RTRMF – BSN LEVEL III
NCM 116 (MEDICAL-SURGICAL NURSING II)
NURSING CARE OF CLIENTS
WITH DISTURBANCES IN
DIGESTION
GASTRITIS
- inflammation of the gastric or stomach mucosa
- “itis” means inflammation
- affects men and women equally but it is more common in
older adults
- may be acute, lasting several hours to a few days, or
chronic, resulting from repeated exposure to irritating
agents or recurring episode of gastritis
1. ACUTE GASTRITIS
- classified into 2: erosive form (caused by local irritants
such as aspirin and other NSAIDS, gastric radiation
therapy) and nonerosive (caused by infection with
Helicobacter pylori)
- a more severe form of acute gastritis is caused by the
ingestion of strong acid or alkali, which may cause the
mucosa to become gangrenous or to perforate.
- if the area heals, it would lead to scarring which would
result to pyloric stenosis (narrowing or tightening) or
obstruction
- may also lead to severe illness, especially when the
patient has had major traumatic injuries; burns; severe
infection; hepatic, kidney or respiratory failure; or major
surgery. (if mapapansin niyo, clients in the surgical or
medical ward are given ranitidine. Ranitidine is a H2-
receptor antagonist which would protect the mucosa of the
stomach.) This type of acute gastritis is often referred to
as stress-related gastritis.
2. CHRONIC GASTRITIS
- often classified according to the underlying causative
mechanism, which most often includes an infection
with H.pylori
- implicated in the development of peptic ulcers, gastric
adenocarcinoma (cancer), and gastric mucosa-
associated lymphoid tissue lymphoma.
- caused by chemical gastric injury (gastropathy) as the
result of long-term drug therapy with same drugs
(aspirin and NSAIDS. (an acute gastritis, diri pan long-
term drug therapy.)
- Autoimmune disorder (Hashimoto thyroiditis, Addison
disease and Graves’disease) is also associated with the
development of chronic gastritis.
PATHOPHYSIOLOGY
- In gastritis, there is a disruption of the mucosal barrier that
normally protects the stomach tissue from digestive juices. The
digestive juices (hydrochloric acid and pepsin) are irritants and
normally mayda iton nag proprotect ha lining. In the stomach,
you have the mucous production which aids in protecting the
stomach by coating the lining of the stomach and maintaining
the buffer system. The stomach is acidic due to the HCl acid. In
gastritis, iton na mga mucosal barrier is disruptive or damage.
Because of the disruption, it would allow your gastric juices
and other irritating agents to come in contact with your gastric
mucosa. Once it comes in contact, since it is irritating, it would
lead to inflammation.
- In acute gastritis the inflammation is usually transient and
self-limiting in nature. Pag sinabi nating self-limiting, it will go
away on it’s own even without treatment and medication. So
inflammation causes the mucosa to become edematous and
hyperemic. Hyperemic ingested in fluid or sometimes will
undergo erosion. With the erosion their maybe superficial
MT#: 8
BATCH TOPAZ
LECTURER: MR. ANDRE DE VEYRA
ulceration. It problem hito dida it ulceration tumamak ha
blood vessel it will lead to hemorrhage.
- It chronic gastritis persistent aggravated result to chronic
inflammatory changes would lead to atrophy or thinning of
the gastric mucosa.
CLINICAL MANIFESTATION
● The patient with acute gastritis may have rapid onset
of symptoms, such as:
○ epigastric pain or discomfort
○ dyspepsia (indigestion; upper abdominal
discomfort associate with eating)
○ anorexia
○ hiccups
○ nausea
○ vomiting
● Erosive gastritis may cause bleeding, which may
manifest as blood in vomit or as melena (black, tarry
stools; indicative of occult blood in stools) or
hematochezia (bright red, bloody stools)
● The patient with chronic gastritis may complain of:
○ fatigue
○ pyrosis (a burning sensation in the stomach and
esophagus that moves up to the mouth;
heartburn) after eating
○ anorexia
○ nausea
○ vomiting
○ mild epigastric discomfort
○ intolerance to spicy or fatty foods
○ slight pain that is relieved by eating
● Patients with chronic gastritis may not be able to
absorb vitamin B12 because of diminished production
of intrinsic factor by stomach’s parietal cells due to
atrophy, which may lead to pernicious anemia.
SYSTEMIC MANIFESTATIONS
● possible signs of shock
● anemia
● fatigue
ASSESSMENT AND DIAGNOSTIC FINDINGS
● endoscopy and histologic examination of a tissue
specimen obtained by biopsy
● CBC (assess anemia as a result of hemorrhage or
pernicious anemia).
MEDICAL MANAGEMENT
● The gastric mucosa is capable of repairing itself after
an episode of acute gastritis. As a rule, the pt recovers
in about 1 day, although the patient’s appetite may be
diminished for an additional 2 or 3 days. Acute gastritis
is also managed by instructing the pt to refrain from
alcohol and food until symptoms subside.
● When the pt can take nourishment by mouth, a non-
irritating diet is recommended. If the symptoms
persist, IV fluids may need to be given if bleeding is
present, management is similar to procedures used to
control upper GI hemorrhage.
● Therapy may include:
○ Insertion of NGT
○ Antacids
○ H2-Receptor Antagonists (Ranitidine, Famotidine etc.)
○ PPIs (Omeprazole, Pantoprazole etc.)
○ Fiberoptic endoscopy
○ In extreme emergency cases, emergency surgery to
remove gangrenous or perforated tissue.
○ Gastric resection or gastrojejunostomy (anastomosis
to detour around the pylorus) to treat gastric outlet
obstruction or pyloric obstruction (brought about by
scarring).
● Chronic gastritis is managed by:
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RTRMF – BSN LEVEL III BATCH TOPAZ
NCM 116 (MEDICAL-SURGICAL NURSING II) LECTURER: MR. ANDRE DE VEYRA

○ modifying diet, promoting rest, reducing stress - another problem is the prostaglandin in the gastric
(which increases secretion of acid in the stomach, mucosa increases the resistance to acids, therefore
causing hyperacidity), medications given reduces prostaglandin or inhibits
○ avoiding alcohol, avoiding gastric irritant medications prostaglandin such as (aspirin, nsaids, alcohol)
(Aspirin & NSAIDs), - (remember that aspirin and nsaids are prostaglandin
○ initiate medications like antacids, H2-Blockers & PPIs. inhibitors para diri ka magka fever or maka experience hin
● H. Pylori is treated by selected drug combinations
pain, since gin inhibit man niya an prostaglandin asya diri
which include PPIs, antibiotic & bismuth salts.
ka naka experience hin fever or pain because of the drug, an
NURSING MANAGEMENT down side hine by inhibiting the prostaglandin kay an iya
● Reducing anxiety, reducing stress. resistance to acids and gastric mucosa is also decreased.)
● If the patient has ingested acids or alkalis, emergency
measures may be necessary (see Chapter 72). The 2. DUODENAL ULCER
nurse offers supportive therapy to the patient and - 80% of incidence, most common
family during treatment and after the ingested acid or - causative agent: H. PYLORI
alkali has been neutralized or diluted. - also associated with (alcohol, smoking, cirrhosis and
● Do we induce vomiting? We do not, as to prevent
stress)
double jeopardy to the esophagus.
- 90-95% of clients with duodenal ulcers are caused by H.
● For acute gastritis, the nurse provides physical and
Pylori
emotional support and helps the patient manage the
- is the chronic break in duodenal mucosa, to the muscular
symptoms, which may include nausea, vomiting, and
mucosae
pyrosis.
● The patient should be NPO—possibly for a few days— - from increase gastric acid secretion, from increase
until the acute symptoms subside, thus allowing the number of parietal cells because of vagal activity and
gastric mucosa to heal. because of secretion of gastrin
● After the symptoms subside, the nurse may offer the - The incidence of this ulcer increases steadily with age and
patient ice chips followed by clear liquids. Introducing peaks at the 6th decade of life.
solid food as soon as possible may provide adequate - It is equally common for both sexes
oral nutrition, decrease the need for IV therapy, and
minimize irritation to the gastric mucosa. RISK FACTORS
● Discourage the intake of caffeinated beverages, ● H. Pylori
because caffeine is a central nervous system stimulant ● Smoking - nicotine diminishes pancreatic bicarbonate
that increases gastric activity and pepsin secretion. and increases secretion of hydrochloric acid
● Discourage alcohol use. Discouraging cigarette ● Pancreatic tumor - Zollinger-Ellison syndrome
smoking is important because nicotine reduces the ● Blood type O - genetically, people with blood type O
secretion of pancreatic bicarbonate, which
has an affinity to H. Pylori
neutralizes gastric acid in the duodenum.
● Foods and drinks
● Promote fluid balance. Monitor I&O to detect early
● Drugs - include steroids, aspirin, and NSAIDs
signs of dehydration (minimal fluid intake of 1.5
L/day, minimal urine output of 0.5 mL/kg/h).
DIFFERENCE BETWEEN GASTRIC ULCER AND DUODENAL
● If food and oral fluids are withheld, IV fluids (3 L/day)
ULCER
usually are prescribed and a record of fluid intake plus
caloric value (1 L of 5% dextrose in water = 170 calories Gastric Ulcer Duodenal Ulcer
of carbohydrate).
● Electrolyte values (sodium, potassium, chloride) are Age > 50 years old 30-60 years old
assessed every 24 hours to detect any imbalance.
● Be alert to any indicators of hemorrhagic gastritis, Gender Equally in male & Common in male
female
which include hematemesis (the bleeding may be
concealed so check signs of shock which include:)
Incidence 15-20% 80%
tachycardia, and hypotension
● Measures to help relieve pain include instructing the
Location Stomach Antrum Pylorus
patient to avoid foods and beverages that may irritate
the gastric mucosa as well as the correct use of Pain 30 mins - 1 hr after 2-3 hrs after meals
medications to relieve chronic gastritis (Antacids, PPIs, meals
H2-Blockers).
Description Churning Gnawing
PEPTIC ULCER DISEASE
- a generic term for ulcers or breaks on the mucosal lining of Relieved by Vomiting Eating
the gi tract, that come in contact with the gastric secretion.
- PUD may be referred to as gastric, duodenal, or Effect Weight loss Weight gain (normal)
esophageal ulcer, depending on its location.
- Risk factors of PUD include H. Pylori, smoking, zollinger-
NURSING ASSESSMENT
ellison syndrome, and family history (especially those from ● Burning, aching, gnawing pain
the blood group “O” are at risk for duodenal ulcer) ● Where is it located? In the epigastrium
● We have to test for H. pylori. Our common antibiotic is
1. GASTRIC ULCER metronidazole (flagyl).
- are 15-20% of incidence
- causative agent: H. PYLORI NURSING INTERVENTIONS
- commonly occurs on a lesser curvature near the pylorus, Check and observe for complications
and results in disruption in the normal protective ● Perforation
mechanism that keeps gastric epithelial pH normal. ● Pain

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RTRMF – BSN LEVEL III
NCM 116 (MEDICAL-SURGICAL NURSING II)
● Peritonitis. Most common sign: board-like abdomen or rigid
abdomen
● Signs of hemorrhage. Hematemesis, tarry stools, stool
positive for occult blood
● Pyloric obstruction because of the stenosis. S/S: vomiting &
feeling of fullness
THERAPEUTIC MANAGEMENT
● Reinforce the importance of following the treatment
regimen.
● No foods have been determined to be ulcerogenic. But
some foods would aggravate PUD such as soda, coffee, tea,
chocolate. food high in sodium, foods which are spicy, and
foods that are rich in spices. These foods should be avoided
during the acute phase. Decaf drinks are not okay to be
consumed because it still stimulates the release of gastrin.
● Cessation of smoking.
DRUGS
● Antacid. To neutralize the acid. When is it given? before or
after meals
● H2-receptor antagonist (-tidine). They block histamine-
stimulated gastric secretion. .when is it given? before sleep
● Proton Pump Inhibitors (-ozole). They suppress the
production of HCl. When is it given? before meals
● Prostaglandin analogues (Misoprostol or cytotec). It
contributes to the mucosal barrier. When is it given? before
meals
● Mucosal barrier fortifier (Sucralfate). They form a
protective barrier over the ulcer crater and prevent
irritation and further erosion of acid and pepsin. When is it
given? before meals.
DIET
● Increased carbohydrates, decreased protein. Decreased
carbohydrates because meat is acidic and stimulates the
release of acid.
● If there is active bleeding the diet is NPO.
TREATMENT
● Vagotomy. Cutting of cranial nerve number 10. To obstruct
nerve stimulation in the stomach
● Billroth I. The removal of the lower portion of the antrum
of the stomach. It is the part that contains cells that
secretes gastrin.
❖ Side effect:
○ Feeling of fullness
○ May suffer from dumping syndrome
● Billroth II or gastrojejunostomy. The removal of the
lower portion, the antrum of the stomach
anastomosis to the jejunum. May lead to dumping
syndrome, anemia, and weight loss.
GASTRIC CANCER
- It is more common in adults with the mean age of 69 years
old.
- Men have higher incidence of gastric ulcer
- Common among hispanic american, african american,
asian than caucasian american.
- Diet appears to be a significant risk factor for the
development of gastric cancer. A diet high in smoked,
salted, or pickled foods and low in fruits and vegetables
may increase the risk of gastric cancer.
- H.pylori infection is a major risk factor the development of
gastric cancer.
- Other factors related to the incidence of gastric cancer
include:
● chronic inflammation
MT#: 8
BATCH TOPAZ
LECTURER: MR. ANDRE DE VEYRA
- would lead to a change in the form of tissue, example
from squamous epithelium to columnar cells.
● pernicious anemia
● smoking
● obesity
● Achlorhydria - absence of hydrochloric acid
● gastric ulcer
● previous partial gastrectomy more than 20 years ago
● genetics
● Vast majority of gastric cancers are sporadic, occurring as a
result of acquired, not a genetic mutation.
○ mayda iba na occurring talaga due to genetic predisposition
specially blood type A
○ those first degree relative
● Prognosis of gastric cancer is poor. 5 years lang. one of the
reasons for poor survival, because of the time that the cancer
is detected, it is in the late stage already, because some are
asymptomatic until it is in the late stages.
● Gastric cancers are adenocarcinoma. which arise from mucus
producing cells in the innermost lining of the stomach. They
can occur anywhere, although 40% in the lower part, 40% in
the middle part, and %15 upper, 10% involve more than 1 part
of the stomach. The lesion penetrates the cells in the deeper
layer of the cell of the mucosa, submucosa, and stomach.
● lymph node involvement and metastasis tend to occur early due
to the abundant lymphatic and vascular networks of the
stomach. the common site of metastasis include the liver,
peritoneum, lungs, and the brain.
CLINICAL MANIFESTATIONS
symptoms of early stage disease may include:
● pain relieved by antacids (ulcer)
Symptoms of advanced disease:
● similar to those of peptic ulcer disease:
○ dyspepsia
○ early satiety
○ weight loss
○ abdominal pain just above the umbilicus
○ loss or decrease in appetite
○ bloating after meals
○ Nausea and vomiting
● fatigue as a result of the cancer itself or blood loss
ASSESSMENT AND DIAGNOSTICS
● advanced cancer may be palpable as mass
● ascites & hepatomegaly are apparent when the cancer is
already metastasized to the liver
● Palpable nodules around the umbilicus, called Sister Mary
with Joseph’s Nodules, are a sign of GI malignancy
DIAGNOSTIC FINDINGS
● Esophagogastroduodenoscopy for biopsy and cytologic
washing - diagnostic study of choice.
● Barium X-ray examination of the upper GI tract
● Computed tomography (CT) Scan – gin uupod it chest,
abdomen, and pelvis for staging gastric cancer. In order to
check if there is already metastasis. Common man gud it
Lungs.
● Endoscopic ultrasound – an important tool to assess
tumor depth and any lymph node involvement.
MEDICAL MANAGEMENT
● A Resectable tumor will undergo a surgical procedure to
remove the tumor and appropriate lymph nodes.
● Surgery: Chemotherapy, Targeted Therapy, and Radiation
Therapy
● If the tumor can be removed while it is still localized to the
stomach, the patient may be cured. In patients with a
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NCM 116 (MEDICAL-SURGICAL NURSING II)
tumor that is not surgically resectable or those with
advanced disease, cure is less likely – so puros nala kita hini
Supportive treatment, Palliative (if it’s already far advanced)
SURGICAL MANAGEMENT
● A total gastrectomy may be performed for a resectable
cancer in the midportion or body of the stomach. The
entire stomach is removed along with the duodenum, the
lower portion of the esophagus, supporting mesentery,
and lymph nodes.
● Reconstruction of the GI tract is performed by
anastomosing the end of the jejunum to the end of the
esophagus, a procedure called an esophagojejunostomy.
● A radical partial (subtotal) gastrectomy is performed for
a resectable tumor in the middle and distal portions of the
stomach.
● A Billroth I or a Billroth II operation is performed.
● A proximal partial (subtotal) gastrectomy may be
performed for a resectable tumor located in the proximal
portion of the stomach or cardia. A total gastrectomy or an
esophagogastrectomy is usually performed in place of this
procedure to achieve a more extensive resection.
● Surgery may be also required to treat common
complications of advanced gastric cancer – mag Gastric
perforation ka ngani it is an emergency situation so it require
immediate surgical intervention as what I said if it is already
far advanced we give Palliative treatment.
● Palliative Procedure - gastric or esophageal bypass,
gastrostomy, or jejunostomy. To temporarily alleviate
symptoms such as nausea and vomiting. Palliative rather
than radical surgery may be performed if there is
metastasis to other vital organs. – an gamit nala hini ma
achieve an better quality of life hit imo patient.
COMPLICATIONS OF GASTRIC SURGERY
● Hemorrhage
● Dumping Syndrome
- It may occur as a result of any surgical procedure that
involves the removal of a significant portion of the
stomach or includes resection or removal of the pylorus.
- So it problema hit dumping syndrome there is rapid passage
of food from the stomach going to the intestine. There isn’t
enough time for digestion and absorption of nutrients some
which happens in the stomach.
- The rapid bolus of hypertonic food from the stomach to
the small intestines draws extracellular fluid into the
lumen of the intestines to dilute the high concentrations
of electrolytes and sugars, which results in intestinal
dilation, increased intestinal transit, hyperglycemia, and
the rapid onset of GI and vasomotor symptoms.– na
draw hiya han fluid extracellularly into the lumen of
intestine
- It is estimated that 25% to 50% of all patients who have
undergone gastric surgery experience at least some
symptoms of dumping syndrome.
- Early symptoms tend to occur within 10 to 30 minutes
after a meal and often include:
● early satiety
● cramping abdominal pain
● nausea, vomiting
● diarrhea.
- Vasomotor symptoms may manifest as a
● headache
● flushing and feelings of warmth
● diaphoresis
● dizziness
● palpations
● drowsiness
● faintness, or syncope.
- Early symptoms tend to resolve within 1 hour or with
bowel evacuation (defecation).
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BATCH TOPAZ
LECTURER: MR. ANDRE DE VEYRA
- Later, the rapid elevation in blood glucose is followed by
the increased secretion of insulin, which results in
hypoglycemia 2 to 3 hours after eating.
- If you have dumping syndrome, you have to take small sips
of water along with meals because fluid increases the
possibility of rapid transit of food. Also, lie flat on bed after
eating.
● Bile reflux
- Bile reflux may occur with any gastric surgery that
involves manipulation or removal of the pylorus, which
acts as a barrier to prevent reflux of duodenal contents
back into the stomach.
- Prolonged exposure of bile acid from the duodenum
results in irritation and damage to the gastric mucosa,
which may lead to gastritis, esophagitis, and possibly
peptic ulcer formation.
- The patient with bile reflux may experience burning
epigastric pain that may increase after meals.
- Vomiting usually does not provide relief from pain.
- PHARMACOLOGIC MANAGEMENT of bile reflux includes
the administration of sucralfate (Carafate) or
cholestyramine (Questran), which may provide relief
from symptoms. Cholestyramine binds with bile acids in
the GI tract to prevent reabsorption and facilitate the
elimination of bile acids in stool. proton pump inhibitors
and ursodiol (ha 15th ed na book :)
● Gastric Outlet Obstruction
- Postoperative gastric outlet obstruction may be caused
by stenosis (narrowing) or stricture (scar tissue)
formation at the surgical anastomosis site.
- Typical clinical manifestations and management of
gastric outlet obstruction would include feeling of
fullness, vomiting,
CHEMOTHERAPY
- Chemotherapeutic agents often include fluorouracil,
carboplatin, capecitabine, cisplatin, docetaxel, epirubicin,
irinotecan, oxaliplatin, and paclitaxel
- For improved tumor response rates, it is more common
to administer combination chemotherapy, primarily
fluorouracil based therapy, with other agents (e.g.,
fluorouracil plus cisplatin or oxaliplatin).
- Trastuzumab (a recombinant humanized anti–HER-2
monoclonal antibody) prescribed in combination with
fluorouracil or capecitabine and cisplatin has shown an
improvement in survival of patients with advanced
gastric cancer who are HER-2 positive.
RADIATION THERAPY
- is primarily used for advanced gastric cancers to slow the
rate of tumor growth or for the palliation of symptoms
related to obstruction, bleeding, and significant pain.
- Radiation therapy may also be used alone or along with
chemotherapy before surgery to decrease the size of the
tumor or after surgery to destroy any remaining cancer
cells and to delay or prevent reoccurrence of the cancer.
- before surgery: to decrease the size of the tumor
- after surgery: to destroy any remaining cancer cells.
- an surgery, it problema hiton dida, the mechanical
manipulation may lead to the mechanical spread of your
cancer cells so to prevent it from happening after mo pagpa
surgery, pwede ka magpa chemo and radiation therapy
para iton na kumalat na cancer cells nga nabibilin
mamatay. But again, this is not an assurance that one will
survive.
- 3- dimensional conformal radiation therapy (3D-CRT) an
problema hit nag raradiation therapy kay na emit hiya hin
radiation. Amo kapag may na fluflush out tikang haiya body,
pag na fluflush ha toilet, diri na pwede gamiton an toilet.
Remember, we maintain a specific distance from the patient
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RTRMF – BSN LEVEL III BATCH TOPAZ
NCM 116 (MEDICAL-SURGICAL NURSING II) LECTURER: MR. ANDRE DE VEYRA

most especially pag may radiation implant. Tapos it area

hiton na gin pa radiation therapy kay bagat na susunog.
Mahapdos hapdosan iton bisan labtan gamit tela. Skin care
is very important.

GERONTOLOGIC CONSIDERATION
- confusion, agitation and restlessness may be the only
symptoms seen. and may have no gastric symptoms until
the tumor are well advanced
- Surgery is more hazardous

NURSING PROCESS (patient with gastric cancer)

● Assessment
- nutritional intake and status: (Can the pt tolerate a full
diet? If not, what foods can they eat? What other
changes in eating habits have occurred? Does the pt
feel full after eating a small amount of food? etc.)
● Nursing Intervention
1. Reducing Anxiety
- by providing a relaxed. non threatening atmosphere
so the patient can express fears, concerns and
possible anger about the diagnosis and prognosis.
Patients would usually undergo DABDA, the grieving
process. Mag dedenial iton, ma seek iton hin second
opinion, etc.
2. Promoting Optimal Nutrition
- eat small frequent portions of non irritating food to
decrease gastric irritations
- diet should be high in calories, as well as vitamins A
and C (to boost immune system) and iron, to
enhance tissue repair.
- small feedings daily that are low in carbohydrates
and sugar and the consumption of fluids between
meals rather than with meals because of the
possibility of dumptin syndrome.
- if a total gastrectomy (kay waray na parietal cells,
waray na gihap intrinsic factor so diri ka na makaka
absorb hin vit B12 and it will lead to pernicious
anemia) is performed, injection of Vitamin B12 will
be required for life.
- Vit B12- helps in RBC production.
- record intake and output and assess for signs of
dehydration (increase thirst, dry mucous
membranes, poor skin turgor, tachycardia and
decreased urine output)

3. Relieving pain
- continuous IV infusion of an opioid or a patient-
controlled analgesia (PCA) pump set
- nonpharmacological methods: position changes,
imagery, distraction, relaxation exercises, backrubs,
massage and periods of rest and relaxation.

4. Providing Psychosocial Support

- allow the patient to verbalize needs, fears, concerns
and grief about the diagnosis
- stay with the patient
- encourage the patient to be involved with the
treatment and decision making
- honestly answer the question of patients most
especially late stage of cancer.
- spiritual and emotional care.

END

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