Med surg 1: GI
Med surg 1: GI
Med surg 1: GI
Pathophysiology Hiatal hernia (diaphragmatic hernia) is a protrusion of the stomach (in part or in total) above the diaphragm
into the thoracic cavity through the hiatus (the opening in
the diaphragm). There are two types of hiatal hernia.
Sliding (more common): A portion of the stomach and
gastroesophageal junction move above the diaphragm.
This generally occurs with increases in intra-abdominal
pressure or while the client is in a supine position.
Paraoesophageal (rolling): Part of the fundus of the
stomach moves above the diaphragm, although the gastroesophageal junction remains below the diaphragm.
Expected Presenting manifestations depend on the type of hiatal hernia and are typically worse following a meal.
Sliding: heartburn, reflux, chest pain, dysphagia, belching
Findings
Paraesophageal (rolling): fullness after eating, sense of breathlessness/suffocation, chest pain, worsening of
manifestations when reclining
Diagnostic Barium swallow with fluoroscopy
Allows visualization of the esophagus
Procedures
Nursing Actions: Instruct the client to use cathartics to evacuate the barium from the GI tract following the procedure.
Failure to eliminate the barium places the client at risk for fecal impaction.
Esophagogastroduodenoscopy (EGD)
Upper GI endoscopy which allows visualization of the esophagus and the gastric lining
Nursing Actions: Verify gag response has returned prior to providing oral fluids or food following the procedure.
Nursing Actions: Ensure there are no contraindications with other prescribed medications (levothyroxine). Evaluate
kidney function in clients taking magnesium hydroxide.
Client Education: Take antacids when acid secretion is the highest (1 to 3 hr after eating and at bedtime), and
separate from other medications by at least 1 hr.
Therapeutic Fundoplication: reinforcement of the LES by wrapping a portion of the fundus of the stomach around the distal
esophagus
Procedures
Contributing factors:
o Excessive ingestion of foods that relax the LES include fatty and fried foods, chocolate, caffeinated
beverages (coffee), peppermint, spicy foods, tomatoes, citrus fruits, and alcohol
o Prolonged or frequent abdominal distention (from overeating or delayed emptying)
o Increased abdominal pressure from obesity, pregnancy, bending at the waist, ascites, or tight clothing at the
waist
o Medications that relax the LES (theophylline, nitrates, calcium channel blockers, anticholinergics, and
diazepam)
o Increased gastric acid caused by medications (NSAIDs) or stress (environmental)
o Debilitation resulting in weakened LES tone
o Hiatal hernia (LES displacement into the thorax with delayed esophageal clearance)
o Gastritis due to helicobacter pylori can increase reflux.
o Lying flat
Expected • Report of dyspepsia (indigestion) after eating an offending food or fluid, and regurgitation.
• Radiating pain (neck, jaw, or back).
Findings
• Report of a feeling of having a heart attack.
• Pyrosis (burning sensation in the esophagus)
• Odynophagia (pain on swallowing).
• Pain that worsens with position (bending, straining, laying down).
• Pain that occurs after eating and lasts 20 min to 2 hr.
• Throat irritation (chronic cough, laryngitis), hypersalivation, bitter taste in mouth (caused by regurgitation).
Chronic GERD can lead to dysphagia.
• Increased flatus and eructation (burping).
• Pain is relieved (almost immediately) by drinking water, sitting upright, or taking antacids.
• Manifestations occurring four to five times per week on a consistent basis are considered diagnostic.
• Dental caries.
• Chest congestion and wheezing due to reflux material entering the tracheobronchial tree.
Esophageal pH monitoring
A small catheter is placed through the nose and into the distal esophagus, or a small capsule is attached to the
esophageal wall during endoscopy. pH readings are taken in relation to food, position, and activity for 24 to 48 hr.
• Most accurate method of diagnosing GERD
• Especially helpful in diagnosis for clients who have atypical manifestations
Nursing Actions: Instruct the client to keep a journal of foods and beverages consumed, manifestations, and activity
during the 24-hr test period.
Esophageal manometry
Esophageal manometry records lower esophageal sphincter pressure and peristaltic activity of the esophagus. The
client swallows three small tubes, and pressure readings and pH levels are tested.
Barium swallow
Barium swallow identifies a hiatal hernia, strictures, or structural abnormalities, which would contribute to or cause
GERD.
Nursing Actions: Instruct the client to use cathartics to evacuate the barium from the GI tract following the procedure.
Failure to eliminate the barium places the client at risk for fecal impaction. Laxative
Prokinetics
Metoclopramide increases the motility of the esophagus and stomach.
Nursing Actions: Monitor the client taking metoclopramide for extrapyramidal adverse effects.
Client Education: Report abnormal, involuntary movement.
Therapeutic Stretta procedure uses radiofrequency energy, applied by an endoscope, to decrease vagus nerve activity. This causes
the LES muscle tissue to contract and tighten.
Procedures
Postoperative Client Education
• Clear liquids for the first 24 hr following the procedure, then advance to a soft diet.
• Do not take NSAIDs for 10 days following the procedure.
• Report chest or abdominal pain, bleeding, difficulty swallowing, dyspnea, nausea, and/or vomiting
immediately.
Fundoplication
Fundoplication might be indicated for clients who fail to respond to other treatments. The fundus of the stomach is
wrapped around and behind the esophagus through a laparoscope to create a physical barrier.
Nursing Actions
Complications following fundoplication include temporary dysphagia (monitor for aspiration), gas bloat syndrome
(difficulty belching to relieve distention), and atelectasis/pneumonia (monitor respiratory function).
Monitor for bowel sounds.
Laboratory Test H. pylori testing: Gastric samples are collected via an endoscopy to test for H. pylori.
Urea breath testing: The client exhales into a collection container (baseline), drinks carbon-enriched urea solution, and is
asked to exhale into a collection container. The client should take nothing by mouth (NPO) prior to the test. If H. pylori is
present, the solution will break down and carbon dioxide will be released. Serologic testing documents the presence of H.
pylori based on antibody assays.
Hemoglobin and hematocrit (findings below the expected reference range secondary to bleeding)
Medications Antibiotics
Metronidazole, amoxicillin, clarithromycin, and tetracycline eliminate H. pylori infection.
Nursing Actions: A combination of two or three different antibiotics can be administered.
Client Education: Complete a full course of medication.
Histamine2-receptor antagonists
Famotidine, cimetidine, and nizatidine suppress the secretion of gastric acid by selectively blocking H2 receptors in
parietal cells lining the stomach.
• Used in conjunction with antibiotics to treat ulcers caused by H. pylori.
• Used to prevent stress ulcers in clients who are NPO after major surgery, have large areas of burns, are
septic, or have increased intracranial pressure.
Nursing Actions
• Famotidine can be administered IV in acute situations.
• Cimetidine and famotidine can be taken with or without food.
• Treatment of peptic ulcer disease is usually started as an oral dose twice a day until the ulcer is healed,
followed by a maintenance dose usually taken once a day at bedtime.
Client Education
• Notify the provider of obvious or occult GI bleeding (coffee-ground emesis).
• Complete the prescribed regimen, even when manifestations subside.
Proton-pump inhibitors (PPI)
Pantoprazole, esomeprazole, omeprazole, lansoprazole, and rabeprazole suppress gastric acid secretion by irreversibly
inhibiting the enzyme that produces gastric acid and inhibit basal and stimulated acid production.
Nursing Actions
• Insignificant adverse effects with short-term treatment.
• Long-term use can increase the risk of fractures, pneumonia, acid rebound, and the possibility of developing
Clostridium difficile.
• Rabeprazole and pantoprazole are enteric-coated tablets and should not be crushed.
Client Education
• Do not to crush, chew, or break sustained-release capsules.
• Take omeprazole and lansoprazole once a day prior to eating the main meal of the day.
• Take rabeprazole after the morning meal.
• Avoid alcohol and irritating medications (NSAIDs).
• Complete the prescribed regimen, even when manifestations subside.
Antacids
• Aluminum hydroxide and magnesium hydroxide neutralize acid in the gut. The medication provides manifestation
relief but generally does not accelerate healing.
• Antacids can be given 7 times per day, 1 to 3 hr after meals and at bedtime, to neutralize gastric acid, which
occurs with food ingestion.
• Aluminum hydroxide can cause constipation.
• Magnesium hydroxide can cause diarrhea.
Nursing Actions
• Give 1 to 2 hr apart from other medications to avoid reducing the absorption of other medications.
• Monitor kidney function of clients prescribed aluminum hydroxide and magnesium hydroxide.
• Encourage compliance by reinforcing the intended effect of the antacid (relief of pain, promote healing of ulcer).
Client Education
• Take all medications at least 1 to 2 hr before or after taking an antacid.
Mucosal protectants
• Sucralfate coats the ulcer and protects it from the actions of pepsin and acid.
• Bismuth subsalicylate prevents H. pylori from binding to the mucosal wall.
Nursing Actions
• Administer on an empty stomach 1 hr before meals and at bedtime.
• Oral suspension is easier for the older adult clients to ingest because the tablet form is large and difficult to
swallow.
• Monitor for adverse effects of constipation.
Client Education
• If taking bismuth subsalicylate, avoid aspirin products to avoid salicylate toxicity.
• If taking bismuth subsalicylate, stools can be black. This is temporary and harmless.
Therapeutic Esophagogastroduodenoscopy (EGD)
Areas of bleeding can be treated with epinephrine or laser coagulation.
Procedures
Nursing Actions
Pre-procedure: Initiate two large-bore IV catheters.
Post procedure: Monitor vital signs. Keep client NPO until gag reflex returns.
Surgical interventions
Can be used in clients when ulcers do not heal following 12 to 16 weeks of medical treatment, hemorrhage, perforation,
or obstruction.
Gastrectomy: All or part of the stomach is removed with laparoscopic or open approach.
Antrectomy: The antrum portion (lower portion of stomach) of the stomach is removed.
Gastrojejunostomy (Billroth II procedure): The lower portion of the stomach is excised, the remaining stomach is
anastomosed to the jejunum, and the remaining duodenum is surgically closed.
Vagotomy: The vagus nerve is cut to decrease gastric acid production in the stomach. Often done laparoscopically to
reduce postoperative complications.
Pyloroplasty: The opening between the stomach and small intestine is enlarged to increase the rate of gastric emptying.
Nursing Actions
o Monitor the incision for evidence of infection.
o Place the client in a semi-Fowler’s position to facilitate lung expansion.
o Monitor nasogastric tube drainage. Scant blood can be seen in the first 12 to 24 hr.
o Notify the provider before repositioning or irrigating the nasogastric tube (disruption of sutures). QS
o Monitor bowel sounds.
o Advance diet as tolerated to avoid undesired effects (abdominal distention, diarrhea).
o Administer medication as prescribed (analgesics, stool softeners).
Client Education
o Take vitamin and mineral supplements due to decreased absorption after a gastrectomy, including vitamin B12,
vitamin D, calcium, iron, and folate.
o Consume small, frequent meals while avoiding large quantities of carbohydrates as directed.
o Avoid NSAID’s and medications that contain aspirin.
o Notify provider of sudden abdominal or epigastric pain.
o Monitor and report bleeding such as black stools or coffee ground emesis.
Interprofessional Care
Nutrition consult: Diet that restricts acid-producing foods: milk products, caffeine, decaffeinated coffee, spicy foods,
medications (NSAIDs)
Complications Perforation/hemorrhage
When peptic ulcers perforate or bleed, it is an emergency situation.
Perforation presents as severe epigastric pain spreading across the abdomen. The pain can radiate into the
shoulders, especially the right shoulder due to irritation of the phrenic nerve. The abdomen can become tender
and rigid (board like). Hyperactive to diminished bowel sounds can be auscultated, and there is rebound
tenderness. The client will display manifestations of shock, hypotension, and tachycardia. Perforation is a
surgical emergency.
Gastrointestinal bleeding in the form of hematemesis or melena can cause manifestations of shock
(hypotension, tachycardia, dizziness, confusion), and decreased hemoglobin.
Nursing Actions
o Perform frequent assessments of pain and vital signs to detect subtle changes that can indicate perforation or
bleeding. QS
o Provide oxygen and ventilator support as needed.
o Start two large-bore IV lines for replacement of blood and fluids.
o Report findings, prepare the client for endoscopic or surgical intervention, replace fluid and blood losses to
maintain blood pressure, insert nasogastric tube, and provide saline lavages.
Pernicious anemia
Occurs due to a deficiency of the intrinsic factor normally secreted by the gastric mucosa.
Manifestations include pallor, glossitis, fatigue, and paresthesias.
Client Education: Lifelong monthly vitamin B12 injections will be necessary.
Dumping syndrome
This can occur following gastrectomy surgery and is a group of manifestations that occur following eating. A shift of
fluid to the abdomen is triggered by rapid gastric emptying or high-carbohydrate ingestion. The rapid release of metabolic
peptides following ingestion of a food bolus causes dumping syndrome.
The client can report a full sensation, weakness, diaphoresis, palpitations, dizziness, and diarrhea. Vasomotor
manifestations that can occur 10 to 90 min following a meal are pallor, perspiration, palpitations, headache,
feeling of warmth, dizziness, and drowsiness.
Late manifestations of dumping syndrome can be related to the rapid release of blood glucose, followed by an
increase in insulin production resulting in hypoglycemia.
Nursing Actions
o Monitor for vasomotor manifestations.
o Assist/instruct the client to lie down when vasomotor manifestations occur.
o Administer medications.
o Octreotide subcutaneously can be prescribed if manifestations are severe and not effectively controlled with
dietary measures. Octreotide blocks gastric and pancreatic hormones, which can lead to findings of dumping
syndrome.
o Acarbose slows the absorption of carbohydrates.
o Malnutrition and fluid electrolyte imbalances can occur due to altered absorption. Monitor I&O, laboratory
values, and weight.
Client Education
o Lying down after a meal slows the movement of food within the intestines.
o Limit the amount of fluid ingested at one time.
o Eliminate liquids with meals, for 1 hr prior to and following a meal.
o Consume a high-protein, high-fat, low-fiber, and low- to moderate-carbohydrate diet.
o Avoid milk and sugars (sweets, fruit juice, sweetened fruit, milk shakes, honey, syrup, jelly).
o Consume small, frequent meals rather than large meals.
Vasomotor Manifestations
Early Manifestations
Onset: Within 30 min after eating
Cause: rapid emptying
Findings: nausea, vomiting, sweating, and dizziness, tachycardia, palpitations
Late Manifestations
Onset: 1.5 to 3 hr after eating
Cause: Excessive insulin release
Findings: dizziness and sweating, tachycardia and palpitations, shakiness and feelings of anxiety, confusion
Acute gastritis has sudden onset, is of short duration, and can result
in gastric bleeding if severe. A severe form of acute gastritis is caused
by the ingestion of an irritant, (such as a strong acid or alkali) and can
result in the development of gangrenous tissue or perforation. Scarring
can result leading to pyloric stenosis.
Chronic gastritis can be related to autoimmune disease, such as pernicious anemia, and H. pylori.
Extensive gastric mucosal wall damage can cause erosive gastritis (ulcers) and increase the risk of stomach cancer.
Erosive gastritis
• Black, tarry stools; coffee-ground emesis
• Acute abdominal pain
• Females assigned at birth, Hgb less than 12 g/dL and RBC less than 4.2 cells/mcL
• Males assigned at birth, Hgb less than 14 g/dL and RBC less than 4.7 cells/mcL
Diagnostic
Upper endoscopy
Procedures
A small flexible scope is inserted through the mouth into the esophagus, stomach, and duodenum to visualize the upper
digestive tract. This procedure allows for a biopsy, cauterization, removal of polyps, dilation, or diagnosis. (See chapter
46: Gastrointestinal Diagnostic Procedures.)
Client Education
• Maintain NPO status after midnight the day of the procedure.
• Have a ride home available after the procedure.
• A local anesthetic will be sprayed onto the back of the throat, but the throat can be sore following the
procedure. QS
• Monitor for indications of perforation (chest or abdominal pain, fever, nausea, vomiting, and abdominal
distention) and have emergency contact numbers available.
Antacids
Action
• Increases gastric pH and neutralizes pepsin
• Improves mucosal protection
Medications: Aluminum hydroxide, Magnesium hydroxide with aluminum hydroxide
Nursing Interventions
• Do not give it to clients who have acute kidney injury or chronic kidney failure.
• Monitor aluminum antacids for aluminum toxicity and constipation. Monitor magnesium antacids for diarrhea
or hypermagnesemia.
Client Education
• Take antacids on an empty stomach.
• Wait 1 hr to take other medications.
Prostaglandins
Action: Replacement for endogenous prostaglandins that stimulate mucosal protection. Reduces gastric acid secretion.
Medications: Misoprostol
Nursing Interventions
• Can be given with NSAIDs to prevent gastric mucosal damage.
• Can cause abdominal pain and diarrhea.
Client Education
• Use contraceptives.
• Do not take if there is a chance of becoming pregnant. QS
• Take with food to reduce gastric effects.
• Anti-ulcer/mucosal barriers
Action: Inhibits acid and forms a protective coating over mucosa
Medications: Sucralfate
Nursing Interventions: Allow 30 min before or after to give antacid.
Client Education
• Take on an empty stomach.
• Do not smoke or drink alcohol.
• Continue to take medication even if manifestations subside.
• Antibiotics
Action: Eliminates H. pylori infection
Medications
Clarithromycin, Amoxicillin, Tetracycline, Metronidazole
Nursing Interventions
• Monitor for increased abdominal pain and diarrhea.
• Monitor electrolytes and hydration if fluid is depleted.
• Should be administered with meals to decrease GI upset.
• Use cautiously in clients who have kidney or hepatic impairment.
Client Education
• Complete prescribed dosage.
• Notify the provider of persistent diarrhea, which can indicate superinfection of the bowel.
Therapeutic Upper endoscopy: Surgery is prescribed for clients who have ulcerations or significant bleeding, or when nonsurgical
interventions are ineffective. (See chapter 49: Peptic Ulcer Disease.)
Procedures
Dehydration
Cause: Loss of fluid due to vomiting or diarrhea
Nursing Actions
• Monitor fluid intake and urine output.
• Provide IV fluids if needed.
• Monitor electrolytes.
Client Education: Contact a provider for vomiting and diarrhea.
Pernicious anemia
Causes
• Chronic gastritis can damage the parietal cells. This can lead to reduced production of intrinsic factor, which
is necessary for the absorption of vitamin B12.
• Insufficient vitamin B12 can lead to pernicious anemia.
Nursing Actions: Instruct the client of the need for monthly vitamin B12 injections.
GASTRIC CANCER
Pathophysiology v This is often asymptomatic in early stages.
v Metastasis frequently occurs due to extensive vascular and lymph
access to the stomach, often to liver, peritoneum, bones, lungs,
and brain.
v Gastric cancer might spread to nearby organs, such as liver,
pancreas, and transverse colon.
v Helicobacter pylori (H. pylori) infection is a primary risk factor
for developing gastric cancer.
v Total gastrectomy might be indicated for clients who have
hereditary diffuse gastric cancer.
Risk Factors • Excessive intake of salty, pickled foods, and foods that contain nitrates (processed foods)
• Minimal intake of fruits and vegetables
• Infection with H.pylori.
• History of gastritis
• Pernicious anemia
• Gastric polyps
• Achlorhydria (inability to produce hydrochloric acid)
• Tobacco use
• Obesity
• Previous gastric surgery
• First-degree relative who had gastric cancer
• Race: Black, non-Hispanic white, Indigenous
Nursing actions: Procedure is performed under moderate sedation. Informed consent is required. Monitor client’s
respirations and oxygen saturation. Keep client NPO until gag reflex returns. Monitor for perforation (bleeding, pain,
dyspnea)
Client education: Instruct clients to avoid NSAIDs or anticoagulants for a few days prior to test. Client should be
NPO for 6 to 8 hrs prior to exam. A local anesthetic spray will be used to suppress the client’s gag reflex. After the
procedure, swallowing might be difficult until anesthetic wears off. Client might have a sore throat, a hoarse voice, and
might experience bloating and belching post procedure.
Endoscopic ultrasound: Performed during endoscopy to determine depth of tumor and lymph node involvement.
Barium swallow
Nursing actions: Check swallowing reflex prior to procedure.
Client education: Client should be NPO for 6 to 8 hrs prior to exam.
CT, MRI
Expected findings: Visualization and location of tumor and/or metastasis
Therapeutic Chemotherapy
Combination chemotherapy can include fluorouracil, carboplatin, cisplatin, and/or oxaliplatin. It is used alone or along
Procedures
with surgery.
Radiation therapy
Radiation therapy is used to treat advanced gastric cancer to slow tumor growth. It is used alone or along with
chemotherapy and surgery. Radiation can be used as a palliative measure to control pain, hemorrhage, or obstruction.
Surgical interventions
Billroth I (Gastroduodenostomy): Removal of lower portion of the stomach (antrum).
Billroth II (Gastrojejunostomy): Removal of 75% of stomach.
Subtotal gastrectomy: Used to treat tumors in the middle or distal area of the stomach.
Total gastrectomy: Removal of the stomach, lymph nodes, and omentum. Esophagus is reattached to the duodenum
or jejunum.
Preoperative Client Education
o Instruct about preoperative diet (clear liquids several days prior to surgery).
o Complete bowel prep with cathartics as prescribed.
o Nasogastric tube (NGT) might be inserted preoperatively for clients who are scheduled for open abdominal
surgery, NGT should remain in place for a few days postoperative to decompress the stomach.
o Nutritional supplements might be required preoperative and postoperative via enteral nutrition or total
parenteral nutrition.
Postoperative Nursing Actions
o Elevate the client’s head of bed.
o Monitor breath sounds, encourage pulmonary exercises.
o Monitor bowel sounds.
o Monitor for bleeding (sanguineous drainage on operative site, tachycardia, hypotension).
o Monitor for infection (swelling, redness, fever).
o Manage pain and instruct the client regarding PCA.
o Maintain nasogastric suction (decompression).
Postoperative Client Education
o Understand the care of the incision, activity limits.
o Monitor for pernicious anemia (beefy, glossy tongue, fatigue, weight loss).
o Avoid heavy lifting. Plan to resume normal activity in 1 to 2 weeks following laparoscopy, or 4 to 6 weeks
following open surgery.
Complications Delayed gastric emptying/gastric outlet obstruction; occurs due to stenosis, edema, or stricture at the site of
surgical anastomosis
Nursing Actions: Maintain nasogastric suction.
Dumping syndrome; occurs due to a rapid bolus of food into the small intestines. Manifestations include abdominal
pain, nausea, tachycardia, syncope, diaphoresis, and palpitations.
Nursing Actions: Provide frequent small meals, drink fluids between meals instead of during meals, provide high
protein, high fat, low carbohydrate diet.
Expected Clients who have at least two of the following conditions meet diagnostic criteria for malnutrition, per the
Academy of Nutrition and Dietetics:
Findings
• Inadequate intake of calories
• Loss of muscle mass
• Loss of subcutaneous fat
• Unintentional weight loss
• Decreased handgrip strength, indicating decreased functional status
• Weight loss masked by localized or generalized edema
Treatments
• Balanced, oral diet
• Liquid supplements
• Multivitamin supplements
• Correction of fluid and electrolyte imbalances
• Enteral feedings if client unable to consume adequate nutrients with oral intake
• Parenteral nutrition if client has GI tract impairments that interfere with absorption of nutrients
Interventions
• Requires collaboration with interdisciplinary team
• Collaborate with provider and dietitian for ordering of diets that promote optimal nutrition.
• Request consult from dietitian for clients with actual or potential for malnutrition.
• Collaborate with dietitian and pharmacist for potential side effects of medications and medication-nutrient
interactions that could affect absorption of nutrients.
• If causes of malnutrition are related to inadequate resources, consult social worker or case manager.
• Consult physical therapy and occupational therapy for functional issues.
• Educate clients about the importance of adequate nutrient intake.
• Counsel clients about drug-nutrient interactions that could affect absorption of nutrients.
Laboratory Tests • Screening to evaluate for cardiovascular disease, diabetes mellitus, fatty liver disease, or thyroid disorders
• Total cholesterol
• Triglycerides
• Fasting blood glucose
• Glycosylated hemoglobin
• Aspartate aminotransferase (AST)
• Alanine aminotransferase (ALT)
Medications Medication management is indicated for clients who have a BMI greater with increased risk factors for other
conditions. It should be used in conjunction with lifestyle modifications, diet modifications and physical activity. Clients
should consider this option before moving to more invasive therapies for weight loss such as bariatric surgery.
• Orlistat inhibits digestion of fats by blocking gastric and pancreatic lipases when taken with a meal.
Adverse effects include oily rectal discharge and stools, flatulence, and reduced food and vitamin absorption.
o Psyllium, a bulk-forming laxative, can increase the absorption of dietary fats and decrease the
gastrointestinal (GI) adverse effects.
o Daily supplementation with a multivitamin can prevent vitamin deficiencies.
o Instruct client that they should not take orlistat with a meal that does not contain fat.
• Phentermine-topiramate suppresses the appetite and induces a feeling of satiety. Adverse effects include
headache, dry mouth, constipation, nausea, change in taste, dizziness, insomnia, and paresthesia.
Contraindicated if the client has hyperthyroidism, glaucoma, or is taking an MAO inhibitor.
o Medication may be taken with meals or on an empty stomach.
o Instruct client to take medication early in the day to prevent insomnia.
• Naltrexone-bupropion suppresses the appetite and decreases cravings. Adverse effects include
constipation, diarrhea, nausea, vomiting, headache, insomnia, and dry mouth. Contraindicated for clients
who have uncontrolled hypertension, eating disorders, seizure disorders, or who are taking MAO inhibitors.
o Client should not take medication with high-fat meals to avoid increased systemic concentration of
naltrexone and bupropion.
o Bupropion has anti-depressant effect – client should be monitored for suicidal ideation.
• Liraglutide – Suppresses appetite and slows gastric emptying to induce satiety. Adverse effects include
nausea, vomiting, diarrhea, constipation, increased heart rate, dyspepsia, and hypoglycemia. Also used for
management of type 2 diabetes mellitus. Should be used with caution for clients who are taking other
medications that lower blood glucose levels.
o Administered by subcutaneous injection
o Medication may be taken with meals or on an empty stomach
Therapeutic Weight management involves balancing of the intake of energy with the expenditure of energy. Some of the
components of weight loss program include modifications of diet and lifestyle and physical activity.
Procedures
Lifestyle Modifications
Client is encouraged to modify their present lifestyle by using strategies such as:
• Setting goals
• Stimulus control
• Cognitive restructuring (correct and address negative thoughts)
• Problem solving
• Relapse prevention
Physical Activity
• Moderate exercise at least 30 minutes each day is recommended (walking 1.5 miles per day)
Dietary Modifications
Used in combination with lifestyle changes and physical activity.
• Diet is usually individualized and balanced with (protein, carbohydrates, decreased fat, increased fiber)
• Calorie restrictions maybe indicated
• Limit alcohol consumption
• Limit consumption of refined sugars
CAM Therapies
• Acupuncture
• Hypnosis
Hydrogel pill– approved by the FDA as an adjunct device to diet and exercise for weight loss for clients who have a
BMI 25-40.
• Pill is taken with meals
• Absorbs water to occupy space in the stomach and reduce stomach capacity
• Passes through GI tract and is excreted
• Adverse effects include constipation, obstruction, diarrhea, dehydration
• Contraindicated for clients who have Crohn’s disease or history of any surgery that altered GI motility
Intragastric balloon therapy – gas-filled or saline filled balloon place in stomach during endoscopic procedure
• Weight loss can be related to increased satiety and decreased gastric emptying
• Adverse effects are nausea and vomiting, potential balloon rupture, and rupture of the stomach or
esophagus. Pancreatitis can occur if balloon is in place longer than 6 months.
Nursing Care Considerations when caring for a client who has obesity
Risks during hospitalization
• Poor wound healing and infection
o Fatty tissue has a poor supply of blood, nutrients, and collagen
• Pressure injury
o Skin folds, moisture, increased friction
o Mobility limitations
• Stress on heart
• Obstructive sleep apnea
o From increased neck circumference and compression of oropharynx
• Reduced lung volume
• Hypoventilation, hypercapnia, and hypoxemia
• Venous thromboembolism (VTE)
• Inadequate pain management
o Might require larger dosages of pain medication
• Injury to client or staff members
Complications
BARIATRIC SURGERIES
Pathophysiology Bariatric surgeries include open and minimally
invasive approaches. These surgeries are performed
to assist with weight loss in clients who are obese
and have been unable to lose weight through lifestyle
modifications and pharmacological interventions.
Bariatric surgeries assist in weight loss through
decreasing the capacity of the stomach, causing
malabsorption by bypassing part of the small
intestine, or through a combination of both
mechanisms. Some clients undergo plastic surgery, including abdominoplasty and breast reduction, to
remove excess skin and tissue following weight loss.
Preoperative clients undergo upper endoscopy to rule out GI disease. Postoperative clients undergo barium
x-ray to evaluate for anastomotic leaks.
Following bariatric surgery, many clients experience decreased complications from previously diagnosed
conditions such as hypertension, CAD, hyperlipidemia, asthma, sleep apnea, and diabetes mellitus.
Indications Bariatric surgeries are a treatment for obesity when other weight control methods have failed. Candidates for
bariatric surgery are clients who have:
• BMI greater than 40 and no comorbidities
• BMI greater than 35 and at least one complication related to obesity (for example, hypertension,
osteoarthritis, type 2 diabetes mellitus)
• BMI 30 to 34.9 and glucose levels inadequately controlled with medications and lifestyle modifications
Types of Restrictive
Bariatric Create decreased capacity of the stomach; allowd for normal digestion. Common types are banding and sleeve
gastrectomy
Surgeries
Gastric banding – Small pouch is created through laparoscopic placement of an adjustable band around the
upper part of the stomach that allows only small portions of food to enter the GI tract.
• Performed laparoscopically
• Bladder in subcutaneous reservoir can be inflated or deflated
Vertical banded gastroplasty – Upper part of stomach is surgically stapled to create a small pouch, and a
band is placed to slow the emptying of food from the pouch to the rest of the stomach.
Sleeve gastrectomy – Pouch (sleeve) is created by removal of a large portion of the stomach through open
or laparoscopic procedure.
Malabsorptive
Procedures combine decreased capacity with malabsorption created from bypassing part of small intestine.
Gastric bypass
o Roux-en-Y (RNYGB) – Small pouch is created with the upper part of the stomach. The jejunum is
attached to the pouch causing food to bypass most of the stomach and the duodenum.
• Often performed as a robotic-assisted surgery, open or laparoscopic
• Increased risk of dumping syndrome related to removal of pyloric valve
o Biliopancreatic diversion with duodenal switch – Part of the stomach is removed, leaving a
pouch that is attached directly to the jejunum.
Expected • Sharp pain in the right upper quadrant, often radiating to the right shoulder
• Pain with deep inspiration during right subcostal palpation (Murphy’s sign)
Findings
• Intense pain (increased heart rate, pallor, diaphoresis) with nausea and vomiting after ingestion of high-fat
food caused by biliary colic
• Rebound tenderness (Blumberg’s sign performed by the provider or advanced practice nurse)
• Dyspepsia, eructation (belching), and flatulence
• Fever
Physical Assessment Findings
• Jaundice, icterus (yellow discoloration of the sclera), clay-colored stools, steatorrhea (fatty stools), dark
urine, and pruritus (accumulation of bile salts in the skin) can manifest in clients who have chronic
cholecystitis (due to biliary obstruction).
• Older adult clients can have atypical presentation of cholecystitis (absence of pain or fever). Delirium might
be the initial manifestation, or the client might have localized tenderness
Medications Analgesics
• Opioid analgesics, such as morphine sulfate or hydromorphone, are preferred for acute biliary pain.
• An NSAID, such as ketorolac, is used for mild to moderate pain. Monitor for GI bleeding.
Bile acid
Bile acid (chenodiol, ursodiol) gradually dissolves cholesterol-based gall stones.
Nursing Actions: Use caution in clients who have liver conditions or disorders with varices.
Client Education: Report abdominal pain, diarrhea, or vomiting. The medication is limited to 2 years of administration
and requires a gallbladder ultrasound every 6 months during the first year to determine effectiveness.
Cholecystectomy
• Removal of the gallbladder with a laparoscopic, minimally invasive, or open approach
• The client usually is discharged within 24 hr if a laparoscopic approach is used. An open approach can
require hospitalization for 1 to 2 days.
Nursing Actions
• Laparoscopic approach: Provide immediate postoperative care.
• Minimally invasive approach: Natural orifice transluminal endoscopic surgery. Explain to the client that this
surgical procedure is performed through entry of the mouth, vagina, or rectum. This approach eliminates
visible incisions and decreases the risk of complications for the client.
• Open approach: The provider can place a Jackson-Pratt drain in the gallbladder bed or a T-tube in the
common bile duct.
• Though used less commonly, clients can have a T-tube placed in the common bile duct to drain bile if there
were intraoperative complications involving the bile duct.
• Care of the drainage tube
o Clients can have a Jackson-Pratt drain or other drainage tube placed intraoperatively to prevent
accumulation of fluid in the gallbladder bed.
o Monitor and record drainage (initially serosanguineous stained with green-brown bile).
o Antibiotics are often prescribed to decrease the risk for infection.
• Care of the T-tube
o Instruct client to report an absence of drainage with manifestations of nausea and pain (can
indicate obstruction in the T-tube).
o Inspect the surrounding skin for evidence of infection or bile leakage.
o If prescribed, elevate the T-tube above the level of the abdomen to prevent the total loss of bile.
o Monitor and record the color and amount of drainage.
o Clamp the tube 1 hr before and after meals to provide the bile necessary for food digestion.
o Assess stools for color (stools clay-colored until biliary flow is reestablished).
o Monitor for bile peritonitis (pain, fever, jaundice).
o Monitor and document response to food.
o Expect removal of the tube in 1 to 3 weeks.
Client Education
• Laparoscopic or NOTES approach
o Ambulate frequently to minimize free air pain, common following laparoscopic surgery (under the
right clavicle, shoulder, scapula).
o Monitor the incision for evidence of infection or wound dehiscence (laparoscopic approach).
o Perform pain control.
o Report indications of bile leak (pain, vomiting, abdominal distention) to the provider.
o Resume activity gradually and as tolerated and resume the preoperative diet.
• Open approach
o Resume activity gradually. Avoid heavy lifting for 4 to 6 weeks.
o Begin with clear liquids and advance to solid foods as peristalsis returns.
o Report sudden increase in drainage, foul odor, pain, fever, or jaundice. QS
o Take showers instead of baths until drainage tube is removed.
o The color of stools should return to brown in about a week, and diarrhea is common.
• Dietary counseling
o Adhere to a low-fat diet (reduce dairy products and avoid fried foods, chocolate, nuts, gravies).
The client can have increased tolerance of small, frequent meals.
o Avoid gas-forming foods (beans, cabbage, cauliflower, broccoli).
o Consider weight reduction.
o Take fat-soluble vitamins or bile salts as prescribed to enhance absorption and aid with digestion.
Bile peritonitis
This can occur if adequate amounts of bile are not drained from the surgical site. This is a rare but potentially
fatal complication.
Nursing Actions
• Monitor for pain, fever, and jaundice.
• Report findings to the provider immediately.
CHOLELITHIASIS
Pathophysiology Cholelithiasis is the presence of stones in the gallbladder related to the
precipitation of either bile or cholesterol into stones. Bile is used for the
digestion of fats. It is produced in the liver and stored in the gallbladder.
It can be acute or chronic, and can obstruct the pancreatic duct, causing
pancreatitis. It can also cause the gallbladder to rupture, resulting in
secondary peritonitis.
Expected Gallstones may be silent, producing no pain and only mild GI symptoms. Such stones may be detected incidentally
during surgery or evaluation for unrelated problems.
Findings
v None or minimal symptoms, acute or chronic
v Pain
v Biliary colic
v Jaundice
v Changes in urine or stool color
v Vitamin deficiency, fat soluble (vitamins A, D, E, and K)
Laparoscopy
o Visualizes anterior surface of liver, gallbladder, and mesentery through a trocar
Ultrasonography
o Shows size of abdominal organs and presence of masses
Cholesterol levels
o Elevated in biliary obstruction; decreased in parenchymal liver disease
Managing Pain
•You may experience pain or discomfort from the gas used to inflate your abdominal area during surgery. Sitting
upright in bed or a chair, walking, or using a heating pad may ease the discomfort.
•Take analgesic medications as needed and as prescribed. Report to your surgeon if pain is unrelieved even with
analgesic use.
Resuming Activity
•Begin light exercise (walking) immediately.
•Take a shower or bath after 1 or 2 days.
•Drive a car after 3 or 4 days.
•Avoid lifting objects exceeding 5 lb after surgery, usually for 1 week.
•Resume sexual activity when desired.
Caring for the Wound
•Check puncture site daily for signs of infection.
•Wash puncture site with mild soap and water.
•Allow special adhesive strips on the puncture site to fall off. Do not pull them off.
Resuming Eating
•Resume your normal diet.
•If you had fat intolerance before surgery, gradually add fat back into your diet in small increments.
Managing Follow-Up Care
•Make an appointment with your surgeon for 7 to 10 days after discharge.
•Call your surgeon if you experience any signs or symptoms of infection at or around the puncture site: redness,
tenderness, swelling, heat, or drainage.
•Call your surgeon if you experience a fever of 37.7°C (100°F) or more for 2 consecutive days.
•Call your surgeon if you develop nausea, vomiting, or abdominal pain.