders esophagus (Hashimoto thyroiditis – wherein out body Disturbances in Digestion doesn’t produce thyroid Gastritis hormones, Adison’s Inflammation of the gastric mucosa disease, Greg’s disease Acute Gastritis: – hyperactive thyroid ○ Erosive — gland) Caused by local irritants (aspirin or other NSAIDS, corticosteroids, alcohol consumption, gastric radiation therapy) How Does Gastritis Develop? ○ Nonerosive — Caused by infection (H. pylori) ○ Most severe form is ingestion of strong acid or alkali may cause damage to the mucosa (gangrenous or perforate) ○ May result in scarring ○ May develop in px who had major traumatic injuries, burns, severe infection, lack of perfusion to the stomach lining, surgery ○ Often referred as stress- related gastritis Characterized by a disruption of the Chronic Gastritis: mucosa barrier which normally protects ○ Classified according to the stomach lining or tissues from any causative mechanism (H. pylori) digestive juices such as hydrochloric ○ Involves exposing the stomach acid and pepsin of the px to H. pylori infection The disruption is the result of exposure ○ CG is being implicated in the to several causative mechanism like development of peptic ulcers local irritants such as ingesting strong diseases – chronic gastritis can acid and alkaline, if the px was exposed lead to peptic ulcers, stomach to infection, long term drug tx, reflux, cancer, gastric adenocarcinoma, autoimmune disease and once the gastric mucosa associated Page 14  OUR LADY OF FATIMA UNIVERSITY - COLLEGE OF NURSING NCMB 316: Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception & Coordination Transcribed By: Tirados, Lagrimas, & Victorino Section: BSN 3 - Y2 - 6 mucosal barrier has been impaired it will Medical Management of Acute Gastritis: allow the hydrochloric acid and pepsin to ○ Refrain from alcohol and food come into contact with the gastric ○ Non Irritating diet: bland diet mucosa which results in inflammation ○ IV fluids if necessary that is usually transient or self-limiting ○ Supportive Therapy — NGT This inflammation can cause the gastric insertion, antacids, H2 blockers, mucosa to become edematous and PPI hyperemic meaning congested with ○ Emergency — fluids and blood and this will undergo Gastrojejunostomy superficial erosion which occurs as a (Billroth II): done result of erosive disease which may lead particularly in gastric to hemorrhage, chronic inflammatory outlet obstructions changes or atrophy Medical Management of Chronic Clinical Manifestations of Acute Gastritis: Gastritis ○ Modify diet ○ Epigastric pain ○ Promote rest ○ Dyspepsia – particularly the ○ Reduce stress upper abdominal discomfort ○ Avoid alcohol and NSAIDS associated with eating ○ Treat H. pylori if appropriate: ○ Anorexia, N&V PPI, antibiotics and bismuth ○ Hiccups salts ○ Blood in vomitus Nursing Management of Gastritis ○ Melena – black tarry stools ○ Manage N&V, pyrosis ○ Hematochezia – blood in the ○ Maintain on NPO while w/ stools symptoms to allow gastric Clinical Manifestations of Chronic mucosa to heal Gastritis ○ Ice chips followed by clear ○ Fatigue liquids if symptoms subsides ○ Pyrosis after eating – heartburn ○ Introduce solid foods ASAP after eating ○ Discourage intake of caffeine ○ Belching (increases gastric activity and ○ Sour taste in mouth pepsin secretion) and alcohol ○ Halitosis ○ Discourage smoking (nicotine ○ Early satiety increases secretion of gastric ○ Anorexia, N&V acids and interfere mucosal ○ Problems Vit. B12 absorption – barrier of GIT) which leads to pernicious ○ Monitor daily 1&0 anemia ○ Assess electrolytes every 24 hrs Diagnosis: ○ WOF signs of hemorrhagic ○ Endoscopy & Biopsy — definitive gastritis diagnostic ○ Observe stools for presence of ○ CBC — used to assess anemia frank bleeding or occult bleeding as a result of hemorrhage or thru stool exam pernicious anemia ○ Avoid foods and fluids that may ○ To determine presence of H. irritate gastric mucosa pylori — Biopsy Peptic Ulcer Disease Serologic testing Excavation of mucosa in an area of the Stool antigen testing GIT(hollowed-out area) Urea breath test Ulceration depends on the location Page 15  OUR LADY OF FATIMA UNIVERSITY - COLLEGE OF NURSING NCMB 316: Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception & Coordination Transcribed By: Tirados, Lagrimas, & Victorino Section: BSN 3 - Y2 - 6 ○ Gastric (pylorus) ○ Duodenal – first part of the intestine ○ Esophageal Ulceration is caused by ulceration of erosion of the circumscribed (limited) area or the GIT mucosa due to the increased concentration or activity of acid pepsin or due to the decreased resistance of the protective mucosal barrier Take note that PUD commonly occurs in Predisposing Factors: the gastro duodenal mucosa bc the ○ Onset between 30 to 60 years tissues around that area can’t withstand old the digestive actions of the gastric acid ○ H. pylori infections — can be or pepsin acquired thru food & water or The cause of erosion in the mucosal is close contact with emesis who bc of the increased concentration or has H. pylori infection activity of gastric acid and pepsin, use of ○ Use of NSAIDS – major risk NSAIDS, presence of H. pylori infections factor of PUD & can lead to and if you are 30-60 yo impairment of the protective A damaged mucosa cannot secrete function of the gastric mucosa enough mucus that acts as a barrier and failure of the GIT to repair against digestive juices and the which lead to ulceration exposure of the mucosa to hydrochloric ○ Smoking and alcohol – acid and pepsin and other irritating inconclusive agents will lead to inflammation and ○ Familial tendency – wherein injury and subsequent erosion of blood type O is more at risk than mucosa other blood types How does the use of NSAIDs contribute Type O: enhanced to the damage of the normally protective binding of H.pylori to the barrier? epithelial cells ○ NSAIDs inhibit the synthesis of ○ COPD, liver cirrhosis, CKD, prostaglandins – associated autoimmune disorders with the disruption of the normal ○ Zollinger-Ellison syndrome protective mucosal barrier and (ZES): rare condition of benign may result to decrease and malignant tumors that resistance to bacteria therefore forms in the pancreas and H.pylori may occur duodenum which secretes the Clinical Manifestations: hormone gastrin — excessive ○ Take Note — many px of PUD secretion may lead to does not have s/sx and they hyperacidity and severe PUD called it silent PUD that is Multiple endocrine common in older adults and neoplasia, type 1 (MEN- those who are taking aspirin & 1) NSAIDs ○ Epigastric pain or back pain Dull, gnawing (somatic pain that occurs in the bones) , burning ○ Pain after eating – Classic Page 16  OUR LADY OF FATIMA UNIVERSITY - COLLEGE OF NURSING NCMB 316: Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception & Coordination Transcribed By: Tirados, Lagrimas, & Victorino Section: BSN 3 - Y2 - 6 Symptom Take note: H2 blockers Gastric Ulcer and PPI are used to ○ Pain 2 to 3 hrs after eating and treat ulcers that is not during night — occurs 50 to 80% associated with H.pylori Duodenal Ulcer Advise client to adhere ○ Pyrosis – either gastric or to drug regimen and duodenal avoid NSAIDs ○ Vomiting Maintenance of H2 ○ Constipation or diarrhea blockers dosages ○ Hematemesis or melena – Octreotide – for px with result of perforations ZES ; this is usually ○ Sour Eructation or Burp – prescribed to suppress common when px stomach is gastrin levels empty Endoscopy: prescribe ○ Hypotension and tachycardia to evaluate Assessment: effectiveness of ○ UGI endoscopy medication therapy ○ Serologic testing 85 - 90% results in ○ Stool Ag test healing following the ○ Urea breath test drug regimen and PPI ○ Periodic CBCS – to determine if Stop smoking! – can decrease secretion patient needs BT of bicarbonate from the pancreas into ○ Stool tests the duodenum which results to increase ○ Gastric Secretory Studies acidity of duodenum ZES ○ Bicarbonate is alkaline that Achlorhydria – lack of neutralizes acid hydrochloride ○ Smoking delays healing of PUD Hypochlorhydria – low Dietary Modifications: levels of hydrochloride ○ Avoid extremes of temperature Hyperchlorhydria – high in foods and beverages levels of hydrochloride ○ Avoid alcohol, coffee, Medical Management: goal is to caffeinated beverages eradicate H. Pylori and manage gastric ○ Eat 3 regular meals a day – to acidity neutralize acid Pharmacologic Treatment: Surgical Management: Recommended ○ Triple Therapy — 2 antibiotics for intractable ulcers or those that fail to and PPI heal after 12 to 16 weeks of medical Metronidazole or treatment, presence of hemorrhage and amoxicillin and perforations that is life threatening and clarithromycin to ZES that is unresponsive to Lansoprazole or medication omeprazole or ○ Vagotomy w/ or w/o rabeprazole pyloroplasty — transecting the ○ Quadruple Therapy nerves that stimulates acid 2 antibiotics secretion and opening of pylorus (metronidazole and ○ Vagotomy — severing of the tetracycline), a PPI and vagus nerve to decrease acid bismuth salts secretion by decreasing Commonly prescribe for cholinergic stimulation to the 10-14 days parietal cells leading to less Page 17  OUR LADY OF FATIMA UNIVERSITY - COLLEGE OF NURSING NCMB 316: Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception & Coordination Transcribed By: Tirados, Lagrimas, & Victorino Section: BSN 3 - Y2 - 6 gastrin response complications Adverse Effect: feeling ○ Hemorrhage and gastritis of fullness, dumping ○ Faintness, Nausea & Dizziness syndrome (group of — may accompany bleeding symptoms such as ○ Perforation & Penetration — diarrhea, nausea, & light involves the erosion of ulcers headedness), diarrhea & thru the gastric serosa into the gastritis peritoneal cavity until it reaches ○ Pyloroplasty — involves pylorus adjacent structures like to assist gastric emptying; pancreas, biliary tract or incision of longitudinal and omentum. suturing vertically to enlarge the Penetration: s/sx may outlet include back pain or ○ Antrectomy w/ Billroth I or epigastric pain that may Billroth II not be relive by ○ Antrectomy — removal medications of the pyloric portion or Perforation: s/sx may the antrum – 50% of the include sudden severe stomach is removed abdominal pain and Both can be done via open or presence of referred laparoscopic procedure pain especially the right shoulder bc of the Nursing Management | Assessment irritation of the phrenic Describe pain and its pattern (whether it nerve in the diaphragm occurs at day or night) ○ Complication: vomiting and Determine how often vomiting is prolapse Note for melena ○ Manifestation: may include Determine usual food Intake (72 hour), extreme tenderness and rigid smoking, ENDS, alcohol intake, use of abdomen upon palpation and NSAIDs, family hx hypertension & tachycardia may indicate shock Nursing Management | Diagnosis ○ Take Note: may require surgical Acute pain associated w/ the effect of interventions based on the gastric juice on damage tissue evidence shown by px. Anxiety associated w/ an acute illness ○ Peritonitis — expect px to undergo exploratory laparotomy Nursing Management | Planning & Goals Relief of pain Nursing Management | Evaluation Reduced anxiety Reports freedom from pain Maintenance of nutritional requirements Maintains weight Absence of complications No evidence of complications Demonstrates knowledge of self-care Nursing Management | Nursing Interventions activities (avoiding irritating foods & Avoid NSAIDs, eat meals at regular beverages, alcohol & NSAIDs and take Intervals(to relieve pain) medications as prescribed by PCP) Explain meds and lab tests (to reduce anxiety) Adhere to medication regimen and dietary restrictions Monitor and manage potential Page 18