Nutrition: Gastric

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Nutrition: Gastric
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2012-03-27 21:35:43
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Nutrition: Gastric
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  1. THE STOMACH
    •  Holding tank for food 
    • Food is exposed to stomach acids and digestive effects of pepsin
    • Saturates food with gastric juices
    • Excretes HCL (hydrochloric acid)
    • Ph 2.0
    • Absorbs H20, alcohol, sugars, salt, electrolytes & some drugs
  2. GASTROESPHAGEAL REFLUX DISEASE (GERD)
    • Caused by gastric acid flowing upward into the esophagus
    • Incompetent lower esophageal sphincter
    • Acid becomes an irritant destroying esophageal lining
  3. GERD Degree of Reaction
    • Heartburn
    • •Most common symptom
    • •Burning chest pain behind breast bone
    • •Moves upward toward throat
    • •Worse after eating, lying down or bending down
  4. GERD – LIFESTYLE VARIABLES
    • – Relaxed lower esophageal sphincter (LES)
    • – Being overweight
    • – Overeating
    • – Caffeine / alcohol (increases amount of HCA)
    • – Smoking
    • – Gastritis
    • – Ulcer disease
    • – Stress
    • – Nonsteroidal antiinflammatory drugs (NSAID’s) (over use of)
    • • Aspirin & Ibuprofen
    • – Certain foods
    • • Citrus
    • • Peppermint
    • • Chocolate
    • • Fatty & Spicy food
  5. GRED Diagnosis
    Upper GI Series (Barium Swallow)
    • – Ingestion of barium followed by x-rays
    • > shows how well the sphincter is closing
  6. GERD Diagnosis
    Esophagogastroduodenoscopy (EGD)
    • – Endoscope used
    • – Direct visualization of stomach and stomach wall
    • – Can perform biopsy
    • – Oral anesthetic (spray in mouth to decrease gag reflex)
    • – Observe for return of “Gag Reflex” (can not eat or drink anything until the gag reflex has returned
  7. GERD Diagnosis
    Esophageal Manometry
    • – Determines the strength of the muscles in the esophagus
    • – Small nasal tube
  8. GERD Diagnosis
    PH Monitoring
    • – Small nasal tube
    • – Rest above LES
    • – Last 12-24 hours

    check to see the presents of acid over a period of time
  9. GERD Diagnosis
    Bernstein Test
    – Mild acid placed in the esophagus

    creating mild signs of GERD
  10. GERD Diagnosis
    BRAVO PH Monitoring
    • - Places capsule next to LES
    • - Detaches after 24 - 48 hours
    • - Then download the results
  11. GERD – TREATMENT
    • Diet and lifestyle changes
    • Medications
    • Quit smoking
    • Observe food intake and food types
    • Eat smaller portions
    • Avoid overeating
    • Watch alcohol consumption
    • Do not lie down or go to bed right after eating
    • Decrease fluid intake
    • Lie on LEFT side, elevate HOB 30°
    • Lose excess weight
    • SURGICAL CORRECTION
    • – Nissen Fundoplication NON-SURGICAL CORRECTION
    • –Stretta Procedure
  12. GERD – Treatment determined by:
    • –Age, overall health and medical history
    • –Extent of condition
    • –Tolerance to specific meds, procedures & therapies
    • –Expectation for the course of the condition
    • –Patient opinion or preference
  13. Heartburn mimics an MI
    - must rule out MI before treating the heartburn
  14. GERD – TREATMENT
    STRETTA PROCEDURE
    • –Done on the LES
    • –Use of Radiofrequency (radio waves)
    • –Tiny cuts leading to scar tissue
    • > which can help close/narrow the esophagal sphincter and relieve some of the symptoms
  15. GERD – MEDICATIONS
    ANTACIDS
    • Excessive use of these leads to an ion imbalance
    • • Sodium bicarbonate
    • • Calcium carbonate
    • • Aluminum hydroxide
    • • Magnesium hydroxide
    • –Neutralize stomach acid
    • –OTC
    • –Tablet or liquid forms
    • – Fast pain relief
  16. GERD – MEDICATIONS
    H2-RECEPTOR BLOCKERS
    • • Zantac (ranitidine)
    • • Pepcid (famotidine)
    • • Tagment (cimetidine)
    • • Axid (nizatidine)
    • - OTC or by prescription
    • - Blocks histamine (in the stomach which produces acid)
    • - Reduces acid and pain
    • - Do not promote healing
  17. GERD – MEDICATIONS
    PROTON PUMP INHIBITORS
    • • Prevacid (lansoprazole)
    • • Aciphex (rabeprazole)
    • • Prilocec (omeprazole)
    • • Protonix (pantoprazole)
    • • Nexium (esomeprazole)
    • - Blocks the enzyme in the stomach that produces acid
    • - Promotes healing of the stomach and esophagus
  18. GERD – MEDICATIONS
    PROKINETIC AGENTS
    • • Reglan (metoclopramide)
    • - Assists the stomach to empty more rapidly
    • - May help tighten the LES
    • - Prescription
  19. GERD – MEDICATIONS
    ANTISPASMOTICS
    • • Bentyl, Dibent (dicyclomine)
    • • Levsin, Cystospaz (hyoscyamine)
    • - Relaxes smooth muscles of intestine
    • - Works to decrease digestion
    • - Prescription
    • - Makes the food move faster through the system
  20. GERD – MEDICATIONS
    CYTOPROTECTIVE AGENTS
    • - Prescription only
    • • Carafate (sucralfate)
    • • Cytotec (misoprostol)
    • - OTC
    • • Pepto-Bismol (bismuth subsalicylate) [black,tarry stool]
    • - Protects lining of stomach & intestine
    • - Does not decrease the amount of acid
    • - Used to prevent ulcer formation
    • - Must give an hour before meals and at bedtime
  21. GERD – COMPLICATIONS
    • ESOPHAGITIS (inflammation of esophagus)
    • ESOPHAGEAL STRICTURE (food can no enter the stomach -projective vomit)
    • BARRETT’S ESOPHAGUS (changes the epithelium and is precancerous, can not return to normal)
    • – Considered Precancerous
    • HIATAL HERNIA
  22. NURSING DIAGNOSES for GERD
    • Altered nutrition
    • Pain (acute versus chronic)
    • Altered sleep pattern
    • Knowledge deficit
    • Risk for fluid volume imbalance
    • Risk for impaired swallowing
  23. GERD – Patient / family teaching
    • – Foods
    • –Smoking cessation
    • –Stress avoidance
    • –Medications and side effects
    • – Importance of following medical regime
    • –S&S to report to physician
    • –Possible pre and post operative care
  24. HIATAL HERNIA CLASSIFICATIONS
    • Type 1 –SLIDING: Stomach moves back and forth through hiatus of the diaphragm
    • Type 2 –PARAESHOPHAGEAL or ROLLING: greater curvature of the stomach move above diaphragm forming a pocket
    • > Food may accumulate in the pocket and cause bacterial changes and physical changes
  25. HIATAL HERNIA PRIMARY PREVENTION
    • – unknown
    • – Weakening of diaphragm muscles
    • – Increased intra-abdomimal pressure
    • – Increased age
    • – Trauma
    • – Poor nutrition
    • – Forced recumbent positioning (if they have had a C1 or C2 fracture were they must lay on back)
    • – Congenital
    • – Obesity
  26. HIATAL HERNIA DEGREE OF REACTION
    • – May be asymptomatic
    • – Heartburn
    • – Nocturnal heartburn
    • – Dysphagia
    • – Mimics gallbladder disease
  27. HIATAL HERNIA PRECIPITATING FACTORS
    • – Large meals
    • – Alcohol
    • – Smoking
    • - no tight clothes or tight belts
  28. HIATAL HERNIA COMPLICATIONS:
    • – GERD (primary problem)
    • – Hemorrhage (by ulcer formation)
    • – Esophageal stenosis
    • – Ulceration
    • – Strangulation
    • – Regurgitation with aspiration
  29. HIATAL HERNIA DIAGNOSIS:
    – EGD and Barium Swallow
  30. HIATAL HERNIA SECONDARY PREVENTION–
    - Conservative Therapy
    • •Lifestyle Modifications
    • •Medications
  31. HIATAL HERNIA SECONDARY PREVENTION–
    Surgical Therapy
    • •Nissen Fundoplication
  32. PEPTIC ULCER DISEASE (PUD)
    • Erosion of the GI mucosa from the action of HCL and pepsin
    • Includes gastric & duodenal ulcers
  33. PHASES OF PUD
    • Erosion
    • Acute Ulcer
    • Perforated Ulcer (eats through all the layers of the stomach wall)
  34. PUD - ETIOLOGY
    HELICOBACTER PYLORI (H. PYLORI)
    • •80-90% OF ALL ULCERS
    • •Bacterium infection
    • •Weakens the stomach’s protective mucus
  35. PUD - ETIOLOGY
    • Lifestyle Overactive acid & pepsin secretion
    • Smoking
    • Caffeine
    • Alcohol
    • Vagal nerve stimulation
    • Stress
    • Physical stress
    • – “Stress Ulcers” (every pt prone)
    • NSAIDs
    • Corticosteroids
  36. PUD – DEGREE OF REACTION
    • May be asymptomatic until serious complications occur.
    • – Heartburn
    • – Gnawing / burning pain
    • – Acid, bitter, slimy taste in mouth
    • – Belching / indigestion
    • – Nausea / vomiting [presence of blood means need for HCP]
    • – Weight loss & poor appetite
    • – Feeling tired and weak
  37. PUD - COMPLICATIONS
    HEMORRHAGE
    • ALL ARE EMERGENCIES!
    • - Most common
    • - Black, tarry stools (MELENA)
    • - Occult blood [in the beginning]
    • - Emesis (coffee ground or fresh)
    • - Have blood in the stomach (possibility of multiple bleeding sites [can loose LOTS OF BLOOD])
  38. PUD - COMPLICATIONS
    PERFORATION
    • ALL ARE EMERGENCIES!
    • - Most lethal complication
    • - Requires surgery
    • - Causes peritonitis
    • - S&S onset sudden and dramatic
    • • Sudden, severe upper abdominal pain
    • • Abdomen muscles contract - rigid & “board-like”
    • • Respirations shallow & rapid
    • • Absent bowel sounds
    • • Tachycardiac

    They need to open and wash the abdomen (may take some time to completly clean all the organs)
  39. PUD - COMPLICATIONS
    GASTRIC OUTLET OBSTRUCTION
    • ALL ARE EMERGENCIES!
    • – Narrowing of pylorus
    • • Scar tissue
    • • Pylorospasm
    • • Edema / Inflammation
    • – Vomiting projectile (nothing getting to the stomach [smells really bad])
    • – Contains food particles
    • – Offensive odor

    Immeadiate NG tube to decompress the stomach
  40. PUD – SECONDARY PREVENTION
    DIAGNOSTIC PROCEDURES
    • –Endoscopy: direct visualization (done 1st) [NPO]
    • –H. pylori testing:
    • sputum, urine, blood, tissue, breath
    • • Urea breath shows active infection
    • –Occult blood
  41. PUD – TREATMENTS
    LIFESTYLE MODIFICATIONS
    • – Bland diet & 6 small meals per day
    • – Protein neutralizes but stimulates gastric secretions
    • – Adequate physical / emotional rest
    • – Stop ASA & NSAID’s (not always possible)
    • – Strict adherence to prescribed meds
    • – Antibiotic therapy for H. pylori
    • • May use two or more antibiotics [long term]
  42. PUD – TREATMENTS DRUG THERAPY
    – CARAFATE (Sucralfate)
    • • Slurry (mix it up)
    • • Give on empty stomach 1 hour before meals and bedtime.
  43. PUD – TREATMENTS DRUG THERAPY
    – PEPTO-BISMOL
    • • Promotes healing
    • • Partially effective against H. pylori
    • • May blacken stools
  44. PUD – TREATMENTS DRUG THERAPY
    – CYTOTEC (Misoprostol)
    • • For pts. taking ASA or NSAIDs who can not stop taking them
    • • Prevents gastric ulcers induced by the above
  45. PUD – TREATMENTS
    SURGICAL THERAPY
    • –20% of ulcer patients
    • – Indications:
    • • Obstruction
    • • Perforation
    • • Hemorrhage
    • • Ulcers unresponsive to treatment
    • • Multiple ulcer sites
    • • Possible malignancy
  46. BILLROTH I
    • is an operation in which the pylorus is removed and the distal stomach is connected directly to the duodenum
  47. BILLROTH II
    • is an operation in which the greater curvature of the stomach is connected to the first part of the jejunum in a side-to-side manner.
    • The surgical procedure is called gastrojejunostomy
    • – For gastric outlet obstruction
    • – Food bypasses the obstruction
  48. VAGOTOMY
    • –Truncal (total)
    • –Cut all or part of the Vagus Nerve
    • –Selective
    • –Reduces acid
    • –↓ gastric motility
    • –Often combined with Billroth I & II
  49. PYLOROPLASTY
    • –Surgical enlargement
    • –Aids gastric emptying
    • –Can do balloon angioplasty
  50. POST-OP COMPLICATIONS
    DUMPING SYNDROME
    • – Biggest issue
    • – Result of large portion of stomach and pyloric sphincter removal
    • – The food enters the small intestines before it can be properly digested/broken down
    • – Do not drink liquids with meal
  51. POST-OP COMPLICATIONS
    POSTPRANDIAL HYPOGLYCEMIA
    • – Form of dumping syndrome
    • – Large bolus of carbohydrates dumps into small intestine resulting in ↓BS (Increased carb diet will cause the pancrease to release insulin causing the blood sugar to drop)
  52. POST-OP COMPLICATIONS
    BILE REFLUX GASTRITIS
    – Related to surgery on pyloric sphincter
  53. PREOPERATIVE TEACHING
    • NPO status (after midnight)
    • The procedure itself
    • C & DB, IS use, incisional splinting
    • IV therapy (supplement IV therapy)
    • NG tube (placed by OR sutured to the nose [DO NOT TOUCH])
    • Pain relief
    • Answering all patient questions
  54. POSTPERATIVE PATIENT CARE
    • Promote comfort
    • Promote effective airway management and gas exchange Monitor I & O
    • – NG drainage: amount, color, odor
    • – Bright red in beginning (normal), then coffeeground
    • – Becomes yellow-green after 36-48 hours
    • –DO NOT IRRIGATE OR REPOSITION
    • Abdominal dressingdrainage, bleeding, odor
    • ALWAYS AT RISK FOR ULCER REDEVELOPMENT
    • Adequate rest, nutrition with avoidance of stressors
    • EMPHASIZE avoidance of meds not prescribed by MD, alcohol and smoking
  55. GASTRIC CANCER
    can migrate to the esophogus, duedoneum, or may mirgrate throught the stomach wall and spread to other organs and to distal lymph nodes
  56. GASTRIC CANCER PRIMARY PREVENTION
    • – Twice as often in men (depends on diet)
    • • Especially from lower socioeconomic class in urban areas
    • – More often occurrence over age 55
    • – Higher in African Americans than Caucasians
    • – Highest incidence in Japan, South America, Eastern Europe and part of the Middle East.
  57. GASTRIC CANCER ETIOLOGY:
    • UNKNOWN
    • DIET
    • – High in nitrates, salt and spiced foods
    • FOOD PREPARATION– Preserved by salt-curing, smoking, pickling or drying
    • PREPARATION ENVIROMENT– Poor drinking water or lack of refrigeration
  58. GASTRIC CANCER
    GENETICS
    • – Hx of GI cancer
    • – Type A blood has higher incidence
  59. GASTRIC CANCER
    MEDICAL CONDITIONS
    – Pernicious anemia, chronic gastritis, intestinal polyps, GERD
  60. GASTRIC CANCER 
    ACQUIRED
    • - Obesity
    • - H. Pylori
    • - Smoking
    • - Occupational (rubber plants and coal mines)
  61. GASTRIC CANCER RISK FACTORS
    • Gastritis
    • Nitrites
    • Poor nutrition
    • Poor sanitation
    • H. Pylori
  62. GASTRIC CANCER
    S&S INDICATE ADVANCED DISEASE
    • Abdominal pain Stool guiac +, GI bleeding
    • Bloating after meals, indigestion, heartburn
    • Diarrhea or constipation
    • Fatigue, weak
    • Anorexia, nausea, vomiting
    • Weight loss
  63. GASTRIC CANCER DIAGNOSTIC STUDIES
    • –Fecal occult blood
    • –Complete blood count
    • –Upper GI series
    • –Endoscopic gastroscopy (EGD)
    • •Permits biopsy
    • –CT scan +/or PET scan (assessing to see if metestasis)
  64. GASTRIC CANCER SURGICAL INTERVENTION
    • –Total Gastrectomy (Esophojejunostomy)
    • • Stomach completely removed
    • • Anastomosis of lower esophagus to the jejunum
    • –Lymph node involvement
    • –Followed by Chemo & Radiation
  65. GASTRIC CANCER
    TERTIARY PREVENTION
    • Compliance of prescribed dietary & drug regimes
    • Keep appointments for chemo &/or radiation
    • Referral to home care (TPN, nurse needs to hang)
    • Long term follow-up stressed

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