RN ADULT MEDICAL SURGICAL NURSING ( PDFDrive.com )_551-561.pdf

chapter 48 Unit 7 Nursing care of clients with Gastrointestinal disorders Section: Upper Gastrointestinal Disorders Chapter 48 Esophageal Disorders Overview The esophagus is a tube that consists of smooth muscle and leads from the throat to the st...

chapter 48 Unit 7 Nursing care of clients with Gastrointestinal disorders Section: Upper Gastrointestinal Disorders Chapter 48 Esophageal Disorders Overview The esophagus is a tube that consists of smooth muscle and leads from the throat to the stomach. Esophageal disorders can affect any part of the esophagus. There are two sphincters (upper esophageal [UES], lower esophageal [LES]) that prevent the reflux of food and fluids into the mouth or esophagus. View Image: Esophageal Sphincters Contractions of the esophagus propel food and fluids toward the stomach, while relaxation of the lower esophageal sphincter allows them to pass into the stomach. Esophageal disorders that nurses should be knowledgeable about include: ◯◯ Gastroesophageal reflux disease (GERD) ◯◯ Esophageal varices GERD Overview Gastroesophageal reflux disease (GERD) is a common condition characterized by gastric content and enzyme backflow into the esophagus. These corrosive fluids irritate the esophageal tissue, causing delay in their clearance. This further exposes esophageal tissue to the acidic fluids, causing more irritation. The primary treatment of GERD is diet and lifestyle changes, advancing to medication use (antacids, H2-receptor antagonists, proton pump inhibitors) and surgery. Untreated GERD leads to inflammation, breakdown, and long-term complications, including adenocarcinoma of the esophagus. Health Promotion and Disease Prevention Maintain a weight below BMI of 30. Stop smoking. Limit or avoid alcohol and tobacco use. 538 RN Adult Medical Surgical Nursing  CHAPTER 48 Esophageal Disorders Assessment Risk Factors ◯◯ Obesity ◯◯ Older age (delayed gastric emptying and weakened LES tone) ◯◯ Sleep apnea ◯◯ Nasogastric tube ◯◯ Contributing factors Excessive ingestion of foods that relax the LES include fatty and fried foods, chocolate, caffeinated beverages (coffee), peppermint, spicy foods, tomatoes, citrus fruits, and alcohol Prolonged or frequent abdominal distention (from overeating or delayed emptying) Increased abdominal pressure from obesity, pregnancy, bending at the waist, ascites, or tight clothing at the waist Medications that relax the LES (theophylline, nitrates, calcium channel blockers, anticholinergics, and diazepam [Valium]) Increased gastric acid caused by medications (NSAIDs) or stress (environmental) Debilitation resulting in weakened LES tone Hiatal hernia (LES displacement into the thorax with delayed esophageal clearance) Lying flat Subjective Data ◯◯ Classic report of: dyspepsia after eating an offending food or fluid, and regurgitation. ◯◯ Pain is “wavelike” and may radiate (neck, jaw, or back). The client reports feeling of having a heart attack. ◯◯ Pain worsens with position (bending, straining, laying down). ◯◯ Pain occurs after eating and may last 20 min to 2 hr. ◯◯ Throat irritation (chronic cough, laryngitis), hypersalivation, bitter taste in mouth (caused by regurgitation). Chronic GERD can lead to dysphagia. ◯◯ Atypical chest pain (from esophageal spasm). ◯◯ Increased flatus and eructation (burping). ◯◯ Pain is relieved (almost immediately) by drinking water, sitting upright, or taking antacids. ◯◯ Manifestations occurring four to five times per week on a consistent basis are considered diagnostic. Objective Data ◯◯ Physical Assessment Findings Tooth erosion Hoarseness ◯◯ Diagnostic Procedures Esophagogastroduodenoscopy (EGD) is done under moderate sedation to observe for tissue damage (present in 60% of clients who have GERD) and possibly to dilate structures. ☐☐ EGD allows visualization of the esophagus, revealing esophagitis or Barrett’s epithelium (premalignant cells). ☐☐ Nursing Actions: Verify gag response has returned prior to providing oral fluids or food following the procedure. RN Adult Medical Surgical Nursing 539 CHAPTER 48 Esophageal Disorders 24-hr ambulatory esophageal pH monitoring – A small catheter is placed through the nose and into the distal esophagus, where pH readings are taken in relation to food, position, and activity. ☐☐ Most accurate method of diagnosing GERD. ☐☐ Especially helpful in diagnosis for clients who have atypical manifestations. ☐☐ Nursing Actions: Instruct client to keep a journal of foods and beverages consumed as well as activity during the 24-hr test period. Esophageal manometry records lower esophageal sphincter pressure. ☐☐ Nursing Actions: Instruct the client to keep a diary of manifestations related to food, position, and activity throughout the day. Barium swallow to identify a hiatal hernia, which would contribute to or cause GERD. Patient-Centered Care Medications ◯◯ Antacids Antacids (aluminum hydroxide [Mylanta]) neutralize excess acid. Nursing Considerations – Ensure there are no contraindications with other prescribed medications (levothyroxine). Client Education – Instruct the client to take antacids when acid secretion is the highest (1 to 3 hr after eating and at bedtime), and to separate from other medications by at least 1 hr. ◯◯ Histamine2 Receptor Antagonists Histamine2 receptor antagonists (ranitidine [Zantac], famotidine [Pepcid], nizatidine [Axid]) reduce the secretion of acid. The onset is longer than antacids, but the effect has a longer duration. ☐☐ Cimetidine (Tagamet) is no longer first-line as it has a higher risk profile in older adult clients and interacts with more than 60 other medications. Nursing Considerations – Use cautiously in clients who have kidney disease. Client Education ☐☐ Take with meals and at bedtime. ☐☐ Do not mix nizatidine (Axid) with vegetable-based juices. ◯◯ Proton Pump Inhibitors (PPIs) PPIs (pantoprazole [Protonix], omeprazole [Prilosec], esomeprazole [Nexium], and lansoprazole [Prevacid]) reduce gastric acid by inhibiting the cellular pump necessary for gastric acid secretion. Nursing Considerations – Sustained release capsules may be opened and sprinkled on food or mixed with applesauce (clients who have swallowing difficulty) or mixed with juice (for clients who have an NG tube). Client Education – Clients who are prescribed rabeprazole (Aciphex) should wear sunscreen daily. ◯◯ Prokinetics Prokinetic medications (metoclopramide hydrochloride [Reglan]) increase the motility of the esophagus and stomach. Nursing Considerations – Monitor the client for extrapyramidal side effects. Client Education – Instruct the client to report abnormal, involuntary movement. 540 RN Adult Medical Surgical Nursing  CHAPTER 48 Esophageal Disorders Therapeutic Procedures – Stretta procedure uses radiofrequency energy, applied by an endoscope, to decrease vagus nerve activity. This causes the LES muscle tissue to contract and tighten. Surgical Interventions ◯◯ Fundoplication may be indicated for clients who fail to respond to other treatments. The fundus of the stomach is wrapped around and behind the esophagus through a laparoscope to create a physical barrier. ◯◯ Client Education Diet ☐☐ Avoid offending foods. ☐☐ Avoid large meals. ☐☐ Remain upright after eating. ☐☐ Avoid eating before bedtime. Lifestyle ☐☐ Avoid clothing that is tight-fitting around the abdomen. ☐☐ Lose weight, if applicable. ☐☐ Elevate the head of the bed 15.2 to 20.3 cm (6 to 8 in) with blocks. The use of pillows is not recommended because this rounds the back, bringing the stomach contents up and closer to the chest. ☐☐ Sleep on the right side. Complications Aspiration of gastric secretion ◯◯ Causes Reflux of gastric fluids into the esophagus can be aspirated into the trachea. Risks associated with aspiration include: ☐☐ Asthma exacerbations from inhaled aerosolized acid. ☐☐ Frequent upper respiratory, sinus, or ear infections. ☐☐ Aspiration pneumonia. Barrett’s epithelium (premalignant) and esophageal adenocarcinoma. ◯◯ Cause – Reflux of gastric fluids leads to esophagitis. In chronic esophagitis, the body continuously heals inflamed tissue, eventually replacing normal esophageal epithelium with premalignant tissue (Barrett’s epithelium) or malignant adenocarcinoma. ◯◯ Nursing Actions – Determine the cause of GERD with the client and review lifestyle changes that can decrease gastric reflux. RN Adult Medical Surgical Nursing 541 CHAPTER 48 Esophageal Disorders Esophageal Varices Overview Esophageal varices are swollen, fragile blood vessels in the esophagus. View Image: Varices When esophageal varices hemorrhage, it is often a medical emergency associated with a high mortality rate. Reoccurrence of esophageal bleeding is common. Health Promotion and Disease Prevention Avoid alcohol consumption. Assessment Risk Factors ◯◯ Portal hypertension (elevated blood pressure in veins that carry blood from the intestines to the liver) is caused by impaired circulation of blood through the liver. Collateral circulation subsequently develops, creating varices in the upper stomach and esophagus. Varices are fragile and can bleed easily. Portal hypertension is the primary risk factor for the development of esophageal varices. ◯◯ Alcoholic cirrhosis. ◯◯ Viral hepatitis. ◯◯ Older adult clients frequently have depressed immune function, decreased liver function, and cardiac disorders that make them especially vulnerable to bleeding. Subjective Data ◯◯ The client may experience no manifestations until the varices begin to bleed. Hematemesis and melena ◯◯ Activities that precipitate bleeding are the Valsalva maneuver, lifting heavy objects, coughing, sneezing, and alcohol consumption. Objective Data ◯◯ Physical Assessment Findings (Bleeding Esophageal Varices) Hypotension Tachycardia ◯◯ Laboratory Tests Liver function tests indicate a liver disorder. Hemoglobin and hematocrit tests can indicate anemia secondary to occult bleeding or overt bleeding. ◯◯ Diagnostic Procedures Endoscopy – Therapeutic interventions can be performed during the endoscopy. ☐☐ Nursing Actions: Administer preprocedure sedation. After the procedure, monitor vital signs and take measures to prevent aspiration. 542 RN Adult Medical Surgical Nursing  CHAPTER 48 Esophageal Disorders Patient-Centered Care Nursing Care ◯◯ If bleeding is suspected, establish IV access with a large bore needle, monitor vital signs and hematocrit, type and crossmatch for possible blood transfusions, and monitor for overt and occult bleeding. Medications ◯◯ Nonselective Beta-Blockers Nonselective beta-blockers (propranolol [Inderal]) are prescribed to decrease heart rate and consequently reduce hepatic venous pressure. Used prophylactically (not for emergency hemorrhage). ◯◯ Vasoconstrictors IV terlipressin (synthetic vasopressin) and natural somatostatin have been proven most effective to increase portal inflow. Vasopressin (Desmopressin) and octreotide (Sandostatin) are avoided due to multiple adverse effects. Nursing Considerations – Vasopressin cannot be given to clients who have coronary artery disease due to resultant coronary constriction. Potent vasoconstriction may also cause problems with peripheral and cerebral circulation. Teamwork and Collaboration – alcohol recovery program (varices secondary to alcohol use disorder) Therapeutic Procedures ◯◯ Endoscopic injection sclerotherapy or variceal band ligation Ligating bands can be placed, and/or injection sclerotherapy can be performed during an endoscopic procedure. Used only for active bleeding and not prophylactically. Nursing Actions: Administer preprocedure sedation. After the procedure, monitor vital signs and take measures to prevent aspiration. Sclerotherapy carries a greater risk of postoperative hemorrhage. Antacids and/or H2 receptor blockers are administered postoperatively. ◯◯ Transjugular Intrahepatic Portal-Systemic Shunt (TIPS) 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 between the portal and hepatic veins bypassing the liver. Portal hypertension is subsequently relieved. Nursing Actions – Monitor vital signs. Keep the head of the bed elevated. ◯◯ Esophagogastric balloon tamponade An esophagogastric tube with esophageal and gastric balloons is used to compress blood vessels in the esophagus and stomach. Traction is applied after balloons are inflated to desired pressure. When the bleeding is stopped, the traction is released and the pressure in the balloons is reduced gradually. Reserved for clients who have unsuccessful TIPS procedures. Clients are typically intubated and placed on mechanical ventilation prior to the procedure to prevent aspiration. Nursing Actions ☐☐ Check balloons for leaks prior to insertion. ☐☐ Monitor placement of the tube and observe for possible obstruction of airway. ☐☐ Monitor for aspiration into the lungs and secretions or blood from the esophagus. RN Adult Medical Surgical Nursing 543 CHAPTER 48 Esophageal Disorders ☐☐ Provide oral suction as needed. ☐☐ Maintain balloon pressure at prescribed pressure for prescribed time to decrease risk of esophageal or gastric necrosis from ischemia. ☐☐ Irrigate the tube as prescribed and document color of return (clear vs. bloody). ☐☐ Monitor the client who has decreased mentation or confusion and who may pull on the tube. Surgical Interventions – considered as a last resort ◯◯ Bypass procedures establish a venous shunt that bypasses the liver, decreasing portal hypertension. Common shunts include splenorenal (splenic, left renal veins), mesocaval (mesenteric vein, vena cava), and portacaval (portal vein, inferior vena cava). Clients commonly have a nasogastric tube inserted during surgery to monitor for hemorrhage. Nursing Actions (pre, post) ☐☐ Monitor for an increase in liver dysfunction or encephalopathy. ☐☐ Monitor nasogastric tube secretions for bleeding. ☐☐ Monitor PT, aPTT, platelets, and INR. Complications Hypovolemic Shock – due to hemorrhage from varices ◯◯ Nursing Actions Observe for manifestations of hemorrhage and shock (tachycardia, hypotension). Monitor vital signs, Hgb, Hct, and coagulation studies. Replace losses and support therapeutic procedures to stop and control bleeding. 544 RN Adult Medical Surgical Nursing  CHAPTER 48 Esophageal Disorders Application Exercises 1. A nurse is caring for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The nurse should anticipate prescriptions by the provider for which of the following medications? (Select all that apply.) A. Antacids B. Histamine2 receptor antagonists C. Opioid analgesics D. Fiber laxatives E. Proton pump inhibitors 2. A nurse is admitting a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Propranolol (Inderal) B. Metoclopramide (Reglan) C. Ranitidine (Zantac) D. Terlipressin (synthetic vasopressin) 3. A nurse is completing an assessment of a client who has GERD. Which of the following is an expected finding? A. Absence of saliva B. Loss of tooth enamel C. Client reports sweet taste in mouth D. Client reports absence of eructation 4. A nurse is teaching a client who has GERD. Which of the following should the client be instructed to limit in his diet? (Select all that apply.) A. Coffee B. Tomatoes C. Bananas D. Chocolate E. Pasta RN Adult Medical Surgical Nursing 545 CHAPTER 48 Esophageal Disorders 5. A nurse is completing discharge teaching to a client who is postoperative following fundoplication. Which of the following statements by the client indicates understanding of the teaching? A. “When sitting in my lounge chair after a meal, I will lower the back of it.” B. “I will try to eat three large meals a day.” C. “I will elevate the head of my bed on blocks.” D. “When sleeping, I will lay on my left side.” 6. A nurse is preparing a poster on GERD to be displayed at a community health fair. What should be included in the poster? Use the ATI Active Learning Template: Systems Disorder to complete this item to include the following sections: A. Description of Disorder/Disease Process B. Risk Factors: Describe at least eight. C. Subjective Data: Describe at least eight. 546 RN Adult Medical Surgical Nursing  CHAPTER 48 Esophageal Disorders Application Exercises Key 1. A. CORRECT: Antacids neutralize gastric acid which irritates the esophagus during reflux. B. CORRECT: Histamine2 receptor antagonists decrease acid secretion, which contributes to reflux. C. INCORRECT: Opioid analgesics are not effective in treating GERD. D. INCORRECT: Fiber laxatives are not effective in treating GERD. E. CORRECT: Proton pump inhibitors decrease gastric acid production, which contributes to reflex. NCLEX® Connection: Physiological Adaptations, Alterations in Body Systems 2. A. INCORRECT: Propranolol is not used for clients who are actively bleeding. It may be given prophylactically to decrease portal hypertension. B. INCORRECT: Metoclopramide decreases motility of the esophagus and stomach. C. INCORRECT: Histamine2-receptor antagonists are administered following surgical procedures for bleeding esophageal varices. D. CORRECT: Terlipressin constricts blood vessels and is used to treat bleeding esophageal varices. NCLEX® Connection: Physiological Adaptations, Alterations in Body Systems 3. A. INCORRECT: Hypersalivation is an expected finding in a client who has GERD. B. CORRECT: Tooth erosion is an expected finding in a client who has GERD. B. INCORRECT: A client who has GERD would report a bitter taste in the mouth. D. INCORRECT: Increased burping is an expected finding in a client who has GERD. NCLEX® Connection: Physiological Adaptations, Pathophysiology 4. A. CORRECT: Coffee relaxes the lower esophageal sphincter and should be avoided by a client who has GERD. B. CORRECT: Tomatoes relax the lower esophageal sphincter and should be avoided by a client who has GERD. C. INCORRECT: Bananas do not affect the client who has GERD and do not need to be limited. D. CORRECT: Chocolate relaxes the lower esophageal sphincter and should be avoided by a client who has GERD. E. INCORRECT: Pasta does not affect the client who has GERD and does not need to be limited. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration RN Adult Medical Surgical Nursing 547 CHAPTER 48 Esophageal Disorders 5. A. INCORRECT: The client is instructed to remain upright after eating following a fundoplication. B. INCORRECT: The client is instructed to avoid large meals after a fundoplication. C. CORRECT: After a fundoplication, the client is instructed to elevate the head of the bed to limit reflux. D. INCORRECT: After a fundoplication, the client is instructed to sleep on the right side. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures 6. Using the ATI Active Learning Template: Systems Disorder A. Description of Disorder/Disease Process Gastroesophageal reflux disease (GERD) is a common condition characterized by gastric content and enzyme backflow into the esophagus. These fluids are corrosive to esophageal tissue, causing a delay in their clearance. This further exposes esophageal tissue to the acidic fluids, increasing tissue irritation. B. Risk Factors Obesity Older age Sleep apnea Excessive ingestion of foods that relax the lower esophageal sphincter (fatty and fried foods, chocolate, caffeinated beverages, peppermint, spicy foods, tomatoes, citrus fruits, and alcohol) Pregnancy Bending at the waist, wearing tight clothing at the waist Medications (theophylline, nitrates, calcium channel blockers, anticholinergics, NSAIDs) Stress Hiatal hernia Lying flat C. Subjective Data Dyspepsia after eating and regurgitation (classic) Throat irritation (chronic cough, laryngitis) Hypersalivation Bitter taste in mouth Chest pain due to esophageal spasm Increased flatus and eructation (burping) Pain relieved by drinking water, sitting upright or taking antacids NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention 548 RN Adult Medical Surgical Nursing