Friday, March 6, 2009

Nursing Lecture about Altered Nutrition:Gastrointestinal System

Altered Nutrition: Gastrointestinal System and Biliary Disorders
    • Group of ulcerative disorders in the upper GI tract caused by resistance of mucosa to acid-pepsin injury
    • Common site: 1 st part of duodenum
    • Risk factors:
      • Helicobacter pylori (H. pylori) –
      • gastric ulcers
      • Cigarrete smoking
      • Alcohol & caffeine intake
      • Stress
      • NSAIDs
      • Curling’s ulcer – 72hrs in clients with severe burns
      • Cushing’s ulcers – resulting from head injury
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    • Gastric Ulcer Duodenal Ulcer
    • Site - antrum of stomach - duodenum (proximal)
    • Problem - weakened mucosa - ↑in HCl
    • Pain - gnawing epigastric pain - gnawing epigastric pain
    • - occurs 1hr after eating - occurs 2hrs after eating
    • - aggravated by eating - relieved by food (closure
    • (increase acid secretion) of pyloric sphincter)
    • - relieved by vomiting
    • (acid is expelled)
    • - no pain at hours of sleep - pain at hours of sleep
    • ( decreased HCl production) (continuous gastric emptying)
    • Bleeding - commonly hematemesis - commonly melena
    • (anemia, weight loss)
    • Demographics
    • - common in older people - middle-age people
    • - females with familial history - males with no significant familial history (stress- related)
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    • History taking – include use of NSAIDs & ASA
    • Lab findings: occult blood
    • Barium contrast / Barium Swallow – radiologic visualization of upper GI
      • NPO 6-8hrs prior
      • 250mL Barium every hour 4hrs prior
      • After procedure: instruct client to increase oral fluids
      • Stool should return to normal brown color within 72hrs
    • Endoscopy (gastroscopy or duodenoscopy) – direct visualization of the GI system by means of lighted flexible tube
      • Secure consent
      • NPO 8hrs prior
      • Local anesthesia is used although sedative s may
      • be prescribed to help the client relax
      • NPO 1-2hrs after or until gag reflex returns
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    • Primary objective: provide stomach rest
    • Small frequent meals
    • Avoid foods that increases acidity (eg. caffeine, alcohol, milk)
    • Bland diet
    • Lifestyle changes: stop smoking
      • Stress management
      • Mental & physical rest
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    • Bismuth subsalicylate (Pepto-Bismol) for H.pylori
        • Promotes ulcer healing through mucosal bicarbonate production
        • Harmless darkening of stool
    • Sucralfate (Caralfate) & prostaglandin analogs; Misoprostol (Cytotec)
      • Provides local protective coat lining the stomach
      • Should not be administered with antacids
      • SE: diarrhea & pruritus
    • Antacids: - given 1-3hrs after meals & at bedtime (empty stomach; ↓ pain
      • administer separately at least 1-2hrs apart (interferes with other drug absorption)
      • Magnesium hydroxide (Maalox, Mylanta) – neutralize HCl ; SE: constipation
      • H 2 antagonists: Cimetidine (Tagamet), Ranitidine (Zantac), Famotidine – histamine antagonist – inhibits HCl production; tx lasts for 4-6wks ; SE: diarrhea & reversible impotence
      • Calcium carbonate – cause constipation; may cause hypercalcemia
      • Aluminum hydroxide (Amphojel)
      • Proton-pump inhibitors: Omeprazole, pantoprazole – inhibits H+ secretion
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    • Gastrectomy
      • Total – resection of the stomach with anastomosis of the esophagus & jejunum
      • Subtotal – partial resection of the stomach
        • Billroth I – gastroduodenostomy
        • Billroth II – gastrojejunostomy
      • Complications: pernicious anemia
      • perforation – (+) abdominal rigidity, tarry stool
      • dumping syndrome – rapid emptying of stomach due to stimulation of gastrocolic reflex (triggered by high-CHO food/concentrated CHO)
      • S/Sx: D iarrhea Mgt: lie down after meals
      • D iaphoresis fluid in between meals
      • D izziness eat dry foods high in CHON & fat (delays emptying) & low in CHO
    • Antrectomy – removal of lower portion of stomach (entire antrum)
    • Vagotomy – interruption of vagus nerve to decrease gastric secretion
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    • Backward movement of gastric contents into the esophagus (causes heartburn)
    • Causes:
      • Weak or incompetent lower esophageal sphincter
      • Delayed gastric emptying – increases gastric volume & pressure
      • Esophageal mucosal injury – related to the destructive nature of the refluxate & amount of time it is in contact with the mucosa (acidic gastric fluids)
      • Hiatal hernia - protrusion of the diaphragm taking place through the opening where the esophagus passes
        • Hernia may retard esophageal acid clearance
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    • Heartburn (pyrosis) – occurs 30-60mins after eating; usually at night
      • Made worse by bending at the waist (relieved by sitting upright)
    • Belching (water brash)
    • Pain – epigastric or retrosternal area (pain may be confused with angina)
      • Burning sensation that moves up & down
      • Occurs after meals
      • Relieved with antacids, by standing, or by walking
      • Precipitated by straining or lifting
    • Dysphagia – resulting from edema
    • wheezing
    • Chronic cough
    • hoarseness
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    • Esopha goscopy – passage of flexible fiber optic endoscope into the esophagus
      • To visualize the lumen of the upper GI tract
      • Permits biopsy
    • 24-hour pH Monitoring – small tube with pH electrode is passed through the nose into the esophagus
      • Data in the electrode are recorded in a small lightweight box attached to the waist
      • Button can be pressed when heartburn or pain occurs
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    • Instruct client to:
    • Have small frequent feedings (4-6x/day) but NPO 3h rs before sleep
    • Avoid caffeine, fats, chocolates in the diet (reduces esophageal sphincter tone)
    • Avoid alcohol & smoking
    • Eat meals sitting up rather (avoid recumbent position for several hours after eating)
    • Avoid bending for long periods – increases intra-abdominal pressure
    • Sleep with head elevated
    • Weight loss for overweight / obese clients
    • Meds:
    • Antacids
    • H 2 blockers: Cimetidine, Ranitidine, Famotidine
    • Proton-pump inhibitors: Omeprazole, pantoprazole
    • Motility agents: Meteclopramide – increases lower esophageal pressure & enhance esophageal clearance
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    • Nissen fundoplication – most frequently used & involves gastric wraparound (fundus around lower esophagus)
    • Hill’s operation – narrows the esophageal opening
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    • Esophageal diverticulum – out-pouching of the esophageal wall due to weakness of mucularis layer
      • Causes: congenital defect, esophageal trauma, scar tissue
      • Tends to retain food; gurgling, belching, coughing, foul-smelling breath
      • Small frequent feedings of semisoft foods
      • Progressive disease; therefore surgical intervention
    • Achalasia – failure of lower esophageal sphincter to relax & swallowed food has difficulty passing into the stomach (“something stuck in the throat”)
      • Cause: idiopathic
      • Enlarged esophagus
      • Small frequent meals (semisoft & warm)
      • Eat slowly & allow time to chew food thoroughly
      • Strict aspiration precaution
      • Dx: endoscopy, barium contrast – determine the site & extent of swallowing disorder
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    • Hiatal hernia – barium swallow (confirmatory)
      • Cause: muscle weakening due to aging, congenital, trauma
    • Esophageal cancer – more common among 50 years of age
      • Squamous cell tumors – associated with dietary & environmental influences (alcohol & tobacco use)
      • Adenocarcinoma – located in the distal esophagus & may invade the adjacent upper part of the stomach
        • Dysphagia – more frequent complain
        • Weight loss, anorexia, fatigue, & pain on swallowing
        • Tx: surgical resection, chemotherapy, irradiation (palliative)
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    • Presence of gallstones
    • Possible causes: gallbladder stasis, infection, genetics
    • Risk factors:
      • DM
      • Vagotomy
      • Long-term TPN
      • Liver cirrhosis
      • Pancreatitis
      • obesity
    • Manifestations: colicky pain, jaundice, nausea & vomiting
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    • inflammation of the gallbladder
    • inflammation believed to be caused by chemical irritation from the concentrated bile, mucosal swelling, ischemia from venous congestion & lymphatic stasis, gallstones
    • Risk factors: sedentary lifestyle & obesity
    • Types:
      • Acute – complete or partial obstruction
      • Chronic – from repeated episodes of acute cholecystitis or irritation of gallbladder by stones
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    • Pain often precipitated by a fatty meal commonly at RUQ
      • Does not spontaneously subside
      • Not responsive to analgesics
    • Tenderness on RUQ
    • Vomiting – bilious in character
    • Fever
    • High WBC count
    • Elevated total serum bilirubin, AST / ALT
    • Intolerance to fatty food
    • belching
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    • Ultrasound – can detect wall thickening (inflammation)
    • - can detect small (1-2cm) gallstones
    • Cholescintigraphy – gallbladder scan
    • - relies on the ability of the liver to extract rapidly injected radionuclide (technetium-99) that is excreted into the bile ducts
    • - reading every 10-15mins of the hour
    • - highly accurate
    • Oral cholecystography – radiologic technique that uses oral tablets containing radiopaque contrast medium
    • - fat-free diet 1-2days prior
    • - dye is taken 10-14hrs prior
    • -may produce nausea & vomiting or diarrhea
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    • Low-cholesterol diet
    • Laparoscopic cholecystectomy – treatment of choice for symptomatic gallbladder disease
    • - longer duration of operation shorter hospital stay (1 day after OR)
    • - client can resume work 1-2wks after
    • ESWL (Extracorporeal Shock-wave Lithotripsy) – uses soundwaves to pulverize gallstones (30-40mins)
    • - suitable only for radiolucent stones
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    • TPN contents:
      • Calories - 25 kCal/kg/day
      • Protein - 1.5g/kg/day
      • Carbohydrate & Fat
      • Electrolytes and water
      • Minerals, Vitamins, Micronutrients - trace elements and water-soluble vitamins, vitamin C, thiamine and zinc
    • monitoring of the following is vital:
      • Metabolic indicators
      • Evidence of complications, notably infection but also line-related thrombosis, and other line complications.
      • Adverse drug interactions
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    • Condition characterized by excess body fat (BMI ≥ 30)
    • May be seen as a sign of lack of self-control
    • Causes:
    • Basic energy imbalance – more energy intake (food) than energy expanded for basal metabolic needs & exercise = weight gain
    • Genetic & family factor – genetic control regulates differences in body fat & sex differences in weight; family food patterns add to genetic factor = social pressure, habits & attitudes toward food
    • Physiological factor – amount of body fat is related to the number & size of fat cells in the body
    • Psychosocial factor – eating under emotional stress; using food for comfort
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    • Hypertension
    • Cardiovascular & pulmonary diseases
    • Gallbladder diseases
    • Glucose intolerance / insulin resistance
    • Stroke
    • Arthritis
    • Infertility
    • Cancer (prostate, colon, breast)
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    • Focused on lifestyle modification
    • Determine client’s motivation & goal/s to lose weight (organizations: eg. TOPS, Weight Watchers, Overeater anonymous)
    • Physical activity – prevention of weight gain
      • Exercise must be started slowly with the duration & intensity increased independent of each other
    • Dietary therapy – individually prescribed based on client’s weight status & risk profile (usually calorie-restricted)
      • Risky practices for weight loss
        • Fad diets
        • Fasting
        • Clothing & body wraps
        • Drugs
        • Surgery
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    • Criteria for Evaluating Weight-reduction Diet
    • Realistic goals – promote 1-2lbs/wk weight loss; easily adapted to lifestyle; based on individual’s calorie requirement
    • Reduce caloric intake (Food consumption)
    • - use food to meet nutritional requirements rather than vitamins & minerals supplement
    • - encourage food from major food groups
    • - decrease fat consumption
    • - increase fruits, vegetables, grains, & fiber
    • Behavior Modification – control of eating behaviors & promotes physical activity
    • Exercise – encourage exercise plan that is acceptable & enjoyable to the client
    • Culturally acceptable – offer a maintenance plan after achievement of weight loss; re-educating of eating habits
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    • Sibutramine – inhibits serotonin, dopamine, norepinephrine re-uptake; decreasing appetite
    • Orlistat – lipase inhibitor; decreases fat absorption in the intestine
    • Surgery: Bariatric Surgery
      • Gastroplasty / Gastric Stapling – staples the top part of the stomach with the creation of a small pouch to receive ingested food
        • Psychiatric evaluation prior to procedure & participation in support groups
        • Comprehensive & extensive pre-op assessment
        • Post op: client can eat only 30mL / 5mins until satisfied via NGT then weaned
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    • Bariatric Surgery – also known as Gastric banding, O besity surgery (group of various procedures)
    • usually for men who are at least 100 pounds overweight and women who are at least 80 pounds overweight
    • limits the amount of food you can take in
    • reduce the size of the stomach
    • stomach is divided into two sections reducing the size of the new pouch from approximately two quarts to two ounces
    • drastic reduction in the size limits its capacity to hold food causing client to feel full after eating only a small amount;
    • also causes the food to bypass part of the digestive system, reducing the amount of calories the body absorbs
    • after surgery, client will find it hard to eat foods high in sugars and fats
    • emphasize that procedure is in no way to be considered cosmetic surgery


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