GI problems

Question 1

What is the most common manifestation of GI diseases?

Answer 1

N/V

Nausea - subjective
Vomiting - objective

Question 2

Vomiting can lead to:

Answer 2

1. dehydration
2. loss of Water and essential electrolytes
   - Metabolic alkalosis – loss of HCl from stomach
   - Metabolic acidosis – when contents of small intestine are lost (less common)

Question 3

What are common S/S of vomiting (dehydration)?

Answer 3

1. Lethargy
2. Sunken eyeballs
3. Pallor
4. Dry mucus membranes
5. Poor skin turgor
6. Decreased urinary output
7. S/S of electrolyte disturbances
   - Hypokalemia – Important bc leads to cardiac issues
   - Metabolic alkalosis

Question 4

What should the nurse assess emesis for?

Answer 4

Amount/frequency/character/color of emesis

Emesis contains partially digested food several hours after meal = gastric outlet obstruction or delayed gastric emptying

Color helps determine presence and source of bleeding (if present)

Blood in emesis could be from a

• Mallory-Weiss tear
• esophageal varices
• gastric/duodenal ulcers or cancer

Question 5

What is a Mallory-Weiss tear?

Answer 5

a tear of the tissue the lower esophagus often caused by violent coughing or vomiting, and if left untreated can lead to anemia, fatigue, shortness of breath, and shock

Question 6

What does blood in emesis look like?

Answer 6

Coffee-ground” appearance

blood turns dark brown when interacting with HCl acid

Question 7

If there is blood in emesis, don’t assume ___.

Answer 7

it’s the only place they are loosing blood!

Check H&H, BP

Question 8

Regurgitation

Answer 8

effortless process where partially digested food slowly comes up from the stomach

Question 9

Projectile vomiting

Answer 9

forceful expulsion of stomach contents w/o nausea (usually a neuro issue)

Question 10

What is cyclic vomiting syndrome?

Answer 10

Disorder that causes recurrent episodes of nausea, vomiting, and lethargy

Episodes of nausea, vomiting, and lethargy last anywhere from an hour to 10 days

Can have 4-12 cycles per year, if left untreated

Between attacks N/V absent

Common triggers: emotional excitement and infection

Often considered to be a variant of migraines

Question 11

What is care for someone with Cyclic vomiting syndrome?

Answer 11

1. When in hospital, NPO and IV fluids until diagnosis is confirmed
2. May need NG tube (persistent vomiting or bowel obstruction)
3. Address dehydration, acid-base and electrolyte imbalances
4. Monitor I/O, VS
5. Quiet/odor-free environment
6. Monitor mental status and risk for aspiration
   - If decreased mental status and risk for vomiting is present, then place side-lying
   - Older/unconscious/altered gag reflex all at increased risk (semi-Fowler’s or side lying)
7. When PO started:
   - Clear liquids when PO is started
   a. Liquids at room temp
   b. progress slowly
   - Advance slowly from clear liquids to dry toast, crackers
   - Next advance to high carbohydrate / low fat
   - Eat slowly & small amounts
   - Fluids between meals (not with meals)

Question 12

For patients who are at higher risk of aspiration with vomiting (Older/unconscious/altered gag reflex), what position do they go in?

Answer 12

Semi-Fowler’s or Side-Lying Position

Question 13

What are the two types of oral cancer?

Answer 13

Oral cavity – starts in the mouth

Oropharyngeal – develops in the throat
-Broadly called HNSCC (Head and Neck Squamous cell carcinoma) - Broad term for oral, pharynx, larynx

Question 14

What are the clinical manifestations of oral cancer?

Answer 14

1. Leukoplakia: “smoker’s patch” – white patch on mouth mucosa or tongue (precancerous lesion)
2. Erythroplasia (or plakia): red, velvety patch on mouth or tongue (precancerous lesion)
3. Ulcer: lip or tongue
4. Soreness of tongue
5. Chronic sore throat
6. Later: dysphagia, increased salivation, jaw movement, slurred speech, tooth/earache

Question 15

What is treatment for oral cancer?

Answer 15

1. SURGERY
2. May be extensive and deforming
3. Mandibulectomy – removal of part of the mandible
4. Radical neck dissection with tracheostomy- Will do a biopsy to check for cancer 1st
5. Glossectomy – removal of the tongue
6. RADIATION THERAPY
7. may be used alone if Cancer small or can’t be removed
8. Also used after surgery (6 weeks)
9. CHEMOTHERAPY
10. can shrink tumors before surgery
11. used after surgery in case of metastasis (a secondary malignant growth)

Question 16

What is post surgery care for a patient who had oral cancer?

Answer 16

Airway maintenance
Communication
Nutrition: may require a PEG tube
Pain relief
Body image

Question 17

What is Gastroesophageal Reflux Disease (GERD)?

Answer 17

Chronic symptoms of mucosal damage caused by reflux of stomach acid into the lower esophagus

Most common UGI problem in adults

Question 18

What are the clinical manifestations of GERD?

Answer 18

Heartburn (pyrosis)
Dyspepsia (pain)
Regurgitations (baby barf)
Hypersalivation
Noncardiac chest pain
May also report
1.	Wheezing
2.	Coughing
3.	Dyspnea
4.	Hoarseness
5.	Sore throat
6.	Lump in throat
7.	Choking
8.	Regurgitation
9.	So pt may not know they have GERD and think its Respiratory

Diagnosis:

1. Mild symptoms 2X/wk or moderate to severe symptoms 1x/wk
2. Response to therapy

Question 19

What are common GERD complications?

Answer 19

1. esophagitis
2. Barrett’s esophagus
3. Respiratory (Cough, Bronchospasm, Laryngospasm, Aspiration leading to pneumonia)
4. Dental erosion

Question 20

What is Barrett’s esophagus? Why is it dangerous?

Answer 20

Precancerous lesion that can lead to esophageal cancer

Can be a complication of GERD and esophagitis

So pay attention to this!!

Monitoring! (endoscopy q2-3 years or ablation)

Question 21

GERD drugs include these classes:

Answer 21

Antacids
Histamine (H2) receptor blockers
Proton Pump Inhibitors (PPI)
Cholinergic
Prokinetics
Prostaglandins (Antiulcer)
Al and Mg

Question 22

Antacids

Answer 22

neutralize HCL acid

Question 23

Histamine (H2) Receptor blockers

Answer 23

decrease HCL secretion

Question 24

Proton Pump Inhibitors (PPI)

Answer 24

decrease HCL secretion

Question 25

Cholinergic

Answer 25

increase LES (lower esophageal sphincter) pressure

Question 26

Prokinetics

Answer 26

increase gastric motility and emptying

Question 27

Prostoglandins (antiulcers)

Answer 27

form a protective layer in the stomach

Question 28

What is patient teaching for GERD patients?

Answer 28

1. Low-fat diet 2. Small, frequent meals, avoid late evening meals and avoid **milk** (an irritant) 3. Avoid alcohol, smoking, caffeine 4. Tell the patient not to lie down for 2-3 hours after eating, wear tight clothing around the waist, or bend over (esp after eating) 5. Avoid eating within 3 hours of bedtime 6. Sleep with HOB on 4-6-inch blocks 7. Provide information of drugs, including reasons for use and common side effects. 8. Weight reduction 9. Avoid Foods / Drinks that lower LES pressure (chocolate, peppermint, fatty foods coffee, tea) or irritate the esophagus (tomato-based foods, orange juice, cola, red wine) 10. Drink fluid between meals (prevents over distention of the stomach)

Question 29

Surgeries for GERD include:

Answer 29

Nissan fundoplication - wrap the stomach around the esophagus LINX Reflux Management System - A series of titanium beads, each with a magnetic core, connected together to form a ring shape -Pts will no longer be able to undergo Magnetic Resonance Imaging (MRI) procedures

Question 30

Postoperative Care for GERD:

Answer 30

Goals: 1. Prevent respiratory complications 2. Maintain fluid/electrolyte balance 3. Prevent infections Respiratory assessment 1. Respiratory rate / rhythm 2. Pulse rate / rhythm 3. Signs of pneumothorax (dyspnea, chest pain, cyanosis) Deep breathing techniques / Incentive spirometer Accurate I&O Pain medication Medications to prevent nausea/vomiting When peristalsis returns 1. start with fluids only 2. Gradually add solids 3. Normal diet gradually resumed Patient should 1. Avoid gas-forming foods 2. Chew food thoroughly

Question 31

What are the two types of hiatal hernias?

Answer 31

Sliding and Paraseophageal/Rolling ``` S/S: Can be asymptomatic Heartburn Dyspepsia (pain midline, upper abdomen) Regurgitation Dysphagia ``` ``` Complications GERD Esophagitis Hemorrhage from erosion Stenosis of esophagus Ulceration in herniated portion of stomach Strangulation of herniated portion stomach Regurgitation with tracheal aspiration ```

Question 32

What is the teaching/nursing care of a hiatal hernia?

Answer 32

**SAME AS GERD** 1. Low-fat diet 2. Small, frequent meals, avoid late evening meals and avoid **milk** (an irritant) 3. Avoid alcohol, smoking, caffeine 4. Tell the patient not to lie down for 2-3 hours after eating, wear tight clothing around the waist, or bend over (esp after eating) 5. Avoid eating within 3 hours of bedtime 6. Sleep with HOB on 4-6-inch blocks 7. Provide information of drugs, including reasons for use and common side effects. 8. Weight reduction 9. Avoid Foods / Drinks that lower LES pressure (chocolate, peppermint, fatty foods coffee, tea) or irritate the esophagus (tomato-based foods, orange juice, cola, red wine) 10. Drink fluid between meals (prevents over distention of the stomach)

Question 33

What is common management of hiatal hernias?

Answer 33

Conservative therapy 1. Eliminate restrictive / tight garments 2. Avoid lifting / straining 3. Eliminate smoking / alcohol 4. Antacids / antisecretory medications 5. Elevate HOB 6. Weight loss Surgery - Can be done laparoscopically 1. Herniotomy (cut the sack off) 2. Herniorrhaphy (close the defect) 3. Gastropexy (attach the stomach under the diaphragm to prevent reherniation)

Question 34

Esophageal cancer is usually a late diagnosis. Risk factors include:

Answer 34

1. Age (older; 70-84) 2. Race (White, Alaskan Native) 3. Male 4. Barrett’s esophagus - Precancerous lesion so pay attention to this!! 5. Lifestyle (smoking) 6. Exposure - asbestos, cement dust 7. Achalasia - delayed emptying of the lower esophagus

Question 35

What are S/S of esophageal cancer?

Answer 35

1. Progressive dysphagia (swallowing difficulty) 2. Weight Loss 3. Pain (late symptom) 4. Regurgitation 5. Hemorrhage 6. Perforation 7. Fistula w/ trachea or lung 8. If tumor is in upper 1/3rd esophagus then will have Sore throat, Choking, and Hoarseness

Question 36

Treatment for esophageal cancer includes:

Answer 36

1. SURGERY esophagesctomy, esophagogastostomy, esophagoenterostomy 2. ENDOSCOPIC THERAPY dilation, stent therapy, radiofrequency ablation, and a few others 3. RADIATION AND CHEMOTHERAPY 4. TARGETED THERAPY (targets specific cells) 5. NUTRITION nutrition is important throughout the course of treatment as it can get difficult to eat/drink -tube feeding when needed

Question 37

Nursing Care for esophageal cancer:

Answer 37

Surgery – post op = ICU 1-2 days Complications: 1. anastomotic leaks, 2. fistula formation, 3. interstitial pulmonary edema, 4. respiratory distress Priorities: 1. NG Tube: Drainage – bloody 8 – 12 hours; NEVER REPOSITION or irrigate without consulting surgeon 2. Emphasis on respiratory care (T,C, DB) 3. VTE prophylaxis and pain management 4. Nutrition- Jejunostomy or Gastrostomy tube note: Monitor for anastomotic leakage into mediastinum s/s: Pain, fever, dyspnea upon resumption of feeding 5. FOWLER'S OR SEMI-FOWLER'S POSITION - prevents reflux - Once drinking or eating, maintain upright 2-3 hours

Question 38

What is gastritis?

Answer 38

Inflammation of gastric mucosa One of most common stomach problems - May be acute or chronic - Diffuse or localized Causes: 1. Breakdown of gastric mucosal barrier 2. HCL & Pepsin into – mucosa 3. Causing tissue edema and disruption of capillary walls

Question 39

What are risk factors for gastritis?

Answer 39

Drugs (ASA, steroids, iron supplements, NSAIDs) -Even though NSAIDS are anti-inflammatory, they irritate the stomach Diet 1. Alcohol 2. spicy food Microorgamisms esp Helicobacter pylori (H. pylori) Environmental 1. Radiation 2. smoking Pathophysiologic conditions 1. Burns, large hiatal hernia, physiologic stress, sepsis, more… Other- endoscopic procedures, NG tube, psychologic stress

Question 40

What are S/S of gastritis?

Answer 40

Acute and Chronic Gastritis: 1. Anorexia 2. Nausea 3. Vomiting 4. Epigastric tenderness 5. Feeling of fullness 6. Hemorrhage 7. Associated with alcohol Chronic Gastritis: Atrophy/loss of parietal cells causes the loss of intrinsic factor (IF) as well which is essential for the absorption of cobalamin (B12). The loss of cobalamin absorption will cause: 1. anemia - IF needed for growth and maturation of RBCs 2. neurologic complications - paresthesias of the feet and hands - reduced vibratory and position senses - ataxia - muscle weakness - impaired thought processes ranging from confusion to dementia

Question 41

What are common diagnostic studies for gastritis?

Answer 41

Patient symptoms and history of alcohol or drug use Endoscopic examination with biopsy - H. pylori infection: breath, urine, serum, stool, and gastric tissue biopsy CBC (anemia due to lack of intrinsic factor) Stool (occult blood) Serum tests for antibodies to parietal cells & intrinsic factor

Question 42

What is care for chronic gastritis?

Answer 42

Eliminate & avoid cause Drug therapy 1. PPI 2. Antibiotic (likely 2 different ones OR PPI, Bismuth [coats and protects], antibiotic, antifungal) Non-irritating diet (six small meals/day) NO smoking

Question 43

What does smoking do?

Answer 43

it causes an almost immediate, marked decrease in lower esophageal sphincter pressure