Health alterations class 6- Nutrition

GERD

Regurgitation of stomach contents into esophagus

Predisposing conditions for GERD

1. Hiatal hernia

2. Incompetent lower esophageal sphincter (LES, often caused by meds that cause relaxation such as nitroglycerin)

3. Impaired esophageal motility

4. Decreased gastric emptying

Signs and symptoms of GERD

1. Pyrosis (heart burn)

2. Wheezing, coughing, dyspnea (aspirating)

3. Sore throat

4. Choking

5. Regurgitation

History and physical assessment questions for GERD

What makes it better/worse? What’s their diet like? Are they in any medications? Etc

When do you do an endoscopy in a patient with GERD

When the patient experiences:

1. Dysphasia

2. Odynophagia

3. Bleeding

4. Vomiting

5. Weight loss

When is a barium swallow often done for patients with GERD

When it gets worse at night

What are esophageal manmetry studies and pH monitoring both looking for in patients with GERD?

The presence of acid

EGD pre procedure

1. Education and consent

2. NPO after MN

3. No dentures

4. Throat sprayed with xylocaine during procedure and patient is sedated

EGD post procedure

1. NPO until gag reflex returns (2-4 hours)

2. Sore throat

3. Monitor for aspiration

4. Vital signs

5. Bleeding (decreased BP and increased HR)

6. Pain (bloating from air used for procedure)

Barium swallow: Pre procedure

1. NPO at least 8 hours before

2. Assess swallowing ability

Barium swallow: post procedure

1. Monitor elimination and encourage fluids (BM to pass contrast material, white stool)

2. Monitor for signs and symptoms of obstruction

3. May need cathartics/laxatives until stool is no longer white

Management of GERD

1. Diet (avoid aggravating foods)

2. Meds

3. Weight loss

4. Smoking

5. Small frequent meals

6. Sit up after meals and avoid eating before bed

GERD medication: step up approach

starting with the weakest/otc option and moving up when it stops working

1. Antacids

2. H2 receptor blockers

3. Proton pump inhibitor

GERD medication: step down approach

Starting with the strongest/ prescription medication and working your way down

1. Proton pump inhibitor

2. H2 receptor blockers

3. Antacids

When is surgical intervention used for GERD

Rarely, when life and med changes don’t work

Antacids

Tums, maalox, mylanta

Antacids on an empty stomach

Reduce acid for a short time

Antacids taken at onset of distress after eating

Reduce acid for longer

How long should you wait to take other meds for after taking an antacid

1 hour

H2 receptor blockers

Ranitidine (Zantac), famotidine (Pepcid)

H2 receptor blockers MOA

Decrease HCL secretion

When should you take H2 receptor blockers

With meals

Proton pump inhibitors

Omeprazole (loser), rabeprazole (pariet), esomeprazole (nexium)

PPI MOA

Reduces gastric acid secretion

What PPI should you take one hour before a meal?

Esomeprazole

What are some effects of long term PPI use

1. Osteoporosis

2. Infection risk (No stomach acid to protect against infection)

Complications of untreated GERD

1. Esophagitis (inflammation can lead to tissue damage and scar tissue)

2. Dysphagia

3. Barrett’s esophagus (change in cells lining esophagus, cells may turn into cancer)

4. Bronchospasm

5. Pneumonia

GERD patient teaching

1. Diet

2. When to take meds

3. Positioning after eating (Sit up)

4. Small, frequent meals

5. Avoid irritating foods

6. Life style changes (decaf coffee, stop smoking…)

Hiatal hernia

Protrusion of stomach into esophagus through an opening in the diaphragm

Types of hiatal hernia

1. Sliding-most common

2. Para-esophageal- “rolling”

What is the most common cause of GERD in older people

Hiatal hernias

What happens to the diaphragm that allows a hiatal hernia to form

It loses elasticity

Why might a person with a hernia feel full faster/easier

Because a portion of their stomach is up near their esophagus

Signs and symptoms of a hiatal hernia

1. Similar to GERD

2. Heartburn after meals

3. Dysphagia

4. Pain when bending or straining

Hiatal hernia diagnosis

1. Barium swallow

2. Endoscopy

Hiatal hernia treatment

Same as GERD

Gastritis

Inflammation of stomach mucosa, breakdown in normal gastric mucosal barrier

Acute gastritis

Lasts hours to days, develops quickly. May be onset after an irritating meal or alcohol

Chronic gastritis

Lasts weeks to years

Causes of gastritis

1. Medications (NSAIDs, digitalis, corticosteroids)

2. Diet (alcohol, spicy, irritating foods)

3. H-Pylori

4. Autoimmune component

5. Infections

Signs and symptoms of acute gastritis

1. Anorexia

2. Nausea and vomiting

3. Epigastric tenderness

4. Feeling full

5. Hemorrhage

Signs and symptoms of chronic gastritis

1. Same as acute

2. Vitamin B12 deficiency (important for growth/maturation of RBCs, can lead to anemia, may need monthly injection)

Gastritis diagnosis

1. History and physical (drug/alcohol use)

2. Endoscopy with biopsy

3. H- pylori testing

4. CBC-anemia

5. Stool sample-occult blood

Nursing care of acute gastritis

1. Eliminate cause

2. Supportive care

3. If vomiting occurs: bed rest, NPO, IV fluids, antiemetics

4. CF when symptoms subside

5. Drug therapy-reduce irritation of gastric mucosa

Nursing care of chronic gastritis

1. Evaluate, eliminate cause (stop ETOH, H-pylori treatment)

2. Non irritating diet (6 small meals a day)

3. No smoking

4. Vitamin B12 (may need injections)

What vitamin is important regarding gastritis

Vitamin B12

Peptic ulcer disease

Erosion of mucosal wall

Acute peptic ulcer disease

Superficial erosion, minimal inflammation

Chronic peptic ulcer disease

Long duration, erosion of muscular wall

Types of peptic ulcer disease

1. Gastric

2. Duodenal

3. Stress related (often result of trauma such as a burn)

Most common cause of PUD

H-pylori

Causes of PUD

1. H pylori

2. Meds (NSAIDs, corticosteroids )

3. Stress (burns, sepsis, trauma)

4. Diet (caffeine, spicy foods)

5. ETOH

6. Smoking

PUD signs and symptoms

1. Common to have no symptoms

2. Pain

3. Weight loss

4. Bleeding (hematemesis (vomiting blood)/gastric or melena/dudodenal)

5. Acute stress related ulcers

PUD gastric signs and symptoms

1. Burning, gaseous pain

2. Occurs 1-2 hours after a meal

Key difference between duodenal and gastric PUD

Duodenal pain occurs 2-4 hours after a meal (at night) and gastric pain occurs 1-2 hours after a meal

Duodenal PUD signs and symptoms

1. Burning, cramp like pain

2. Pain at night

3. Pain 2-4 hours after a meal

4. Dark, bloody stool

PUD diagnostic tests

1. Endoscopy

2. H-pylori testing

3. Barium studies/swallow

4. Labs:

5. CBC (bleeding/inflammation)

6. Urinalysis (can detect h pylori)

7. Liver enzymes may be elevated

8. Amylase (pancreas)

9. Stools (looking for h pylori and blood)

H pylori testing

Non invasive: serum blood tests (IgG, indicates H pylori has been present at some point), urea breath tests (increase in CO2 value if H pylori is present), stool test (not as accurate as breath test)

Invasive: biopsy of stomach (endoscopic procedure)

Conservative therapy Care of PUD

1. Rest

2. Bland diet

3. No smoking

4. Meds

5. Reduce stress

Care for acute exacerbation of PUD

1. IV fluids

2. NPO

3. NG to suction if complications occur

PUD medications

1. H2 receptor blockers

2. PPI

3. Antibiotics

4. Antacids

5. Anticholinergic

6. Cytoprotective agents

H pylori treatment

Triple therapy for 7-14 days, first line of therapy (teach pt to stay in full course of meds even if symptoms subside)

1. PPI (Prilosec/omeprazole)

2. Amoxicillin

3. Biaxin (clarithromycin)

Complications of PUD (emergencies)

1. Hemorrhage

2. Perforation (sudden, severe abdominal pain, rigid abdomen, shallow, rapid rests, peritonitis)

3. Gastric outlet obstruction (abdominal discomfort, projectile vomiting, loud, visible peristalsis)

Nursing care of PUD

1. History and physical-detect and prevent

2. Rest

3. Diet changes (may be NPO during acute exacerbation—> NG, fluid replacement and oral care)

4. Drug therapy

5. Stop smoking

6. Long term follow up and care

7. Physical and emotional rest