Generally the patient needs hospitalization with administration of intravenous fluids to help restore blood volume. Medication for pain and nausea are provided to ease these symptoms and food is withheld until these symptoms have subsided considerably. Antibiotics are often prescribed in cases of severe acute pancreatitis or if infection occurs. Surgery is sometimes needed when complications such as infection, cysts or bleeding occur. 

Chronic pancreatitis. Chronic pancreatitis is an ongoing inflammation of the pancreas, an organ located behind the stomach.  This progressive disorder associated with the destruction of the pancreas may be confused with acute pancreatitis due to the similarities of the symptoms. Upper abdominal pain and back pain with nausea and vomiting are the main symptoms of chronic pancreatitis. As the disease becomes more chronic, patients may develop malnutrition, weight loss and insulin-dependent diabetes.   The treatment for chronic pancreatitis depends on the symptoms.  However, most therapies centers focus on pain management ( Demerol and morphine sulfate)and nutritional support. Oral pancreatic enzyme supplements are utilized to aid in the digestion of food.(Creon, Bioglan, Panazyme Donnazyme, Entozyme) (Pancrease, ultrase, viokase, Zymase, Pancreacarb)

Hereditary Pancreatitis. Hereditary Pancreatitis is a rare inherited condition characterized by recurrent episodes of acute pancreatitis attacks. In about half of these cases the problem progresses to chronic pancreatitis, which is severe scarring of the pancreas. Laboratory tests performed during an attack usually detect high blood levels of amylase and lipase, which are enzymes released from the pancreas. The first attack typically occurs within the first two decades of life, but can begin at any age. Patients with hereditary pancreatitis may have chronic abdominal pain, diarrhea, nausea, vomiting, malnutrition, or diabetes. The treatment for hereditary pancreatitis depends on the symptoms.  However, the primary treatment focuses on pain control and pancreatic enzyme replacement. Surgery may be indicated to improve symptoms. Removal of the entire pancreas can be performed to eliminate the source of the problem, however in most cases this results in permanent insulin-dependent diabetes.

Cholecystitis.

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct.

A typical attack of cholecystitis usually lasts two to three days. The following are the most common symptoms of gallstones. However, each individual may experience symptoms differently. Symptoms may include:

• intense and sudden pain in the upper right part of the abdomen
• recurrent painful attacks for several hours after meals
• pain (often worse with deep breaths and extends to lower part of right shoulder blade), nausea, vomiting, rigid abdominal muscles on right side, slight fever, chills
• jaundice – yellowing of the skin and eyes, itching (rare), loose, light-colored bowel movements, abdominal bloating .

Treatment for acute cholecystitis usually involves a hospital stay, to reduce stimulation to the gallbladder. Antibiotics are usually administered to reduce the inflammation and/or fight the infection. Sometimes, the gallbladder is surgically removed.

Medical and surgical management.

When the gallbladder is acutely inflamed, the client takes nothing by mouth. Instead, a nasogastric tube is inserted. And antibiotics and parental fluids are prescribed until the inflammation subsides. Treatment of mild or chronic cholecystitis involves a low-fat diet. To relieve pain and discomfort, analgesic, anticholinergics, and even nitroglycerin are prescribed.Fat soluble vitamins may be ordered to compensate for their reduced absorption. A bile-binding resin, such as cholestyramine (questran), is prescribed to relieve pruritus. Client who are a surgical risk receive oral bile acids, either chenodeoxycholic acid (ursodiol, Actigall or UDCA, in attempt to dissolve the gallstones.

Lithotripsy.- is a non surgical procedure to break some types of gallstones. See pag 898 on timby.  LAPAROSCOPIC CHOLECYSTECTOMY, is a surgical procedure for gallbladder removal. This procedure requires general anesthesia.

Nursing Management.

During an attack of biliary colic, the nurse ensures that the client rests, monitors the ability to digest a bland liquid diet, and prescribed antispasmodic or analgesics. If gastric descompression  is required the nurse will insert a nasogastric tube and connects it to suction.

•Obtain vital signs immediately (shock is an outstanding symptom of pancreatitis).
•May have high blood pressure due to hypovolemia from release of protein rich fluids into the peritoneal space.
•Severe mid to upper abdominal pain, radiating to both sides and straight to the back.
•Nausea vomiting and flatulence are usually present.
•Complaints of steatorrhea (foul smelling or frothy stool)
•Symptoms are relieved when the client sits up and leans forward or curls into a fetal position.
•Upon physical examination may notice jaundice, abdomen is tender on palpations.
•As abdominal distention worsens bowel sounds may diminish.
•Cullen’s sign (bluish-gray discoloration to the skin about the umbilicus).
•Turner’s sign (bluish-gray discoloration to the skin about the umbilicus).
•Both Cullen’s sign and Turner’s sign indicate bleeding into abdominal area.
•Fever, tachycardia, and shallow breathing.
•Facial twitching (Chvostek’s sign)
•Spasms of fingers when taking blood pressure (Trousseau’s sign)
•Obtain complete medical history
•Inquire the frequency and amount of alcohol ingestion and determine when they had their last drink (may experience alcohol withdrawal).

Diagnostics for Pancreatitis:

•Serum lipase (may be elevated)
•Serum amylase (may be elevated)
•Serum trypsinogen (may be low)
•Fecal fat test show fatty stools
•Abdominal CT scan (may show pancreatic edema and necrosis)
•Abdominal ultrasound (may determine presence of pancreatic cysts, abscesses, and pseudocysts).
•ERCP-Endoscopic retrograde cholangiopancreatography (used to identify stones, tumors, and possible stenosis of bile ducts).

Assessement for Carcinoma of Pancreas:

•Most common symptom is left upper abdominal pain
•Abdominal pain may refer to back.
•Jaundice
•Anorexia and weight loss
•Light color stools and dark urine (symptoms associated with obstructive jaundice).
•Palpable mass in left upper quadrant (possible tumor or enlarged gallbladder).
•Ascites in the later stages of disease.

Diagnostics for Carcinoma of Pancreas:

•Abdominal CT scan or ultrasonography (may show pancreatic enlargement).
•Biopsy provides evidence of malignant cells. (ERCP or needle aspiration).
•Serum amylase, alkaline phosphatase, and bilirubin levels (supporting evidence of diseased pancreas).

Med-Surg Management for Carcinoma of Pancreas:

•Radical pancreatoduodenectomy (Whipple procedure), removes head of the pancrease, resects the duodenum and stomach, and redirects the flow of secretions from the stomach, gallbladder, and pancreas into the jejunum.
•Splenectomy may be preformed due to common metastasis to spleen.
•Deposit of radioactive seeds may be implanted during surgery.
•May perform total pancreatectomy.
•Radiation therapy or chemotherapy (5-fluorouracil or mitomycin).
•Poor prognosis is given to clients with Carcinoma of the pancreas, most clients die months after onset of symptoms, despite medical, or surgical treatment.

Outpatient Care for Cholecystitis:

Pre-op:
•Teach about: pre-surgical procedure, laboratory testing, consent form.
•Complete skin preparation, insert IV lines, administer sedation.

Post-op:
•Provide intensive intructions about self care to client, and caregiver.
•Perform follow up measures such as telephoning the client day after surgery.

If patient is having a cholecystectomy nurse should discuss:
•Location of pain or discomfort
•Ask weather specific foods cause pain or discomfort
•Discuss other problems like N/V or abdominal cramping
•Inspects the skin and sclera for jaundice and palpates the abdoment for tenderness

Routine assessments pre-surgical and post-surgical are necessary after surgery.

If T-Tube is in place after cholecystectomy:
•Monitor and record drainage
•Maintain tube patency by keeping collector below incision (prevents backflow of bile).
•Measure bile drainage every 8 hours.
•If 500 ml of bile drains notify physician.

Patient and Family teaching:
•Have client meet with dietician to see what foods to avoid
•Teach client to read labels to determine fat content.
•Discuss potential side effects of Medication.
•Inform client not to stop medication until physician verifies it.
•Discuss importance of reporting to physician severe pain, jaundice, fever, or if the color of stool or urine changes.

References:

Introductory Medical-Surgical Nursing
Lippincott Williams & Wilkins a Wolters Kluwer business

Diagnostic tests for Cholelithiasis and Cholecystitis
-cholecytography x-ray procedure used to examine gallbladder when gallstones are suspected
-CT scan shows infecton and any rupture
-Radionuclide Biliary Scan to see if common bile duct is blocked
-ERCP (Endoscopic Retrograde Cholangiopancreatography) to locate stone that have been collected in the common bile duct

Signs and Symptoms
The initial s/s -belching
-nausea
-RUQ discomfort with pain or cramps after high fat meals
Acute Cholecystitis
-fever
-vomiting
-tenderness over liver
-severe pain (biliary colic) pain radiates to back and shoulders
Gallbladder becomes swollen
Slight jaundice, urine dark brown, stool light in color

Jaundice (Icterus)
-Greenish yellow discoloration of tissue. It is a result from an abnormally high concentration of the pigment bilirubin in the blood. It is visable in the skin, oral mucous membranes and sclera.

Obstructive Jaundice
Gallstones, inflammation or tumors obstruct the bile duct, causing reabsorption of bile into the blood. Elevated conjugated bilirubin levels.

Nursing management for terminal malignant disorder
Evaluate general physical condition
Obtain history of all symptoms present before admissions

• Ask client about symptoms, weight loss, bleeding tendencies, and type of pain

Physical exam includes
• Inspect for jaundice
• Visual exam of stool & urine
• Palpate abdomen for tenderness or distention
• Labs include blood and urine analysis, detection for glucose
• Record vitals and weight and nutritional status

See chapter 20 of Timby for post operative

JCurransvnec
JLopezsvnec
J Lopez spn

2. Food enters the GI system at the mouth, where it is chewed and swallowed. Then the food enters the esophagus where the muscle layers move it down to the stomach in a wave like motion known as peristalsis. The esophageal sphincter prevent the food from coming back up. When food reaches the stomach it is temporarily held so that the food can be mechanically and chemically be broken down so it can then be deposited into the small intestine ( duodenum, jejunum, ileum) the duodenum is the first part of the small where bile and pancreatic enzymes enter which continue to breakdown food and transform chime into an alkaline state. Peristalsis then moves down the semi liquid mixture into the jejunum and ileum. The main function of the small intestine is to absorb nutrients from the chime. The large intestine ( cecum, colon, rectum, and anal canal) then receives waste from the small intestine and propels waste toward the anus. The large intestine absorbs water some electrolytes and bile acids. The unabsorbed material becomes fecal matter which is composed of water food residue, microorganisms, digestive secretions, and mucus. As fecal matter accumulates it distends the rectal wall, creating the urge to defecate.

Accessory structures:

There are 3 accessory structures the liver, gall bladder, and pancreas.

LIVER: it forms and releases bile, processes vitamins, proteins, fats, and carbohydrates, stores glycogen, contributes to blood coagulation, metabolizes and biotransforms many chemicals, bacteria, and foreign matter forms antibodies and immunizing substances.

GALLBLADDER: when the bile reaches the gallbladder from the common hepatic duct water and minerals are absorbed to form a more concentrated product. Gallbladder contraction triggered by ingested food causes bile to be released into the cystic duct and the then common bile duct into the duodenum where it aids in the absorption of fats, vitamins, iron and calcium.

PANCREAS: the pancreatic enzymes are released in inactive forms into the duodenum where they are activated. Chapter 50 pg. 809-810 timby

3. The digestive system, also called the gastrointestinal tract, is a passageway that extends through the body like a hallway through a building. Food must be broken down or digested and then absorbed through the walls of the digestive tube before it can actually enter the body and be used by cells. The breakdown of food is both a mechanical and chemical process. Teeth are used for the physical breakdown of food, where salivary amylase begins the chemical digestion of carbohydrates. It is then swallowed and goes through the pharynx by peristalsis. It then enters into the esophagus that leads to the stomach through the esophageal sphincters and into the stomach. Contraction of the stomach’s muscular walls mixes the food thoroughly with gastric juice and breaks it down into a semisolid mixture called chime. It is then passed through the small intestines and absorbs carbohydrates and protein digestion (sugars and amino acids.) After passing through the small intestine and then enters the large intestine and reabsorbs water, salts and vitamins. After going through the process of the large intestine  the substance from the large intestines become fecal matter that is eliminated from the body through the external opening of the anus.

4. The purpose of these wrinkles and projections is to increase surface area for absorption of nutrients. Each villus is covered in microvilli, which increase the surface area manyfold. Each villus contains a lacteal and capillaries. The lacteal absorbs the digested fat into the lymphatic system which will eventually drain into the circulatory system. The capillaries absorb all other digested nutrients.The surface of the cells on the microvilli are covered with a water layer, which has a number of functions in absorption of nutrients.

Absorption of the majority of nutrients takes place in the jejunum, with the following notable exceptions:

Iron is absorbed in the duodenum Vitamin B12 and bile salts are absorbed in the terminal ileum. Water and lipids are absorbed by passive diffusion throughout Sodium is absorbed by active transport and glucose and amino acid co-transport.Fructose is absorbed by facilitated diffusion.

5. Metabolism- The chemical processes occurring within a living cell or organism that are necessary for the maintenance of life. In metabolism some substances are broken down to yield energy for vital processes while other substances, necessary for life, are synthesized.

Resources the Human Body and Health Disease by Thibodeu Patton

American Heritage Dictionary

Inroductory medical-surgical nursing TIMBY

Wikipedia

Gastritis is a group of conditions characterized by inflammation of the lining in the stomach. Usually, the inflammation comes from infection with the same bacteria that causes most stomach ulcers. Traumatic injury and regular use of certain pain relievers also contribute to gastritis. There are two types of gastritis’s, first is acute gastritis which occurs suddenly and second is chronic gastritis which occurs slowly over time.

Nursing Management Responsibilities

The nurse must monitor the patient’s symptoms. Also evaluating the patient’s response to dietary modifications and prescribed medications is very important. The nurse should also observe the color and characteristics of any vomit or stool that the patient passes. The nurse also needs to provide patient teaching. Nurses should instruct the patient to eat smart by eating smaller but frequent meals to ease the effects of stomach acid. Along with that instruct the patient to avoid foods that are irritating like spicy, acidic, fried, and fatty. Inform the patients to avoid or limit alcohol use because it can irritate and erode the mucous lining of the stomach. Patients that are taking NSAIDs for pain should ne instructed to use medications with acetemetiphen. NSAIDs can cause stomach inflammation or irritation to worsen.

2. Define peptic ulcers?

Peptic ulcers are open sores that develop on the inside lining of the stomach, upper small intestine, or esophagus. These ulcers form when they come in contact with hydrochloric acid and pepsin.

3. DISCUSS THE PATHOPHYSIOLOGY OF GASTRITIS?

Gastric secretions are very acidic. Parietal cells in the stomach increase acid production known as hydrochloric acid in response to seeing, smelling and eating food. The parasympathetic vagus nerve releases histamine and acetylcholine, chemicals that also stimulate the parietal cells. An increasing level of acid may trigger the break down of pepsinogen to pepsin, creating a chemical mixture strong enough to break down the stomach wall. Because mucus protectively coats the stomach lining, however, pepsin normally will have little effect. Prostaglandin E, a lipid compound secreted in the stomach, promotes the production of mucus, which contains buffer substances and mechanically bars penetration by stomach acids. The submucosal layers of the stomach can be inflamed, however, when irritating substances reduce or penetrate the mucous layer the person feels epigastric discomfort, can also be known as heart burn. Chronic irritation leads to ulceration.

DISCUSS THE PATHOPHYSIOLOGY OF DUODENAL DISORDER?

The pathophysiology of a duodenal disorder occurs when the normal balance between factors that promote mucosal injury such as gastric acid, pepsin, bile acid, ingested substances, and factors that protect the mucosa is bothered. The greatest factor for development of PUD is infection of an organism called helicobacter pylori. Transmission of the disease maybe by fecal, oral or oral, oral pathway. It appears that H. pylori secrete an enzyme that depletes gastric mucus, making it more susceptible to injury.

4. MEDICATION THERAPY WITH PEPTIC ULCER?

If the bacterium H. pylorus is present extensive therapy is started. A combination of antibiotics is started such as tetracycline used to treat the bacteria, Flagyl which eliminates the bacteria or microorganisms, proton pump inhibitors such as Protonix the acid production at the surface of parietal cells. Further treatment may include and bismuth salts such as Pepto Bismol suppresses the H. pylori and helps heal mucosal lesions. Zantac blocks histamine antagonist’s receptors and decreases acid secretion in the stomach.

5. List the common symptoms?

Common symptoms of Gastritis are:

Epigastric fullness
Pressure
Pain
Anorexia
Nausea & vomiting
Diarrhea
Fever
Gastric bleeding

Common symptoms of Peptic Ulcer Disease (PUD) are:

First sign of ulcer is bleeding
Burning, gnawing, dull pain after meals
Pain during night time
Hemorrhage
Hematemesis
Melena
Dizziness & syncope

6. Complete basic assessment, and recognize “high risk” clients?

Nursing assessment for client with gastritis and peptic ulcer disease:

Ask client about symptoms like indigestion, fullness, heartburn, nausea and vomiting?
How long has the client had these symptoms?
When the symptoms occur and what aggravates it?
What the client does to relieve symptoms?
Does the client have any past gastric problems or treatments?
Assess the clients abdomen noting any changes in the abdomen such as:

Distention
Tenderness
Pain

Clients at high risk for gastritis and peptic ulcer disease are:

Clients using NSAIDs, alcohol, caffeine, corticosteroids, salicylates.
Smokers
Ingestion of poisons or corrosive substances
Bacteria Infection (Helicobacter Pylori)
Clients under physiological stress

7. List the primary nursing responsiblities?

Nursing Responsibilities:

The nurse must explore each symptom of PUD in depth. For example, if pain occurs, the nurse determines its type, onset in relation to eating food, location, and duration. A dietary history must include relevant questions pertaining to foods that cause distress, the amount of foods eaten at each meal, and whether eating food relieves pain. For a client to continue eating, it may be necessary to modify ingredients, temperature, or consistency of foods, as well as to use smaller portions on smaller plates. Clients need nutritional supplements. If the client is receiving tube feedings, rein stilling the gastric residual is necessary because it contains partially digested nutrients and essential electrolytes. In addition, the nurse notes the client’s bowel patterns and stool characteristics. Nurse evaluates the client’s emotional status and response to activity. The nurse monitors the nonsurgical client closely for medical complications, which includes assessing vital signs and fluid status.

8. Recognize the most common complications of peptic ulcer?

What are the complications of peptic ulcers?
Gastrointestinal bleeding is one of the most serious complications of ulcers. It results when the ulcer erodes into a blood vessel in the wall of the stomach or duodenum. The common signs of bleeding include vomiting fresh, bright red blood or passing bloody or tarry, black stools. Pepto Bismol, often taken for relief of ulcer symptoms, may also cause black

discoloration of the stools. In the case of severe hemorrhage, weakness, fatigue, loss of consciousness and or shock may result.

Another serious ulcer complication is perforation. This can develop as stomach acid erodes through the intestinal wall and spills into the abdominal cavity. The first sign of perforation is sudden, intense, steady abdominal pain. Ulcer perforation leads to the leakage of gastric contents into the abdominal (peritoneal) cavity, resulting in acute peritonitis (infection of the abdominal cavity). These patients report a sudden onset of extreme abdominal pain, which is worsened by any type of motion. Abdominal muscles become rigid and board-like. Urgent surgery is usually required.

A third complication of ulcers is obstruction of the digestive tract, usually at the junction of the stomach and duodenum, as old ulcer scars accumulate and narrow the passageway through this area. As a result, food and fluid passing from the stomach to the duodenum may be restricted or blocked altogether, producing a distended stomach (from retained food and secretions), intense pain, and continued vomiting. The obstruction usually occurs at or near the pyloric canal. The pyloric canal is a naturally narrow part of the stomach as it joins the upper part of the small intestine called the duodenum. Upper endoscopy is useful in establishing the diagnosis and excluding gastric cancer as the cause of the obstruction.

9. List signs and symptoms of G.I. bleeding?

Bleeding from the esophagus can be caused by:

Esophagitis and gastroesophageal reflux. Stomach acid that refluxes (returns) back into the esophagus from the stomach can cause damage that may lead to bleeding at the lower end of the esophagus called esophagitis.
Varices. Abnormally enlarged veins located at the lower end of the esophagus, called varices, may rupture and bleed massively. Cirrhosis of the liver is the most common cause of esophageal varices.
Mallory-Weiss tear. This is a tear in the lining of the esophagus that usually is caused by prolonged vomiting but may also result from other causes of increased abdominal pressure, such as coughing, hiccupping, or childbirth.
Bleeding from the stomach can be caused by:

Gastritis. Alcohol, aspirin, aspirin-containing medicines, pain medicines –collectively called NSAIDs (nonsteroidal anti-inflammatory drugs) — such as Motrin, Aleve, or ibuprofen and many others can cause stomach ulcers or inflammation (gastritis).
Stomach ulcers and intestinal ulcers. Ulcers in the stomach may enlarge and erode through a blood vessel, causing bleeding. Aside from medication, the most common cause of a stomach ulcer is an infection with bacteria called Helicobacter pylori. Also, patients suffering from burns, shock, head injuries or cancer, as well as those who have undergone extensive surgery, may develop stress-related stomach ulcers. Intestinal ulcers are believed to be caused by excess stomach acid and infection with Helicobacter pylori.
Cancer of the stomach.
Hemorrhoids. These are probably the most common cause of visible blood in the lower digestive tract, especially blood that appears bright red. Hemorrhoids are enlarged veins in the anal area that can rupture and produce bright red blood, which can show up in the toilet or on toilet paper.
Anal fissures. Tears in the lining of the anus can also cause bleeding.
Colon polyps. These are growths that can occur in the colon. They can be the precursor of cancer and may cause bleeding.
Colorectal cancer.
Intestinal infections. Inflammation and bloody diarrhea can result from intestinal infections.
Ulcerative colitis. Inflammation and extensive surface bleeding from tiny ulcerations can be the reason for blood showing up in the stool.
Crohn’s disease. This condition can result in spotty bleeding.
Diverticular disease. Caused by diverticula — outpouchings of the colon wall — can result in massive bleeding.
Blood vessel abnormalities. As one gets older, abnormalities may develop in the blood vessels of the large intestine, which may result in recurrent bleeding.
How Is Bleeding in the Digestive Tract Recognized?

The signs of bleeding in the digestive tract depend on the site and severity of bleeding.

If blood is coming from the rectum or the lower colon, bright red blood will coat or mix with your stool. The stool may be mixed with darker blood if the bleeding is higher up in the colon or at the far end of the small intestine.

When there is bleeding in the esophagus, stomach or duodenum, the stool is usually black or tarry. Vomit may be bright red or have a “coffee-grounds” appearance when bleeding is from the esophagus, stomach or duodenum.

If bleeding is occult, or hidden, you might not notice any changes in stool color.

If sudden massive bleeding occurs, a person may feel weak, dizzy, faint, short of breath or have cramp-like abdominal pain or diarrhea. Shock may occur, with a rapid pulse, drop in blood pressure and difficulty in producing urine. You may become very pale.

If bleeding is slow and occurs over a long period of time, a gradual onset of fatigue, lethargy, shortness of breath and pallor (or paleness of the skin) from anemia will result. Anemia is a condition in which the blood’s iron-rich substance, hemoglobin, is diminished.

Note that iron and some foods, such as beets, can give the stool a red or black appearance, falsely indicating blood in the stool.

What Signs Indicate Bleeding in the Digestive Tract?

Bright red blood coating the stool
Dark blood mixed with the stool
Black or tarry stool
Bright red blood in vomit
“Coffee-grounds” appearance of vomit

http://www.apsfa.org/gibleed.htm

10. Define duodenal ulcer, and discuss usual assessment and nursing care?

A duodenal ulcer is a raw area in the lining in the upper part of the small intestine (duodenum), where it connects to the stomach

People who have a family history of duodenal ulcer are more likely to get them, and the problem is four times greater in men than in women over fifty years of age. Other risk factors include having a Helicobacter pylori infection, using nonsteroidal anti-inflammatory drugs such as aspirin and ibuprofen, and the use of cigarettes and alcohol.

A duodenal ulcer is caused when the lining of the stomach is eaten away by stomach acid and digestive juices.

Duodenal ulcers respond well to treatment, but changes in lifestyle may be recommended to prevent reoccurrences. Patients should consider not smoking or using other tobacco products and reduce their alcohol consumption and caffeine intake. Patients may also want to avoid drugs that cause stomach inflammation, such as aspirin, ibuprofen and naproxen. Other lifestyle changes may include eating balanced, nutritious meals, learning how to manage stress, and getting plenty of rest and exercise.

References

www.cdc.gov

www.mayoclinic.com

Introductory Medical-Surgical Nursing 9th Edition Barbara Timby and Nancy Smith

http://www.hmc.psu.edu/healthinfo/d/duodenalulcer.htm

T. SVN, C. SVN, H. SVN, E. SVN, D. SVN

1. S/S of Diarrhea:

Stools are watery and frequent

Some cases, blood and mucus in stool

Experiences urgency (tenesmus) and abdomen discomfort 

Bowel sounds are hyperactive

 Fever may be present

 Skin around anus may become excoriated

Management:

Rest the bowel by limiting intake to clear liquids for one or two meals and gradually advancing to a regular diet.

Administer antidiarrheal agent, such as Lomotil, Imodium, or a combination product such as Kaopectate

 Fluid and electrolyte replacement by either the oral or IV route

Dietary adjustments, may involve eliminating foods that cause diarrhea

TPN if diarrhea is severe and prolonged and if the introduction of oral fluid and food results in another episode of diarrhea

Ro re-colonize the bowel take or eat probiotics. Example eat yogurt Low residue diet to manage it

S/S of constipation

 Bowel elimination is infrequent or irregular. Feel “bloated”

 Bowel sounds may be hypoactive, abdomen May be distended or tympanic

Stool that is passed may be hard and dry

Rectal bleeding from stretching and tearing the tissue from hard, dry stools

Scybala (stool feels like small rocks) when having a rectal exam If constipated for a long time, client may pass liquid stool that goes around the obstructed mass of stool (encorpresis) This is the most common symptom of nursing home residents, school-aged children who have chronic constipation, and stool withholding behavior.

Management:

For quick symptomatic relief physician prescribes an enema or a laxative in oral or suppository form, followed by prophylactic administration of stool softener High fiber Diet

 Drugs such as Senokot, MOM, Metamucil, Colace

2. Appendicitis

Define: inflammation of a narrow, blind protrusion called the vermiform appendix located at the tip of the cecum in the right lower quadrant of the abdomen

Clinical signs:

v Positive Rovsing’s sign which is examiner does deep palpation in the left lower abdominal quadrant and the client feels pain in the right lower abdominal quadrant. This suggests acute appendicitis.

v Early s/s abdominal pain in epigastric or umbilical area, or associated with abdominal discomfort and accompanied by fever and N/V.

v Intermediate (acute) stage: over period of few hours pain shifts from mid-abdomen to RLQ, and is aggravated by walking, coughing, and movement. Pain may be accompanied by sensation of constipation.

v Anorexia, malaise, occasional diarrhea and diminished peristalsis can occur. Pain may come from urinating.

Pre and post-operative care:

Pre:

v An informed consent form must be signed acknowledging that the patient understands the procedure, the potential risks, and that they will receive certain medications.

v Preoperative tests vary according to the patient’s age and health, but a blood test, chest x-ray, and electrocardiogram (EKG) are standard.

v Antibiotics are given, client restricted from eating & drinking, including oral medications, while decision is being made about surgery if surgery is already known client needs to restrict eating and drinking after midnight the night before.

v IV fluids are prescribed to meet clients fluid needs

v If symptoms worsen the surgeon performs an appendectomy before the appendix ruptures.

v Prepare client quickly for surgery to avoid delaying surgical complications.

v know about any other medical conditions; if the patient is taking any medication (prescription or OTC); if any dietary supplements or herbal products are being used; if there has been recent illicit drug use; if the patient smokes cigarettes or drinks alcohol; if the patient has a history of allergies, especially to medications; or has had a previous reaction to anesthesia, or a family history of problems with anesthesia.

Post:

v Following surgery, the patient is taken to the postanesthesia care unit (PACU) until the anesthesia wears off.

v During this time, the nursing staff checks temperature, heart rate, and breathing at frequent intervals. When the anesthesia wears off and vital signs stabilize, the patient is transferred to their hospital room

v A healthy young patient may return to activities soon; age, general physical condition, and extent of complications depend on how fast client recovers.

v Avoid heavy lifting after surgery

3. Peritonitis

Causes:

v Perforation by a peptic ulcer, bowel, or the appendix

v Abdominal trauma (gun shot or knife wound)

v IBD

v Ruptured ectopic pregnancy

v Infection introduced during peritoneal dialysis

Nursing responsibilities:

v Administer analgesics

v Ng tube to connected to suction

v Urinary retention catherter

v V/S taken frequently and monitor central venous and pulmonary artery pressures

v Assess fluid balance, dressing drainage, pain level (1-10), frequent explanations and emotional support

v Monitor for continued abdominal infection

v Notify physician quickly if anything worsens (changes in level of conciousness, deviations in V/S)

Sources:

v Introductory Medical surgical nursing, by Barbara K. Timby & Nancy E. Smith

v http://www.surgerychannel.com/appendectomy/postop.shtml

4. HERNIAS

A hernia is a protrusion of any organ from the cavity that normally confines it; most commonly used to describe the protrusion of the intestine through a defect in the abdominal wall.

Five common types of hernia’s are;

1. Inguinal hernia: is a protrusion of the hernial sac and contains the intestine at the inguinal opening

2. Umbilical hernia: occurs in the umbilical region, through which the hernial sac protrudes. This type occurs in children when the umbilical orifice fails to close shortly after birth. It may occur in obese adults who have prolonged abdominal distention.

3. Femoral: intestines descent through the femoral ring where the femoral artery passes into the femoral canal, below the inguinal ligament. Incidence of strangulation is high.

4. Incisional: Occurs through the scar of a surgical incision when healing is impaired. Obese, older, or malnourished clients are prone to the development of incisional hernias.

5. Hiatus hernia: Occurs in the chest and afftects the digestive tract.

Common treatments: surgery is the only method of eliminating a hernia. If a pt does not want to have surgery or is not a candidate for surgery then they can wear a truss (an apparatus that press over the hernia and prevents protrusion). Another treatment is the pt can lie supine while manual pressure is applied over the protruding area to reduce the hernia periodically.

Surgery is called a herniorrhaphy and when performed the protruding intestine is repositioned in the abdominal cavity and the defect in the abdominal wall is repaired. It’s performed under local, spinal or general anesthesia or can be treated using laparoscopic approach.

If a person is prone to recurrence of the hernia ie: obese pt’s a hernioplasty may be performed. The procedure being performed is reinforcing with wire, fascia, or mesh, this is done so that the weak lining can help hold the herniated organ in place. Before being performed the obese pt is asked to loose some weight.

Nursing Care: Before surgery, obtain med history and drug history because of malnutrition and diabetes, or concurrent use of corticosteroids or antimetabolite cancer drugs which can affect wound healing, obtain pt allergy and smoking history because can cause sneezing and coughing which increases intra abdominal pressure after surgery, auscultate lungs to check for infection in respiratory and document pt’s weight and duration of hernia.

After surgery: (post-op) the nurse teaches the family and pt verbal and written instructions, and advise of signs and symptoms (ie: bleeding, infection) to cll healthcare provider asap, avoid constipation and straining to have a bowel movement, pt is to avoid strenuous exertion and heavy lifting

5. DIVERTICULOSIS (IT IS)

Diverticulosis is an asymptomatic diverticula

Diverticulitis is the inflammation of the diverticula

Diverticula are sacs/pouches caused by herniation of the mucosa through a weakened portion of the muscular intestine or other structures (can appear anywhere in the GI tract)

Diverticula are common in the colon and in the sigmoid area in people over 50yrs of age, and people with low fiber diet have more incidence of diverticula. Diverticula become inflamed when fecal material becomes trapped in one or more blind pouches. Inflammation causes swelling of the tissue, edema may be severe enough to cause intestinal obstruction.

Sources from timby pg 865-868

And www.hernia.org

c.fernandez svn

Austin Sherer

Thursday, August 14, 2008

GI Assignment – #6, 7, 8

6) “Define Crohn’s disease, and differentiate between care in Crohn’s and ulcerative colitis”

a. Crohn’s Disease: A chronic, inflammatory disease that can involve any part of the GI tract from the mouth to the anus. Typically, the disease occurs in segments, leaving portions of healthy bowel in between the diseased areas.

b. The difference between care of a client with Crohn’s Disease versus ulcerative colitis varies. Even though they both share a lot of the same medicinal treatments such as corticosteroids, Remicade is a primary medicine used for Crohn’s Disease, whereas it isn’t used in clients with ulcerative colitis. Surgically, portions of the bowel may be removed in Crohn’s disease since it affects portions of the bowel. In ulcerative colitis, the entire section of the colon is removed. Also, after a colectomy, several pouches can be made with portions of the small intestine. For a client with Crohn’s disease, these pouches are not recommended since Crohn’s can occur in the pouch.

7) “Discuss the incidence of cancer of the colon.”

a. Cancer of the colon develops from colorectal tumors that have derived from benign adenomas in the mucosal and submucosal intestinal layers. The benign polyps become malignant, which begin to attack the surrounding tissues. Colorectal cancer can be catalyzed by the presence of ulcerative colitis, chronic bowel inflammation such as Crohn’s Disease and a lifestyle of eating low-fiber, high-fat foods.

“Recognize specific nursing responsibilities for clients with a colostomy.”

a. Nursing responsibilities for clients with a colostomy would include inspecting the stoma for any changes in appearance, such as size and color. Other nursing responsibilities would include encouraging the client to eat a regular diet while avoiding gas-producing foods, eliminate food items from their diet that result in diarrhea, eat slowly with mouth closed and chew food well to decrease gas intake from swallowing additional air with the food. More nursing responsibilities would include checking the body weight regularly, irrigate the site of the stoma at the same time everyday (typically best after a meal since food in the digestive tract stimulates peristalsis and defecation).

Sources: “Introductory Medical-Surgical Nursing”, Timby.

Austin Sherer, SVN

INTESTINAL DISORDERS

9. Recognize the importance of wound hygiene, and carry out appropriate care to reduce infection and enhance client comfort
Wound healing is monitored, and complications that develop are managed. Possible post-op complications include: intestinal obstruction, bleeding, impaired blood supply to, stenosis of, or prolapse or excessive protrusion of the stoma.

Different ostomies include: a colostomy, temporary colostomy, permanent colostomy, sigmoid or descending colostomy, transverse colostomy, loop colostomy, ascending colostomy, ileostomy, ileoanal reservoir (J-Pouch), and continent ileostomy (Kock Pouch).

Before beginning wound care, the wound must be assessed for healthy or unhealthy characteristics by assessing the color, size, opening, surface, length, and sensation. Then the nurse begins the wound care:

· Perform hand hygiene and organize equipment, and prepare new stoma pouch.

· Explain procedure to patient, then provide privacy

· Position mirror to reveal stoma area to client.

· Put on gloves.

· Place waterproof pad on abdomen around and below stoma opening.

· Remove pouch (and place in a plastic waste bag) by gently lifting corner with fingers of dominant hand while pressing skin downward with fingers of nondominant hand at small sections at a time.

· Place 4×4 gauze over stoma opening.

· Empty pouch, measure waste in graduated container before discarding.

· Remove gloves and perform hand hygiene.

· Clean entire stoma and the skin surrounding the stoma with a washcloth soaked in warm, soapy water. Rinse and pat dry.

· Use measuring guide to trace opening on back of wafer.

· Leaving intact adhesive covering of skin-barrier wafer, cut out circle, allowing an extra 1/8 inch for placement over stoma.

· Remove gauze and apply stomal paste around stoma or to the edges of the opening in the wafer.

· Remove gloves and discard all necessary equipment.

· Spray room deodorizer if needed.

· Perform hand hygiene

[see Smith-Temple, Johnson: Nurse’s Guide to Clinical Procedures 5th edition, pg 535-537, 544-547]

10. List the types of ostomy equipment necessary for caring for colostomy, and perform necessary procedures to ensure good hygiene

· Two pairs of nonsterile gloves

· Graduated container

· Disposable waterproof bed pad

· Basin of warm, soapy water (soap should be mild without oils, perfumes, or creams)

· Washcloth and towel

· 4×4 gauze

· Scissors

· Pen or pencil

· New pouch appliance

· Peristomal skin paste and wafer

· Stoma measuring guide

· Mirror

· Room deodorizer

OTHER OSTOMY ACCESSORIES

· Convex Inserts- Convex shaped plastic discs that are inserted inside the flange of specific two-piece products.

· Ostomy Belts- Belts that wrap around the abdomen and attach to the loops found on certain pouches. Belts can also be used to help support the pouch or as an alternative to adhesives if skin problems develop. A belt may be helpful in maintaining an adequate seal when using a convex skin barrier.

· Pouch Covers- Made with a cotton or cotton blend backing, easily fit over the pouch and protect and comfort the skin. They are often used to cover the pouch during intimate occasions. Many pouches now include built-in cloth covers on one or both sides, reducing the need for separate pouch covers.

· Skin Barrier Liquid/Wipes/Powder- Wipes and powder help protect the skin under the wafer and around the stoma from irritation caused by digestive products or adhesives. They also aid in adhesion of the wafer.

· Skin Barrier Paste- Paste that can be used to fill in folds, crevices or other shape or surface irregularities of the abdominal wall behind the wafer, thereby creating a better seal. Paste is used as a “caulking” material; it is not an adhesive.

· Tapes- Tapes are sometimes used to help support the wafer or flange (faceplate) and for waterproofing. They are available in a wide range of materials to meet the needs of different skin sensitivities.

· Adhesive Remover- Adhesive remover may be helpful in cleaning the adhesive that might stick to the skin after removing the wafer or tape, or from other adhesives.

[see United Ostomy Associations of America, Inc. http://www.uoaa.org/ostomy_info/whatis.shtml]

—————————————————————————————F. Pada SVN-EC

11. Define intestinal obstruction. Discuss the implications for nursing care.

     Intestinal obstruction occurs when a blockage interferes with the normal progression of intestinal contents through the intestinal tract. The causes are classified as mechanical or functional and as partial or complete. The severity depends on the region of the bowel affected, degree to which the lumen is obstructed, and degree to which the blood circulation to the intestine is impeded. An intestinal obstruction is extremely dangerous and maybe fatal if not treated promptly.

     The care of a client with an intestinal obstruction involves managing pain, maintaining fluid balance to prevent deficits related to fluid shifts and losses from vomiting, and helping the client deal with fear related to severe, possibly life-threatening symptoms and an unstable condition. The nurse also manages pain by maintaining the patency of the decompression tube and administering a prescribed narcotic analgesic as long as blood pressure and respiratory rate indicate that doing so is safe. The nurse maintains uninterrupted infusion of IV fluids and shortens the siege of vomiting by maintaining intestinal decompression, even though intestinal fluid is lost in suctioning. It is crucial to monitor urinary output hourly and to report output below 50 mL/hour, a finding that may indicate that the client is going into shock.

12. List important nursing considerations for a client undergoing rectal surgery and assist in planning care and carrying out appropriate measures.

• Getting Ready for Surgery
  To prepare for rectal surgery—
  • Do not eat or drink anything after midnight the night before surgery; this includes water and chewing gum.
  • Continue to take medication as prescribed, but with only a sip of water. Do not take ibuprofen, aspirin or any medication containing aspirin for one week before surgery.
  • Do not smoke after midnight the night before surgery.
  • Do not wear artificial nails or nail polish. Patient’s nails are monitored during surgery to identify oxygen and blood circulation.
  • Bring a list of all medications and their dosages.

Most anorectal surgical procedures are done in same-day surgery. A few more extensive procedures require hospitalization for one to three days. Patient’s ability to tolerate the pain postoperatively and doctor’s concern about patient’s wounds determine the time of discharge.

Anorectal Nursing Care Plan after surgery:

Instruct client, unless contraindicated, to increase intake of water to 2 L/day.

Provide a list of high-fiber foods.

Instruct client in use of laxatives or stool softeners as ordered.

Teach the client to heed the urge to have a bowel movement.

Encourage client to rest in a comfortable position that removes pressure from surgical site, or to use a flotation device.

Administer pain medications as ordered.

Apply ice and analgesic ointments as indicated.

Instruct client to cleanse perianal area with warm water and to dry with cotton wipes.

Teach client how to do sitz baths at home, using warm water, and three to four times each day.

Encourage client to follow diet and medication instructions.

>Encourage moderate exercise.

Bowel Function
Bowel movements after anorectal surgery are usually associated with moderate to severe discomfort. Constipation and diarrhea make the pain much worse and must be avoided. The trauma to the anal wounds caused by hard bowel movements will slow down the healing process.

Constipation
Client should be sure to have a bowel movement at least every other day. If two days pass without one, take an ounce of milk of magnesia; if there is no result; repeat this dose in six hours. Client can also use an over-the-counter phosphate enema or tap water enema.

Diarrhea
Diarrhea, usually caused by overuse of laxatives, is also a concern if patient have more than three watery bowel movements during a 24-hour period. If diarrhea occurs, stop taking milk of magnesia or other laxatives. Continue the bulk-forming agents. If the diarrhea persists, call the physician.

Bathing
After bowel movements, use a wet wash cloth, toilet paper, cotton, or perianal pads (Tucks, Preparation H pads) to clean. If possible, take a sitz bath or tub bath immediately. Baths should last at least 10 to 15 minutes with the water as warm as client can comfortably tolerate. Try to take at least three baths (or showers with a hand-held sprayer) a day.

Discharge/Infection
Some bloody discharge after bowel movements is normal for at least two to four weeks after rectal surgery. If client have profuse, continuing bleeding, call the doctor immediately. Postoperative infection around the rectal opening is surprisingly uncommon despite the obvious contamination by stool. This is probably because of the very excellent blood supply to the area.

Urination
If client  have trouble urinating, do so while sitting in a warm tub of water, or run the water faucet while sitting on the toilet. If the problem is severe or persistent, the doctor may prescribe oral bladder stimulants.

Diet
Eat a high-fiber general diet, including plenty of fruits and vegetables. Try to drink at least six to eight glasses of water or juice per day to help keep the stool soft.

Activity
On discharge there are generally no restrictions on walking, climbing stairs, or riding in a car. After some procedures client will be asked to avoid strenuous activity or heavy lifting for 7 to 14 days.

Sources:

 Barbara K. Timby and Nancy E. Smith Book

 http://www.colonrectal.org/index.htm

Atlanta Colon & Rectal Surgery,P.A.

can start in the mouth or present as a burning in the Throat all the way down to the upper abdominal area. Sometimes cardiac chest pain can present as a gastric disorder so it is important to get a medical diagnosis.

Endoscopy is a routine, outpatient procedure in which the inside of the upper digestive system is examined.

The procedure is commonly used to help identify the causes of:

Abdominal or chest pain

Nausea and vomiting

Heartburn

Bleeding

Swallowing disorders

Endoscopy can also help identify inflammation, ulcers and tumors.

An endoscope is a thin, flexible tube with a tiny camera on the end.

Three separate X-ray examinations may be done:

Barium Swallow, an examination of the canal in the throat that leads from the mouth to the opening of the stomach
Upper GI (UGI), an examination of the stomach
Small-bowel series, an examination of the small intestine
Three different types of tests are available to detect H pylori:

– Blood tests: These tests detect the bacteria by measuring antibodies to the bacteria. Antibodies are proteins produced by the immune system to defend against an “invader” such as H pylori. The blood test is inexpensive and can be done in a medical office. The down side is that it can be positive in a person who had an ulcer before and was already treated for it.

– Breath test: This test detects H pylori by measuring carbon dioxide in the breath of a person who has drunk a special liquid. H pylori bacteria break down the liquid, increasing the amount of carbon in the blood. The body gets rid of this carbon by breathing it out as carbon dioxide. This test is more accurate than the blood test but is more difficult to carry out. It is often used after treatment to check whether H pylori bacteria have been eradicated.

– Tissue tests: These tests are used only if an endoscopic biopsy has been done, because a sample of tissue from the stomach is needed to detect the bacteria.

During the care of the client with oral conditions and GI disorders a nurse may need to place a gastrointestinal intubation tube for feedings or medications, and decompression.

There are several types of tubes, here are a few examples:

– Levin (plastic or rubber)

– Gastric Sump Salem (plastic)

– Moss

– Sengstaken-Blakemore (rubber)

Nasoenteric Decompression Tubes

– Miller-Abbott (rubber)

– Harris

– Cantor (rubber)

– Baker (plastic)

Nasoenteric Feeding Tubes

– Dobhoff or Keofeed II (polyurethane or silicone rubber)

References:

http://www.charlotteradiology.com/

Timby, p. 365, 825,839, 844

E. H. VNS

Basic signs and symptoms of CONDITIONS OF THE MOUTH

List common management and implement appropriate nursing actions for each

Cold sores are painful sores that are red and crusted on your patient’s lip or on the outer edges of lips. Cold sores are caused by a herpes simplex virus. Explain to patient that cold sores usually go away on their own. Advise to use analgesics, such as acetaminophen, and cold sore medications, such as Acyclovir and Abreva, can help relieve the discomfort.

Canker sores are small open and painful sores that are white or yellowish with a red border on the inner lips or cheek, gums or tongue which are caused by a virus. Explain to patient these sores usually heal on their own. To relieve patient discomfort, advise to rinse with salt water or diluted hydrogen peroxide, or apply an over-the-counter oral gel. Patient may also use an analgesic such as acetaminophen or ibuprofen to relieve pain. Advise to see their doctor if their symptoms don’t improve.

Thrush are creamy white patches on the tongue, inner cheek or gums that are painful when scraped which are caused by a yeast infection. Explain to patient this condition usually goes away on its own. Advise patient to eat unsweetened yogurt with live cultures to restore the natural balance of bacteria in their body. They should gargle with salt water and use analgesics, such as acetaminophen, to relieve discomfort. If patient’s symptoms get worse or don’t improve, advise to see their doctor. He or she may prescribe an antifungal medicine, such as Nystatin.

Leukoplakia are painless white or gray sores that may have a hard, raised coating on the tongue, the inside of the cheeks, or gums. This condition is common in smokers. Advise patient to see their doctor. Patient should stop smoking or using other tobacco products to help prevent oral cancers. Advise to see their dentist if sharp or rough teeth or dental work are causing irritation.

References:

http://www.nlm.nih.gov/medlineplus/mouthdisorders.html

http://familydoctor.org/online/famdocen/home/tools/symptom/509.printerview.html

Brandee – SVN

Common disorders of the SALIVARY GLANDS and usual management

Salivary glands may become obstructed. Obstruction to the flow of saliva most commonly occurs in the parotid and submandibular glands, usually because stones have formed. Sialolithiasis is a condition where tiny salivary stones form in the glands. The stones, called sialoliths, are made of calcium. Some stones do not cause any symptoms, but some block the ducts. Saliva production starts to flow, but cannot exit the ductal system, leading to swelling of the involved gland and significant pain, sometimes with an infection. Unless stones totally obstruct saliva flow, the major glands will swell during eating and then gradually subside after eating, only to enlarge again at the next meal. Infection can develop in the pool of blocked saliva, leading to more severe pain and swelling in the glands. If untreated for a long time, the glands may become abscessed. Another possible cause of obstruction could be that the duct system of the major salivary glands, which connects the glands to the mouth, may be abnormal. These ducts can develop small constrictions, which decrease the salivary flow, leading to infection and obstructive symptoms.

Another common disorder of the salivary glands is infection. The most common salivary gland infection in children is mumps. Mumps, a viral infection, involves the parotid glands. Mumps occurs most often in children who have not been immunized, but may also occur in adulthood. Infections also occur because of ductal obstruction or sluggish flow of saliva because the mouth has abundant bacteria. Sialadenitis is a painful infection of a salivary gland. Staphylococcus, streptococcus, Haemophilus influenzae or anaerobic bacteria are usually the cause. The condition is common with elderly adults who have salivary gland stones, but infants can also develop sialadenitis during the first few weeks of life. Sialadenitis can become a severe infection if not treated properly.

Tumors are also a common disorder of the salivary glands. Most salivary tumors are benign. The parotid is the most common gland for salivary tumors to grow. Pleomorphic adenomas are the most common parotid tumor. It grows slowly and is benign.

A pleomorphic adenoma begins as a painless lump at the back of the jaw, just below the earlobe. These are more common in women.

Benign pleomorphic adenomas can also grow in the submandibular gland and minor salivary glands, but less often than in the parotid. Warthin’s tumor is the second most common benign tumor of the parotid gland.

It is more common in older men and can grow on both sides of the face. Cancerous (malignant) tumors are rare in the salivary glands and usually occur between ages 50 to 60. Some types grow fast and some are slow-growing.

http://www.entnet.org/HealthInformation/salivaryGlands.cfm

Gastrointestinal Cancers:

Cancer of the Oral Cavity – As cancer cells in the oral cavity increase, the mass may distort a client’s appearance; exert pressure on surrounding tissue, making it difficult to masticate, cause local pain, or produce difficulty swallowing.

NURSING MANAGEMENT:

Maintain a patent airway
Promote adequate fluid and food intake.
Supporting communication that the tumor or treatment may have impaired; substitute written forms is speech is impaired.
Administer prescribed antiemetics.
Promote effective coping and therapeutic grieving at this time
Modify diet according to the client’s ability to chew and swallow.

Cancer of the esophagus – affects men more than women; it is a squamous cell carcinoma, although some tumors are classified as adenocarcinomas. As the cancer advances, the mass occupies space and interferes with swallowing.

NURSING MANAGEMENT:

1. Improve nutrition and stabilize weight; encourage small, frequent meals.

Client needs soft foods or high calorie, high protein semi liquid foods
Elevate head of bed during and after meals to minimize dyspnea.
Adhere to therapeutic regimen.

Cancer of the stomach – is a malignancy characterized by either an enlarged mass or ulcerating lesion that expands or penetrates several tissue layers.

NURSING MANAGEMENT:

Teaching the public especially susceptible ethnic groups or clients with a family history.
Diet modification to reduce the predisposition for this disease; limit high fat foods.
Therapeutic regimen to reduce hydrochloric acid formation.
Liberal fluid intake.

List the nursing responsibilities of clients undergoing radical neck surgery.

Client will have a permanent tracheal stoma; keep stoma clean.
Client has no voice; keep pen and paper on bedside as an alternative way of communication. Call light must be within reach.
Ability to swallow remains; offer liquids to keep client hydrated.
Continue exercises for neck muscles to help increase circulation and hasten recovery of the surgery site.

Nursing implications for clients undergoing intermaxillary fixation:

VII. POSTOPERATIVE CONSIDERATIONS

A. MMF Precautions at Bedside

1. Patient requires instruction as to care and precautions

2. Wire cutters should be carried with patient in case of airway problems (oral swelling, vomiting)

3. Suction at bedside

B. Oral Hygiene

1. Brushing

2. Oral rinses (Cepacol or Peridex)

C. Diet Consult

High-calorie, high-protein full liquids; feeding tube and syringe

V111. FOLLOW-UP

A. Use of dental wax may decrease the lip trauma induced by the arch bars.

B. The arch bars should be removed only after the fractures are healed and stable.

References:

www.lib.uiowa.edu

www.cancer.gov

www.cancer.org

www.nyp.org

Timby, p. 365, 825,839, 844

Cory- SVN

Common Esophageal Disorders:

GERD (gastroesophageal reflux disease): Results from disorders of the lower esophageal sphincter where stomach acid enters the esophagus, damaging the esophageal lining and causing chronic heartburn, pain or regurgitation.

Esophageal Dysphagia:

Difficulty moving food from your mouth into your upper esophagus which results in food to “stick” in the esophagus on its way to the stomach.Circopharyngeal Incoordination: A dysfunction of the upper esophageal sphincter. The sphincter opens incorrectly, increasing the risk of food entering the respiratory system and causing lung disease.

Achalasia: A motor disorder that affects the smooth muscles of the esophagus, causing dysphagia and relaxation of the lower esophageal sphincter, which increases the risk of esophageal damage due to contact with stomach contents.

Diverticula: Abnormal esophageal pockets. Food may become trapped in diverticula, increasing the risk of esophageal infection. Food trapped in diverticula may also be regurgitated when affected individuals lie down.

Esophagus Cancer: A malignant tumor of the esophagus. It often begins in the lower third of the esophagus.

What is a Hiatal Hernia?

A hiatal hernia also known as diaphragmatic hernia is an anatomical abnormality in which a part of the stomach protrudes through the diaphragm and up into the lower portion of the thorax

There are two types of hiatal hernias:

1) Axial or sliding: The junction of the stomach and esophagus and part of the stomach slide in and out through the weakened portion of the diaphragm.

2) Paraesophageal: The fundus is displaced upward, with greater curvature of the stomach going through the diaphragm next to the gastroesophageal junction.

Treatment:

A combination of medications and lifestyle changes such as weight loss and exercise may be the treatment for minor cases. Patients who do not respond to a rigid medical regimen are treated surgically by stretching the narrowed esophagus endoscopically or by restoring the stomach to its proper position and repairing the diaphragmatic defect.

Nursing Responsibility:

- Intubation for gastric decompression to prevent stomach distention and avoid pressure on the surgical site.

- Encourage patient to eat frequent, small, well-balanced meals.

- Instruct patient to eat slowly and to chew food thoroughly.

- Tell patient to avoid very hot or cold fluids or spicy foods.

- Record daily weight (particularly in the morning before breakfast).

- Instruct patient to avoid alcohol or tobacco products.

- Inform client to remain upright for at least 2 hours after meals.

- Discourage patient from eating 2-3 hours before bedtime.

- Tell patient to avoid activities that may involve the Valsalva maneuver

(e.g., lifting heavy objects, straining for bowel movement).

- Instruct patient to take medications as prescribed.

- Keep surgical site clean and dry.

- Provide patient comfort.

References:

www.healthlink.mcw.edu

www.nlm.nih.gov

www.cancer.gov

Book: Introductory Medical-Surgical Nursing By: Barbara K. Timby and Nancy E. Smith

*** S. L. SVN