N120 Martin Week 5 Nutrition

Obtain medical history

• GI disorders

• Ulcers

• Cancer

• Family history

• Surgeries

• Medication

Diet

•  usually tied into culture

• Certain culture gravitate towards certain spices that may cause GI irritation/upset

Elimination/Bowel movement 

• Occurrence

• Frequency 

• Diarrhea vs constipation 

• Bleeding when going or in stool

  • Can help indicate where bleeding is located depending on color of blood 

NSAID

• long term or frequent use can lead to ulcers or breakdown of stomach lining 

• Inhibits prostaglandin 

  • Responsible for regulating stomach acid by stimulating bicarbonate secretion in stomach and duodenum 

  • Maintains neutral pH in stomach

  • Protect mucosal lining from damage 

• Note: bicarbonate secretions is key defense mechanism against the acidic environment in digestive tract 

Opioid

•  slow down gastric motility and increase absorption

Laxative

•  promote bowel movement

Anticoagulants

• increase bleeding

Aspirin

•  increase development of complications such as bleedings and ulcers 

Stress

•  can affect function as it induces cortisol 

• Can lead to…

  • Altered digestion

  • Increased blood sugar

  • Decreased nutrient absorption (less effective)

  • Development of GI disorders

Esophagogastroduodenoscopy (EGD) or Endoscopy

• Camera in GI tract to visually lining of upper GI (esophagus to small intestine)

• Can diagnose

  • Gastritis

  • Esophageal fistula

  • Ulcers

  • Take biopsies 

• Procedure

  • Patients are given MAC anesthesia which is considered conscious sedation 

    • Pt does not remember event at all 

    • Induces temporary anesthesia 

  • NPO before procedure to ensure clear visual field

  • If ulcer is present, cauterization can be performed then and there 

  • Verify gag reflex before giving oral fluids

Esophageal pH monitoring

Most accurate method of diagnosing GERD (gold standard)

• Evaluates the frequency and duration of acid reflux episodes

Catheter with pH sensors is placed through the nose 

• Measures pH changes/readings related to:

  • Food

  • Body position 

  • Activity 

• Records acid levels (pH) continuously for 24 to 48 hours

• Helps correlate acid reflux episodes with symptoms like heartburn or regurgitation

• pH <4 = acidic reflux episodes

• Useful when symptoms persist despite PPI therapy.
  

Per Lewis:

• Stop PPIs and antacids several days before the test

• Maintain normal activities and eating habits during the monitoring

Esophageal Manometry

• Measures pressure of the lower esophageal sphincter (LES) to determine its strength 

• LES acts as a valve that prevents backflow of stomach acid into esophagus

• Weakened or incompetent LES is a major contributor to GERD 

  • Can increase risk of developing cancer

Can diagnose…

• GERD

Procedure

• NG Tube through nare 
  

Barium Swallow Study

• Identifies, structural abnormality which could contribute to or cause GERD

• AKA helps detect things that may cause or contribute to GERD

• Drinking barium to coat GI tract to see structural abnormalities through x-ray 

• NPO 8 hours before

Barium - thick, white, chalky contrast

• Not broken down by body

• Cause stool to be white and chalky (important patient education) 

• Encourage fluids to prevent constipation from bari

Stool Exam

• Looking for blood or microbes in stool

• Stool Occult - positive result is abnormal 

  • Cannot be seen by naked eye

CT/MRI

To diagnose… 

• Tumors

• Abscess

• Fistulas

• Obstructions

Barium Enema

• Administered rectally to differentiate Crohn’s vs. Ulcerative Colitis

• Crohn’s Disease - inflammation anywhere in the GI tract (patchy) affects all mucosal layers 

• Ulcerative Colitis - continuous inflammation of the colon

Colonoscopy

• Visualize large intestine to the rectum using a camera inserted through rectum

• Prep is very important

  • 5 days before

    • Decrease fiber consumption

    • Avoid corns/nuts or anything that is hard to digest by the stomach

  • 24 hours before

    • Clear liquid diet only

      • No red, purple or orange dye as they can stain lining of colon and make them look inflamed 

  • Bowel prep

    • Patient is given laxative (i.e. go lightly)

    • Extremely salty 

    • Drink whole 1L one day before procedure or split dose and drink half evening before and half morning of 

    • Alternative: take sutab (24 pills + 1L water)

GERD

•  reflux of stomach acid into LES (think: heartburn)

• Etiology

  • Weakened LES

• Risk Factors

  • Obesity

  • Diet

  • NSAID use

  • Laying flat after eating

  • Tight clothing

  • Corticosteroid use

  • Large consumption of meals at one time

• Nursing Intervention

  • Treatment - lifestyle modifications

    Medicine 

    • PPIs

    • H2 receptor blockers 

    Procedures

    • Nissen Fundoplication - wrap top of stomach around lower esophagus 

      • Reinforces LES and prevent stomach acid from flowing back to esophagus 

      • Eradicates ability to vomit permanently 

    STRETTA or LINX - uses adiology to scar and tighten KES

    • Least invasive

Gastritis

• Inflammation of the gastric mucosa 

• Etiology

  • Environmental

  • Diet

  • Drugs

  • H. pylori

    Expected Findings

  • Anorexia

  • N/V

  • Epigastric pain

    Treatment

  • Eliminate causes

  • Manage symptoms

  • NG tube

  • Antibiotics if H. pylori → vancomycin 

  • Medications for symptom

  • Increase fluids

    Complications

  • Upper GI bleed 

  • Gastric obstruction 

  • Dumping Syndrome 

  • Pernicious Anemia
    

Peptic Ulcer

•  erosion of the gastric mucosa

• Etiology

  • Environmental

  • Diet

  • Drugs

  • H. pylori

• Expected Findings

  • Burning gaseous pain 1 to 5 hours after food

  • Bleeding

  • Dehydration

• Treatment

  • Drugs

  • Diet

  • NG tube

  • Manage symptoms 

    • Can heal on its own 12 to 15 weeks as long as bleeding is slow

• Lab and Diagnostic Tests

  • H. pylori

    • C13 urea breath test 

    • Stool sample

    Bleeding

    • Hgb and Hct (H&H)

    • Occult stool

      
      Endoscopy - visualize ulcer vs. inflammation

• Complications

  • Upper GI bleed

    • Coffee ground emesis

    • Dark stool

    • Closely monitor vital signs (BP + HR) during position changes as orthostatic hypotension will be a sign but it is a LATE sign 

  • Perforation - erosion of mucosal lining 

    • ABD pain

    • Fever (sudden → acute)

    • Rigid ABD 

  • Dumping syndrome

Gastric Bleeding Anemia

• Causes - due to gastritis that extends into the stomach muscle

  Nursing Interventions

  • Monitor IV fluids

  • Provide fluid replacement and blood products

  • Monitor CBC and clotting factors

  • Insert NGT for gastric lavage 

    • Obtain x-ray after insertion to confirm location of NGT

  • Monitor NGT for absence or presence of blood

Gastric Outlet Obstruction

• A blockage at the pylorus, the area between the stomach and duodenum.

• Simple: A blockage where food leaves the stomach. It gets stuck and can’t move into the small intestine.

• Because food and fluid can’t leave the stomach, they build up → the only way out is up (vomiting).

Causes - due to acute gastritis with deep tissue inflammation that extends into stomach muscle 

Nursing Interventions

• Monitor fluid and electrolytes because continuous vomiting results in loss of chloride 

• Can cause…

  • Metabolic alkalosis

  • Fluid and electrolyte depletion 

• Monitor I&O

• Prepare NGT to empty stomach contents

• Prepare for diagnostic EGD

• Report vomiting, bloating and nausea 

Pernicious Anemia

• Causes - gastritis damages parietal cells 

  • More like chronic complication 

  • Decreases absorption of VB12

  Nursing interventions 

  • Monthly vitamin B12 injections

Dumping Syndrome

• Cause - rapid release of metabolic peptides after eating food bolus 

  • Stool looks like undigested food

  Nursing Interventions 

  • S/Sx: 

    • Fullness

    • Weakness

    • Dizziness

    • Palpitations

    • Sweating

    • ABD cramping 

    • Diarrhea 

  • S/Sx resolve after a bowel movement 

  • Late manifestation can occur 10 minutes to 3 hours after eating 

  Treatment 

  • GI rest to heal

  • NPO

  • PPN/TPN

Dehydration

• Cause - Loss of fluid due to vomiting and diarrhea

  Nursing Intervention

  • Monitor I&O

  • Provide IV fluids if needed

  • Monitor electrolytes

Antacids

• neutralize stomach acid 

  • Usually magnesium or aluminum based 

Mucosal Protectant

• shield lining of stomach and intestines from damage caused by acid, pepsin or other irritants

  • Usually end in -fate (ex. sucralfate)

  • Important patient ed: take in an empty stomach 

    • 1 to 2 hours before/after meals 

    • Coating will coat food otherwise instead of GI tract

Prostaglandin Analog

•  powerful inhibitor of gastric acid and pepsin secretion (protective against increased acid)

• Decrease acid secretion

• Increase bicarb secretion

• Increase protective mucus

• Prompt vasodilation 

• Patient ed: avoid when pregnant

  • Same thing used to induce miscarriage/abortions 

  • Ex. misoprostol 

  
  

H2 Blocker

• reduces amount of stomach acid suppresses secretion of stomach acid and decreases concentration of hydrogen ions in the stomach

  • Usually end in “dine”

Cellular Level

• cannot be for acute or active symptoms because they’ll take time/longer to work or provide relief 

  • PPI - inhibit proton pumps in stomach lining that are responsible for producing acid 

    • Usually end in “zole” or “ozole”

    • Not for long term use, should only be 4 to 8 weeks 

    • Can cause… 

      • Bone fractures and osteoporosis 

        • Decreased acid production → decreased calcium absorption and magnesium

      • Rebound acid hypersecretion 

        • Taper medication

        • Take low dose if possible