Med surg 1: GI

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HIATAL HERNIA

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.

Risk Factors • Increasing age


• Increased BMI
• Elevated intra-abdominal pressure (COPD, chronic coughing, pregnancy)
• Smoking

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.

CT scan of the chest with contrast


Allows visualization of the esophagus and stomach
Nursing Actions: Assess for iodine allergies if IV contrast is to be used. Contrast media (iodine) may not always be a
contraindication in clients who have a shellfish allergy. Further assessment may be needed. Encourage fluids following
procedure to promote dye excretion and minimize risk of renal injury. Monitor BUN/creatinine.

Medications Proton pump inhibitors


Pantoprazole, omeprazole, esomeprazole, rabeprazole, and lansoprazole reduce gastric acid by inhibiting the cellular
pump of the gastric parietal cells necessary for gastric acid secretion.
Nursing Actions
o Monitor for electrolyte imbalances, such as hypomagnesemia (tremors, muscle cramps)
o Long-term use has been related to the development of community-acquired pneumonia and Clostridium
difficile infections.
Client Education: Long-term use of PPIs increases the risk for fractures, especially in older adults.
Antacids
Aluminum hydroxide, magnesium hydroxide, calcium carbonate, and sodium bicarbonate neutralize excess acid and
increase LES pressure.

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

Laparoscopic Nissen fundoplication: minimally invasive with fewer complications


Nursing Actions: Elevate the head of the bed to promote lung expansion. Instruct the client to support the incision
during movement and coughing to minimize strain on the suture lines.
Client Education: Consume a soft diet for the first week postoperatively. Avoid carbonated beverages. Ambulate, but
avoid heavy lifting.
Complications: Temporary dysphagia, gas bloat syndrome (difficulty burping and distention), atelectasis/pneumonia

Client Education Health Promotion and Disease Prevention


ü Avoid eating immediately prior to going to bed.
ü Avoid foods and beverages that decrease LES pressure (fatty and fried foods, carbonated drinks,
chocolate, coffee, peppermint, spicy foods, tomatoes, citrus fruits, and alcohol).
ü Exercise regularly.
ü Maintain a healthy weight.
ü Elevate the head of the bed on 6-inch blocks.
ü Avoid straining or excessive vigorous exercise.
ü Avoid wearing clothing that is tight around the abdomen.

Complications • Volvulus: twisting of the esophagus and/or stomach


• Obstruction (paraoesophageal hernia): blockage of food in the herniated portion of the stomach
• Strangulation (paraoesophageal hernia): compression of the blood vessels to the herniated portion of the
stomach
• Iron-deficiency anemia (paraoesophageal hernia): resulting from bleeding into the gastric mucosa due to
obstruction
Gastroesophageal reflux disease (GERD)
Pathophysiology a common condition characterized by gastric content and enzyme backflow into the esophagus. Some
backflow of stomach contents into the esophagus is normal. When the reflux is excessive due to any of the
following conditions—an incompetent LES, pyloric
stenosis, hiatal hernia, excessive intra-abdominal or
intragastric pressure, or motility problems—the corrosive
fluids irritate the esophageal tissue, causing delay in their
clearance. This exposes esophageal tissue to the acidic
fluids, causing more irritation.

The primary treatment of GERD is diet and lifestyle


changes, advancing to medication use (antacids, H2-receptor antagonists, proton pump inhibitors) and
surgery.
Untreated GERD leads to inflammation, breakdown, and long-term complications, such as esophageal
strictures, Barrett’s esophagus, or adenocarcinoma of the esophagus.

Risk Factors • Obesity


• Older age (delayed gastric emptying and weakened LES tone)
• Sleep apnea
• Nasogastric tube

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.

Diagnostic Esophagogastroduodenoscopy (EGD)


v EGD is done under moderate sedation to identify tissue damage and to dilate strictures in the esophagus. The
Procedures
esophageal lining should be pink but is often red with persistent GERD. Biopsies can be done to determine if
high-grade dysplasia (HGD) is present.
v HGD is evidenced by squamous mucosa of the esophagus replaced by columnar epithelium (cells seen in the
stomach or intestines). When HGD is found, there is an increased chance of developing cancer.
v EGD allows visualization of the esophagus, revealing esophagitis or Barrett’s epithelium (premalignant cells).
Nursing Actions: Verify gag response has returned prior to providing oral fluids or food following the procedure to
reduce the risk for aspiration. Monitor client for manifestations of esophageal perforation (fever, pain, dyspnea,
bleeding). QS

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

Medications Proton pump inhibitors (PPIs)


Pantoprazole, omeprazole, esomeprazole, rabeprazole, and lansoprazole reduce gastric acid by inhibiting the cellular
pump of the gastric parietal cells necessary for gastric acid secretion.
Nursing Actions
• Monitor for electrolyte imbalances, such as hypomagnesemia (tremors, muscle cramps).
• Monitor for abdominal cramping, fever, and diarrhea. These can indicate presence of Clostridium difficile-
associated diarrhea (CDAD).
Client Education: Long-term use of PPIs increases the risk for fractures, especially in older adults.
Antacids
Aluminum hydroxide, magnesium hydroxide, calcium carbonate, and sodium bicarbonate neutralize excess acid and
increase LES pressure.
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.

Histamine2 receptor antagonists


Famotidine, cimetidine, and nizatidine reduce the secretion of acid by inhibiting histamine at the gastric parietal cells.
The onset is longer than antacids, but the effect has a longer duration.
Nursing Actions: Use cautiously in clients who have kidney disease.
Client Education
• Take with meals and at bedtime.
• Separate dosages from antacids (1 hr before or after taking antacid).

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.

Client Education Diet


• Maintain a soft diet for 1 week following procedure.
• Avoid foods that cause reflux, such as carbonated and caffeinated beverages.
• Avoid large meals.
• Avoid carbonated beverages.
• Remain upright after eating.
• Avoid eating before bedtime.
• Consume four to six small meals throughout the day.
Lifestyle
• Avoid clothing that is tight-fitting around the abdomen.
• Lose weight, if applicable.
• Elevate the head of the bed 15.2 to 20.3 cm (6 to 8 in) with blocks.
• Avoid lifting heavy objects.
• Walk daily.
• Report fever, nausea, vomiting, severe pain, dysphagia, or persistent bloating to the surgeon.

Health Promotion and Disease Prevention


ü Maintain a weight below BMI of 30.
ü Stop smoking.
ü Limit or avoid alcohol and tobacco use.
ü Eat a low-fat diet.
ü Avoid foods that lower the LES pressure, such as caffeinated drinks, chocolate, nitrates, citrus fruits, and
alcohol.
ü Avoid eating or drinking 2 hr before bed.
ü Avoid tight-fitting clothes.
ü Elevate the head of the bed 6 to 8 inches.

Complications Aspiration of gastric secretion


Causes: Reflux of gastric fluids into the esophagus can be aspirated into the trachea.
Risks associated with aspiration
• Asthma exacerbations from inhaled aerosolized acid
• Frequent upper respiratory, sinus, or ear infections
• Aspiration pneumonia
Nursing actions
• Place the client in a semi-Fowlers position for meals and for 1 to 2 hrs after meals.
• Keep oral suction equipment at the client's bedside.

Barrett’s epithelium (premalignant) and esophageal adenocarcinoma


Cause: Reflux of gastric fluids leads to esophagitis. In chronic esophagitis, the body continuously heals inflamed tissue,
eventually replacing normal esophageal epithelium with premalignant tissue (Barrett’s epithelium) or malignant
adenocarcinoma.
Nursing Actions: Determine the cause of GERD with the client and review lifestyle changes that can decrease gastric
reflux. Monitor nutritional status.
PEPTIC ULCER DISEASE
Pathophysiology v an erosion of the mucosal lining of the stomach, esophagus, or duodenum.
v The mucous membranes can become eroded to the point that the
epithelium is exposed to gastric acid and pepsin, which can precipitate
bleeding and perforation. Perforation that extends through all the layers
of the stomach or duodenum can cause peritonitis.
v Most peptic ulcers are caused by an infection from gram-negative
bacteria Helicobacter pylori (H. pylori). Contact with the bacteria
occurs from food, water, or exposure to body fluids such as saliva.
Some people infected with the H. pylori bacteria do not develop ulcers.
v An individual who has a peptic ulcer has peptic ulcer disease.

Risk Factors Causes of peptic ulcers


• Helicobacter pylori (H. pylori) infection
• NSAID and corticosteroid use
• Severe stress
• Familial tendency
• Hypersecretory states
• Gastrin-secreting benign or malignant tumors of the pancreas
• Type O blood
• Excess alcohol consumption
• Chronic pulmonary or kidney disease
• Zollinger-Ellison syndrome (combination of peptic ulcers, hypersecretion of gastric acid, and gastrin-secreting
tumors)
• Pernicious anemia

Expected Expected Findings


Dyspepsia: heartburn, bloating, nausea, and vomiting (vomiting is rare but can be caused by a gastric outlet
Findings o
obstruction). Can be perceived as uncomfortable fullness or hunger.
o Dull, gnawing pain or burning sensation at the mid-epigastrium or the back

Ulcer Pain: Gastric Ulcer


Pain most commonly occurs 30 to 60 min after a meal
Less often pain at night (30% to 40% of clients)
Pain exacerbated by ingestion of food
Malnourishment
Hematemesis
Ulcer Pain: Duodenal Ulcer
Pain occurs 1.5 to 3 hr after a meal
Awakening with pain during the night
Pain relieved by ingestion of food or antacid
Well-nourished
Melena
Physical Assessment Findings
o Pain or epigastric tenderness or abdominal distension
o Bloody emesis (hematemesis) or stools (melena)
o Weight loss

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.

Stool sample tests for the presence of the H. pylori antigen

Hemoglobin and hematocrit (findings below the expected reference range secondary to bleeding)

Stool sample for occult blood

Diagnostic Esophagogastroduodenoscopy (EGD)


Refer to chapter 46: Gastrointestinal Diagnostic Procedures. An EGD provides a definitive diagnosis of peptic ulcers
Procedures
and can be repeated to evaluate the effectiveness of treatment. Gastric samples are obtained to test for H. pylori.
Nursing Actions: Monitor vital signs until sedation wears off. Keep client NPO until return of gag reflex. Monitor for
manifestations of perforation: pain, bleeding, fever.
Client Education: NPO 6 to 8 hr prior to the exam.

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.

Client Education Nursing Care


ü Instruct clients to avoid foods that cause distress (coffee, tea, carbonated beverages).
ü Monitor for orthostatic changes in vital signs and tachycardia, as these findings are suggestive of
gastrointestinal bleeding or perforation.
ü Administer saline lavage via nasogastric tube.
ü Administer medication as prescribed.
ü Decrease environmental stress.
ü Encourage rest periods.
ü Encourage smoking cessation and avoiding alcohol consumption.
ü Monitor laboratory results (hemoglobin, hematocrit, coagulation studies).

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

Pyloric (gastric outlet) Obstruction


Pyloric obstruction occurs due to scarring, edema, or spasm of the area distal to the pyloric sphincter and
prevents emptying of the stomach.
Manifestations include feeling of fullness, distention, nausea after eating, and emesis consisting of undigested
food.
Nursing Actions
Insert an NG tube for gastric decompression.
Monitor fluid and electrolyte status.
GASTRITIS
Pathophysiology is an inflammation in the lining of the stomach, either erosive or nonerosive, and can be acute or chronic.
Types of gastritis
Nonerosive gastritis (acute or chronic) is most often caused by an
infection, Helicobacter pylori.

Erosive gastritis is likely caused by NSAIDs, alcohol use disorder, or


recent radiation treatment.

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.

Risk Factors • Family member who has H. pylori infection


• Family history of gastritis
• Prolonged use of NSAIDs, corticosteroids (stops prostaglandin synthesis)
• Excessive alcohol use
• Bile reflux disease
• Advanced age
• Radiation therapy
• Smoking
• Caffeine
• Excessive stress
• Exposure to contaminated food or water
Bacterial infection: Helicobacter pylori, Salmonella, Streptococci, Staphylococci, or Escherichia coli
Autoimmune diseases: Systemic lupus, rheumatoid arthritis, and pernicious anemia

Expected • Dyspepsia, general abdominal discomfort, indigestion


• Headache
Findings
• Hiccuping that can last for a few hours to several days
• Upper abdominal pain or burning which can increase or decrease after eating
• Nausea and vomiting
• Reduced appetite and weight loss
• Abdominal bloating or distention
• Hematemesis (bloody emesis) and stools that test positive for occult blood
• Gastric hemorrhage
• Anorexia
• Pernicious anemia
• Intolerance of spicy and fatty foods
• Manifestations can have rapid onset with acute gastritis.

Erosive gastritis
• Black, tarry stools; coffee-ground emesis
• Acute abdominal pain

Laboratory Test Noninvasive tests

CBC to check for anemia

• 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

Blood and stool antibody/antigen test for presence of H. pylori

C13 urea breath test: Used to measure H. pylori

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.

Medications Histamine2 antagonists


Action: Decreases gastric acid output by blocking gastric histamine2 receptors
Medications
Nizatidine, Famotidine, Cimetidine
Nursing Interventions
• Allow 1 hr before or after to administer antacid. Antacids can decrease the effectiveness of H2 receptor
antagonists.
• Monitor for neutropenia and hypotension.
• Dilute and administer slowly when given IV; rapid administration can cause bradycardia and hypotension.
Client Education
• Do not smoke or drink alcohol.
• Take oral dose with meals. Take famotidine 1 hr before meals or at bedtime to decrease heartburn, acid
indigestion, and sour stomach.
• Wait 1 hr prior to or following H2 receptor antagonist to take an antacid.
• Monitor for indications of GI bleeding (black stools, coffee-ground emesis).

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.

Proton pump inhibitors


Action: Reduces gastric acid by stopping the hydrogen/potassium ATPase enzyme system in parietal cells, blocking
acid production
Medications: Omeprazole, Lansoprazole, Rabeprazole sodium, Pantoprazole, Esomeprazole
Nursing Interventions
• Can cause nausea, vomiting, and abdominal pain.
• Use filter for IV administration for pantoprazole and lansoprazole.
Client Education
• Allow 60 min before eating when taking esomeprazole.
• Do not crush or chew if any of the medications are enteric-coated or sustained-release.
• It can take up to 4 days to see the effects.
• Take medication with or without food according to the instructions.

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

Partial gastrectomy: Removal of the involved portion of the stomach.

Client Education • Monitor fluid intake and urine output.


• Administer IV fluids as prescribed.
• Monitor electrolytes. (Diarrhea and vomiting can deplete electrolytes and cause dehydration.)
• Assist the client in identifying foods that are triggers.
• Provide small, frequent meals and encourage the client to eat slowly.
• Advise the client to avoid alcohol, caffeine, and foods that can cause gastric irritation.
• Assist the client in identifying ways to reduce stress.
• Monitor for indications of gastric bleeding (coffee-ground emesis; black, tarry stools).
• Monitor for findings of anemia (tachycardia, hypotension, fatigue, shortness of breath, pallor, feeling
lightheaded or dizzy, chest pain).
Health Promotion and Disease Prevention
ü Assist in the reduction of anxiety related to gastritis.
ü Follow a prescribed diet.
ü Decrease or eliminate alcohol use.
ü The client who has pernicious anemia will need vitamin B12 injections due to a decrease of the intrinsic
factor by the stomach parietal cells.
ü Watch for indications of GI bleeding.
ü Follow the prescribed medication regimen.
ü Eat small, frequent meals, avoiding foods and beverages that cause irritation.
ü Report constipation, nausea, vomiting, or bloody stools.
ü Stop smoking.

Complications Gastric bleeding


Causes
• Severe acute gastritis with deep tissue inflammation extending into the stomach muscle.
• In chronic erosive gastritis, bleeding can be slow or profuse as in a perforation of the stomach wall.
Nursing Actions
• Monitor vital signs and airway.
• Provide fluid replacement and blood products.
• Monitor CBC and clotting factors.
• Insert a nasogastric (NG) tube for gastric lavage (irrigate with normal saline or water to stop active gastric
bleed) as indicated. Obtain an x-ray to confirm placement of NG tube prior to fluid instillation to prevent
aspiration. QEBP
• Monitor NG tube for absence or presence of blood, assess the amount of bleeding, and prevent gastric
dilation.
• Administer IV medications (proton-pump inhibitors, H2-receptor antagonists) as prescribed.
Client Education: Monitor for indications of slow gastric bleeding (coffee-ground emesis; black, tarry stools). Seek
immediate medical attention with severe abdominal pain or vomiting blood. Take medications as directed.

Gastric outlet obstruction


Cause: Severe acute gastritis with deep tissue inflammation extending into the stomach muscle
Nursing Actions
• Monitor fluids and electrolytes because continuous vomiting results in loss of chloride (metabolic alkalosis)
and severe fluid and electrolyte depletion.
• Provide fluid and electrolyte replacement. Monitor I&O.
• Prepare to insert an NG tube to empty stomach contents.
• Prepare for a diagnostic endoscopy.
Client Education: Seek medical attention for continuous vomiting, bloating, and nausea.

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

Expected Early-stage gastric cancer


Dyspepsia
Findings o
o Abdominal discomfort
o Epigastric or back pain
o Abdominal fullness, indigestion
Advanced-stage gastric cancer
o Unexplained weight loss
o Decreased appetite
o Nausea and vomiting
o Iron deficiency anemia
o Palpable epigastric mass
o Enlarged lymph nodes
o Blood in stool
o Fatigue
Diagnostic Esophagogastroduodenoscopy (EGD) with biopsy
Expected findings: Visualization and location of tumor and/or metastasis
Procedures

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

Carcinoembryonic antigen (CEA)


Expected findings: Positive (denotes malignancy; not specific to gastric cancer)
Client education: Positive CEA can be indicative of many types of cancer.

Therapeutic Chemotherapy
Combination chemotherapy can include fluorouracil, carboplatin, cisplatin, and/or oxaliplatin. It is used alone or along
Procedures
with surgery.

Targeted medication therapy


Given to treat advanced gastric cancer. Can include trastuzumab, fluorouracil, cisplatin.

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.

Client Education Health Promotion/Disease Prevention


ü Consume a diet rich in fresh fruits and vegetables, and avoid excessive intake of processed, pickled, and
smoked foods.
ü Screening (upper endoscopy) might be indicated for clients who have inherited cancer syndromes, such as
Lynch syndrome or familial adenomatous polyposis.
ü Maintain a healthy weight and participate in regular exercise.
ü Avoid or reduce alcohol intake.
ü Avoid use of tobacco.
Interprofessional care
ü Dietician referral to promote nutritional intake and prevent dumping syndrome.
ü Case manager or social worker for ongoing client and family support

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.

Pernicious anemia; due to lack of intrinsic factor following a total gastrectomy.


Nursing Actions: Injection of vitamin B12.
MALNUTRITION
Pathophysiology Malnutrition is caused by a lack of adequate nutrients or
an imbalanced intake of nutrients and can be identified in
clients who are underweight, overweight, or obese.
It is a major cause of morbidity and mortality, decreased
quality of life, and increased health care costs.
It can affect all organ systems, cause impaired cognition,
and slow healing processes in clients who have had
surgery. As a global health issue, poor nutrition increases
risk for infectious diseases and conditions related to
nutrient deficiencies, such as anemia.
Types of Protein-energy malnutrition (PEM)
Malnutrition Also called protein-energy undernutrition
• Calorie deficit due to inadequate intake of protein, carbohydrates, and fat
o May be starvation-related and is common in children affected by malnutrition, as well as older
adults. Starvation is a complete lack of nutrients and does not involve inflammation.
o Marasmus – Inadequate intake of calories and protein. Serum proteins may be within established
ranges, but body fat and protein in the tissue are wasted.
o Kwashiorkor – Lack of protein intake or intake of poor-quality protein in diet; calorie consumption
may be adequate. Body weight may be within established ranges. Serum protein levels are low.

Chronic disease-related malnutrition


May occur in clients who have chronic disease processes
• Mild to moderate inflammation causes decreased appetite
• Underutilization of nutrients
• Examples:
o Chronic alcohol use disorder is associated with poor diet.
§ Clients may have associated liver disorders.
§ Multivitamins and other oral nutritional supplements may be needed. Clients should use
caution with any over-the-counter vitamins or other supplements that are not
prescribed.
§ Thiamin absorption is impaired, and deficiency increases risk of alcoholic
encephalopathies
§ If client has cirrhosis, deficiency of vitamins A, D, E, K is likely.
§ Ascites and abdominal pain from liver disease may affect appetite and comfort while
eating.
o COPD increases the work of breathing, which increases calories burned and increases risk for
loss of muscle mass and strength
§ Poor appetite
§ Nausea
§ Abdominal bloating that leads to feeling of fullness
§ Dyspnea while eating
o HIV and AIDS increase the risk of wasting syndrome with loss of muscle mass
§ Diarrhea and malabsorption
§ Anorexia
§ Nausea
§ Difficulty swallowing if candida infection of throat or esophageal lesions are present
§ Medications may cause intolerance to fat
o Cystic fibrosis—decreased absorption of fat because of lack of pancreatic enzyme
§ Work of breathing increases calorie expenditure
§ Abdominal distention, GERD may affect intake
§ Deficiency of vitamins, especially A, D, E, and K, is likely
o Chronic kidney disease increases risk of uremia and electrolyte imbalances
§ Protein and calorie needs are based on:
§ Height-to-weight ratio
§ Muscle tone
§ Serum albumin, hemoglobin, hematocrit
§ Protein restriction early in disease preserves kidney function
§ Protein needs may be different for clients who are undergoing hemodialysis or peritoneal
dialysis

Acute disease-related or injury-related malnutrition


May occur in clients who have major infections, major traumas, or other critical conditions
• Clients may have been adequately nourished before illness or injury.
o Severe inflammatory response during critical illness or injury causes decreased appetite and
impaired digestion and absorption of nutrients. May require total parenteral nutrition (TPN) if
gastrointestinal (GI) tract function is compromised.
• Malnutrition related to critical illnesses is associated with higher mortality rates, increased inpatient hospital
days, and higher costs related hospitalization.
• Goals of nutritional support are to decrease morbidity from infections, total number of ventilator-dependent
days, and length of stay in critical care units.
• Oral diet is preferred if possible. Enteral nutrition (EN) is preferred over parenteral nutrition (PN) if the GI
tract is functioning.
• Fluid requirements must be individualized based on the presence of blood loss, diarrhea, vomiting, fever, and
exudates.
• Indirect calorimetry (IC) provides the most accurate, predictive assessment of caloric needs.
o Weight-based formula may be used if IC not available.
§ For clients who have BMI less than 30, 25 to 30 cal/kg/day, based on weight upon
admission
§ For clients who have BMI 30 to 50, 11 to 14 cal/kg/day, based on weight upon
admission
§ For clients who have BMI greater than 50, 22 to 25 cal/kg/day of ideal body weight
• For clients who have acute, critical illnesses, adequate protein intake may be more crucial than total calories.
o For clients who have BMI less than 30, 1.2 to 2 g/kg/day of actual weight (may be higher for
clients who have burns)
o For clients who have BMI 30 to 40, 2 g/kg/day of ideal body weight
o For clients who have BMI greater than 40, 2.5 g/kg/day of ideal body weight
• High doses of vitamins C and E and selenium, zinc, and copper are recommended.
• Examples:
o Burns – caloric and nutrient needs increase because of increased metabolism and catabolism
§ Calorie-dense and protein-dense foods and oral supplements are sufficient if burns
cover less than 20% of total body surface area (TBSA). Supplemental EN may be
indicated if calorie and protein intake are less than 75% of estimated need for more
than 3 days.
§ If client unable to meet calorie needs with oral intake, initiation of EN (or PN if the GI
tract is not functioning) within 4 to 6 hours of injury is associated with decreased risk
for infection and improved function of the GI tract.
§ High metabolic rate may persist for years after injury.
o Sepsis
§ Indirect calorimetry or weight-based equations should be used to calculate requirements
for kcal/day.
§ Nutritional support through EN, or PN if the GI tract is not functioning, should be
initiated as soon as possible.
o Multi-trauma
§ Acute tissue injury and inflammation cause decreased prealbumin and albumin levels.
§ Head injuries
§ Client assumed to be in catabolic state
§ If skull fracture suspected or confirmed and client requires enteral feeding, oral
feeding tube should be inserted instead of NG tube
§ After extubation, oral intake may be inadequate if diet is restrictive, if client is routinely
NPO for tests and procedures, and if anorexia, nausea, or fatigue persist.

Risk Factors Social Determinants of Health that Contribute to Malnutrition (SDOH)


• Low income
• Lack of transportation
• Language barriers
• Lack of social support
• Lack of education about nutrition and food safety
• Low literacy level
• Contaminated soil and water

Risk factors for malnutrition


Nutritional status and quality of life.
• Dental problems and difficulty swallowing
• Decreased senses of smell and taste
• Gastrointestinal manifestations, including constipation and dry mouth
• Musculoskeletal and neurological conditions
• Multiple medications increase likelihood of side effects and drug-nutrient interactions
• Challenges with purchasing and preparing food
• Losses of spouse or partner, friends, family members
• Social isolation

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

Laboratory Test Monitor laboratory studies:


v Electrolytes and minerals
§ Decreased levels are associated with decreased nutrient intake.
§ Increased levels could be associated with high intake of one or more nutrients but lack of
other nutrients in diet.
§ Hypernatremia could result from dehydration associated with malnutrition.
v BUN - Negative nitrogen balance leads to decreased production of urea and decreased BUN.
v Creatinine – Decreased creatinine level is associated with decreased muscle mass.
v CBC – Anemias cause decreased red blood cell count (RBC), hematocrit (Hct), hemoglobin (Hg).
v Liver function tests – May be indicated for clients who have substance use disorders or other conditions
that involve liver damage.
v Albumin and prealbumin
§ Because of shorter half-life than albumin, prealbumin is the best indicator of nutritional
status – indicates what body has recently ingested, absorbed, digested, and metabolized.
§ Albumin and pre-albumin are synthesized in liver, so liver dysfunction causes decreased
albumin and pre-albumin levels.

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

Nursing Actions Ongoing Assessment


• Document appetite, daily weights, and I&O. These activities may be delegated to AP with ongoing
supervision.
• Monitor daily calorie count for some clients, for example, clients with burns
• Monitor manifestations of refeeding syndrome, which may occur with clients who are undernourished or
malnourished when carbohydrates are reintroduced into the diet.
• Replacement of carbohydrates stimulates insulin secretion and increases the need for nutrients involved in
metabolism of carbohydrates.
• Increased breakdown of carbohydrates leads to thiamin deficiency.
• Electrolytes move into cells from the bloodstream.
• Supplementation of thiamin and electrolytes may be needed.
• If client is receiving EN or PN, rate may need to be slowed.
• Complications of refeeding syndrome include seizures, edema, heart failure, decreased serum levels of
electrolytes, and hemolysis.

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.

NURSING ACTIONS TO PROMOTE OPTIMAL INTAKE


Environment
o Provide pain management interventions before meals.
o Decrease strong odors. For example, remove lids from foods before placing in front of client.
o Eliminate environmental distractions as much as possible.
o Clear eating area of urinals, bedpans, and emesis basins.
Comfort
o Provide opportunity for hygiene activities before meals; for example, toileting, oral care, hand hygiene.
o Assist client to a sitting position, in a chair if possible.
o Encourage client to use hearing aids, eyeglasses, and other assistive devices during meals.
Function
o Eliminate or minimize non-urgent care activities and procedures during mealtimes.
o Ensure appropriate temperature of foods and fluids.
o Encourage client to feed themselves as much as possible.
o Assist client to open packages and cut food if needed.
o Assist client with feeding if needed. Allow adequate time for client to chew and swallow.
o Observe and document intake.

Nutrition Diet Assist clients with nutrient-dense food selection.


Therapy • May require pureed, soft, or liquid diet if client has chewing or swallowing difficulties
• If the client is unable to meet nutrient requirement through oral intake, they may require supplemental enteral
feedings or parental nutrition.
• In addition to choosing calorie-dense foods for meals and snacks, examples of other ways to increase
calorie intake include these suggestions:
o Add butter, mayonnaise, cream cheese, or olive oil to food
o Add honey to cereals
o Use gravy on meats and potatoes
o Add whipped cream to desserts and beverages
• In addition to choosing protein-dense foods for meals snacks, examples of ways to increase protein intake
include these suggestions:
o Add cheese to vegetables, sandwiches, and salads
o Add peanut butter to cereal or dip fruit into peanut butter
o Add nuts to cereals, desserts, and salads
o Mix fruit with yogurt
o Use milk instead of water in recipes
OBESITY
Pathophysiology Obesity is defined as a BMI greater than 30.
It is a chronic condition caused by calorie intake in excess of energy
expenditure. It can be affected by numerous factors (culture,
metabolism, environment, socioeconomics, individual behaviors).
SDOH
It might be linked to protective measures within the body to prevent
weight loss during calorie restriction, which cause it to secrete
hormones that stimulate the appetite to maintain a specific weight.
As weight increases, the body accepts a higher weight as the expected weight and seeks to maintain it.

Risk Factors • Lifestyle factors (decreased physical activity)


• Medications (corticosteroids, antidepressants)
• Genetic predisposition
• Cardiovascular disease
• Hypertension
• Stroke
• Stress
• Mood disorders (depression)
• Hyperlipidemia
• Type 2 diabetes mellitus
• Bone/joint conditions
• Gallstones

Expected Body Mass Index (BMI)


• Overweight: BMI 25 to 29.9
Findings
• Class 1 Obesity: BMI 30 to 34.9
• Class 2 Obesity: BMI 35 to 39.9
• Class 3 Obesity: BMI 40 or greater
Waist circumference (central obesity) is a strong predictor of long-term complications related to obesity, such as
coronary artery disease.
Central Obesity
• Females: greater than 88.9 cm (35 in)
• Males: greater than 101.6 cm (40 in)
Waist-to-hip ratio (WHR)
• Measurement of difference between peripheral lower body obesity and central obesity
• Can be used as a predictor of coronary artery disease
• Indicates excess fat at the waist and abdomen
Males: 0.95 or greater
Females: 0.8 or greater

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

Client Education Health Promotion and Disease Prevention


Lifestyle modifications include establishing a healthy eating pattern, increasing physical activity, and implementing
behavior changes such as:
• Reducing calorie intake
• Incorporating cultural preferences
• Increasing aerobic and resistance training exercises
• Avoiding triggers
• Setting goals
• Managing stress
• Using social support
• Identifying emotions related to food intake

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.

Nursing Actions Pre-procedure


Nursing Actions
• To identify psychosocial factors related to obesity, provide the client the opportunity to express emotions
about eating behaviors, weight, and weight loss.
• Assess the clients understanding of needed diet and lifestyle changes.
• Arrange for availability of a bariatric room, furniture, and other equipment, such as correct size of blood
pressure cuff for the client.
• Ensure adequate staff available for ambulation and transfers.
• Use mechanical lifting devices to prevent client/staff injury.
• Review lab results (CBC, electrolytes, BUN, creatinine, HbA1C, iron, vitamin B12, thiamine, and folate).
• Ensure sequential compression stockings are applied to reduce the risk for deep vein thrombosis.
Post procedure
Nursing Actions
• Monitor airway and oxygen saturation per facility protocol. Maintain client in a semi-Fowler’s position to
promote lung expansion.
• If the client had an NG tube inserted during surgery, do not reposition it. Repositioning can disrupt the
sutures. Postoperatively, an NG tube should not be inserted for a client who has had bariatric surgery.
• Monitor for postoperative complications. Clients who have had bariatric surgery are at a greater risk for
developing atelectasis, thrombo-emboli, skin fold breakdown, incisional hernia, and peritonitis.
• Monitor bowel sounds and measure the abdominal girth daily or as prescribed.
• For open surgical procedures, apply an abdominal binder as prescribed to reduce the risk for dehiscence..
• Implement measures to prevent VTE
o Clients who have bariatric surgery are at moderate to high risk for developing VTE
o Ambulate the client as soon as possible.
o Apply sequential compression stockings
o Administer low-molecular-weight heparin as prescribed.
• Resume fluids as prescribed. Fluids might be restricted for the first few days and then increased in
frequency and volume.
o Diet progresses from clear liquids to full liquids. Clients are usually discharged on a full liquid diet.
o Pureed foods one week after surgery.
o Solid foods at six to eight weeks postoperatively
§ Four to six small meals per day
§ Teach client to wait for 30 minutes before drinking liquids following a meal.
§ Teach client to observe for manifestations of dumping syndrome (cramps, diarrhea,
tachycardia, dizziness, fatigue)
§ Empty calories, such as beverages with sugar increase the risk of dumping
syndrome for clients who have RYGB)
• Collaborate with case management and mental health resources to assist with long-term
behavior modification.
Client Education • Adhere to the limited diet of liquids or pureed foods for the first 6 to 8 weeks, as well as the volume that
can be consumed (often not to exceed 240 mL or 1 cup).
• Avoid carbonated beverages.
• Walk daily for at least 30 min.
o Collaborate with physical therapy for exercise instructions.
• Remain in low-Fowler position for 20 to 30 minutes after eating to delay gastric emptying.

Complications Anastomotic leak


• A frequent, serious complication of gastric bypass surgery
• Life-threatening emergency
• Monitor for manifestations of leak of anastomosis and notify the provider immediately
o increasing back, shoulder, abdominal pain
o restlessness
o tachycardia
o oliguria
Dehydration
• Warn the client that excessive thirst or concentrated urine can be an indication of dehydration and the
surgeon should be notified.
• Work with the client to establish goals and schedule for adequate daily fluid intake – at least 1.5 L daily.
Malabsorption/malnutrition
Because bariatric surgeries reduce the size of the stomach or bypass portions of the intestinal tract, fewer nutrients
are ingested and absorbed.
Nursing Actions
• Common nutrient deficiencies are vitamin B12, vitamin D, thiamine, calcium, iron, and folate.
• Monitor the client’s tolerance of increasing amounts of food and fluids.
• Refer the client for dietary management.
• Encourage the client to consume meals in a low-Fowler’s position and to remain in this position for 30 min
after eating to delay stomach emptying and minimize dumping syndrome.
Client Education
• Protein recommendations vary, depending on the ideal body weight of the client. Client may need up 60 to
80 grams of protein per day.
• Eat only nutrition-dense foods. Avoid empty calories (colas and fruit juice drinks) and limit carbohydrates.
• Take vitamin and mineral supplements for life.
CHOLECYSTITIS
Pathophysiology Cholecystitis is an inflammation of the gallbladder wall.
It is most often caused by gallstones (cholelithiasis)
obstructing the cystic and/or common bile ducts (bile flows
from the gallbladder to the duodenum) causing bile to back up
and the gall bladder to become inflamed.

Risk Factors o More common in females


o Estrogen therapy and use of some oral contraceptives
o Obesity (impaired fat metabolism, high cholesterol)
o Genetic predisposition
o Older adults (decreased gall bladder contractility, more likely to develop gallstones)
o Type 2 diabetes mellitus (high triglycerides) or Crohn’s disease
o Low-calorie, liquid protein diets
o Rapid weight loss (increases cholesterol)
o Native American or Mexican American ethnicity

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

Laboratory Tests Ø Increased WBC indicates inflammation.


Ø Direct, indirect, and total blood bilirubin can be increased if a bile duct is obstructed.
Ø Amylase and lipase can be increased with pancreatic involvement.
Ø Aspartate aminotransferase (AST), lactate dehydrogenase (LDH), and alkaline phosphatase (ALP)
(increased with liver dysfunction) can indicate the common bile duct is obstructed.

Diagnostic Ultrasound visualizes gallstones and a dilated common bile duct.


Abdominal x-ray or CT scan can visualize calcified gallstones and an enlarged gallbladder.
Procedures
Hepatobiliary scan (HIDA) assesses the patency of the biliary duct system after an IV injection of contrast.
Endoscopic retrograde cholangiopancreatography allows for direct visualization using an endoscope that is inserted
through the esophagus and into the common bile duct via the duodenum. A sphincterotomy with gallstone removal can
be done during this procedure.
Magnetic resonance cholangiopancreatography combines the use of oral/IV contrast with an MRI. This test
assists the provider in determining the cause of cholecystitis or cholelithiasis.

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.

Therapeutic Extracorporeal shock wave lithotripsy


Shock waves are used to break up stones. This can be used more on nonsurgical candidates of
Procedures o
normal weight who have small, cholesterol-based stones.
Nursing Actions
• Instruct and assist the client to lay on a fluid-filled pad for delivery of shock waves.
• Administer analgesia.
Client Education: Several procedures can be required to break up all stones. There can be pain intraprocedural due to
gallbladder spasms or movement of the stones.

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.

Nursing Care Administer analgesics as needed and prescribed.

Client Education Health Promotion and Disease Prevention


• Consume a low-fat diet rich in HDL sources (seafood, nuts, olive oil).
• Participate in a regular exercise program.
• Do not smoke.

Complications Obstruction of the bile duct


This can cause ischemia, gangrene, and a rupture of the gallbladder wall. A rupture of the gallbladder wall can cause
a local abscess or peritonitis (rigid, board-like abdomen, guarding), which requires a surgical intervention and
administration of broad-spectrum antibiotics.

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.

Post cholecystectomy syndrome


Manifestations of gallbladder disease can continue after surgery. The client should report findings similar to those
experienced prior to surgery related to pain and nausea. Manifestations can recur immediately or months later.
Nursing Actions: Assess pain characteristics and other reported findings.
Client education: Possible further diagnostic evaluation can be needed.

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.

Risk Factors • Cystic fibrosis


• Diabetes
• Frequent changes in weight
• Ileal resection or disease
• Low-dose estrogen therapy—carries a small increase in the risk of gallstones
• Obesity
• Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease)
• Treatment with high-dose estrogen
• Women, especially those who have had multiple pregnancies or who are of Native American or U.S.
southwestern Hispanic ethnicity

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)

Diagnostic Magnetic resonance cholangiopancreatography (MRCP)


Visualizes the biliary tree and capable of detecting biliary tract obstruction
Procedures o
Cholecystogram, cholangiogram
o Visualize gallbladder and bile duct

Celiac axis arteriography


o Visualizes liver and pancreas

Laparoscopy
o Visualizes anterior surface of liver, gallbladder, and mesentery through a trocar

Ultrasonography
o Shows size of abdominal organs and presence of masses

Helical computed tomography and magnetic resonance imaging


o Detect neoplasms; diagnose cysts, pseudocysts, abscess, and hematomas; determine severity of
pancreatitis based on the presence of necrosis or peripancreatic fluid collections

Endoscopic retrograde cholangiopancreatography


o Visualizes biliary structures and pancreas via endoscopy

Endoscopic ultrasound (EUS)


o Identifies small tumors and other abnormalities and facilitate fine-needle aspiration biopsy of
tumors or lymph nodes for diagnosis

Serum alkaline phosphatase


o In the absence of bone disease, to measure biliary tract obstruction

Gamma-glutamyl, gamma-glutamyl transpeptidase, lactate dehydrogenase


o Markers for biliary stasis; also elevated in alcohol abuse

Cholesterol levels
o Elevated in biliary obstruction; decreased in parenchymal liver disease

Medications Ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (chenodiol or CDCA)


• used to dissolve small, radiolucent gallstones composed primarily of cholesterol.
• treatment with UDCA can reduce the size of existing stones, dissolve small stones, and prevent new stones
from forming.
• 6-12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient for
recurrence of symptoms or the occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required
during this time.
• The effective dose of medication depends on body weight.
• This method of treatment is generally indicated for patients who refuse surgery or for whom surgery is
contraindicated.
Therapeutic Cholecystectomy
• (removal of the gallbladder) through traditional surgical approaches has largely been replaced by
Procedures
laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus).
As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period
required after standard surgical cholecystectomy.

Nutritional and Supportive Therapy


• The diet immediately after an episode is usually low-fat liquids. These can include powdered supplements
high in protein and carbohydrate stirred into skim milk. Cooked fruits, rice or tapioca, lean meats, mashed
potatoes, non–gas-forming vegetables, bread, coffee, or tea may be added as tolerated. The patient should
avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol.

Client Education Managing Self-Care After Laparoscopic Cholecystectomy


The nurse instructs the patient about pain management, activity and exercise, wound care, nutrition, and follow-
up care as described below.

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.

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