HAMDALLAH HASSAN KHALID

RN,BSN,MMHS
IBN SINA COLLEGE
PALESTINE

1
 Assessment of Digestive and
Gastrointestinal Function
Functions of the Digestive System
 The breakdown of food particles into the
molecular form for digestion
 The absorption into the bloodstream of
small nutrient molecules produced by
digestion
 The elimination of undigested
unabsorbed foodstuffs and other waste
products
2
3
Assessment:
Health History:
• Past and current medication use.
• Previous diagnostic studies.
• Treatments.
• Surgery.
• Current nutritional status
• Serum values and complete blood count [CBC]).
• Questioning about the use of tobacco and alcohol
• Changes in appetite or eating patterns
• Unexplained weight gain or loss over the past year.
• Psychosocial, spiritual, or cultural assessment.

4
Clinical Manifestations:
Pain
• The character, duration, pattern,
frequency, location, distribution of referred
pain and time of the pain vary greatly
depending on the underlying cause.
• Other factors such as meals, rest, activity,
and defecation patterns may directly affect
this pain.
5
Dyspepsia
• Dyspepsia, upper abdominal
discomfort, or distress associated
with eating (commonly called
indigestion).
• Typically, fatty foods, salads and
coarse vegetables as well as highly
seasoned foods may also cause
considerable GI distress.
6
Intestinal Gas
•The accumulation of gas in the
GI tract may result in belching
(expulsion of gas from the
stomach through the mouth)
or flatulence (expulsion of gas
from the rectum).
7
Nausea and Vomiting
• Nausea is a vague, intensely unsettling
sensation of sickness or “queasiness” that
may or may not be followed by vomiting.
• It can be triggered by odors, activity,
medications, or food intake.
• The emesis, or vomitus, may vary in
color and content and may contain
undigested food particles, blood
(hematemesis), or bilious material mixed
with gastric juices.
8
 The causes of nausea and
vomiting are many:
(1) Visceral afferent stimulation
(2) CNS disorders
(3) Irritation of the chemoreceptor
trigger zone from radiation
therapy, systemic disorders,

9
Change in Bowel Habits and
Stool Characteristics
• Changes in bowel habits may signal colonic
dysfunction or disease.
• Diarrhea, an abnormal increase in the
frequency and liquidity of the stool or in
daily stool weight or volume
commonly occurs when the contents move
so rapidly through the intestine and colon
that there is inadequate time for the GI
secretions and oral contents to be
absorbed.
10
• Constipation, a decrease in the
frequency of stool, or stools that are
hard, dry, and of smaller volume
than normal.
• Stool is normally light to dark
brown; however, specific
disease processes and ingestion
of certain foods and medications
may change the appearance of
stool
11
•Blood in the stool can present in
various ways and must be
investigated.
•If blood is shed in sufficient
quantities into the upper GI tract,
it produces a tarry-black color
(melena)

12
• Whereas blood entering the
lower portion of the GI tract or
passing rapidly through it will
appear bright or dark red.
• Lower rectal or anal bleeding
is suspected if there is
streaking of blood on the
surface of the stool or if blood
is noted on toilet tissue.
13
Physical Assessment
Assessment of the mouth, abdomen,
and rectum and requires:
• Good source of light
• Full exposure of the abdomen
• Warm hands with short fingernails
• Comfortable, relaxed patient with an
empty bladder.
• The patient lies supine with knees
flexed slightly for inspection
auscultation, palpation, and percussion
of the abdomen 14
 Expected contours of the
anterior abdominal wall can be
described as flat, rounded, or
scaphoid.
 The frequency and character
of the sounds are usually heard
as clicks and gurgles that occur
irregularly and range from 5 to
35 per minute.
15
 The terms normal (sounds
heard about every 5 to 20
seconds)
 Hypoactive (one or two
sounds in 2 minutes).
 Hyperactive (5 to 6 sounds
heard in less than 30 seconds).
 Absent (no sounds in 3 to 5
minutes).
16
 Percussion is used to assess
the size and density of the
abdominal organs and to detect
the presence of air-filled, fluid-
filled, or solid masses.
 Use of light palpation is
appropriate for identifying areas
of tenderness or muscular
resistance, and deep palpation
is used to identify masses. 17
18
Diagnostic Evaluation
General nursing interventions
• Establishing the nursing diagnosis
• Providing needed information about
the test and the activities required
of the patient
• Providing instructions about
postprocedure care and activity
restrictions
19
• Providing health information and procedural
teaching to patients and significant others
• Helping the patient cope with discomfort
and alleviating anxiety
• Informing the physician or nurse
practitioner of known medical conditions or
abnormal laboratory values that may affect
the procedure
• Assessing for adequate hydration before,
during, and immediately after the
procedure, and providing education about
maintenance of hydration
20
:Stool Tests
• Consistency, color, and occult (not visible)
blood, fecal urobilinogen, fecal fat, nitrogen,
Clostridium difficile, fecal
leukocytesparasites, pathogens…..
• Random specimens should be sent promptly
to the laboratory for analysis.
• However, the quantitative 24- to 72-hour
collections must be kept refrigerated until
transported to the laboratory.
• Fecal occult blood testing (FOBT)
21
Breath Tests
• The hydrogen breath test was developed to
evaluate carbohydrate absorption, in addition to
aiding in the diagnosis of bacterial overgrowth in
the intestine and short bowel syndrome.
• This test determines the amount of hydrogen
expelled in the breath after it has been produced
in the colon.
• Urea breath tests detect the presence of
Helicobacter pylori, the bacteria that can live in
the mucosal lining of the stomach and cause
peptic ulcer disease.
22
• After the patient ingests a capsule of
carbon-labeled urea, a breath
sample is obtained 10 to 20 minutes
later.
• Because H. pylori metabolizes urea
rapidly, the labeled carbon is
absorbed quickly; it can then be
measured as carbon dioxide in the
expired breath to determine whether
H. pylori is present. 23
Abdominal Ultrasonography:
• Ultrasonography is a noninvasive diagnostic
technique in which high-frequency sound
waves are passed into internal body
structures and the ultrasonic echoes are
recorded on an oscilloscope as they strike
tissues of different densities.
• It is particularly useful in the detection of an
enlarged gallbladder or pancreas, the
presence of gallstones, an enlarged ovary, an
ectopic pregnancy, or appendicitis.
• It cannot be used to examine structures that
lie behind bony tissue.

24
Nursing Interventions
 The patient is instructed to fast for
8 to 12 hours before the test to
decrease the amount of gas in the
bowel.

 If gallbladder studies are being

performed, the patient should eat a
fat-free meal the evening before the
test.
25
DNA Testing
Imaging Studies
Upper Gastrointestinal Tract
Study
• It aids in the diagnosis of ulcers,
varices, tumors, regional enteritis,
and malabsorption syndromes.
• Barium swallow
• Barium meal
26
Nursing Interventions:
 Clear liquid diet, with nothing by mouth (NPO)
from midnight the night before the study
 However, each physician may prefer a specific
bowel preparation for specific studies.
 When a patient with insulin-dependent diabetes
is NPO, his or her insulin requirements will need to
be adjusted accordingly.
 Smoking, chewing gum, and using mints can
stimulate gastric motility

27
After the upper GI procedure:
 Ensure that the patient has
eliminated most of the ingested
barium.

 Fluids may be increased to facilitate

evacuation of stool and barium.

28
Lower Gastrointestinal Tract
Study
 Visualization of the lower GI tract is
obtained after rectal installation of barium.
 The barium enema can be used to
detect the presence of polyps, tumors, or
other lesions of the large intestine and
demonstrate any anatomic abnormalities or
malfunctioning of the bowel.
 After proper preparation and evacuation of
the entire colon, each portion of the colon
may be readily observed.
29
• The procedure usually takes about
15 to 30 minutes, during which time
x-ray images are obtained.
• A double-contrast or air-contrast
barium enema involves the
instillation of a thicker barium
solution, followed by the instillation
of air
To detect smaller lesions.
30
Nursing Interventions
• Preparation of the patient includes
emptying and cleansing the lower
bowel.
• This often necessitates a low-residue
diet 1 to 2 days before the test
• A clear liquid diet and a laxative the
evening before; NPO after midnight
31
• Barium enemas are
contraindicated in patients with:
– Active inflammatory disease.
– Signs of perforation or obstruction;
instead
– A water-soluble contrast study may be
performed.
– Active GI bleeding may prohibit the use of
laxatives and enemas.

32
Computed Tomography:
CT may be performed with or without
oral or intravenous (IV) contrast

Any allergies to contrast agents,

iodine, or shellfish

Patient's current serum creatinine

level, and urine human chorionic
gonadotropin
33
Magnetic Resonance Imaging
 MRI is used in gastroenterology to
supplement ultrasonography and CT.
 This noninvasive technique uses magnetic fields
and radio waves to produce an image of the area
being studied.
 MRI is contraindicated for patients with:
Permanent pacemakers
Artificial heart valves and defibrillators
 Implanted insulin pumps
Because the magnetic field could cause
malfunction.
34
 Positron
Emission
Tomography (PET)

 Scintigraphy

35
Endoscopic Procedures
 Fibroscopy/esophagogastroduodenoscopy
(EGD)
 Small-bowel enteroscopy
 Colonoscopy
Sigmoidoscopy
 Proctoscopy
Anoscopy
 LAPROSCOPY
ERCP

36
37
Nursing Interventions
NPO for 8 hours prior to the examination.
local anesthetic gargle or spray.
Midazolam (Versed), a sedative
Atropine (to reduce secretions)
Glucagon (to relax smooth muscle)
left lateral position to facilitate clearance of
pulmonary secretions and provide smooth
entry of the scope.
•.
38
After gastroscopy:
 Assess level of consciousness
 Vital signs, oxygen saturation,
pain level.
 Monitor for signs of perforation:
(ie, pain, bleeding, unusual
difficulty swallowing, and rapidly
elevated temperature).

39
Fiberoptic Colonoscopy

40
Nursing Interventions
 Adequate colon cleansing
 Laxative for two nights before
 The use of lavage solutions is
contraindicated in patients with
intestinal obstruction or
inflammatory bowel disease.

41
Gastric Analysis, Gastric Acid
Stimulation Test, and pH
Monitoring
NPO for 8 to 12 hours before
Any medications that affect gastric secretions
are withheld for 24 to 48 hours before
Smoking is not allowed on the morning of the
test
Histamine
Nasogastric tube
Gastric specimens are collected after the
injection every 15 minutes for 1 hour
42
Management of Patients
with Oral And
Esophageal Disorders

43
 Disorders of the Lips, Mouth,
and Gums
Abnormalities
Nursing Possible Causes Signs and
of the Lips
Considerations
Condition and sequelae Symptoms
Sun protection Exposure to sun; Irritation of lips Actinic cheilitis
Protective ointment More common in associated with
Checkup by physician fair-skinned people scaling, crusty,
fissure; white
overgrowth of horny
layer of epidermis
(hyperkeratosis)
Acyclovir (Zovirax) Immunosuppresse Symptoms may be Herpes
ointment or systemic d patients delayed up to 20
simplex 1
Analgesics Very contagious days
Avoid irritating foods May recur with singular or (cold sore or
menstruation clustered painful fever blister
Fever, or sun vesicles that may
exposure rupture

44
 Nursing Considerations Possible Causes and Signs and Symptoms Abnormalities
sequelae of the
Mouth
 Follow up if leukoplakia  Fewer than 2%are  White patches; Leukoplakia
persists longer than 2 malignant  usually in buccal mucosa
weeks  Common among tobacco  usually painless
 Eliminate risk factors users
 Comfort measures,  Associated with  Shallow ulcer with a white Aphthous
such as saline rinses, emotional or mental or yellow center and red Stomatitis
soft diet stress, fatigue border (canker sore)
 Antibiotics  hormonal factors  Seen on the inner side of
 Corticosteroids  minor trauma (such as the lip and cheek or on the
biting) tongue;
 allergies  It begins with a burning or
 acidic foods tingling sensation
 dietary deficiencies  Slight swelling
 Associated with HIV  Painful; usually lasts 7–10
infection days and heals without a
 May recur scar
 Prophylactic mouth  Chemotherapy  Mild redness (erythema) Stomatitis
care  Radiation therapy  Edema
 Use of a soft-bristled  Severe drug allergy  Painful ulcerations
toothbrush  myelosuppression (bone  Bleeding and secondary
 Avoid alcohol based marrow depression) infection
mouth rinses and hot or
spicy foods
 Apply topical anti-
inflammatory, antibiotic,
and anesthetic agents
as prescribed 45
Nursing Possible Causes Signs and Abnormalities
Considerations and sequelae Symptoms of the Gums

Teach patient proper  Poor oral hygiene:  Painful, inflamed, Gingivitis

oral hygiene food debris, swollen gums
bacterial plaque, and  Usually the gums
calculus bleed in response
(tartar)accumulate; to light contact
the gums may also
swell in response to
normal processes
such as puberty and
pregnancy
 Oral hygiene  Poor oral hygiene  Gray-white Necrotizing
 Irrigate with 2%  Bacterial infection pseudomembrano
to 3% hydrogen  Inadequate rest us ulcerations gingivitis
peroxide or  Emotional stress affecting the
normal saline  Smoking edges of the
solution  Poor nutrition gums, mucosa of
 Avoid irritants the mouth, tonsils,
such as smoking and pharynx
and spicy foods  Foul breath
 Painful, bleeding
gums
 Swallowing and
talking are painful 46
 Apply • Herpes Burning Herpetic
simplex virus; sensation with gingivostomatitis
topical
• streptococcal the appearance
anesthetics pneumonia, of small
 May need meningococcal vesicles 24–48
opioids if meningitis, hours later;
pain is and malaria vesicles may
severe rupture, forming
sore, shallow
 Oral care ulcers covered
 Antiviral with a gray
membrane

47
Cancer of the Oral Cavity
• occur in any part of the
mouth or throat
• curable if discovered early.
• 5-year survival rate(80%) if
detected before spreading to
lymph nodes.
48
Risk factors:
Tobacco
Ingestion of alcohol
Dietary deficiency
Ingestion of smoked meats.
Age: more than 40 years
Gender: men
Exposure to the sun and wind
(Lip Ca) 49
Clinical Manifestations
 Asymptomatic in the early stages.
 Later, the most frequent
symptom is a painless sore or mass
that will not heal.
 A typical lesion in oral cancer is a
painless indurated (hardened) ulcer
with raised edges.
50
As the cancer progresses
 Tenderness
 Difficulty in chewing,
swallowing, or speaking
 Coughing of blood-tinged
sputum
 Enlarged cervical lymph nodes.
51
Assessment and
Diagnostic Findings
 Oral examination as well as an
assessment of the cervical lymph
nodes to detect possible
metastases.
 Biopsies are performed on
suspicious lesions (those that have
not healed in 2 weeks).
52
Medical Management:
 Surgical resection, radiation
therapy, chemotherapy, or a
combination
 Surgical procedures include
hemiglossectomy (surgical removal
of half of the tongue) and total
glossectomy (removal of the
tongue).
53
Disorders of the Esophagus
Hiatal Hernia
• The opening in the diaphragm
through which the esophagus passes
becomes enlarged, and part of the
upper stomach tends to move up into
the lower portion of the thorax.
• Hiatal hernia occurs more often in
women than in men.
54
There are two types of hiatal
:hernias

55
Sliding, or type I:
 Occurs when the upper stomach
and the gastroesophageal
junction are displaced upward and
slide in and out of the thorax.
 About 90% of patients with
esophageal hiatal hernia have a
sliding hernia.
56
 Paraesophageal hernia
 Occurs when all or part of the
stomach pushes through the
diaphragm beside the esophagus.
 Paraesophageal hernias are
further classified as types II, III,
or IV, depending on the extent of
herniation.
57
Clinical Manifestations
Sliding hernia:
– Heartburn, regurgitation, and dysphagia
– 50% of patients are asymptomatic.
Paraesophageal hernia:
• Sense of fullness after eating or chest pain,
or there may be no symptoms.
• Reflux usually does not occur, because the
gastroesophageal sphincter is intact.

58
• Hemorrhage, obstruction,
and strangulation can occur
with any type of hernia
Assessment and Diagnostic
Findings
• Diagnosis is confirmed by x-ray
studies, barium swallow, and
fluoroscopy.

59
Management for an axial
hernia includes:
 Frequent, small feedings that can pass easily
through the esophagus.
The patient is advised not to recline for 1
hour after eating, to prevent reflux or
movement of the hernia
 Elevate the head of the bed on (10- to 20-
cm) blocks to prevent the hernia from sliding
upward.
 Surgery is indicated (15% of patients).
60
Medical and surgical
management of a
paraesophageal hernia
 May require emergency
surgery to correct torsion
(twisting) of the stomach or
other body organ that leads
to restriction of blood flow to
that area.
61
Gastroesophageal Reflux
Disease
Some degree of gastroesophageal
reflux (back-flow of gastric or duodenal
contents into the esophagus) is normal
in both adults and children.
Excessive reflux may occur because of
an incompetent lower esophageal
sphincter, pyloric stenosis, or a motility
disorder.
62
Clinical Manifestations
• Pyrosis (burning sensation in the esophagus)
• Dyspepsia (indigestion)
• Regurgitation
• Dysphagia or odynophagia (pain on
swallowing)
• Hypersalivation
• Esophagitis.
• The symptoms may mimic those of a heart
attack.
63
Assessment and
Diagnostic Findings
 Endoscopy or barium swallow
 Ambulatory 12- to 36-hour
esophageal pH monitoring
(acid reflux)
 Bilirubin monitoring (Bilitec)
(bile reflux)
64
Management
The patient is instructed to:
–Eat a low-fat diet.
–Avoid caffeine, tobacco, beer,
milk, foods containing
peppermint or spearmint, and
carbonated beverages
65
– Avoid eating or drinking 2 hours
before bedtime
– Maintain normal body weight
– Avoid tight-fitting clothes
– Elevate the head of the bed on
(15- to 20-cm) blocks

66
Pharmacological therapy:
• Antacids or H2 receptor antagonists,
such as famotidine (Pepcid), or ranitidine
(Zantac).
• Proton pump inhibitors (medications that
decrease the release of gastric acid, such as
esomeprazole [Nexium])
• Prokinetic agents, which accelerate
gastric emptying.
Domperidone (Motilium) and
metoclopramide (Reglan).
67
 Surgical intervention:
 Fundoplication (wrapping of a portion
of the gastric fundus around the
sphincter area of the esophagus).

 A Nissen fundoplication can be

performed by the open method or by
laparoscopy.

68
Cancer of the Esophagus
Pathophysiology
• Esophageal cancer can be of two cell types:
adenocarcinoma and squamous cell carcinoma.
• Risk factors for adenocarcinoma of the esophagus
include GERD.
• Risk factors for squamous cell carcinoma:
– Chronic ingestion of hot liquids or foods.
– Nutritional deficiencies
– Poor oral hygiene.
– Cigarette smoking
– Chronic alcohol exposure
69
Tumor cells .lymphatics
muscle layers
esophageal mucosa
may spread

obstruction of
the esophagus

possible perforation mediastinum

and erosion great vessels

70
Clinical Manifestations
• Dysphagia, initially with solid foods and
eventually with liquids
• Sensation of a mass in the throat
• Painful swallowing.
• Substernal pain or fullness
• And, later, regurgitation of undigested
food with foul breath and hiccups,
hemorrhage and progressive loss of
weight and respiratory difficulty.
71
Assessment and
Diagnostic Findings
• EGD with biopsy
• CT of the chest and abdomen
• Endoscopic ultrasound

72
Medical Management
• Surgery, radiation, chemotherapy, or a
combination of these modalities
• A standard treatment plan for a person who
is newly diagnosed:
combination chemotherapy/radiation
therapy for 4 to 6 weeks
followed by a period of no medical
intervention for 4 weeks
and, lastly, surgical resection of the
esophagus. 73
 Esophagectomy
• A total resection of the esophagus
• With removal of the tumor plus a wide
tumor-free margin of the esophagus and the
lymph nodes in the area.
• When tumors occur in the cervical or
upper thoracic area, esophageal continuity
may be maintained by a free jejunal graft
transfer
• or the stomach can be elevated into the
chest and the proximal section of the
esophagus anastomosed to the stomach.
74
Tumors of the lower thoracic
esophagus

• Gastrointestinal tract
integrity is maintained by
anastomosing the lower
esophagus to the stomach

75
76
Nursing Management
• Intervention is directed toward improving the
patient's nutritional and physical status
• Parenteral or enteral nutrition.
• Preparation for surgery, radiation therapy, or
chemotherapy.
• Chest drainage, nasogastric suction, parenteral
fluid therapy, and gastric intubation.
• postoperative care
• Chest physiotherapy
• The nasogastric tube is not manipulated
• The nasogastric tube is removed 5 to 7 days after
surgery
77
Special Nutritional Modalities
Gastrostomy
A gastrostomy is a surgical procedure in which an
opening is created into the stomach for the
purpose of administering foods and fluids via a
feeding tube.
gastrostomy is preferred for prolonged enteral
nutrition support (longer than 4 weeks)
Gastrostomy is also preferred in comatose patient
because the gastroesophageal sphincter remains
intact. Regurgitation and aspiration are less likely
to occur
 Stamm (temporary and permanent)
 Janeway (permanent)
78
Percutaneous endoscopic
gastrostomy (temporary)

(10 to 14 days) 79
Low-profile gastrostomy
device (LPGD)

(3 to 6 months after initial gastrostomy tube

placement)
80
Nursing Diagnoses
Imbalanced nutrition, less than body
requirements, related to enteral feeding
problems
Risk for infection related to presence of
wound and tube
Risk for impaired skin integrity at tube
insertion site
Ineffective coping related to inability to eat
normally
Disturbed body image related to presence of
tube
81
Nursing Interventions
• Meeting Nutritional Needs:
– The first fluid nourishment is administered soon
after surgery.
– Usually consists of tap water and 10% dextrose.
– At first, only 30 to 60 mL is given at one time,
but the amount administered is increased
gradually.
– By the second day, 180 to 240 mL may be given
at one time, provided it is tolerated and no
leakage of fluid occurs around the tube.

82
Water and enteral feeding can be
infused after 24 hours for a permanent
gastrostomy.
Blenderized foods can be added
gradually to clear liquids until a full diet
is achieved.
Powdered feedings that are easily
liquefied are commercially available.

83
 Providing Tube Care and Preventing
Infection
 Providing Skin Care
 The nurse washes the area around the tube with
soap and water daily, removes any encrustation
with saline solution, rinses the area well with
water, and pats it dry
 Skin at the exit site is evaluated daily for signs of
breakdown, irritation, excoriation, and the
presence of drainage or gastric leakage.
 Enhancing Body Image

84
 Monitoring and Managing Potential
Complications
 Wound infection
 Cellulitis
 Abscesses
 Bleeding
 Premature removal of the tube
 The tract will close within 4 to 6 hours if
the tube is not replaced promptly

85
Teaching Patients Self-Care
 Showing the patient how to check for residual
gastric contents before the feeding.
 The patient then learns how to check and
maintain the patency of the tube
 All feedings are given at room temperature or
near body temperature.
 Raising or lowering the receptacle to no higher
than 45 cm (18 in) above the abdominal wall
regulates the rate of flow.
 The patient and caregiver must understand
that keeping the head of the bed elevated a
minimum of 45 degrees for at least 1 hour
after feeding facilitates digestion and decreases
the risk of aspiration.
86
Parenteral Nutrition
• Parenteral nutrition (PN) is a method
of providing nutrients to the body by
an IV route
• Admixture containing proteins,
carbohydrates, fats, electrolytes,
vitamins, trace minerals, and sterile
water in a single container.

87
The goals of PN are to
Improve nutritional status,
establish a positive nitrogen balance,
Maintain muscle mass,
 promote weight maintenance or gain
 and enhance the healing process.

88
Establishing Positive Nitrogen
Balance
As a state of negative nitrogen balance
results.
 In response, the body begins to convert
the protein found in muscles into
carbohydrates to be used to meet energy
needs.
The result is muscle wasting, weight loss,
fatigue, and, if left uncorrected, death.
89
 PN solutions, which supply nutrients such
as dextrose, amino acids, electrolytes,
vitamins, minerals, and fat emulsions,
provide enough calories and nitrogen to
meet the patient's daily nutritional needs.

 In general, PN usually provides 25 to 35

kcal/kg of ideal body weight and 1.0 to 1.5
g of protein/kg of ideal body weight.

90
Clinical Indications
• The indications for PN include a 10% deficit in body weight
(compared with pre-illness weight),
• PN is indicated in the following situations:
• The patient's intake is insufficient to maintain an anabolic
state (eg, severe burns, malnutrition, sepsis, and cancer).
• The patient's ability to ingest food orally or by tube is
impaired (eg, paralytic ileus)
• The patient is unwilling or unable to ingest adequate
nutrients (eg, anorexia nervosa, postoperative elderly
patients).
• Preoperative and postoperative nutritional needs are
prolonged (eg, extensive bowel surgery).

91
Formulas
A total of 2 to 3 L of solution is administered over
a 24-hour period using a filter
Intravenous fat emulsions (IVFEs, Intralipids) may
be infused simultaneously with PN through a Y-
connector
Usually 500 mL of a 10% emulsion or 250 mL of
20% emulsion is administered over 6 to 12 hours,
one to three times a week.
 IVFEs can provide up to 30% of the total daily
calorie intake.

92
Administration Methods
Peripheral Method
PPN formulas are not nutritionally complete: there
is typically less dextrose content.
Dextrose concentrations of more than 10% should
not be administered through peripheral veins
because they irritate the intima (innermost walls)
of small veins, causing chemical phlebitis.
 Lipids are administered simultaneously to buffer
the PPN and to protect the peripheral vein from
irritation.
 The usual length of therapy using PPN is 5 to 7
days
93
Central Method

• Therefore, to prevent phlebitis and

other venous complications, these
solutions are administered into the
vascular system through a catheter
inserted into a high-flow, large blood
vessel (the subclavian vein).

94
Discontinuing Parenteral
Nutrition
• The PN solution is discontinued
gradually to allow the patient to adjust
to decreased levels of glucose.
• If the PN solution is abruptly
terminated, isotonic dextrose is
administered for 1 to 2 hours to
protect against rebound hypoglycemia.
95
Management of Patients With
Gastric and Duodenal Disorders
Gastritis:
• Gastritis (inflammation of the gastric or
stomach mucosa)
• Gastritis may be acute, lasting several
hours to a few days, or chronic, resulting
from repeated exposure to irritating agents
or recurring episodes of acute gastritis.

96
Acute gastritis is often
caused by:
Dietary indiscretion— irritating food
Overuse of aspirin and other nonsteroidal anti-
inflammatory drugs (NSAIDs)
excessive alcohol intake
Bile reflux
Radiation therapy.
 A more severe form of acute gastritis is caused by
the ingestion of strong acid or alkali
Acute illnesses, traumatic injuries; burns; major
surgery.
Gastritis may be the first sign of an acute systemic
infection.
97
:Chronic gastritis
• Prolonged inflammation of the stomach may
be caused:
– Either by benign or malignant ulcers of the
stomach
– Or by the bacteria Helicobacter pylori (H. pylori).
• Chronic gastritis is sometimes associated with
– autoimmune diseases such as pernicious anemia
– dietary factors such as caffeine
– the use of medications such as NSAIDs
– Alcohol; smoking
– Chronic reflux irritating of pancreatic secretions
and bile into the stomach. 98
Pathophysiology
Inflammation

Edematous mucous
membrane

Hyperemic

superficial erosion
Superficial
↓ gastric juice hemorrhage
↑acid ↓ but mucus ulceration

99
100
Clinical Manifestations
Acute gastritis
Rapid onset of symptoms, such as:
Abdominal discomfort
Headache
Lassitude
Nausea
Anorexia
Vomiting
Hiccupping, which can last from a few hours to
a few days.
101
Chronic gastritis
• Anorexia
• Heartburn after eating
• Belching
• A sour taste in the mouth
• Nausea and vomiting.

102
Some patients may have only
• Mild epigastric discomfort or
• Report intolerance to spicy or fatty foods
• Or slight pain that is relieved by eating.
Chronic gastritis /pernicious anemia
Malabsorption of vitamin B12
• Some patients with chronic
gastritis have:
No symptoms

103
 Assessment and Diagnostic
Findings

• Upper GI x-ray series

• Endoscopy
• Histologic examination/ biopsy
• H. pylori

104
Medical Management
• The gastric mucosa is capable of
repairing itself after a bout of
gastritis.
• As a rule, the patient recovers in
about 1 day, although the appetite
may be diminished for an additional
2 or 3 days.
105
Acute gastritis is also managed
by:
• Risk reduction
• If the symptoms persist,
intravenous (IV) fluids
• If bleeding is present
Hemorrhage management

106
If gastritis is caused by
ingestion of strong acids or
alkalis
Emergency treatment
• Ddiluting and neutralizing the offending
agent
• To neutralize acids, common antacids (eg,
aluminum hydroxide)
• To neutralize an alkali, diluted lemon juice
or diluted vinegar.
• If corrosion is extensive or severe, emetics
and lavage are avoided (perforation and
damage to the esophagus).
107
Supportive Therapy
• Nasogastric (NG) intubation
• Analgesic agents and sedatives
• Antacids
• IV fluids.
• Fiberoptic endoscopy may be
necessary

108
In extreme cases, emergency
surgery
• To remove gangrenous or perforated
tissue.
• A gastric resection or a
gastrojejunostomy (anastomosis of
jejunum to stomach to detour around
the pylorus) may be necessary to treat
pyloric obstruction

109
110
Chronic gastritis
management
• Modifying the patient's diet
• Promoting rest
• Reducing stress
• Recommending avoidance of alcohol and
NSAIDs
• Initiating pharmacotherapy.
• H. pylori may be treated with selected
drug combinations
111
Nursing Process
The Patient With Gastritis
Assessment:
• History and presenting signs and symptoms.
• OPQRST scale
• Recent weight gain or loss
• History of previous gastric disease or surgery?
• A diet history plus a 72-hour dietary recall.
• Signs to note during the physical examination
include abdominal tenderness, dehydration, and
evidence of any systemic disorder.
112
 Nursing Diagnoses
• Anxiety related to treatment
• Imbalanced nutrition, less than body requirements,
related to inadequate intake of nutrients
• Risk for imbalanced fluid volume related to
insufficient fluid intake and excessive fluid loss
subsequent to vomiting
• Deficient knowledge about dietary management
and disease process
• Acute pain related to irritated stomach mucosa

113
PLANNING:
The major goals for the patient may
include
 reduced anxiety
 avoidance of irritating foods
 adequate intake of nutrients
 maintenance of fluid balance
 increased awareness of dietary
management
 relief of pain
114
Nursing Interventions
Reducing Anxiety
• The patient may be anxious because of pain
and planned treatment modalities.
• The nurse uses a calm approach to assess
the patient and to answer all questions as
completely as possible.
• It is important to explain all procedures and
treatments based on the patient's level of
understanding.
115
Promoting Optimal Nutrition
• NPO until healing
• I @ O + Electrolytes assessment
• If IV therapy until oral intake tolerated
• Offer the patient ice chips followed by
clear liquids.
• Solid food as soon as possible
• The nurse discourages the intake of:
 caffeinated beverages
 alcohol
cigarette smoking
116
 Promoting Fluid Balance
• IV fluids (3 L/day) usually are prescribed
and a record of fluid intake plus caloric
value (1 L of 5% dextrose in water = 170
calories of carbohydrate)
• Assess for Hemorrhage:
Hematemesis
Tachycardia
Hypotension.
117
Relieving Pain
Instructing the patient to avoid
foods and beverages
Instructing the patient about the
correct use of medications to
relieve chronic gastritis.

118
Peptic Ulcer Disease
• A peptic ulcer is an excavation (hollowed-out area)
that forms in the mucosal wall of the stomach, in
the pylorus, in the duodenum, or in the esophagus.
• Erosion of a circumscribed area of mucous
membrane is the cause
• This erosion may extend as deeply as the muscle
layers or through the muscle to the peritoneum.
• Peptic ulcers are more likely to be in the duodenum
than in the stomach.
• As a rule they occur alone, but they may occur in
multiples.
119
• Chronic gastric ulcers tend to occur in
the lesser curvature of the stomach,
near the pylorus.
• Esophageal ulcers occur as a result of
the backward flow of HCl from the
stomach into the esophagus ( GERD).
• Peptic ulcers in the body of the
stomach can occur without excessive
acid secretion.

120
•In the past, stress and
anxiety were thought to
be causes of ulcers
•But research
Infection with the gram-
negative bacteria H. pylori

121
• Excessive secretion of HCl in the stomach
may contribute to the formation of peptic
ulcers
• Predisposing factors:
Stress
Ingestion of milk and caffeinated beverages,
smoking, and alcohol also may
Chronic use of NSAIDs
Zollinger-Ellison syndrome
Familial tendency
Chronic pulmonary disease or chronic renal
disease.
122
Pathophysiology
• The erosion is caused by the:
1. increased concentration or activity
of acid-pepsin,
2. or by decreased resistance of the
mucosa.
• A damaged mucosa cannot secrete enough
mucus to act as a barrier against HCl.
• Patients with duodenal ulcer disease secrete more
acid than normal, whereas patients with gastric
ulcer tend to secrete normal or decreased levels
of acid.
123
• Damage to the gastroduodenal mucosa
allows for decreased resistance to bacteria,
and thus infection from H. pylori bacteria
may occur.
• Stress ulcer is the term given to the acute
mucosal ulceration of the duodenal or
gastric area that occurs after physiologically
stressful events, such as:
– Burns, shock, severe sepsis, and multiple organ
traumas. ventilator-dependent patients after
trauma or surgery.

124
Clinical Manifestations
• Symptoms of an ulcer may last for a few
days, weeks, or months and may
disappear only to reappear, often without
an identifiable cause.
• Many people with ulcers have no
symptoms, and perforation or hemorrhage
may occur in 20% to 30% of patients who
had no preceding manifestations.

125
• Dull, gnawing pain
• Burning sensation in the midepigastrium or
in the back.
• Sharply localized tenderness can be elicited
by applying gentle pressure to the
epigastrium at or slightly to the right of the
midline.
• Pyrosis (heartburn), vomiting, constipation
or diarrhea, and bleeding.
• Fifteen percent of patients with peptic ulcer
experience bleeding. (melena).
126
Comparison of Duodenal and Gastric Ulcers
Gastric Ulcer Duodenal Ulcer
Incidence
Usually 50 and over Age 30 to 60
Male: female 1:1 Male: female 2-3:1
15% of peptic ulcers are gastric 80% of peptic ulcers are duodenal

Signs, Symptoms, and Clinical

Normal—hyposecretion of stomach acid (HCl)
Weight loss may occur
Pain occurs 1/2 to 1 hour after a meal; rarely occurs
at night; may be relieved by vomiting; ingestion of
food does not help, sometimes increases pain
Vomiting common
Hemorrhage more likely to occur than with duodenal
ulcer; hematemesis more common than melena
Findings
Hypersecretion of stomach acid (HCl)
May have weight gain
Pain occurs 2-3 hours after a meal; often
awakened 1-2 am; ingestion of food relieves pain
Vomiting uncommon
Hemorrhage less likely than with gastric ulcer, but
if present, melena more common than
Hematemesis
More likely to perforate than gastric ulcers

Malignancy Possibility
Occasionally Rare
H. pylori, gastritis, alcohol, smoking, use of NSAIDs, Risk Factors
stress H. pylori, alcohol, smoking, cirrhosis, stress 127
Assessment and
Diagnostic Findings
• Physical examination
• Barium study
• Endoscopy,
• Stools study: occult blood, stool
antigen test
• Serologic testing for H. pylori
antigen
• Urea breath test. 128
Medical Management
Pharmacologic Therapy:
1. Recommended therapy for 10 to 14 days
includes triple therapy with two
antibiotics (eg, metronidazole [Flagyl] or
amoxicillin [Amoxil] and clarithromycin)
plus a proton pump inhibitor (omeprazole)
2. Quadruple therapy with two antibiotics
(metronidazole [Flagyl] and tetracycline)
plus a proton pump inhibitor and bismuth
salts (Pepto-Bismol).
129
3. Histamine-2 (H2) receptor
antagonists and proton pump
inhibitors are used to treat NSAID-
induced ulcers and other ulcers
not associated with H. pylori
infection
• Maintenance dosages of H2
receptor antagonists are usually
recommended for 1 year.
130
•Stress Reduction and
Rest
•Smoking Cessation
•Dietary Modification

131
 Surgical Management
• Surgery is usually recommended
for patients with intractable
ulcers (those that fail to heal
after 12 to 16 weeks of medical
treatment)

132
Severing of the vagus
nerve.
Decreases gastric acid by
diminishing cholinergic
stimulation to the
parietal cells, making
them less responsive to
gastrin.
May be done via open
surgical approach,
laparoscopy, or
thoracoscopy
133
• A surgical procedure in
which a longitudinal
incision is made into
the pylorus and
transversely sutured
closed to enlarge the
outlet and relax the
muscle

134
• Removal of the lower
portion of the antrum of
the stomach (which
contains the cells that
secrete gastrin) as well as
a small portion of the
duodenum and pylorus.
• The remaining segment is
anastomosed to the
duodenum (Billroth I) or to
the jejunum (Billroth II)

135
• Removal of distal third
of stomach;
anastomosis with
duodenum or jejunum.
• Removes gastrin-
producing cells in the
antrum and part of the
parietal cells.

136
Gastric Cancer
Risk factors:
• Age:
40 and 70 years of age
but can occur in people
younger than 40.
• Gender:
Men higher than women
137
• Dietary habits:
smoked, salted, or pickled foods and low in
fruits and vegetables
• Others:
chronic inflammation of the stomach
H. pylori infection
pernicious anemia
Smoking
achlorhydria
gastric ulcers,
previous subtotal gastrectomy (more than 20 years
ago)
genetics.
138
 Clinical Manifestations
Some studies show that early symptoms,
such as pain relieved with antacids,
resemble those of benign ulcers.
Symptoms of progressive disease may
include anorexia, dyspepsia (indigestion),
weight loss, abdominal pain, constipation,
anemia and nausea and vomiting.

139
 Assessment and Diagnostic
Findings
Endoscopy for biopsy
Barium x-ray
CT
A complete x-ray examination of the GI
tract should be performed when any
person older than 40 years of age has
had indigestion (dyspepsia) of more
than 4 weeks’ duration

140
Medical Management
No successful treatment for gastric carcinoma
except removal of the tumor. If the tumor can be
removed while it is still localized to the stomach,
the patient can be cured.
If a radical subtotal gastrectomy is performed, the
stump of the stomach is anastomosed to the
jejunum, as in the gastrectomy for ulcer.
Chemotherapy
Radiation therapy

141