Student Unit 1 Lecture 1 Gastric PDF

NUR 144 Adult Health/Mental Health Rose Frowd, RN, MSPH, CASAC Christina Haggarty, RN, MSN, CASAC Cynthia Lasman, RNC-OB, MSN, CNE, C-EFM FAQ: Fall 2024  Clinical groups will have some meetings on campus, in the hospital, independent rotation, and/or online learning.  Things can change and we w...

NUR 144 Adult Health/Mental Health Rose Frowd, RN, MSPH, CASAC Christina Haggarty, RN, MSN, CASAC Cynthia Lasman, RNC-OB, MSN, CNE, C-EFM FAQ: Fall 2024  Clinical groups will have some meetings on campus, in the hospital, independent rotation, and/or online learning.  Things can change and we will adjust.  PLEASE reach out to your clinical instructor or to me with your questions and concerns!!  Exams will use ExamSoft on campus.  Alternate clinicals will use Vsims (you must purchase this) Test Dates Unit 1 (Gastrointestinal) – 10/10/24 @ 3:00 pm Unit 2 (Psychiatric) – 12/5/24 @ 3:00 pm Comprehensive – 12/19/24 @ 3:00 pm Refer to Nursing Program Policies on Brightspace Orientati on You may record (audio only – no video) Please do not share my lectures outside of your class Office Hours Schedule through the link in Brightspace Choose online or in my office Tuesday-online Thursday- office 8:30am-9:30am and 12pm-2pm Orientati on D2L Brightspace Syllabus Medications Detailed Course Outline (not guarenteed to be all-inclusive) Pre- and Co-requisite classes Accessibility Volunteer Note-taker Academic Conflicts Religious Pronouns Orientati on topics for some Difficult Be respectful! Reach out to your family, friends, classmates, and me! Inez Rivera [email protected] Unit one Gastrointesti nal System Lecture 1 GI assessment Gastric Duodenal Lecture 2 Hepatic Lecture 3 Biliary Alternative nutrition Lecture 4 Colon Lecture 5 Alternative elimination Gastrointestinal Assessment Professor Rose Frowd MS, RN BC-PMH, CASAC [email protected] Adapted from Wolters Kluwer Objectives  Review anatomy and physiology of the GI system  Discuss terms related to the GI system  Describe common assessments of the GI system  Organs of the Digestive System Functions of the Digestive Tract  Breakdown of food for digestion  Absorption into the bloodstream of small nutrient molecules produced by digestion  Elimination of undigested unabsorbed foodstuffs and other waste products Terms  Digestion: begins with the act of chewing, in which food is broken down into small particles that can be swallowed and mixed with digestive enzymes  Absorption: Absorption is the major function of the small intestine. Vitamins and minerals absorbed are essentially unchanged. Absorption begins in the jejunum and is accomplished by active transport and diffusion across the intestinal wall into the circulation  Elimination: phase of the digestive process that occurs after digestion and absorption when waste products are eliminated from the body  Major Enzymes and Secretions  Chewing and swallowing COLOR KEY  Saliva (mechanical breakdown)  Salivary amylase Starch / Sugar Protein  Gastric function  Hydrochloric acid Fat  Pepsin  Intrinsic factor (absorption of vitamin B12)  Small intestine (via the common bile duct)  Amylase  Lipase  Trypsin  Bile Knowledge Check Is the following statement true or false? Lipase is an enzyme that aids in the digestion of protein. ANSWER False Rationale: Lipase is an enzyme that aids in the digestion of fats. Trypsin is an enzyme that aids in the digestion of protein.  Knowledge Check What is ingestion? A. Occurs when food is taken into the GI tract via the mouth and esophagus B. Occurs when enzymes mix with ingested food and when proteins, fats, and sugars are broken down into their component molecules C. Occurs when small molecules, vitamins, and minerals pass through the walls of the small and large intestine and into the bloodstream D. Occurs after digestion and absorption when waste products are eliminated from the body ANSWER A. Occurs when food is taken into the GI tract via the mouth and esophagus Rationale: Ingestion occurs when food is taken into the GI tract via the mouth and esophagus. Digestion occurs when enzymes mix with ingested food and when proteins, fats, and sugars are broken down into their component molecules. Absorption occurs when small molecules, vitamins, and minerals pass through the walls of the small and large intestine and into the bloodstream. Elimination occurs after digestion and absorption when waste products are eliminated from the body.  Assessment of the GI System  Health history:  Information about abdominal Common Sites of pain, dyspepsia, gas, nausea and vomiting, diarrhea, constipation, Referred Abdominal fecal incontinence, jaundice, and Pain previous GI disease is obtained  Pain:  Character, duration, pattern, frequency, location, distribution of referred abdominal pain, and time of the pain vary greatly depending on the underlying cause Assessment of the GI System Dyspepsia (Indigestion)  Upper abdominal discomfort associated with eating  Pain, fullness, bloating, early satiety, belching, heartburn, regurgitation  Most common symptom of patients with GI dysfunction  Increased symptoms with fatty foods, coarse vegetables, highly seasoned foods  Intestinal gas  Bloating, distention, or feeling “full of gas”  Belching and/or excessive flatulence  Often a symptom of food intolerance or gallbladder disease Assessment of the GI System  Nausea  Vague, uncomfortable sensation of sickness or “queasiness” that may or may not be followed by vomiting  Often with distention of the duodenum or upper GI tract  Vomiting (emesis)  Forceful emptying of stomach and intestinal contents through the mouth  Causes  Visceral pain, motion, anxiety, medication, torsion, trauma, metabolic abnormalities, toxins, chemotherapy, radiation, inner ear disorders, anticipatory Assessment of the GI System  Change in bowel habits and stool characteristics  May signal colonic dysfunction or disease  Constipation, diarrhea  Other common abnormal stool characteristics  Bulk, greasy foamy stools – foul smelling (may or may not float)  Light gray or clay colored stool (absence of conjugated bilirubin)  Stool with mucus threads or pus (visible on gross inspection)  Loose, watery stool (may or may not be streaked with blood) Assessment of the GI System  Past health, family and social history  Oral care and dental visits  Lesions in mouth  Discomfort with certain foods  Use of alcohol and tobacco  Dentures  Previous diagnostic studies, treatments, or surgery  Weight gain or loss (unintended)  Medications  Dietary intake Physical Assessment of the GI System  Oral cavity  Lips  Color, hydration, texture, symmetry, ulcerations, fissures  Gums  Inflammation, bleeding, retraction, discoloration, odor  Tongue  Texture, color, lesions, symmetry  A thin white coat and large “V” on the distal tongue are normal findings Physical Assessment of the GI System  Abdominal assessment  Position Dorsal Recumbent  Inspection  Auscultation  Percussion  Palpation  Rectal inspection  Position lithotomy or side-lying  Note abnormalities and hygiene Knowledge Check Which is the correct order to complete an abdominal assessment? A. Inspection, auscultation, percussion, and palpation B. Auscultation, inspection, palpation, and percussion C. Percussion, palpation, inspection, and auscultation D. Palpation, percussion, auscultation, and inspection ANSWER A. Inspection, auscultation, percussion, and palpation Rationale: The correct order for an abdominal assessment is inspection, auscultation, percussion, and palpation. Auscultation must be completed before manipulation of the abdomen because it has an impact on motility and can lead to an inaccurate interpretation of bowel sounds. Gastric and Duodenal Disorders Cynthia Lasman, RNC-OB, MSN, CNE, C-EFM [email protected] Adapted from Wolters Kluwer Objectives  Review anatomy and physiology of the upper GI tract  Discuss common laboratory tests and diagnostic tools for upper GI dysfunction  Consider the etiology and incidence of upper GI dysfunction  Describe common assessment findings with upper GI dysfunction  Describe select conditions of the upper GI dysfunction  Explain appropriate nursing care and rationales for the care of patients experiencing upper GI dysfunction A&P: UPPER GI  Esophagus  In the mediastinum  Anterior to the spine  Posterior to the trachea and heart  Hollow 10” muscular tube  Passes through the diaphragm at an opening called the diaphragmatic hiatus Stomach In the peritoneum Left upper quadrant Capacity of approximately 1500 mL Stores food during eating, secretes digestive fluids, and propels the partially digested food, or chyme, into the small intestine Gastroesophageal junction is the inlet Pyloric sphincter is the outlet Laboratory and Diagnostic Studies  Serum laboratory studies  Stool tests  Breath tests  Abdominal ultrasonography  Genetic testing  Upper GI tract study  GI motility studies Laboratory and Diagnostic Studies  Endoscopic Procedures  Esophagogastroduodenoscopy (EGD)  Gastroscopy  Manometry and electrophysiologic studies  Ultrasound  Computed Telemetry (CT)  Magnetic Resonance Imagery (MRI) Disorders of the Oral Cavity  Periodontal disease  Includes gingivitis – inflammation of the gums  Common cause of tooth loss  Dental plaque and Caries  Tooth decay – erosive process  Prevention includes cleaning teeth several times a day (brushing and flossing), use of fluoride toothpaste and fluoridated community water sources  Nursing Implications  Poor oral intake reduces saliva production – increased oral care is required  Soft bristle brush is best, wipe with gauze pad if unable to tolerate brushing  Oral inflammatory disease is linked to cardiovascular disease, diabetes, rheumatoid disease, premature birth, low birth weight, stroke  Encourage adequate food intake  Minimize mouth pain  Support positive self-image Disorders of the Esophagus  Achalasia – absent or ineffective peristalsis  Dysphasia with solid food, regurgitation,  Diagnosed with x-ray  Teach patient to eat slowly and drink fluids with meals  Dilation can be done, or surgery if severe  Esophageal Spasm – muscular spasm interrupting normal peristalsis  Dysphasia, pyrosis, regurgitation, chest pain  Diagnosed with esophageal manometry  Treated with muscle relaxants and proton pump inhibitors Disorders of the Esophagus (cont.)  Diverticulum  Outpouching of mucosa through the musculature  Most common is Zenker diverticulum (ZD)  Dysphasia, fullness in the neck, belching, regurgitation, gurgling noises, halitosis  Diagnosed with barium swallow or manometric studies  Avoid NG tube insertion!  Perforation (rupture)  Excruciating retrosternal pain and dysphasia  Life-threatening disorder, requires immediate surgical intervention, antibiotics  Diagnosed with xray, barium swallow, chest CT  NPO Post-op Hiatal Hernia  The opening for the esophagus becomes enlarged and the upper stomach moves into the lower chest  Assessment  Dysphagia, pyrosis, regurgitation, intermittent epigastric pain, fullness after eating, nausea/vomiting, may be asymptomatic  Diagnosis is made with x-ray studies, barium swallow, EGD, esophageal manometry, CT  Medical Management  Used to treat if the patient is symptomatic (for example, GERD)  Surgery (usually laparoscopic)  Patient Teaching  Frequent small meals  Do not recline for 1 hour after eating  Elevate HOB (4-8 in)  If post-op, advance diet slowly Gastroesophageal Reflux Disease (GERD)  Common disorder  Backflow of gastric or duodenal contents into the esophagus  Troublesome symptoms and/or mucosal injury to the esophagus  Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or a motility disorder  Incidence: increases with age; irritable bowel syndrome and obstructive airway disorders (asthma, COPD, cystic fibrosis); Barrett esophagus, peptic ulcer disease, and angina  Other risk factors: tobacco use, coffee drinking, alcohol consumption, gastric infection with Helicobacter pylori Gastroesophageal Reflux Disease (GERD)  Backflow of gastric/duodenal contents into the esophagus and can lead to mucosal injury  Assessment  Pyrosis and regurgitation (hallmark of GERD)  Dyspepsia, dysphagia, hypersalivation, esophagitis  pH monitoring (gold standard diagnosis)  Endoscopy, barium swallow to evaluate for complications  Complications  Dental erosion, ulcerations in the pharynx/esophagus, laryngeal damage, esophageal strictures, adenocarcinoma, pulmonary complications Gastroesophageal Reflux Disease (GERD)  Medical Management  Medications  Surgery  Teaching  Low-fat diet  Avoid caffeine, tobacco, beer, milk, foods containing peppermint or spearmint, and carbonated beverages  Avoid eating or drinking 2 hours before bedtime  Elevate the head of the bed by at least 30 degrees  Tobacco cessation  Limit alcohol  Maintain healthy weight Gastritis  Disruption of the mucosal barrier that normally protects the stomach tissue from digestive juices  Acute  rapid onset of symptoms  usually caused by dietary indiscretion  self-limiting  other causes; medications, alcohol, bile reflux, and radiation therapy, ingestion of strong acid or alkali (may cause serious complications)  Chronic  prolonged inflammation  atrophy of gastric tissue  benign or malignant ulcers of the stomach  Helicobacter pylori  Other causes; autoimmune diseases (Hashimotos, Addison, Graves), dietary factors, medications, alcohol, smoking, or chronic reflux of pancreatic secretions or bile  Acute Gastritis  Can be classified as erosive or nonerosive Image reproduced with permission from Strayer, D. S., Saffitz, J. E., & Rubin, E. (2015). Rubin’s pathology: Mechanisms of human disease (8th ed., Fig. 19-15).  Erosive Philadelphia, PA: Lippincott Williams & Wilkins.  Local irritants (aspirin, NSAIDS, corticosteroids, alcohol, radiation)  Severe – caused by ingestion of strong acid or alkali  Nonerosive  Helicobacter pylori (H. pylori)  Can cause peptic ulcers  Stress-related  severe burns, infection, lack of perfusion, surgery  Complications – perforation, scarring, pyloric stenosis, tissue atrophy, hemorrhage Manifestation of Gastritis  Acute: epigastric pain, dyspepsia, anorexia, hiccups, nausea, vomiting. Erosive gastritis can lead to melena, hematemesis or hematochezia  Chronic: fatigue, pyrosis, belching, sour taste in the mouth, halitosis, early satiety, anorexia, nausea and vomiting, pernicious anemia due to malabsorption of B12.  Some are asymptomatic  Mild epigastric discomfort with intolerance of spicy or fatty food, relieved by eating  Definitive diagnosis by endoscopy and histologic examination of biopsy specimen  Medical Management of Gastritis  Acute  Recovery in 1-3 days  Refrain from alcohol and food until symptoms subside  Supportive therapy: IV fluids, nasogastric intubation, antacids, histamine-2 receptor antagonists, proton pump inhibitors  Chronic  Modify diet, promote rest, reduce stress, avoid alcohol and NSAIDs  Pharmacologic therapy including a variety of medications  Tx may include placement of NG tube, endoscopy, surgery (perforation or hemorrhage) Nursing Management of Gastritis  Reduce anxiety; use calm approach and explain all procedures and treatments  Promote optimal nutrition; for acute gastritis, the patient should take no food or fluids by mouth. Introduce clear liquids and solid foods as prescribed. Evaluate and report symptoms. Discourage caffeinated beverages, alcohol, cigarette smoking. Refer for alcohol counseling and smoking cessation  Promote fluid balance; monitor I&O, for signs of dehydration, electrolyte imbalance, and hemorrhage  Measures to relieve pain: diet and medications  Peptic Ulcer Disease  Erosion of a mucous membrane forms an excavation in the stomach, pylorus, duodenum (more common), or esophagus  Most often cause by infection of H. pylori  Less often stress ulcer from burn, shock, sepsis, MODS, TBI, mechanical ventilation (probably from tissue ischemia)  Risk factors include excessive secretion of stomach acid, dietary factors, chronic use of NSAIDs, alcohol, smoking, and familial tendency, blood type O, COPD, liver cirrhosis, chronic kidney disease, autoimmune disorders Peptic Ulcer Disease  Assessment  May be asymptomatic (silent peptic ulcer)  Symptoms may come  Manifestations include a dull gnawing pain or burning in the midepigastrium; sour eructation (burping), heartburn and vomiting (undigested food in emesis, relieves pain)  Duodenal ulcers – symptoms occur 2-3 hours after eating (often pain will occur at night, waking patient), eating may relieve symptoms  Sudden onset of severe pain (especially sharp upper abdominal pain referred to the shoulder), hypotension and tachycardia may indicate perforation  Diagnosis with physical exam, upper endoscopy (with histologic exam), urea breath test Peptic Ulcer Disease  Treatment includes medications (includes antibiotics if H. pylori is present), lifestyle changes, and occasionally surgery if wounds don’t heal in 12-16 weeks Reprinted with permission from Strayer, D. S., Saffitz, J. E., & Rubin, E. (2015). Rubin’s pathology: Mechanisms of human disease (8th ed., Fig. 19-23).  Teaching Philadelphia, PA: Lippincott Williams & Wilkins.  Tobacco cessation  Dietary modification  Avoid extremes in temperature, alcohol, coffee, caffeine  Regular meals Knowledge Check Is the following statement true or false? The most common site for peptic ulcer formation is the pylorus. ANSWER False Rationale: The most common site for peptic ulcer formation is not the pylorus. The most common site for peptic ulcer formation is the duodenum.  Assessment for Gastritis or Peptic Ulcer Disease  History including presenting signs and symptoms  Dietary history and dietary associations with symptoms such as predictable time for pain  72-hour diet; diary may be helpful  Abdominal assessment, vital signs  Medications; include use of NSAIDs  Sign and symptoms of anemia or bleeding  Abdominal assessment Goals for Patient with Gastritis or Peptic Ulcer  Major goals may include:  Relief of pain  Reduced anxiety  Maintenance of nutritional requirements  Absence of complications Nursing Interventions  Relieving pain  Reducing anxiety  Maintaining optimal nutritional status  Monitoring and managing potential complications  Hemorrhage  Perforation and penetration  Gastric outlet obstruction  Patient education Knowledge Check What is the duration of treatment for proton pump inhibitors in a patient diagnosed with peptic ulcer disease? A. 1–2 weeks B. 7 days C. At least 2 years based on risk factors D. 4–8 weeks ANSWER D. 4–8 weeks Rationale: Proton pump inhibitors should be used for 4–8 weeks to allow complete peptic ulcer heading. Patients at high risk require a maintenance dose for 1 year. Review of Objectives  Review anatomy and physiology of the upper GI tract  Discuss common laboratory tests and diagnostic tools for upper GI dysfunction  Consider the etiology and incidence of upper GI dysfunction  Describe common assessment findings with upper GI dysfunction  Describe select conditions of the upper GI dysfunction  Explain appropriate nursing care and rationales for the care of patients experiencing upper GI dysfunction  Review anatomy and physiology of the GI system  Discuss terms related to the GI system  Describe common assessments of the GI system