WEEK 10 UPPER GI

Question 1

Main functions

OF THE GI

Answer 1

Ingestion
Digestion
Absorption
Elimination

Question 2

GI ASSESSMENT

Answer 2

Subjective –
Past health history
Medications
Surgery, treatments

Objective –
Physical exam

Question 3

GI Diagnostic Studies

Answer 3

Signed consent

Educate patient

Ensure appropriate prep

Check for allergies or drugs, or contrast media

GI tract often must be cleansed prior
Often uses a ‘tracer’, or contrast
Watch for dehydration during preps

Main types of studies:
Radiological 
Endoscopy
Biopsies
Lab testing (LFT)
Paracentesis

Question 4

Malnutrition

Answer 4

Consider determinants of health and healthy living

Poor nutrition is a key preventable risk factor for major chronic diseases

Nurses can have a strong influence on the nutritional practices of our patients/families

Question 5

Over-nutrition

Answer 5

Ingestion of more food than is required (obesity)

Question 6

Under-nutrition (focus for PNH401)

Answer 6

Poor nourishment, r/t inadequate diet, diseases interfering with appetite and/or assimilation of ingested food

Question 7

Protein – Calorie Malnutrition

Answer 7

High risk of delayed wound healing, susceptiblility to infection, decreased immune function

Question 8

Lab – FOR MALNURTITION

Answer 8

 pre albumin indicates severity; transferrin (protein)

Question 9

Anthropometric assessments –

Answer 9

skinfold thickness, midarm muscle

Question 10

ASSESSMENT FOR MALNUTRITION

Answer 10

Key Areas: skin, eyes, mouth, muscles, CNS
Muscles – wasted, flabby
Delayed wound healing – d/t  protein & WBC’s
Anemia –  folic acid, & iron

Question 11

Main Goals of Care:

FOR MALNUTRITION

Answer 11

Achieve weight gain
Consume appropriate calories per day
Have no adverse consequences

Question 12

Wounds –

Answer 12

require increased protein

Question 13

Fever –

Answer 13

require increased protein and calories

Question 14

Dysphagia –

Answer 14

Difficulty swallowing

Consider type of diet (puree, soft, thickened)

Question 15

Oral thrush –

Answer 15

candida albicans, yeast like fungus

noted in debilitated patients, those with ongoing antibiotics, or steroid therapy

pearly bluish white milk curd on tongue, mucosa of mouth, painful, yeasty breath

Treat – nystatin oral rinses; good oral hygiene

Question 16

GERD

Answer 16

Acid related disorder of the esophagus
Main complaint – Heart burn

Any clinically significant symptomatic condition presumed to be 20 reflux of gastric contents into lower esophagus

Question 17

Multiple factors contribute and/or cause

GERD

Answer 17

Can also include incompetent sphincter, hiatal hernia, decreased clearance of esophagus, decreased gastric emptying

Question 18

Complications/Concerns

OF GERD

Answer 18

Esophagitis

Repeat irritation can cause scar tissue stricture

Barrett’s esophagus – pre cancerous lesion

Aspiration pneumonia

Bronchospasm, laryngospasm

Question 19

Manage via lifestyle modifications +/- drugs

FOR GERD

Answer 19

Elevate HOB
High protein, low fat diet
Avoid foods that decrease LES sphincter (Table 44-7)
Antacids
Quit smoking
Avoid foods that increase acid secretion (milk)

Question 20

GERD PHARM

Answer 20

– Antisecretory agents, H2 Receptor Blockers, Proton pump inhibitors, Prokinetic drugs, Cholinergic drugs

Pharm – often used in a ‘step up’ or ‘step down’ approach
(start with antacids and move up; or start with PPI Rx and over time titrate down to OTC)

Surgery is a late option –

Question 21

GERD ONGOING HEALTH TEACHING

Answer 21

Weight loss
Small frequent meals
Avoidance of smoking, alcohol, caffeine
Remain upright for 2 -3 hours post eating
HOB elevated
Meds with magnesium  diarrhea; aluminum constipation
Observe for drug effectiveness
If surgery – usual post op care, usually a high incision; DB&C

Question 22

Hiatal Hernia

Answer 22

Herniation of a portion of stomach into the esophagus through an opening (hiatus) – usually with no symptoms
AKA – diaphragmatic hernia, or esophageal hernia

More often in women than men
Possible r/t weakening muscles of diaphragm, obesity (increased intra abdominal pressure, pregnancy, ascites, tumours, intense activity, heavy lifting on ongoing basis)

Question 23

Hiatal Hernia

Answer 23

May be asymptomatic and found on routine CXR

Similar presentation if symptomatic as GERD

Therefore similar care as in GERD

Surgical care is to enhance the integrity of the LES

Question 24

Gastritis

Answer 24

Inflammation of the gastric mucosa

Acute or chronic
Diffuse or localized

Likely some connection to H. Pylori infection and gastric cancer

Question 25

Gastritis - Assessment | ACUTE

Answer 25

``` Anorexia N & V Epigastric tenderness Feeling of fullness Hemmorhage (single symptom; associated with ETOH abuse) ```

Question 26

Gastritis - Assessment | CHRONIC

Answer 26

As above + Anemia (cobalamin deficiency) Note: gastritis is self limiting, and the mucosa heals well

Question 27

Gastritis – Care | ACUTE

Answer 27

Eliminate the cause Supportive care for symptoms Antiemetics Observe for dehydration if vomiting, nausea Start with clear fluids and increase to bland solid food If hemmorage likely – monitor VS carefully and follow care for UGI bleed Pharma – reducing irritation of the mucosa; symptomatic relief

Question 28

Gastritis -- Care | CHRONIC

Answer 28

Evaluate and eliminate cause (ETOH, medications, H. Pylori) Antibiotics for H. Pylori Anemia – Cobalamin injections Small frequent meals Antacids after meals No SMOKING

Question 29

LOOK FOR THE TABLE FOR THE Pharmacology for Gastritis, GERD, HH

Answer 29

.

Question 30

Peptic Ulcer Disease (PUD)

Answer 30

Erosion of the GI mucosa from digestive action of HCL and pepsin Any section of the GI tract that comes in contact with gastric secretions is susceptible

Question 31

PUD – Assessment

Answer 31

``` Inquire about ETOH abuse, smoking, caffeine Any chronic diseases? Medication use – NSAIDs, ASA Recent weight loss N & V? Stool changes to black tarry? Burning, when does it occur, where? Epigastric tenderness on palpation Anemia? ```

Question 32

PUD GOAL

Answer 32

Reduce degree of gastric acidity | Enhance mucosal defense mechanisms

Question 33

PUD TX

Answer 33

``` Consists of: Adequate rest Dietary modification Drug therapy Elimination of smoking and alcohol Long-term follow-up care Stress management ```

Question 34

PUD Generally treated in ambulatory care clinics

Answer 34

May require upper GI scope, barium swallow CBC, LFT’s, Lytes Ulcer healing requires many weeks of therapy. Pain disappears after 3 to 6 days. Aspirin and nonselective NSAIDs may be stopped Smoking cessation Similar pharm as for GERD, HH, Gastritis Avoid foods/beverages irritating to stomach 6 small meals per day Bland food

Question 35

Three major complications include | PUD

Answer 35

Hemorrhage (most common) Perforation Gastric outlet obstruction

Question 36

PUD Develops from erosion of

Answer 36

Granulation tissue found at base of ulcer during healing | Ulcer through a major blood vessel

Question 37

Upper GI Bleed (UGI Bleed)

Answer 37

High association with morbidity and mortality Mortality rate 6 to 10% Often in women, older adults, r/t use of NSAID’s Can be sudden onset, or occult bleeding – both major and significant Severity of bleed depends on type of vessel Can be an emergency, depending on volume of blood lost, and if continuous Often will stop on own Cause must be identified and corrected

Question 38

Esophageal | BLEED

Answer 38

Chronic esophagitis Mallory-Weiss tear (from severe retching, vomiting) Esophageal varices (cirrhosis of liver)

Question 39

Stomach and Duodenal | BLEED

Answer 39

Erosion of blood vessel from an ulcer Ingestion of drugs, ETOH Tumours, vascular lesions that erode

Question 40

BLEEDS NURSING ASSESSMENT

Answer 40

Close monitoring of VS – BP and HR Q 15 mins Peripheral perfusion Observe for shock Once stable, do full assessment

Question 41

UGI Bleeds – Initial Care

Answer 41

Obtain patient history – think of source, cause Lab studies – CBC, BUN, lytes, BS, PTT Prepare for blood transfusions (previous reactions?) Large bore IV lines, more than one Foley catheter IV fluids – RL – volume Start IV PPI’s

Question 42

Endoscopy

Answer 42

Ability to sclerose for hemostasis, clips to clamp bleeder, heat probes to coagulate blood

Question 43

Surgery

Answer 43

If bleeding not being controlled | High incidence of recurrent bleed within 5 years

Question 44

Obtain detailed history – what precipitated bleed?

Answer 44

``` All medications -- N, V, weight loss Stools – characteristic Weakness, fainting Epigastric pain, abdominal pain ```

Question 45

BLEEDS CARE

Answer 45

Maintain IV line Monitor U/O If older, or CVD, monitor for fluid overload Avoid ‘red’ foods Be aware of stool colour – black is a slow bleed; bright red is acute and from the lower GI If bloody vomitus, and no tarry stools, bleed is of short duration Introduce fluids slowly, monitor for bleeding recurrence ETOH abuse – observe for DT’s, withdrawal

Question 46

BLEEDS EXTRA NOTES

Answer 46

Always consider which patients are at high risk (chronic gastritis, PUD, previous bleed, bleeding tendencies) If requires medications likely to precipitate bleed, ensure it is EC if possible, or changed to less toxic drug, and/or is administered with meds for ulcer preventers