GI

NSC 386 Lecture Notes

Objectives For This Lecture

  • Overview of the following disorders:

    • Oral Cancer

    • Mandibular Fractures

    • Food Poisoning

    • Gastroesophageal Reflux Disease (GERD) and Peptic Ulcer Disease (PUD)

    • Esophageal Varices and Cancer

    • Stomach Cancer

  • Discuss patient presentation, diagnostics, treatment, and nursing care associated with these disorders.

Oral Cancer

Overview

  • Definition: A growth or sore in the mouth that does not heal quickly.

  • Locations: Can occur on the lips, tongue, floor of mouth, tonsils.

  • Prognosis: Carcinomas of the lip carry the most favorable prognosis (most commonly seen).

Risk Factors and Symptoms

  • Demographics: More common in men.

  • Risk Factors include:

    • Tobacco use

    • Alcohol consumption

    • Sunlight exposure

    • HPV infections

  • Symptoms include:

    • First sign of cancer to the tongue: [Expected symptoms here]

    • Leukoplakia/Erythroplasia

    • Can progress to: [Identify progression]

    • Symptoms related to increased tobacco use: Smokers patch, prevalent precancerous lesions, ulcer or area of dysphagia, thickening, or round velvet texture leading to difficulty swallowing.

Treatment

  • Diagnosis: Typically confirmed via biopsy.

  • Treatment options include:

    • Nonsurgical: Chemotherapy and radiation.

    • Surgical: Radical surgeries, may include removal of the mandible and/or tongue.

Nursing Care

  • Watch for:

    • Pain management.

    • Mouth care (due to compromised oral integrity).

    • Psychosocial support for body image disturbances, difficulty communicating, and nutrition imbalance (less than body requirements).

Mandibular Fracture

Overview

  • Definition: The mandible is the lower jaw and the largest and strongest bone in the face.

  • Causes of fractures include:

    • Assault

    • Sports injuries

    • Motor vehicle accidents (MVA).

  • Demographics: More likely to sustain fractures: [Gender statistics not indicated].

Symptoms and Treatment

  • Symptoms include:

    • Jaw pain

    • Bleeding

    • Malocclusion

  • Complications: [Identify complications].

  • Treatment options include:

    • Ensuring proper seal of teeth

    • Airway obstruction and dysphagia management

    • Immobilization, which may involve wiring of jaws.

Nursing Management

  • Concerns when caring for a patient:

    • Nutrition management.

    • Airway concerns.

    • Management of vomiting.

    • Ensure:

    1. Airway management, including when to cut wires if necessary.

    2. Nutrition considerations, focusing on liquid diet (100% liquids and protein shakes).

    3. Pain management protocols.

    4. Mouth care suggestions.

    5. Have wire cutters available at all times for emergencies.

    6. Discharge considerations and protocols in emergencies.

Food Poisoning

Definition

  • Illness caused by the intake of contaminated food or fluids.

  • Common culprits include bacterial infections, such as:

    • Escherichia coli (E. coli) found in ground beef.

    • Salmonella found in chicken.

    • Staphylococcus through improper hand washing.

Symptoms

  • Common symptoms include:

    • Nausea and vomiting

    • Diarrhea

    • Abdominal cramping

  • Specific to E. coli food poisoning: [List specific symptoms].

  • Watch for:

    • Bloody stool

    • Dehydration (monitor potassium and other electrolyte imbalances).

Prevention Strategies

  • Clean thoroughly.

  • Separate raw and cooked foods.

  • Cook food to safe internal temperatures.

  • Chill immediately after preparation.

  • Emphasis: "When in doubt, throw it out!"

Botulism

Overview

  • Definition: Rare but most serious type of food poisoning caused by a neurotoxin produced by Clostridium botulinum, found in soil.

  • Causes include improper canning of foods or contaminated foods (like honey in infants).

  • Types of botulism:

    1. Foodborne

    2. Wound

    3. Infant (due to contamination like honey).

Symptoms and Diagnosis

  • Onset of symptoms: [Expected range here].

  • Symptoms include:

    • Slurred speech

    • Dizziness

    • Muscle weakness

    • Breathing difficulties (mechanical ventilation may be required).

  • If untreated, may lead to [Complications if untreated].

  • Diagnosis based on the presence of neurotoxin in blood, stool, or vomit (12-36hr post-exposure).

Treatment and Prevention

  • Treatment: Initiate antitoxin immediately upon positive diagnosis.

  • Prevention measures include:

    • Do not give honey to children under 1 year of age.

    • Ensure proper canning of foods.

Gastroesophageal Reflux Disease (GERD)

Overview

  • Definition: Reflux of gastric contents into the lower esophagus due to lower esophageal sphincter (LES) dysfunction.

  • Prevalence: Estimated 20% of Americans are affected.

  • Risk factors include:

    • Obesity

    • Cigar/cigarette smoking

    • Hiatal hernia.

Contributing Factors and Symptoms

  • Contributing factors leading to GERD: [Identify factors here].

  • Symptoms include:

    • Gastroesophageal regurgitation

    • Non-cardiac chest pain

    • Bloating

    • Sore throat

    • Possible respiratory symptoms: check for myocardial infarction (MI) first.

Complications

  • Complications of GERD include:

    • Barrett’s Esophagus (precancerous lesions).

    • Respiratory symptoms such as cough, bronchospasm, and pneumonia occurring every 2-3 years due to aspiration.

Diagnosis

  • Typically based on patient symptoms:

    • Endoscopy may be required if complications arise.

    • Esophagogastroduodenoscopy (EGD) to examine the stomach.

Nursing Care Before and After EGD

  • Before EGD:

    • NPO (nothing by mouth).

    • Establish IV line for sedation.

    • Baseline vital signs and education for the patient that throat numbing may occur.

  • After EGD:

    • Monitor vital signs, oxygen levels, and cardiac monitoring.

    • Monitor for gag reflex (nothing by mouth until returns).

    • Education regarding aspiration precautions.

Video Capsule Endoscopy

  • Utilized to visualize the small and large intestines.

  • Requires patient preparation: [Identify preparations here] (not first line, NPO and bowel prep).

Treatment

  • Lifestyle Modifications:

    • Avoid known triggers (i.e., caffeine, chocolate).

    • Nutritional adjustments and weight loss.

    • Avoid lying down for 2-3 hours after meals and avoid eating within 2-3 hours before bedtime.

    • Elevate the head of bed (HOB) at least 4-6 inches.

Drug Therapy

  • Medications include:

    • H2 Receptor Blockers (i.e., famotidine) to reduce HCl acid secretion.

    • Proton Pump Inhibitors (i.e., pantoprazole) which are more effective in reducing HCl acid secretion.

    • Antacids neutralize HCl acid.

Nursing Care in the Hospital

  • Ensure HOB is elevated.

  • Implement prophylaxis against aspiration.

  • Provide patient education regarding lifestyle changes and medication compliance.

Hiatal Hernia

Overview

  • Definition: Occurs when part of the stomach bulges upward into the chest cavity.

  • Demographics: More common in older adults and women.

Types of Hiatal Hernia

  • Sliding Hiatal Hernia:

    • More common type where the stomach slides through the diaphragm.

  • Paraesophageal Hernia:

    • Medical emergency where the stomach part may become strangulated.

Causes and Symptoms

  • Causes include:

    • Increased abdominal pressure (obesity, pregnancy).

    • Repeated heavy lifting.

    • Age.

  • Symptoms generally resemble those of GERD.

Diagnostic Procedures

  • Barium Swallow: Patient swallows barium, a contrast medium, visible on X-ray.

  • Nursing Considerations: NPO prior to the procedure, encourage fluid and fiber intake post-procedure, expect white chalky stool for 72 hours as a normal outcome.

Surgical Care

  • Nissen Fundoplication: Surgical procedure where the fundus of the stomach is wrapped around the esophagus to prevent reflux.

Laparoscopic versus Open Abdominal Surgery

  • Advantages to Laparoscopic surgery include:

    • Quicker recovery time, less risk of infection and pain, and less invasive.

Post-Operative Care following Nissen Fundoplication

  • Priorities include:

    • Pulmonary hygiene to prevent infection.

    • Maintenance of fluids and electrolytes, especially important with open surgery.

    • Slowly advance diet from clear liquids to solid foods, monitoring for complications.

Considerations for a Patient with GERD

  1. Importance of education regarding potential dangers of GERD.

  2. Priority education points include lifestyle modifications and adherence to therapies.

  3. Important nursing care aspects for hospitalized patients include: Maintaining HOB elevation, timing meals, and monitoring for possible complications such as Barrett’s esophagus, aspiration pneumonia, bronchospasm.

Peptic Ulcer Disease (PUD)

Overview

  • Definition: Erosion of the gastrointestinal mucosa resulting from digestive secretions.

  • Prevalence: Affects approximately 1 in 12 people in the U.S.

  • Causes of PUD include:

    • Use of NSAIDs, aspirin, corticosteroids.

    • Alcohol consumption and stress leading to increased acid production.

    • Infection with Helicobacter pylori.

Types of Ulcers

  • Acute Ulcers: Short duration; resolves quickly; superficial erosion.

  • Chronic Ulcers: Long duration; can last several months; involve deep erosion through the muscular wall.

Gastric vs. Duodenal Ulcers

  • Gastric Ulcer

    • Prevalence: More common in women.

    • Peak age: Older adults (50-60 years).

    • Pain occurs shortly after eating.

  • Duodenal Ulcer

    • Prevalence: More common in men.

    • Peak age: Younger adults (35-45 years).

    • Pain occurs 2-3 hours after eating.

Diagnosis and Treatment

  • Diagnosis is made via:

    • EGD (Esophagogastroduodenoscopy) and urea breath test for H. pylori infection.

  • Treatment strategy consists of:

    • Lifestyle changes

    • Medications to manage symptoms and address root causes (like H. pylori).

Drug Therapy

  • Medications include:

    • H2 Receptor Blockers (i.e., famotidine) to hasten ulcer healing.

    • Proton Pump Inhibitors (i.e., pantoprazole) which are more effective for ulcer healing; may use a pantoprazole drip for up to 72 hours.

    • Antibiotics to eradicate H. pylori.

    • Antacids to neutralize stomach acid.

Surgical Therapy

  • Bilroth I (Gastroduodenostomy): Distal 2/3 of stomach is removed and reconnected to the duodenum.

  • Bilroth II (Gastrojejunostomy): 1/2 to 2/3 of the stomach is removed and reconnected to the jejunum.

Nursing Care Following Bilroth I and II

  • Priorities include:

    1. Monitor NG tube, appearance of aspirate.

    2. Prevent complications like VTE and infections.

    3. Vital signs and pain management.

    4. Fluid and electrolyte management, caution with blood replacement.

Complications After PUD Surgery

  • Dumping Syndrome: Occurs when food moves too rapidly from the stomach to the small intestine.

    • Symptoms typically occur 15-30 minutes after eating.

    • Management includes smaller meals, protein drink intake with meals, avoiding simple sugars, and lying back for 10-30 minutes after eating.

  • Pernicious Anemia: Results from vitamin B12 deficiency due to the absence of intrinsic factors post-surgery. - Requires lifelong B12 injections.

  • Hemorrhage: Symptoms include signs of low blood pressure and tachycardia and require immediate evaluation and management.

  • Perforation: Lethal complication that results in infection and requires urgent surgical intervention.

Esophageal Varices

Overview

  • Definition: Abnormally enlarged veins in the lower part of the esophagus often due to portal hypertension from liver cirrhosis.

  • Risks associated: If they rupture, they can cause internal hemorrhaging resulting in shock.

  • Symptoms of rupture include:

    • Hematemesis (bloody vomit)

    • Melena (black stool).

Risk Factors

  • Liver cirrhosis leading to increased portal vein pressure.

  • Continuous alcohol use.

  • Dietary concerns: Avoid certain food items known to irritate the esophagus.

Nursing Care

  • Administer beta-blockers to decrease portal vein pressure.

  • Primary goal: Prevent rupture.

  • If varices rupture, management involves:

    • IV fluids/blood replacement

    • Vital signs monitoring

    • NPO status

    • Administer Octreotide for vasoconstriction.

Balloon Tamponade

  • Sengstaken Blakemore Tube:

    • Important to label lumens for different purposes.

    • Airway management is critical; if loss of gastric balloon occurs, precautions should be in place to prevent migration.

    • Deflate the esophageal balloon intermittently to minimize pressure-related complications.

Esophageal Cancer

Overview

  • Definition: Rare but increasingly prevalent cancer with typically poor prognosis.

  • Risk Factors:

    • Predominantly affects Caucasian males.

    • History of Barrett’s Esophagus, smoking, and alcohol use.

  • Symptoms:

    • Progressive dysphagia (difficulty swallowing)

    • Weight loss

    • Chest pain

Diagnosis and Treatment

  • Diagnostic procedures include:

    • Radiation therapy

    • Chemotherapy

    • Surgical intervention (esophagectomy).

  • Surgical procedures may involve open or laparoscopic techniques.

Post-Operative Care After Esophagectomy

  • Nutritional needs assessment, starting with clear liquids up to a week post-operation.

  • Possible placement of a feeding tube (gastrostomy).

  • Monitor for leaks via swallowing tests and X-ray.

  • Emphasis on oral and nasal care, effective pain control, and strict NPO status with NG tube monitoring.

Stomach Cancer

Overview

  • Definition: Malignant stomach cells leading to tumor formation.

  • Risk Factors include:

    • Males of Hispanic, African-American, and Asian-American descent

    • Infection with Helicobacter pylori

    • Riskier diets consisting of smoked foods, salted fish/meats, and pickled vegetables.

Symptoms and Diagnosis

  • Symptoms include:

    • Anemia (common finding)

    • Weight loss and abdominal pain.

  • Diagnosis typically involves upper GI endoscopy and other imaging to assess for metastasis.

Nursing Management

  • Surgical therapy may involve Billroth procedures or total gastrectomy.

  • Postoperative care considerations include monitoring for nutritional challenges, managing anemia, and potentially referring for palliative care when indicated.