Unit 1; Gastro-Intestinal Disorders (1).pptx
- 1. Gastrointestinal Disorders Unit-I Subject: AHN I Awal Sher Khan & Sohaib Ali Shah Faculty of Nursing Sciences Khyber Medical University 1
- 2. Learning Objectives By the end of the session learners will be able to: 1. Review the anatomy and physiology of gastrointestinal system (GIT) 2. Discuss the causes, pathophysiology and manifestation of the following GIT disorders 3. Discuss the diagnostic, medical and surgical management of the below mentioned disorders 4. Apply nursing process including assessment, planning, implementation and evaluation of care provided to the clients with GIT disorders 5. Develop a teaching plan for a client experiencing disorders of the GIT 2
- 3. A & P of Gastrointestinal Tract 3
- 4. Disorders of mouth and esophagus • Stomatitis • Oral cancer/tumor • Salivary gland disorders • Gastro esophageal reflux disorder • Hiatal hernia • Achalasia • Diverticula • Esophageal cancer/tumor 4
- 5. Disorders of mouth and esophagus Stomatitis Inflammation of the mucous membrane of the mouth. It may be due to local lesion in the mouth, infection, nutritional deficiency, chemotherapy, immune suppression or a feature of a systemic disease. OR Stomatitis is inflammation of the mucosal tissue of the mouth (inner cheeks, tongue, lips, throat and gums etc.). 5
- 6. Sign and symptoms •swelling, •pain, •ulcerations, • excessive salivation, •halitosis, (bad breath) •sore mouth •In ability to chewing •bleeding •Bad smell 6
- 7. Causes of stomatitis •Infection: • Viruses: measles, primary herpes simplex. • Bacteria: streptococcus, diphtheria. • Fungus: Candida albicans . •Eruption stomatitis: associated with eruption of teeth. •Traumatic: cheek biters. •Local reactions: due to sensitivity to contact substances from foods. •Immunological impairment: in leukemias. •Drugs and poisons •Chemotherapy •Radiation therapy 7
- 8. Investigations •Oral swab culture •Physical examination • Learning Objectives 8
- 9. Types of Stomatitis: There are two main types of stomatitis •Herpes simplex Stomatitis/cold sore •Aphthous Stomatitis 9
- 10. Cont…. •Herpes simplex Stomatitis • Herpes simplex Stomatitis (cold sore/fever blister): • It is an externally common viral infection that produces characteristic blisters commonly called cold sore or fever blister. • It is caused by herpes simplex virus type I (HSV-1) predisposing factors of upper respiratory infections, excessive exposure to sunlight, food allergies, emotional stress and onset of menstruation. • The virus is harbored in a dormant (inactive) state by cells in the sensory nerve ganglia. • Reactivation of the virus can occur with emotional stress, fever, exposure to cold or ultraviolet rays. 10
- 11. 11 Cold Sore
- 12. Cont… • The lesions appear more common on the mucous membranous border junction of the lips in the form of small vesicles, which then erupt and form painful shallow ulcers. • Vesicle formation may be single or clustered. • Painful vesicles and ulceration of mouth, lips or edge of nose; may have prodromal itching or burning, fever, malaise, lymphadenopathy may occur. • Prodromal: relating to or denoting the period between the appearance of initial symptoms and the full development of a rash or fever. • Lymphadenopathy: A disease affecting the lymph nodes 12
- 13. /Pathophysiology of HSS • Etiology: HSV I (less commonly HSV II) Transmission: • via mucous membranes or open skin • Kissing • Fomites (e.g. shared towels, utensils) • Incubation: 2-20 days after contact. • Shedding: 48-60 hour duration (not longer than 96 hours) 13
- 14. Aphthous Stomatitis • Aphthous Stomatitis (cancer sore) it is recurrent and chronic form of infection secondary to systemic disease, trauma, stress or unknown causes. The cause remains unknown, an autoimmune base is suspected. Self-limited, they usually resolve within a few weeks, but they may recur in the same or a different location. • It produces well-circumscribed ulcers on the soft tissues of the mouth, including lips, tongue, insides of the cheeks, pharynx and soft palate. • Ulcers of the mouth and lips causing extreme pain, ulcers surrounded by erythematous base. • Painful small ulceration on oral mucosa heals in 1 to 3 weeks. 14
- 15. Risk Factors •Aging •Nutritional deficiency •Poor oral hygiene •Smoking •Alcohol •Specific chemotherapeutic agents •Bone marrow transplantation •Radiotherapy 15
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- 17. Pathophysiology •Characterized by damage to the epithelium of the oropharyngeal cavity . •Rapidly dividing basal cells of the oral mucosa are among the body cells vulnerable to damage by chemotherapy and radiation therapies. 17
- 18. Treatment •pain relief, • removal of causative factor, •oral hygiene with saline, Gentian violet, glycerin •Broad spectrum antibiotic in sever case •Anti fungal drugs i.e. Nystatin, Daktarin • soft bland diet •IV infusion in sever case 18
- 19. Nursing diagnosis •Pain related to lesion of mouth. •Alteration in nutrition less than body requirement related to ulceration in the mouth and chewing problem. •Alter sleep pattern related to pain secondary to stomatitis. •Difficulty in talking (dysphasia) related to blisters and sores on the tongue. 19
- 20. Nursing Intervention • Check for oral burning, pain, or change in tolerance to temperature. • Do oral examination noting evidence of lesions within the mouth and tongue. • Administer the respective medication. • Give analgesic to relieve from pain. • Advice soft food and avoid spicy food. • Do oral hygiene with soothing solution. • Administer topical medication e.g. nylstate and bonjela to relieve from pain to enhance sleep. 20
- 21. Oral cancer Oral cancer is a subtype of head and neck cancer, is any cancerous tissue growth located in the oral cavity. 21
- 22. Signs and symptoms •lesion, lump, or ulcer that do not resolve in 14 days located: •On the tongue, lip, or other mouth areas •Usually small •Most often pale colored, be dark or discolored •Early sign may be a white patch (leukoplakia) or a red patch (erythroplakia) on the soft tissues of the mouth •Usually painless initially •May develop a burning sensation or pain when the tumor is advanced 22
- 23. Cont… •Additional symptoms that may be associated with this disease: •Tongue problems •Swallowing difficulty •Mouth sores •Pain and paresthesia are late symptoms. •Feeling of something caught in the throat •Difficulty or pain with chewing or swallowing •Swelling in jaw •Voice changes •Pain in ear 23
- 24. Oral Cancer •Occurs most often in people over age 40 Symptoms •Sore that does not heal •Lump on lip or mouth •White or red patch on gum, tongue, or buccal mucosa •Unusual bleeding, numbness, or pain 24
- 25. 25 Squamous Cell Carcinoma (SCC)
- 26. Risk factors • Uncommon (5% of all cancers) but has high rate of morbidity, mortality • Highest among males over age 40 • Risk factors include • smoking and • using oral tobacco, • drinking alcohol, • marijuana use, • occupational exposure to chemicals, • viruses (human papilloma virus) • History of leukoplakia • Erythroplakia 26
- 27. Pathophysiology a. Squamous cell carcinomas b. Begin as painless oral ulceration or lesion with irregular, ill- defined borders c. Lesions start in mucosa and may advance to involve tongue, oropharynx, mandible, maxilla d. Non-healing lesions should be evaluated for malignancy after one week of treatment 27
- 28. Investigation a. Elimination of causative agents b. Determination of malignancy with biopsy c. Determine staging with CT scans and MRI 28
- 29. Treatment 1. Surgery and/or 2. Radiation • Treatment usually involves surgery or radiation or both • Chemotherapy primarily used as an adjunctive procedure in advanced cases • Advanced lesions < 30% 5-year survival rate • 9 - 25% of patients develop additional mouth or throat cancer 3. Chemotherapy • Several drugs currently being used include: • Paclitaxel (Taxol, Bristol) • Methotrexate • Bleomycin • Cisplatin • 5-Fluorouracil 29
- 30. Nursing Diagnosis • Pain related to oral lesion or treatment • Imbalanced nutrition less than body requirements, related to inability to ingest adequate nutrients secondary to oral condition. • Risk for infection related to disease or treatment • Alter sleep pattern related to pain secondary to stomatitis. • Impaired verbal communication related to treatment 30
- 31. Nursing Intervention •Pain management •Oral hygiene •Preparation for surgery or radiation •Nutritional management •Post operative care and dressing •Symptomatic treatment. •Administration of chemotherapy •Monitoring of client response to any treatment •Emotional support to client and family •Care of symptom associated with treatment 31
- 32. Cont…. Health promotion: Teach risk of oral cancer associated with all tobacco use and excessive alcohol use Need to seek medical attention for all non-healing oral lesions (may be discovered by dentists); early precancerous oral lesions are very treatable Work out for following possible Nursing Diagnoses 1. Risk for ineffective airway clearance 2. Imbalanced Nutrition: Less than body requirements 3. Impaired Verbal Communication: establishment of specific communication plan and method should be done prior to any surgery 4. Disturbed Body Image 32
- 33. Salivary Glands disorder • The salivary glands make saliva and release it into the mouth. There are three pairs of relatively large, major salivary glands: • Parotid glands: Located in the upper part of each cheek, close to the ear. The duct of each parotid gland empties onto the inside of the cheek, near the molars of the upper jaw. • Submandibular glands: Under the jaw. They have ducts that empty behind the lower front teeth. • Sublingual glands: Beneath the tongue. They have ducts that empty onto the floor of the mouth. oIn addition to these major glands other minor salivary glands are scattered throughout the mouth and throat. 33
- 34. Cont…. 34
- 35. Classification of Salivary Glands disorder 1-Obstructions: this could be by calculi or cystic type (stone, mucocele, ranula) 2-Infections: viral (Mumps), bacterial (acute & chronic Sialadenitis) 3-Degenerative changes: Sjogren syndrome, radiation. 4-Functional disorders. 5- Neoplasms. 35
- 36. Investigations for salivary glands 1- Sialometery: measures the amount of saliva production in a certain time. 2- Sialochemistry: measures the composition of saliva. 3- Sialography: by introducing the iodine containing contrast media through the opening of the duct. 4- Sonography: Ultrasonic patterns when dealing with minor salivary glands. 5- Cytology: by aspiration. 6- Biopsy. 36
- 37. Cont…. Some of the most common salivary gland disorders include: Sialolithiasis Sialadenitis Viral infections Cysts Benign tumors Malignant tumors Sjogren's syndrome Sialadenosis 37
- 38. Sialolithiasis Sialolithiasis (salivary gland stones) Tiny, calcium-rich stones sometimes form inside the salivary glands. 70-90% of stones occur in the submandibular gland due to long twisted path of the duct & thick secretion of the gland. about 6% in parotid gland & 2% in sublingual gland & minor S.G. • Etiology: The exact cause of these stones is unknown. Some stones may be related to: • Dehydration, which thickens the saliva. • Decreased food intake, which lowers the demand for saliva. • Medications that decrease saliva production, including certain antihistamines, anti-hypertensive drugs and psychiatric medications. • Deposition of ca++ salt around a nidus of debris within the duct lumen 38
- 39. Cont…. • Some stones sit inside the gland without causing any symptoms. In other cases, a stone blocks the gland's duct, either partially or completely. When this happens, the gland typically is painful and swollen, and saliva flow is partially or completely blocked. This can be followed by an infection called sialadenitis. • Signs & Symptoms The most common symptom are dry mouth and a painful lump, usually in the floor of the mouth. Pain may worsen during eating. • Treatments • Gentle probing: If the stone is located near the end of the duct, the doctor may be able to press it out gently. • Therapeutic sialdenoscopy • Surgery: If stone are in deeper part • Shock wave treatment 39
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- 41. Sialadenitis Sialadenitis: (infection of a salivary gland) Sialadenitis is a painful infection. It is more common among elderly adults with salivary gland stones. Sialadenitis also can occur in infants during the first few weeks of life. •Etiology It is usually caused by bacteria. •Sign and symptoms: Symptoms may include: oA tender, painful lump in the cheek or under the chin. oIn severe cases, fever, chills and general weakness. 41
- 42. Cont…. Treatment Treatment includes: •Drinking fluids or receiving fluids intravenously •Antibiotics •Warm compresses on the infected gland •Encouraging saliva flow by chewing gums, sugarless candies or by drinking orange juice. •If these methods do not cure the infection, surgery can be done to drain the gland. 42
- 43. Viral infections Viral infections: Systemic (whole-body) viral infections sometimes settle in the salivary glands. This causes facial swelling, pain and difficulty in eating. The most common example is mumps. •Etiology These infections are caused by viruses. • Sign and symptoms The first symptoms often include: •Fever and poor appetite •Headache, •Muscle aches •Joint pain and malaise. 43
- 44. Cont…. •Treatment: These infections almost always go away on their own. Treatment focuses on relieving symptoms through: •Rest •Drinking fluids to prevent dehydration •Taking acetaminophen (Tylenol) to relieve pain and fever 44
- 45. Cysts Cysts: (tiny fluid-filled sacs) Babies sometimes are born with cysts in the parotid gland because of problems related to ear development before birth. Later in life, other types of cysts can form in the major or minor salivary glands. • Etiology They may result from traumatic injuries, infections, or salivary gland stones or tumors. • Sign and symptoms: A cyst causes a painless lump. It sometimes grows large enough to interfere with eating. • Treatment : A small cyst may drain on its own without treatment. Larger cysts can be removed using traditional surgery or laser surgery. 45
- 46. Benign tumors Benign tumors: (noncancerous tumors) Most salivary gland tumors occur in the parotid gland. The majority are benign. The most common type of benign parotid tumor usually appears as a slow-growing, painless lump at the back of the jaw, just below the earlobe. • Etiology Risk factors include radiation exposure and possibly smoking. • Sign and symptoms A slow-growing lump is the most common symptom. The lump is sometimes painful. This lump may be found in the cheek, under the chin, on the tongue or on the roof of the mouth. • Treatment Non cancerous tumors usually are removed surgically. In some cases, radiation treatments are given after surgery to prevent the tumor from returning. 46
- 47. Malignant tumors • Malignant tumors: (cancerous tumors) Salivary gland cancers are rare. They can be more or less aggressive. • Etiology The only known risk factors for salivary gland cancers are Sjogren's syndrome and exposure to radiation. Smoking also may play some role. • Sign and symptoms A slow-growing lump is the most common symptom. The lump is sometimes painful. This lump may be found in the cheek, under the chin, on the tongue or on the roof of the mouth. • Treatment Smaller, early stage, low-grade tumors often can be treated with surgery alone. However, larger, high-grade tumors usually require radiation following surgery. Tumors that cannot be operated are treated with radiation or chemotherapy. 47
- 48. Sjogren's syndrome • Sjogren's syndrome Sjogren's syndrome is a chronic autoimmune disorder. The body's immune defenses attack the salivary glands, the lacrimal glands (glands that produce tears), and occasionally the skin's sweat and oil glands. • Classification: Primary: xerostomia + xerophthalmia Secondary: xerostomia + xerophthalmia + C.T. disease usually rheumatoid arthritis. • Etiology Over activity of the immune system. • Sign and symptoms The main features of Sjogren's syndrome are swelling of the salivary glands, dry eyes and a dry mouth. • Immune system attacks parts of your own body by mistake. In Sjogren's syndrome, it attacks the glands that make tears and saliva. This causes a dry mouth and dry eyes. 48
- 49. Cont…. Treatment •The main symptom related to the salivary glands is a dry mouth. Options include: •Medication to stimulate more saliva secretion, such as pilocarpine (Salagen) and cevimeline (Evoxac). •Sugarless gum and candy to stimulate saliva production. •Avoiding medications that can make dry mouth worse. •Avoid smoking. •Good oral hygiene is must. People with Sjogren's have teeth and gum problems because of low saliva secretion. 49
- 50. Sialadenosis Sialadenosis (nonspecific salivary gland enlargement) Sometimes, the salivary glands become enlarged without evidence of infection, inflammation or tumor. This nonspecific enlargement is called sialadenosis. It most often affects the parotid gland. • Etiology Its cause remains unknown. • Sign and symptoms This condition typically causes painless swelling of the parotid glands on both sides of the face. • Treatment: Treatment is aimed at correcting any underlying medical problem. Once the medical problem improves, the salivary glands should shrink to normal size. 50
- 51. Medical Diagnosis • Medical history. • Smoking history. • Current medications. • Blood tests. • X-rays. • Magnetic resonance imaging (MRI). • Computed tomography (CT) scans. • Sialography. • Salivary gland biopsy. • Salivary function test. 51
- 52. Complications • Abscess of salivary gland. • Infection returns. • Spread of infection. • Facial nerve injury (Sialorrhea). • Hematoma. • Deformity. • Dry mouth (xerostomia). • Mumps. 52
- 53. Prevention • We can lower our risk of viral infections of the salivary glands. To do so, get immunized against mumps and influenza. • There are no specific guidelines to protect against other types of salivary gland disorders. However, it is helpful to: • Avoid smoking. • Eat a healthy diet. • Drink six to eight glasses of water daily to avoid dehydration. • Practice good oral hygiene, with regular tooth brushing and flossing. 53
- 54. Nursing Diagnosis • Low secretion of saliva related to stone in the salivary gland. • Dry mouth related to blockage of saliva. • Pain related to tumor & inflammation in the mouth. • Difficulty in eating related to painful lump in the mouth. • Poor appetite related to disease. • Fever related to infection of salivary gland. 54
- 55. Nursing Interventions • Give medication to stimulate more saliva secretion, such as pilocarpine (Salagen) and cevimeline (Evoxac). • Give sugarless gum and candy to stimulate saliva production. • Avoiding medications that can make dry mouth worse. • Provide analgesic to relief pain. • Administer tube feeding. • Give acetaminophen (Tylenol) to relieve fever. • Cold sponging to relieve from fever. 55
- 56. Gastroesophageal Reflux Disease (GERD) • Gastroesophageal reflux is the backward flow of gastric content into the esophagus. • People with asthma are at higher risk of developing GERD. Asthma flare-ups can cause the lower esophageal sphincter to relax, allowing stomach contents to flow back, or reflux, into the esophagus. • GERD common, affecting 15 – 20% of adults • 10% persons experience daily heartburn and indigestion 56
- 57. Pathophysiology • When you eat, food passes from the throat to the stomach through the esophagus. A ring of muscle fibers in the lower esophagus prevents swallowed food from moving back up. These muscle fibers are called the lower esophageal sphincter (LES). • When this ring of muscle does not close all the way, stomach contents can leak back into the esophagus. This is called reflux or gastroesophageal reflux. Reflux may cause symptoms. Harsh stomach acids can also damage the lining of the esophagus. • Gastroesophageal reflux results from transient relaxation or incompetence of lower esophageal sphincter, or increased pressure within stomach 57
- 58. Factors contributing to gastroesophageal reflux • Increased gastric volume (post meals) • Position pushing gastric contents close to gastroesophageal juncture (such as bending or lying down) • Increased gastric pressure (obesity or tight clothing) • Hiatal hernia 58
- 59. Cont.. • Normally the peristalsis in esophagus and bicarbonate in salivary secretions neutralize any gastric juices (acidic) that contact the esophagus; during sleep and with gastroesophageal reflux esophageal mucosa is damaged and inflamed; prolonged exposure causes ulceration, friable mucosa, and bleeding; untreated there is scarring and stricture. Manifestations • Heartburn after meals, while bending over, or recumbent and worse at night • May have regurgitation of sour materials in mouth, pain with swallowing • Chest pain • Nausea • Bloating, gas and belching • Sensation of lump in throat 59
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- 61. Cont.. Complications • Esophageal strictures, which can progress to dysphagia • Barrett’s esophagus: changes in cells lining esophagus with increased risk for esophageal cancer diagnosis • Esophagitis Diagnostic tests • Barium swallow (evaluation of esophagus, stomach, small intestine) • Upper GI endoscopy: direct visualization; biopsies may be done • 24-hour ambulatory pH monitoring (gold standard of GERD) • Esophageal motility studies/ Esophageal manometry, which measure pressures of esophageal sphincter and peristalsis 61
- 62. Cont.. Treatment • Life style changes • Diet modifications • Medications 62
- 63. Cont.. Medications • Antacids: for mild to moderate symptoms, e.g. Mucain, Tricel, Mylanta, Gaviscon • H2-receptor blockers: decrease acid production; given BID or more often, e.g. cimetidine, ranitidine, famotidine, nizatidine • Proton-pump inhibitors: reduce gastric secretions, promote healing of esophageal erosion and relieve symptoms, e.g. omeprazole (risek); lansoprazole (Prevacid) initially for 8 weeks; or 3 to 6 months • Promotility agent: enhances esophageal clearance and gastric emptying, e.g. metoclopramide (reglan) 63
- 64. Cont.. Surgery • Surgery indicated for persons not improved by diet and life style changes • Laparoscopic procedures to tighten lower esophageal sphincter • Open surgical procedure: Nissen fundoplication 64
- 65. Cont.. Dietary and Lifestyle Management • Elimination of acid foods (tomatoes, spicy, citrus foods, coffee) • Avoiding food which relax esophageal sphincter or delay gastric emptying (fatty foods, chocolate, peppermint, alcohol) • Maintain ideal body weight • Eat small meals and stay upright 2 hours post eating; no eating 3 hours prior to going to bed • Elevate head of the bed 6 – 8 inches to decrease reflux • No smoking • Avoiding bending and wear loose fitting clothing • Limit meal size and avoid heavy evening meal 65
- 66. Nursing Diagnosis • Imbalanced nutrition: less than body requirements related to inability to intake enough food because of reflux. • Acute pain related to irritated esophageal mucosa. • Imbalanced nutrition: more than body requirements related to eating to try to assuage pain. • Impaired tissue integrity related to esophageal exposure to gastric acid. • Nausea related to irritation of gastric mucosa secondary to Gastroesophageal Reflux Disease (GERD) 66
- 67. Nursing Management • Avoid factors that cause reflux • Stop smoking • Avoid acid or acid producing foods • Elevate HOB ~30° • Do not lie down 2 to 3 hours after eating • Patient teaching • Drug therapy • Evaluate effectiveness • Observe for side effects 67
- 68. Hiatal Hernia • Hiatal hernia also known as diaphragmatic hernia a condition in which a portion of the stomach or the lower part of the esophagus protrudes upward into the thoracic cavity through a defect in the wall of the diaphragm. 68
- 69. Cont.. Causes: • Loss of muscle strength and tone • Factors that cause increased intra-abdominal pressure (such as obesity or multiple pregnancies) • Congenital defects • Trauma 69
- 70. Cont.. Manifestations • Often no signs and symptoms unless there is reflux of stomach acid • Indigestion, belching, • substernal or epigastric pain • feelings of pressure after eating • Regurgitation of a hot, sour liquid coming into the throat or mouth • Nighttime coughing that may awaken the patient 70
- 71. Cont.. Pathophysiology: • A defect in the wall of the diaphragm where the esophagus passes through Protrusion of part of the stomach or the lower part of the esophagus up into the thoracic cavity • Herniated portion often slides back beneath the diaphragm 71
- 72. Cont.. 72
- 73. Cont.. Diagnostic procedure: • History & P.E • UGI series or barium swallow • X-ray, CT or MRI • Endoscopy 73
- 74. Cont.. Medical management: • Weight reduction • Avoidance of tight-fitting clothes around the abdomen • Administration of antacids, H2-receptor antagonists, or proton pump inhibitors • Elevating the head of the bed 6 to 8 inches • Instructing the patient not to eat within 3 hours of going to bed • Limiting intake of alcohol, chocolate, caffeine, and fatty food, and avoiding smoking • Surgical correction of the hernia if bleeding or discomfort cannot be controlled. • Anchoring the lower esophageal sphincter by wrapping a portion of the stomach around it to anchor it in place 74
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- 76. Cont.. Nursing management: • Encouraging weight reduction if necessary • Reminding the patient to stay upright for 2 hours after eating and not to eat 3 hours before bedtime • Advising against lifting or moving heavy items • Using a wedge pillow to elevate the upper body if the head of the bed cannot be raised • Encouraging the patient to take prescribed H2-receptor antagonists or proton pump inhibitors at bedtime to prevent reflux and damage from acid entering the esophagus • Advising the patient to avoid foods that cause bloating, which increases abdominal pressure and may push the stomach upward through the diaphragmatic defect. 76
- 77. Cont.. Nursing Diagnosis for Hiatal Hernia • Risk for aspiration related to reflux of gastric contents and impaired esophageal sphincter function. • Acute pain related to esophageal inflammation and irritation caused by reflux of gastric contents. • Imbalanced nutrition: less than body requirements related to decreased oral intake and fear of eating due to pain and discomfort. • Anxiety related to symptoms and potential complications of GERD and hiatal hernia. • Risk for ineffective coping related to chronic illness and lifestyle changes required for disease management. 77
- 78. Cont.. Nursing Diagnosis for Hiatal Hernia • Ineffective self-health management related to lack of knowledge about disease process and treatment options. • Risk for impaired gas exchange related to decreased lung expansion due to upward displacement of the diaphragm in hiatal hernia. • Risk for injury related to potential complications of hiatal hernia such as bleeding or obstruction. • Disturbed sleep pattern related to nighttime symptoms of GERD and hiatal hernia. • Impaired swallowing related to esophageal inflammation and obstruction caused by hiatal hernia. 78
- 79. Achalasia • Achalasia is absent or ineffective peristalsis of the distal esophagus, accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. 79
- 80. Cont.. Causes: • Idiopathic (unknown cause) in most cases • degeneration of the nerves in the esophagus • Dysfunction of (LES) • Inflammation of the esophageal muscles • Viral infections • Autoimmune disorders • Hereditary factors • Environmental factors such as exposure to chemicals or radiation 80
- 81. Cont.. Clinical Manifestations: • difficulty in swallowing both liquids and solids • sensation of food sticking in the lower portion of the esophagus • regurgitation, either spontaneously or intentionally • chest pain and heartburn (pyrosis). 81
- 82. Cont.. Diagnostic procedure: • X-ray studies • Barium swallow • computed tomography (CT) • endoscopy may be used for diagnosis; • however, the diagnosis is confirmed by manometry, a process in which the esophageal pressure is measured by a radiologist or gastroenterologist. 82
- 83. Cont.. Medical and Surgical management: • The patient should be instructed to eat slowly and to drink fluids with meals. • As a temporary measure, calcium channel blockers and nitrates have been used to decrease esophageal pressure and improve swallowing. • Injection of botulinum toxin (Botox) to quadrants of the esophagus via endoscopy has been helpful because it inhibits the contraction of smooth muscle. Periodic injections are required to maintain remission. • If these methods are unsuccessful, pneumatic (forceful) dilation or surgical separation of the muscle fibers may be recommended (Heller myotomy) 83
- 84. Cont.. Nursing Diagnosis: • Impaired Swallowing related to esophageal dysfunction and dysphagia manifested by difficulty swallowing solid and liquid foods, regurgitation, and chest pain. • Risk for Aspiration related to decreased lower esophageal sphincter (LES) function and difficulty swallowing manifested by coughing, choking, and respiratory distress. • Imbalanced Nutrition: Less than Body Requirements related to inadequate oral intake due to difficulty swallowing manifested by weight loss, poor oral intake, and malnutrition. • Anxiety related to fear of choking or complications related to the disease process manifested by restlessness, nervousness, and apprehension. 84
- 85. Cont.. Nursing Diagnosis: • Ineffective Coping related to chronic illness and its impact on daily activities manifested by poor self-care, social isolation, and decreased quality of life. • Risk for Injury related to fatigue, weakness, or impaired mobility manifested by falls, accidents, and decreased ability to perform activities of daily living. 85
- 86. Cont.. Nursing Intervention: • Nutrition management: ensure adequate nutrition and hydration, such as providing small, frequent meals and thickening liquids if needed. • Medication administration: Nurses may administer medications that help relax the LES. • Positioning: Positioning the patient in an upright position during and after meals can help reduce the risk of aspiration and improve digestion. • Patient education: about the disease process, the importance of adhering to treatment plans, and warning signs of complications such as weight loss or recurrent chest pain. 86
- 87. Cont.. Nursing Intervention: • Emotional support: Patients with achalasia may experience anxiety or depression due to their symptoms or difficulty swallowing. Nurses can provide emotional support, assess for any psychosocial issues, and refer the patient to appropriate resources such as counseling or support groups. • Monitoring for complications: Nurses should monitor for complications such as aspiration pneumonia, weight loss, or chest pain, and report any changes in the patient's condition to the healthcare team. 87
- 88. Diverticulum • Diverticulum is an outpouching of mucosa and submucosa through a weak portion of the musculature in the esophagus. • Zenker's diverticulum is the most common type, occurring in the upper area of the esophagus in people over 60. • Other types include midesophageal, epiphrenic, and intramural diverticula. 88
- 89. Cont.. Causes: • Improper functioning of the lower esophageal sphincter or motor disorders of the esophagus. • Age-related changes in the esophagus. 89
- 90. Cont.. Clinical Manifestations: • Difficulty swallowing, fullness in the neck, belching, regurgitation of undigested food, and gurgling noises after eating. • Undigested food regurgitation when in a recumbent position. • Halitosis and sour taste in the mouth. 90
- 91. Cont.. Diagnostic procedure: • Barium swallow to determine the exact nature and location of a diverticulum. • Manometric studies to rule out a motor disorder. • Esophagoscopy is usually contraindicated due to the danger of perforation of the diverticulum. 91
- 92. Cont.. Medical Management: • Management of symptoms such as dysphagia and chest pain. • Intramural diverticula usually regress after the esophageal stricture is dilated. Surgical Management: • Surgery is indicated if symptoms are troublesome and becoming worse. 92
- 93. Cont.. Nursing Diagnosis: • Impaired Swallowing related to pharyngoesophageal pulsion diverticulum as evidenced by difficulty swallowing, regurgitation of undigested food, and gurgling noises after eating. • Imbalanced Nutrition: Less Than Body Requirements related to pharyngoesophageal pulsion diverticulum as evidenced by weight loss, anorexia, and inadequate dietary intake. • Risk for Aspiration related to pharyngoesophageal pulsion diverticulum as evidenced by difficulty swallowing, regurgitation of undigested food, and coughing. • Anxiety related to surgical intervention for diverticulum as evidenced by verbalization of fears, restlessness, and increased heart rate. • Risk for Infection related to surgical intervention for diverticulum as evidenced by surgical wound site drainage, fever, and elevated white blood cell count. 93
- 94. Cont.. Nursing Management: • Diet: Patients with diverticulum should be advised to consume a high-fiber diet to prevent constipation and reduce the pressure on the diverticulum. Additionally, patients may need to avoid certain foods that can irritate the diverticulum, such as seeds, nuts, and popcorn. • Medications: Patients may need to take medications to manage symptoms such as pain, reflux, and constipation. Nurses should ensure that patients understand the correct dosage and potential side effects of these medications. 94
- 95. Cont.. Nursing Management: • Post-operative care: For patients who undergo surgery to remove a diverticulum, nurses should closely monitor the surgical incision for signs of infection or leakage. Patients may also require a nasogastric tube and may need assistance with maintaining proper nutrition and hydration during the post-operative period. • Education: Nurses should educate patients on the importance of following a high-fiber diet, staying well hydrated, and avoiding activities that can increase intra- abdominal pressure (such as heavy lifting or straining during bowel movements). Patients should also be advised to seek medical attention if they experience worsening symptoms or develop complications such as fever or severe abdominal pain. 95
- 96. Esophageal cancer/tumor • Cancer of the esophagus, also known as esophageal cancer, is a malignant tumor that develops in the tissues of the esophagus. • Esophageal cancer typically arises from the inner lining of the esophagus and can spread to nearby tissues and organs if not diagnosed and treated at an early stage. • There are two main types of esophageal cancer: Adenocarcinoma: Begins in glandular cells that lines the esophagus which produce and release mucus. It usually form in the lower part of esophagus near stomach and often caused by Barrett’s esophagus. Squamous cell carcinoma: Found in upper and middle section of esophagus and risk factor is smoking and alcohol ingestion. 96
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- 98. Cont.. Causes • Smoking. • Heavy alcohol consumption. • Chronic heartburn or acid reflux. • Gastroesophageal reflux disease (GERD) • Barrett's esophagus, a condition that sometimes develops in people with GERD. • Achalasia, a rare disorder of muscles in the lower esophagus. 98
- 99. Cont.. Manifestations • Progressive dysphagia (difficulty swallowing) • Hoarseness • Regurgitation of foods • Foul breath • Persistent cough • Dysphagia initially with solids, then with soft foods, and eventually even with liquids • Late occurrence of pain (substernal, epigastric, or back) with swallowing • Weight loss 99
- 100. Cont.. Diagnostic Procedures • Barium swallow with fluoroscopy may reveal a narrowed esophagus. • Definitive diagnosis is made through esophagogastroduodenoscopy (EGD) • Biopsy • Biomarker testing • Cytosponge is a new diagnostic test being introduced by NHS Scotland to identify important oesophageal conditions such as Barrett's oesophagus 100
- 101. Cont.. Medical Management: 1. Endoscopic ablative therapy (photodynamic therapy, radiotherapy ablation, endoscopic mucosal resection) 2. Radiofrequency ablation burns away abnormal cells using radiofrequency energy. 3. Photodynamic therapy uses medication to make damaged cells sensitive to light, which is then used to destroy them. 4. Endoscopic mucosal resection involves injecting a saline solution under the lining of abnormal tissue to facilitate its removal. 5. Palliative care for advanced stage cancer may include external beam radiation, chemotherapy, esophageal dilation, electrocoagulation, photodynamic therapy, and the insertion of expanding metal stents to relieve severe dysphagia. 101
- 102. Cont.. Surgical Management: • Esophagectomy (removal of sections of the esophagus) with reconstruction using part of the stomach is occasionally performed but carries multiple potential complications. 102
- 103. Cont.. Nursing Diagnosis: • Risk for Infection related to impaired swallowing and compromised immune system as evidenced by presence of fever, increased white blood cell count, signs of respiratory infection (e.g., cough, chest congestion). • Deficient Knowledge about the disease process, treatment options, and self-care measures as evidenced by patient or family member’s express confusion or lack of understanding about the disease, treatment options, or self-care instructions. • Disturbed Body Image related to changes in physical appearance and functional abilities as evidenced by expressions of dissatisfaction or discomfort with changes in body image, social withdrawal, low selfesteem. • Risk for Aspiration related to impaired swallowing and reflux as evidenced by coughing, choking, history of aspiration pneumonia, dyspnea. 103
- 104. Cont.. Nursing Diagnosis: • Impaired Swallowing related to tumor obstruction and/or radiation therapy as evidenced by difficulty swallowing (dysphagia), coughing or choking during eating or drinking, regurgitation, weight loss. • Imbalanced Nutrition: Less Than Body Requirements related to dysphagia and treatment-related side effects as evidenced by weight loss, decreased oral intake, malnutrition, fatigue, altered taste sensation. • Anxiety related to diagnosis, treatment, and prognosis as evidenced by restlessness, increased heart rate, nervousness, difficulty sleeping, verbal expressions of worry or fear. • Acute Pain related to esophageal inflammation, tumor invasion, or surgical interventions as evidenced by sharp or burning pain in the chest or upper abdomen, pain with swallowing or eating, pain at the surgical site. 104
- 105. Cont.. Nursing Interventions: • The intervention focuses on improving the patient's nutritional and physical condition before surgery, radiation therapy, or chemotherapy. • A high-calorie and high-protein diet, in liquid or soft form, is provided to promote weight gain if the patient can consume adequate food orally. • If oral intake is not possible, parenteral (intravenous) or enteral (tube feeding) nutrition is initiated. • The patient's nutritional status is monitored throughout the treatment process. • The patient is informed about the postoperative equipment that will be used, such as closed chest drainage, nasogastric suction, parenteral fluid therapy, and gastric intubation. 105
- 106. Cont.. Nursing Interventions: • After recovering from anesthesia, the patient is placed in a low Fowler's position and later in a Fowler's position to prevent reflux of gastric secretions. • Close observation is maintained for regurgitation, dyspnea, and the possibility of aspiration pneumonia. • The patient's temperature is monitored to detect any elevation that may indicate aspiration or fluid seepage into the mediastinum. • If jejunal grafting has been performed, the nurse checks the graft viability hourly for at least the first 12 hours. 106
- 108. Objectives: • At the end of this lecture the students will be able to: • Define Gastritis and types of Gastritis. • Elaborate etiology of Gastritis • Explain Pathophysiology of Gastritis • Sign and symptoms of Gastritis. • Discuss diagnosis , and medical management of Gastritis • Apply Nursing Process to the patients suffering from Gastitis
- 109. Gastritis: • Definition; • Gastritis is an inflammation, irritation or erosion of the stomach mucosa. • Gastritis is a condition that inflames stomach lining (the mucosa), causing belly pain, indigestion (dyspepsia), bloating and nausea. • Gastritis can come on suddenly (acute) or gradually (chronic).
- 110. Cont'd • Gastritis is a general term for a group of conditions with one thing in common: inflammation of the lining of the stomach • In some cases, gastritis can lead to ulcers and an increased risk of stomach cancer. • Pangastritis; Inflammation of the whole stomach is called Pangastritis • Antral gastritis ;Inflammation of a part of stomach.
- 114. Types of Gastritis • Gastritis can broadly be divided into acute gastritis and chronic gastritis. • Acute gastritis Acute gastritis is a sudden inflammation of the lining of the stomach. •Acute gastritis can be divided in to; 1.Acute superficial gastritis 2.Erosive gastritis 3.Acute gastric ulceration
- 115. Cont'd • Chronic gastritis; inflammation of the lining of the stomach that occurs gradually and persists for a prolonged time. • Chronic gastritis can divided into: 1.TypeA chronic gastritis (autoimmune gastritis) 2.Type B chronic gastritis (chronic antral gastritis)
- 118. Etiology of Gastritis • Bacterial infections(.Hpylori): A bacteria that lives in the mucous lining of the stomach; without treatment, the infection can lead to ulcers, and in some people, stomach cancer. • Autoimmune Gastritis • Bile reflux: A backflow of bile into the stomach from the bile tract (that connects to the liver and gallbladder) • Regular use of pain relievers (NSAID) • Bile reflux disease • Stress • Alcohol addiction • Cocaine • Radiation and chemotherapy
- 120. Pathophysiology; • The gastric mucosa is protected from high acidity in stomach by mucous secretion. • Mucosal damage occur through; • Hypersecretion of acid • Reduction of mucus production • Generalized inflammation results
- 121. Pathophysiology;
- 122. Sign & Symptoms • Abdominal pain and burning, often in the upper center of the abdomen called the epigastric area • Bloating • Weight loss • Belching • Indigestion • Anorexia • Nausea with or without vomiting • Hiccups
- 123. Cont'd • Severe gastritis can lead to life-threatening symptoms including: • Severe chest pain • Feeling faint or short of breath • Severe abdominal pain • Sudden onset of bloody stools (blood may be red, black or tarry in texture) • Vomiting blood or black material (resembling coffee grounds)
- 126. Diagnosis of Gastritis; • Gastritis is diagnosed on the basis of medical history and physical examinations of the patient and the following tests: • Test for H pylori • Blood test • Stool test • Upper gastrointestinal X ray • Upper gastrointestinal endoscopy .An endoscope, a thin tube containing a tiny camera, is inserted through your mouth and down into your stomach to look at the stomach lining.
- 129. Medical treatment of Gastritis • T aking antacids and other drugs (such as proton pump inhibitors or H-2 blockers) to reduce stomach acid • Avoiding hot and spicy foods • For gastritis caused by H. pylori infection, your doctor will prescribe a regimen of several antibiotics plus an acid blocking drug (used for heartburn)
- 130. Cont'd • If the gastritis is caused by pernicious anemia, B12 vitamin shots will be given. • Eliminating irritating foods from your diet such as lactose from dairy or gluten from wheat • Once the underlying problem disappears, the gastritis usually does, too.
- 134. Nursing diagnosis for Gastritis • 1.Fluid And Electrolyte Imbalances related to inadequate intake, vomiting. • 2.Imbalanced Nutrition Less Than Body Requirements related to inadequate intake, anorexia. • 3. Impaired sense of comfort: acute pain related to gastric mucosal inflammation. • 4. Activity Intolerance related to physical weakness. • 5. Knowledge deficit related to lack of information.
- 135. Nursing Interventions • If thepatient is vomiting, give antiemetics. • Administer I.V. fluids as ordered to maintain fluid and electrolyte imbalance. • When the patient can tolerate oral feedings, provide a bland diet that takes into account his food preference. Restart feedings slowly. • Offer smaller, more frequent servings to reduce the amount of irritating gastric secretions. • Help patient identify specific foods that cause gastric upset and eliminate them from his diet.
- 136. Cont'd • Administer antacids and other prescribed medications as ordered. • If pain or nausea interferes with the patient’s appetite, administer pain medications or antiemetics about 1 hour before meals. • Monitor the patient’s fluid intake and output and electrolyte levels. • Assess the patient for presence of bowel sounds. • Monitor the patient’s response to antacids and other prescribed medications.
- 138. Nursing process • 1,Nursing Assessment for Gastritis • During the gathering health history, the nurse asked about the signs and symptoms in patients. • Does the patient have heartburn, can not eat, nausea or vomiting? • Does the patient have symptoms occur at any time, before or after meals?
- 139. Cont'd • Does the patient have symptoms associated with anxiety, stress, allergies, eating or drinking too much, or eating too fast? how the symptoms disappear? • Is there a history of previous gastric or stomach surgery? • Historical diet plus a new type of diet eaten for 72 hours, would help.
- 140. Cont'd • Full history is essential in helping nurses to identify whether excess dietary known, associated with current symptoms, whether others in the same patient has symptoms, whether the patient vomited blood, and if the elements are known to have ingested causes.
- 141. Nursing Diagnosis • Based on all the data assessment, nursing diagnosis is the major include the following: • Anxiety related to treatment. • Imbalanced Nutrition, Less Than Body Requirements related to inadequate nutrient input
- 142. Cont'd • Risk for Fluid Volume Deficit related to insufficient fluid intake and excessive fluid loss due to vomiting. • Knowledge Deficit r/t unfamiliarity with the disease process • Acute Pain related to gastric mucosal irritation.
- 143. Nursinh Care Plans for Gastritis • Imbalanced Nutrition: less than body requirements r/t insufficient absorption of nutrients • Expected Outcome: The patient can absorb an adequate amount of nutrients • Assessment and Intervention.Obtain the patient’s weight and other body measurements .
- 144. Cont'd • Admission weight serves as a baseline metric and helps guide. • Obtain information about the patient’s eating habits(Some food items can exacerbate the symptoms of gastritis. Acidic or citrus food items may worsen symptoms. ) • Place the patient NPO (nothing by mouth) in case of vomiting.
- 145. Cont'd • Discourage the patient from consuming spicy foods, caffeine, and alcohol. • Anticipate total parenteral nutrition (TPN). • Consult a dietitian if indicated. The patient might need an addition of supplements to compensate for insufficient nutrient intake. • Encourage small, frequent meals rather than three full meals.
- 146. Cont'd • 2 Risk for Fluid Volume Deficit: Risk factors: Vomiting; Decreased intake • Expected Outcome: The patient will have a stable fluid volume as evidenced by normal blood pressure, at least 30ml hourly urine output, and elastic skin turgor. • Assess for signs of dehydration. • Vital signs, especially blood pressure, urine output, and skin turgor.
- 147. Cont'd • Monitor how many times the patient vomits and note the amount of emesis each time. • Frequent vomiting causes fluid loss and can lead to dehydration. • Monitor the patient’s BP and HR. • Monitor electrolytes closely. • Frequent vomiting can cause a loss of electrolytes, especially potassium.
- 148. Cont'd • Monitor urine output hourly and note the color. • Provide oral care frequently. • Often patients are unable to eat or drink, which can leave the mouth dry. • Administer antiemetics as prescribed. • Antiemetics will reduce the feeling of nausea and vomiting and, therefore, the risk of insufficient fluid volume.
- 149. Cont'd • 3.Knowledge Deficit r/t unfamiliarity with the disease process • Expected Outcome: The patient will verbalize information about the causes, treatment, and prevention of gastritis • Assessment and Interventions: • Assess the patient’s knowledge about gastritis.
- 150. Cont'd • This information provides a baseline for further educational content. The patient might not be aware of the disease. • Teach about appropriate eating intervals and the types of food in case of a flare-up • Teach the patient not to take additional medication over the counter.
- 155. By the end of the session learners will be able to: Review the anatomy and physiology of gastrointestinal system (GIT) Define Peptic Ulcer disease. Discuss the causes, pathophysiology and manifestation of Peptic Ulcer disease. Discuss the diagnostic and medical and surgical management of Peptic Ulcer disease. Apply nursing management for patient with Peptic Ulcer disease. 5. Develop a teaching plan for a client experiencing Peptic Ulcer disease.
- 157. An Ulcer is … Erosion in the lining of the stomach or the first part of the small intestine, an area called the duodenum. Ulcers damage the mucosa of the alimentary tract, which extends through the muscularis mucosa into the sub mucosa or deeper.
- 158. A peptic ulcer is an excavation that forms in the mucosal wall of the stomach, in the pylorus, in the duodenum, or in the esophagus. The erosion of a circumscribed area may extend as deep as the muscle layers or through the muscle to the peritoneum. A peptic ulcer may be referred to as a gastric, duodenal, or esophageal ulcer, depending on its location.
- 159. Gastric ulcer. Gastric ulcer tend to occur in the lesser curvature of the stomach, near the pylorus. Duodenal ulcer. Peptic ulcers are more likely to occur in the duodenum than in the stomach. Esophageal ulcer. Esophageal ulcer occur as a result of the backward flow of HCl from the stomach into the esophagus
- 160. Ulcers that form in the stomach are called gastric ulcers; in the duodenum, they are called duodenal ulcers. Both types are referred to as peptic ulcers.
- 162. The gastroduodenal mucosal integrity is determined by protective (defensive) & damaging (aggressive) factors.
- 164. • Bicarbonate • Mucus layer • Prostaglandins • Mucosal blood flow • Epithelial renewal Defensive • Helicobacter pylori • NSAIDs • Pepsins • Bile acids • Smoking and alcohol Aggressive Mucosal damage erosions & ulcerations
- 165. Erosion. The erosion is caused by the increased concentration or activity of acid-pepsin or by decreased resistance of the mucosa. Damage. A damaged mucosa cannot secrete enough mucus to act as a barrier against HCl. Acid secretion. Patients with duodenal ulcers secrete more acid than normal, while patients with gastric ulcers tend to secrete normal or decreased levels of acid. Decreased resistance. Damage to the gastro duodenal mucosa results in decreased resistance to bacteria and thus infection from the H. pylori bacteria may occur.
- 166. • In the past it was believed lifestyle factors, such as stress and diet caused ulcers. Later, researchers determined that stomach acids -- hydrochloric acid and pepsin -- contributed to ulcer formation. • Today, research shows that most ulcers (80 percent of gastric ulcers and 90 percent of duodenal ulcers) develop as a result of infection with a bacterium called Helicobacter pylori (H. pylori). • It is believed that, although all three of these factors -- lifestyle, acid and pepsin, and H. pylori -- play a role in ulcer development, H. pylori is considered to be the primary cause.
- 168. Factors for the development of peptic ulcers include: Helicobacter pylori Research shows that most ulcers develop as a result of infection with bacterium called Helicobacter pylori (H. pylori). The bacterium produces substances that weaken the stomach's protective mucus and make it more susceptible to the damaging effects of acid and pepsin, as well as produce more acid.
- 169. Smoking: Studies show smoking increases the chances of getting an ulcer, slows the healing process of existing ulcers, and contributes to ulcer recurrence. Caffeine: Caffeine seems to stimulate acid secretion in the stomach, which can aggravate the pain of an existing ulcer. However, the stimulation of stomach acid cannot be attributed solely to caffeine
- 170. • Acid and pepsin It is believed that the stomach's inability to defend itself against the powerful digestive fluids, hydrochloric acid and pepsin, contributes to ulcer formation. • Nonsteroidal anti-inflammatory drugs (NSAIDs) These drugs (such as aspirin, ibuprofen, and naproxen sodium) make the stomach vulnerable to the harmful effects of acid and pepsin. They are present in many non-prescription medications used to treat fever, headaches, and minor aches and pains.
- 171. The following are the most common symptoms for ulcers, however, each individual may experience symptoms differently. Belching Nausea Vomiting Poor appetite Loss of weight Feeling tired and weak
- 172. Symptoms of ulcer may last for a few days, weeks, months, and may disappear only to reappear, often without an identifiable cause. Pain. As a rule, the patient with an ulcer complains of dull, gnawing pain or a burning sensation in the midepigastrium or the back that is relieved by eating. Pyrosis. Pyrosis (heartburn) is a burning sensation in the stomach and esophagus that moves up to the mouth.
- 173. Vomiting. Vomiting results from obstruction of the pyloric orifice, caused by either muscular spasm of the pylorus or mechanical obstruction from scarring. Constipation and diarrhea. Constipation or diarrhea may occur, probably as a result of diet and medications. Bleeding. 15% of patients may present with GI bleeding as evidenced by the passage of melena (tarry stools).
- 174. Bleeding. Perforation. Narrowing and obstruction.
- 175. Esophagogastroduodenoscopy. Confirms the presence of an ulcer and allows cytologic studies and biopsy to rule out H. pylori or cancer. Physical examination. A physical examination may reveal pain, epigastric tenderness, or abdominal distention. Barium study. A barium study of the upper GI tract may show an ulcer. Endoscopy. Endoscopy is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. Occult blood. Stools may be tested periodically until they are negative for occult blood.
- 176. Helicobacter pylori. Research has documented that peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water. H. pylori damage the mucous coating that protects the stomach and duodenum. Salicylates and NSAIDs. Encourages ulcer formation by inhibiting the secretion of prostaglandins. Various illnesses. Pancreatitis, hepatic disease, Crohn’s disease, gastritis, and Zollinger-Ellison syndrome are also known causes.
- 177. Excess HCl. Excessive secretion of HCl in the stomach may contribute to the formation of peptic ulcers. Irritants. Ingestion of milk and caffeinated beverages and alcohol also increase HCl secretion. These contribute by accelerating gastric emptying time and promoting mucosal breakdown. Blood type. Gastric ulcers tend to strike people with type A blood while duodenal ulcers tend to afflict people with type O blood.
- 178. Lifestyle changes: In the past, physicians advised people with ulcers to avoid spicy, fatty, or acidic foods. Smoking: Smoking has been shown to delay ulcer healing and has been linked to ulcer recurrence; therefore, people with ulcers should not smoke.
- 179. Medications: Physicians treat stomach and duodenal ulcers with several types of medications, including: H2-blockers to reduce the amount of acid the stomach produces by blocking histamine, a powerful stimulant of acid secretion. E.g. Cimetidine, Ranitidine, and Famotidine. Proton pump inhibitors to more completely block stomach acid production by stopping the stomach's acid pump -- the final step of acid secretion. E.g. Omeprazol.
- 180. • Mucosal protective agents to shield the stomach's mucous lining from the damage of acid, but do not inhibit the release of acid. E.g. Bismuth, Sucralfate • When treating H. pylori, these medications are often used in combination with antibiotics. • Antibiotics: The discovery of the link between ulcers and H. pylori resulted in a probable new treatment option -- antibiotics for patients with H. pylori.
- 181. H. pylori Therapy: • Triple therapy: Proton pump inhibitor Clarithromycin Amoxicillin.
- 182. At present, surgery is performed to treat ulcers. Types of surgery include: Vagotomy Pyloroplasty Antrectomy
- 183. Vagotomy: a surgical operation in which one or more branches of the vagus nerve are cut, typically to reduce the rate of gastric secretion (e.g. in treating peptic ulcers).
- 184. Pyloroplasty is surgery to widen the opening in the lower part of the stomach (pylorus) so that stomach contents can empty into the small intestine (duodenum). The pylorus is a thick, muscular area. When it thickens, food cannot pass through.
- 185. Surgical removal of the walls of an antrum, especially the antrum of the stomach.
- 186. Hemorrhage. Hemorrhage, the most common complication, occurs in 10% to 20% of patients with peptic ulcers in the form of hematemesis or melena. Perforation and penetration. Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning, while penetration is the erosion of the ulcer through the gastric serosa into adjacent structures. Pyloric obstruction. Pyloric obstruction occurs when the area distal to the pyloric sphincter becomes scarred and stenosed from spasm or edema or from scar tissue that forms when an ulcer alternately heals and breaks down.
- 187. Pharmacologic therapy. Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and bismuth salts that suppress or eradicate the infection. Stress reduction and rest. Reducing environmental stress requires physical and psychological modifications on the patient’s part as well as the aid and cooperation of family members and significant others.
- 188. Smoking cessation. Studies have shown that smoking decreases the secretion of bicarbonate from the pancreas into the duodenum, resulting in increased acidity of the duodenum. Dietary modification. Avoiding extremes of the temperature of food and beverages and overstimulation from consumption of meat extracts, alcohol, coffee, and other caffeinated beverages, and diets rich in cream and milk should be implemented.
- 190. Assessment for a description of pain. Assessment of relief measures to relieve the pain. Assessment of the characteristics of the vomitus. Assessment of the patient’s usual food intake and food habits.
- 191. Acute pain related to the effect of gastric acid secretion on damaged tissue. Anxiety related to an acute illness. Imbalanced nutrition related to changes in the diet. Deficient knowledge about prevention of symptoms and management of the condition.
- 192. Relief of pain. Reduced anxiety. Maintenance of nutritional requirements. Knowledge about the management and prevention of ulcer recurrence. Absence of complications.
- 193. Administer prescribed medications. Avoid aspirin, which is an anticoagulant, and foods and beverages that contain acid-enhancing caffeine (colas, tea, coffee, chocolate), along with decaffeinated coffee. Encourage patient to eat regularly spaced meals in a relaxed atmosphere; obtain regular weights and encourage dietary modifications. Encourage relaxation techniques
- 194. Assess what patient wants to know about the disease, and evaluate level of anxiety; encourage patient to express fears openly and without criticism. Explain diagnostic tests and administering medications on schedule. Interact in a relaxing manner, help in identifying stressors, and explain effective coping techniques and relaxation methods. Encourage family to participate in care, and give emotional support.
- 195. Assess for faintness or dizziness and nausea, before or with bleeding; test stool for occult or gross blood; monitor vital signs frequently (tachycardia, hypotension, and tachypnea). Insert an indwelling urinary catheter and monitor intake and output; insert and maintain an IV line for infusing fluid and blood. Monitor laboratory values (hemoglobin and hematocrit). Insert and maintain a nasogastric tube and monitor drainage; provide lavage as ordered. Monitor oxygen saturation and administering oxygen therapy. Place the patient in the recumbent position with the legs elevated to prevent hypotension, or place the patient on the left side to prevent aspiration from vomiting.
- 196. Note and report symptoms of penetration (back and epigastric pain not relieved by medications that were effective in the past). Note and report symptoms of perforation (sudden abdominal pain, referred pain to shoulders, vomiting and collapse, extremely tender and rigid abdomen, hypotension and tachycardia, or other signs of shock).
- 197. Assist the patient in understanding the condition and factors that help or aggravate it. Teach patient about prescribed medications, including name, dosage, frequency, and possible side effects. Also identify medications such as aspirin that patient should avoid. Instruct patient about particular foods that will upset the gastric mucosa, such as coffee, tea, colas, and alcohol, which have acid-producing potential. Encourage patient to eat regular meals in a relaxed setting and to avoid overeating. Explain that smoking may interfere with ulcer healing; refer patient to programs to assist with smoking cessation.
- 198. Alert patient to signs and symptoms of complications to be reported. These complications include hemorrhage (cool skin, confusion, increased heart rate, labored breathing, and blood in the stool), penetration and perforation (severe abdominal pain, rigid and tender abdomen, vomiting, elevated temperature, and increased heart rate), and pyloric obstruction (nausea, vomiting, distended abdomen, and abdominal pain).
- 199. Relief of pain. Reduced anxiety. Maintained nutritional requirements. Knowledge about the management and prevention of ulcer recurrence. Absence of complications.
- 201. Gastric Carcinoma Subject: AHN I Sohaib Ali Shah Faculty of Nursing Sciences Khyber Medical University 201
- 202. Gastric Cancer • The incidence of stomach cancer in the United States has been decreasing, but it still causes a significant number of deaths annually. • More common in individuals over 40 years of age • Men have a higher incidence of gastric cancer than women. • The incidence of gastric cancer is higher in Japan, where mass screening programs have been implemented for early detection. • The prognosis for gastric cancer is generally poor, as most patients are diagnosed with metastases already present. 202
- 203. 203
- 204. Causes • Chronic stomach inflammation • Barrett's esophagus • Pernicious anemia • Achlorhydria • Gastric ulcers • H. pylori infection • Genetics • Food preservatives such as nitrates • Diet high in smoked, highly salted, or spiced foods 204
- 205. Manifestations •Early symptoms, such as pain relieved with antacids, can resemble those of benign ulcers. •Progressive disease may manifest with symptoms such as: anorexia (loss of appetite) dyspepsia (indigestion) weight loss abdominal pain Constipation Anemia nausea and vomiting 205
- 206. Pathophysiology 206
- 207. Diagnostic Procedure • Physical examination: Usually not helpful as most gastric tumors are not palpable. • Ascites: Apparent if the cancer cells have metastasized to the liver. • Endoscopy • Barium x-ray examination • Computed tomography (CT) scan • Bone scan • Liver scan • Complete x-ray examination of the GI tract 207
- 208. Medical & Surgical Management • Surgical removal: The only successful treatment for gastric carcinoma is the removal of the tumor. Cure is possible if the tumor is localized to the stomach and can be completely excised. • Palliative surgery: If the tumor has spread beyond resectable areas, palliative surgery may be performed to alleviate symptoms caused by obstruction or dysphagia. • Subtotal gastrectomy • Total gastrectomy • Chemotherapy • Pre-surgical chemotherapy • Radiation therapy • Tumor marker assessment • Learning Objectives 208
- 209. 209
- 210. Nursing Diagnosis • Imbalanced Nutrition: Less Than Body Requirements related to anorexia, altered taste sensation, and effects of cancer treatment. • Acute Pain related to tumor growth, invasion, or surgery. • Anxiety related to the diagnosis of gastric cancer, fear of treatment, or uncertainty about the future. • Risk for Infection related to impaired immune function secondary to cancer and/or treatment. • Risk for Imbalanced Fluid Volume related to vomiting, anorexia, and inadequate intake. • Disturbed Body Image related to changes in physical appearance due to cancer and treatment. • Fatigue related to the disease process, anemia, or cancer treatments. 210
- 211. Nursing Interventions Reduce Anxiety: • Provide a relaxed, non-threatening atmosphere for the patient to express fears, concerns, and anger • Encourage family support and positive coping measures • Advise patient about procedures and treatments • Suggest talking to a support person (e.g., spiritual advisor) Promote Optimal Nutrition: • Encourage small, frequent portions of non-irritating foods • Provide high-calorie food supplements with vitamins A and C and iron • Monitor intake, output, and daily weight • Assess for signs of dehydration and metabolic abnormalities • Administer antiemetics as prescribed 211
- 212. Nursing Interventions Relieve Pain: • Administer analgesics as prescribed • Assess the effectiveness of pain management • Suggest non-pharmacologic pain relief methods Provide Psychosocial Support: • Help the patient express fears, concerns, and grief • Answer patient's questions honestly and encourage participation in treatment decisions • Recognize mood swings and defense mechanisms • Reassure patients and family members that emotional responses are normal 212
- 213. Cont.. • Offer emotional support and involve family members and significant others • Make the services of healthcare professionals available if needed • Project an empathetic attitude and spend time with the patient 213