Chapter 29
Care of Patients with Disorders of the
Upper Gastrointestinal System
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
Theory Objectives



Discuss obesity and its management,
including bariatric surgery.
Compare the signs and symptoms of oral,
esophageal, and stomach cancer.
Illustrate the cause of gastroesophageal
reflux disease (GERD).
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
1
Theory Objectives (cont.)



Explain the etiology and prognosis for
Barrett’s esophagus.
Describe the pathophysiology, means of
medical diagnosis, and treatment for gastritis.
Compare and contrast the treatment and
nursing care of the patient with GERD and a
patient with a peptic ulcer.
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
2
Theory Objectives (cont.)


Review the difference in the care of the
patient with a nasogastric tube for
decompression and care of the patient with a
feeding tube.
Compare the care for a patient receiving total
parenteral nutrition with care of the patient
receiving enteral feedings.
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
3
Clinical Practice Objectives



Prepare a teaching plan for a patient who has
GERD.
Plan postoperative care for a patient having
gastric surgery.
Demonstrate proper care of the patient with a
Salem sump tube for gastric decompression.
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
4
Clinical Practice Objectives
(cont.)


Manage a tube feeding for the patient
receiving formula via a feeding pump.
Devise a nursing care plan for the patient with
a gastrointestinal disorder.
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
5
Anorexia Nervosa


The patient with anorexia nervosa refuses to
eat adequate quantities of food and is in
danger of literally starving to death
Diagnosis requires extensive interviewing,
and treatment—including behavior
modification and nutrition support—which
may take months to years
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
6
Bulimia Nervosa




The bulimic patient consumes large quantities
of food and then induces vomiting to get rid of
it so that weight is not gained
Laxatives
Some patients with anorexia nervosa also are
bulimic
Some individuals practice bulimia
occasionally without harm
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
7
Bulimia Nervosa (cont.)


It can lead to severe fluid and electrolyte
imbalances, starvation, and death
Treatment of bulimia includes psychotherapy,
antidepressant medication, and behavior
modification
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
8
Obesity



Etiology and pathophysiology
Signs and symptoms
Diagnosis



Height and weight chart
Waist and hip circumference
Body mass index (BMI)
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
9
Obesity Treatment

Bariatric surgery



Extensive counseling and assessment
Modify lifestyle and stringent regimen required to
lose weight and keep weight off
Types
• Gastric restrictive
• Malabsorptive
• Gastric restrictive combined with malabsorptive surgery
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
10
Bariatric Surgery

Preoperative care

There is greater risk of pulmonary and thrombus
formation, as well as death, for the obese patient
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
11
Restrictive Procedures


Laparoscopic adjustable gastric banding is
performed by placing an inflatable band
around the fundus of the stomach
The band is inflated and deflated via a
subcutaneous port to change the size of the
stomach as the patient loses weight
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
12
Restrictive Procedures (cont.)


For vertical banded gastroplasty, the surgeon
creates a small stomach pouch by placing a
vertical line of staples
A band is placed to provide an outlet to the
small intestine
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
13
Gastric Bypass
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
14
Vertical Banded Gastroplasty
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
15
Circumgastric Banding
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
16
Malabsorptive and Combination
Procedures


The total gastric bypass procedure causes
severe nutritional deficiencies and is no
longer recommended
The roux-en-Y gastric bypass (RYGB) limits
the stomach size, and the duodenum and
part of the jejunum are bypassed. This limits
the absorption of calories
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
17
Complications




Leakage of stomach contents
Gastric stretching
Dumping syndrome
Nutritional deficiencies—iron, vitamin B12,
calcium, and folate
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
18
Healthy People 2020 Goals Related
to Losing Weight and Obesity



Increase the proportion of adults who are at a
healthy weight
Reduce the proportion of adults who are
obese
Reduce the proportion of children and
adolescents who are overweight or obese
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
19
Assessment







Family history
Contributing factors
Record of eating patterns for a 7-day period
Weight and height
BMI
Skinfold thickness measurement
General health assessment
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
20
Expected Outcomes


Patient will make positive statements about
decreasing body size
Patient will verbalize feelings of self-worth
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
21
Implementation






Diet and exercise plan
Lifestyle and preferences
Eating and exercise diary
Guidance and support
Discourage fad diets and emphasize the
importance of a well-balanced, nutritious, lowcalorie diet
Commercial programs on weight reduction
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
22
Upper GI Disorders


Stomatitis
Dysphagia




Causes
Diagnosis
Treatment
Nursing management
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
23
Implementation



Aspiration
Suctioning
Nutrition and gastrostomy
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
24
Cancer of the Oral Cavity






Etiology
Pathophysiology
Signs and symptoms
Diagnosis—physical examination and biopsy
Treatment—radiation, chemotherapy, and
surgery
Nursing management
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
25
Cancer of the Esophagus



Cigarette smoking is a major cause of
esophageal cancer in the United States
When combined with heavy alcohol
consumption, the risk for esophageal cancer
greatly increases
Esophageal cancer is the second most
common cancer in China, but is seen less in
North America
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
26
Cancer of the Esophagus (cont.)

Gastroesophageal reflux disease (GERD) is a
cause of Barrett’s esophagus, which is a
precancerous condition
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
27
Cancer of the Esophagus (cont.)


Signs, symptoms, and diagnosis
Treatment


Esophagectomy
Nursing management


Postoperative care
Nutrition
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
28
Audience Response Question 1
When screening for the presence of risk factors for
oral and pharyngeal cancers, the nurse would ask
which question(s)? (Select all that apply.)
1.
“How much alcohol do you consume?”
2.
“Have you had any oral lesions?”
3.
“Do you have family members who have
cancer?”
4.
“What do you smoke?”
5.
“Have you been exposed to hepatitis virus?”
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
29
Hiatal Hernia (Diaphragmatic Hernia)



Etiology and pathophysiology
Signs and symptoms
Treatment
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
30
Treatment of Hiatal Hernia





Reduce weight
Avoid tight-fitting clothes around the
abdomen
Take antacids and histamine (H2)-receptor
antagonists
Elevate head of the bed on 6- to 8-inch
blocks
Take proton pump inhibitors
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
31
Treatment of Hiatal Hernia (cont.)



Instruct not to eat within several hours of
going to bed
Limit intake of alcohol, chocolate, caffeine,
and fatty foods
Avoid smoking
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
32
Nursing Management



Teach ways to prevent pain and reflux
Encourage weight reduction
Remind the patient to stay upright for 2 hours
after eating and not to eat for 3 hours before
bedtime
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
33
Nursing Management (cont.)



If the head of the bed cannot be raised, a
wedge pillow should be used to elevate the
upper body; this position helps prevent reflux
and assists gravity in maintaining the
stomach in the abdominal cavity
H2 or proton pump inhibitors
Avoid foods that cause bloating
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
34
Gastroesophageal Reflux
Disease (GERD)




Etiology and pathophysiology
Signs and symptoms
Diagnosis and treatment
Nursing management


Diet therapy, lifestyle changes, drug therapy, and
education
Complications
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
35
Gastroenteritis



Caused by food or water contaminated with a
virus, a pathogenic bacteria, or parasites
Signs and symptoms
Management
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
36
Gastritis





Etiology
Pathophysiology
Signs and symptoms
Diagnosis
Treatment
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
37
Treatment for Gastritis


Acute versus chronic gastritis
Chronic gastritis





Antispasmodics
Antacids
H2-receptor antagonist such as ranitidine
Proton pump inhibitor
Antibiotic therapy for H. pylori
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
38
Peptic Ulcers

Etiology





Helicobacter pylori
Duodenal ulcers and some pre-pyloric ulcers
Gastric ulcers
Tension, anxiety, and prolonged stress
Drug-induced ulcers
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
39
Peptic Ulcers (cont.)


Pathophysiology
Signs and symptoms



Daily pattern of pain
Gastrointestinal bleeding
Diagnosis


Endoscopy
Gastric acid analysis
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
40
Peptic Ulcers (cont.)
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
41
Treatment





Antacids
Gastric bleeding and normal saline lavage
H2-receptor antagonist
Proton pump inhibitors
Presence of H. pylori—administration of
clarithromycin (Biaxin) plus another antibiotic,
an H2 inhibitor, and a proton pump inhibitor
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
42
Nursing Management

Complications



Hemorrhage
Perforation
Obstruction
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
43
Surgical Treatment of Peptic
Ulcer



Pyloroplasty with truncal or proximal gastric
vagotomy
Subtotal gastrectomy (gastric resection)
Total gastrectomy
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
44
Nursing Care of the Patient
Undergoing Gastric Surgery


Preoperative care
Postoperative care



Specific patient teaching
Diet restrictions
Dumping syndrome
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
45
Gastric Cancer






Etiology
Signs and symptoms
Pathophysiology
Diagnosis
Treatment
Nursing management
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
46
Gastric Cancer (cont.)

Treatment




Surgical intervention
Radiation therapy
Chemotherapy
Adjuvant therapy
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
47
Common Therapies for Disorders
of the Gastrointestinal System



Gastrointestinal decompression
Enteral nutrition
Total parenteral nutrition
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
48
Small-Bore Feeding Tube
Placement
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
49
Audience Response Question 2
Regarding the care of enteral feeding tubes, which
nursing behavior(s) demonstrate(s) appropriate
nursing care? (Select all that apply.)
1.
2.
3.
4.
5.
Aspirating contents of jejunostomy tube
Gentle flushing of a clogged enteral tube with 30 mL of
water
Checking for 1-inch play on a gastrostomy tube
Monitoring BUN, prealbumin, hematocrit, electrolytes,
and glucose
Rotating a jejunostomy tube 360 degrees each day
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.
50