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 DESCRIPTION

• The backflow of gastric and duodenal


contents into the esophagus
• Caused by an incompetent lower
esophageal sphincter, pyloric stenosis, or a
motility disorder
• Symptoms may mimic those of a heart
attack
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for
positive outcomes, ed 6, Philadelphia: W.B. Saunders.
ASSESSMENT
• Pyrosis
• Dyspepsia
• Regurgitation
• Pain and difficulty with swallowing
• Hypersalivation
IMPLEMENTATION
• Instruct the client to avoid factors that
decrease lower esophageal sphincter
pressure or cause esophageal irritation
• Instruct the client to eat a low-fat, high-fiber
diet; avoid caffeine, tobacco, and
carbonated beverages; avoid eating and
drinking 2 hours before bedtime; avoid
wearing tight clothes; and to elevate the
head of the bed on 6- to 8- inch blocks
 IMPLEMENTATION
• Avoid the use of anticholinergics, which delay
stomach emptying
• Instruct the client regarding prescribed
medications, such as antacids, histamine H2-
receptor antagonists, or gastric acid pump
inhibitors
• Instruct the client regarding the
administration of prokinetic medications if
prescribed, which accelerate gastric
emptying
IMPLEMENTATION
• If medical management is unsuccessful,
surgery may be required and involves a
fundoplication (wrapping a portion of the
gastric fundus around the sphincter area of
the esophagus); may be performed by
laparoscopy
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.
DESCRIPTION
• Also known as esophageal or diaphragmatic
hernia
• A portion of the stomach herniates through
the diaphragm and into the thorax
• It results from weakening of the muscles of
the diaphragm and is aggravated by factors
that increase abdominal pressure such as
pregnancy, ascites, obesity, tumors, and
heavy lifting
DESCRIPTION
• Complications include ulceration,
hemorrhage, regurgitation and aspiration of
stomach contents, strangulation, and
incarceration of the stomach in the chest
with possible necrosis, peritonitis, and
mediastinitis
From Monahan FD, Neighbers M: Medical-surgical nursing: foundations for clinical
practice, ed. 2, Philadelphia, 1998, W.B. Saunders.
ASSESSMENT
• Heartburn
• Regurgitation or vomiting
• Dysphagia
• Feeling of fullness
IMPLEMENTATION
• Medical and surgical management is similar
to that for GER
• Provide small, frequent meals and minimize
the amount of liquids
• Advise the client not to recline for 1 hour
after eating
• Avoid anticholinergics, which delay stomach
emptying
DESCRIPTION
• Inflammation of the stomach or gastric
mucosa
• Can be acute or chronic
 ACUTE
• Caused by the ingestion of food contaminated
with disease-causing microorganisms or food
that is irritating or too highly seasoned, the
overuse of aspirin or other nonsteroidal
antiinflammatory drugs (NSAIDs), excessive
alcohol intake, bile reflux, or radiation therapy
 ASSESSMENT
• Abdominal discomfort
• Headache
• Anorexia, nausea, and vomiting
• Hiccuping
 CHRONIC
• Caused by benign or malignant ulcers, or by
the bacteria Helicobacter pylori; may also be
caused by autoimmune diseases, dietary
factors, medications, alcohol, smoking, or
reflux
 ASSESSMENT
• Anorexia, nausea, and vomiting
• Heartburn after eating
• Belching
• Sour taste in the mouth
• Vitamin B12 deficiency
From Stevens A, Lowe J: Pathology, London, 1995, Mosby.
IMPLEMENTATION
• Acute: Food and fluids may be withheld until
symptoms subside; then ice chips followed
by clear liquids and then solid food is
introduced
• Monitor for signs of hemorrhagic gastritis
such as hematemesis, tachycardia, and
hypotension, and notify the physician if
these signs occur
IMPLEMENTATION
• Instruct the client to avoid irritating foods,
fluids, and other substances such as spicy
and highly seasoned foods, caffeine,
alcohol, and nicotine
• Instruct the client in the use of prescribed
medications, such as antibiotics and
bismuth salts (Pepto-Bismol)
• Provide the client with information about
the importance of vitamin B12 injections, if a
deficiency is present
DESCRIPTION
• An ulceration in the mucosal wall of the
stomach, pylorus, duodenum, or esophagus,
in portions that are accessible to gastric
secretions; erosion may extend through the
muscle
• May be referred to as gastric, duodenal, or
esophageal ulcer depending on location
• The most common peptic ulcers are gastric
ulcers and duodenal ulcers
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management
for positive outcomes, ed 5, Philadelphia: W.B. Saunders.
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical
thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Wilcox CM: Atlas of clinical gastrointestinal endoscopy, Philadelphia, 1995, W.B. Saunders.
From Damjanov I, Linder J, editors: Anderson’s pathology, ed. 10, St. Louis, 1996, Mosby.
 DESCRIPTION
• Involves ulceration of the mucosal lining that
extends to the submucosal layer of the
stomach
• Predisposing factors include stress, smoking,
the use of corticosteroids, nonsteroidal
antiinflammatory drugs (NSAIDs), alcohol, a
history of gastritis, a family history of gastric
ulcers, or infection with Helicobacter pylori
• Complications include hemorrhage,
perforation, and pyloric obstruction
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical
thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Cotran KS, Kumar V, Collins T: Robbins’ pathologic basis of disease, ed. 6,
Philadelphia, 1999, W.B. Saunders.
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical
management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for
positive outcomes, ed 6, Philadelphia: W.B. Saunders.
ASSESSMENT
• Gnawing, sharp pain in or left of the
midepigastric region 1 to 2 hours after
eating
• Nausea and vomiting
• Hematemesis
IMPLEMENTATION
• Monitor vital signs and for signs of bleeding
• Administer small, frequent, bland feedings
during the active phase
• Administer histamine H2-receptor
antagonists as prescribed to decrease the
secretion of gastric acid
• Administer antacids as prescribed to
neutralize gastric secretions
IMPLEMENTATION
• Administer anticholinergics as prescribed to
reduce gastric motility
• Administer mucosal barrier protectants as
prescribed 1 hour before each meal
• Administer prostaglandins as prescribed for
their protective and antisecretory actions
CLIENT EDUCATION
• Avoid consuming alcohol and substances
that contain caffeine or chocolate
• Avoid smoking
• Avoid aspirin or NSAIDs
• Obtain adequate rest and reduce stress
IMPLEMENTATION: ACTIVE BLEEDING
• Monitor vital signs closely
• Assess for signs of dehydration,
hypovolemic shock, sepsis, and respiratory
insufficiency
• Maintain NPO status and administer IV fluid
replacement as prescribed; monitor I&O
• Monitor hemoglobin and hematocrit
IMPLEMENTATION: ACTIVE BLEEDING
• Administer blood transfusions as prescribed
• Assist with the insertion of a nasogastric (NG)
tube for decompression and for lavage access
• Assist with normal saline or tap water lavage at
room temperature to reduce active bleeding
• Prepare to assist with administering vasopressin
(Pitressin) by IV as prescribed to induce
vasoconstriction and reduce bleeding
 TOTAL GASTRECTOMY
• Also called esophagojejunostomy
• Removal of the stomach with attachment of the
esophagus to the jejunum or duodenum
 VAGOTOMY
• Surgical division of the vagus nerve to
eliminate the vagal impulses that stimulate
hydrochloric acid secretion in the stomach
 GASTRIC RESECTION
• Also called antrectomy
• Involves removal of the lower half of the
stomach and usually includes a vagotomy
 BILLROTH I
• Also called gastroduodenostomy; partial
gastrectomy, with remaining segment
anastomosed to duodenum
 BILLROTH II
• Also called gastrojejunostomy; partial
gastrectomy, with remaining segment
anastomosed to jejunum
 PYLOROPLASTY
• Enlarges the pylorus to prevent or decrease
pyloric obstruction, thereby enhancing
gastric emptying
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical
thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking
for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking
for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.
Monitor vital signs
Position in Fowler's for comfort and to
promote drainage
Administer fluids and electrolyte
replacements by IV as prescribed;
monitor I&O
Assess bowel sounds
Monitor NG suction as prescribed
 Do not irrigate or remove the NG tube; assist
the physician with irrigation or removal
 Maintain NPO status as prescribed for 1 to 3
days until peristalsis returns
 Progress the diet from NPO to sips of clear
water to 6 small, bland meals a day as
prescribed when bowel sounds return
 Monitor for postoperative complications of
hemorrhage, dumping syndrome, diarrhea,
hypoglycemia, and vitamin B12 deficiency
 DESCRIPTION
• A break in the mucosa of the duodenum
• Risk factors and causes include alcohol intake,
smoking, stress, caffeine, the use of aspirin,
corticosteroids, and NSAIDs, and infection with
Helicobacter pylori
• Complications include bleeding, perforation,
gastric outlet obstruction, and intractable
disease
• Surgery is performed only if the ulcer is
unresponsive to medications or if hemorrhage,
obstruction, or perforation occurs
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking
for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From McCance, K. & Huether, S. (2002). Pathophysiology, ed 4, St Louis: Mosby. Courtesy of David
Bjorkman, MD, University of Utah, School of Medicine, Department of Gastroenterology.
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for
positive outcomes, ed 6, Philadelphia: W.B. Saunders.
 ASSESSMENT
• Burning pain in the midepigastric area 2 to
4 hours after eating and during the night
• Pain that is often relieved by eating
• Melena
IMPLEMENTATION
• Monitor vital signs
• Perform abdominal assessment
• Instruct the client in a bland diet with small,
frequent meals
• Provide for adequate rest
• Encourage the cessation of smoking
IMPLEMENTATION
• Instruct the client to avoid alcohol intake,
caffeine, the use of aspirin, corticosteroids,
and NSAIDs
• Administer antacids as prescribed to
neutralize acid secretions
• Administer histamine H2-receptor
antagonists as prescribed to block the
secretion of acid
DESCRIPTION
• Rapid emptying of the gastric contents into
the small intestine
• Occurs following gastric resection
ASSESSMENT
• Symptoms occurring 30 minutes after
eating
• Nausea and vomiting
• Feelings of abdominal fullness and
abdominal cramping
• Diarrhea
• Palpitations and tachycardia
• Perspiration
• Weakness and dizziness
• Borborygmi
CLIENT EDUCATION
• Eat a high-protein, high-fat, low-
carbohydrate diet
• Eat small meals and avoid consuming fluids
with meals
• Avoid sugar and salt
• Lie down after meals
• Take antispasmodic medications as
prescribed to delay gastric emptying
DESCRIPTION
• Results from either an inadequate intake of
vitamin B12 or a lack of absorption of
ingested vitamin B12 from the intestinal tract
• Pernicious anemia results from a deficiency
of intrinsic factor, which is necessary for
intestinal absorption of vitamin B12
ASSESSMENT
• Severe pallor
• Fatigue
• Weight loss
• Smooth, beefy, red tongue
• Slight jaundice
• Paresthesias of the hands and feet
• Disturbances with gait and balance
IMPLEMENTATION
• Increase dietary intake of foods rich in
vitamin B12 if the anemia is the result of a
dietary deficiency
• Administer vitamin B12 injections as
prescribed on a weekly basis initially, and
then monthly for maintenance (lifelong) if
the anemia is the result of a deficiency of
the intrinsic factor
DESCRIPTION
• Dilated and tortuous veins in the
submucosa of the esophagus
• Caused by portal hypertension, often
associated with liver cirrhosis, and high risk
for rupture if portal circulation pressure
rises
• Bleeding varices is an emergency
• The goal of treatment is to control bleeding,
prevent complications, and prevent the
reoccurrence of bleeding
From Gitlin N, Strauss RM: Atlas of clinical hepatology, Philadelphia, 1995, W.B. Saunders.
ASSESSMENT
• Hematemesis
• Tarry stools, melena
• Ascites
• Jaundice
• Hepatomegaly and splenomegaly
• Dilated abdominal veins
• Hemorrhoids
• Signs of shock
IMPLEMENTATION
• Monitor vital signs
• Elevate the head of the bed
• Monitor for orthostatic hypotension
• Monitor lung sounds and for the presence of
respiratory distress
• Administer oxygen as prescribed to prevent
tissue hypoxia
• Monitor level of consciousness (LOC)
IMPLEMENTATION
• Maintain NPO status
• Administer IV fluids as prescribed to restore
fluid volume and correct electrolyte
imbalances; monitor I&O
• Monitor hemoglobin, hematocrit, and
coagulation factors
• Administer blood transfusions or clotting
factors as prescribed
IMPLEMENTATION
• Assist in inserting an NG tube or a balloon
tamponade as prescribed
• Assist with the administration of iced saline
irrigations to achieve vasoconstriction of the
varices
• Prepare to assist with administering
vasopressin (Pitressin) by IV or intra-arterial
infusion as prescribed to induce
vasoconstriction and reduce bleeding
IMPLEMENTATION
• Prepare to assist with administering
nitroglycerin (Tridil) with vasopressin
(Pitressin) to prevent vasoconstriction of the
coronary arteries
• Instruct the client to avoid activities that will
initiate vasovagal responses
• Prepare the client for endoscopic
procedures or surgical procedures as
prescribed
ENDOSCOPIC INJECTION
(SCLEROTHERAPY)
• Injection of a sclerosing agent into and
around bleeding varices
• Complications include chest pain, pleural
effusion, aspiration pneumonia, esophageal
stricture, and perforation of the esophagus
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking
for collaborative care, ed 4, Philadelphia: W.B. Saunders.
ENDOSCOPIC VARICEAL LIGATION
• Ligation of the varices with an elastic rubber
band
• Sloughing, followed by superficial
ulceration, occurs in the area of ligation
within 3 to 7 days
SPLENORENAL
• Involves splenectomy, with anastomosis of
the splenic vein to the left renal vein
PORTACAVAL
• Shunting of the blood from the portal vein
to the inferior vena cava
MESOCAVAL
• Involves a side anastomosis of the superior
mesenteric vein to the proximal end of the
inferior vena cava
From Beare, P. & Myers, J. (1998). Adult health nursing, ed 3, St Louis: Mosby.
TRANSJUGULAR INTRAHEPATIC
PORTAL/SYSTEMIC
• Uses the normal vascular anatomy of the
liver to create a shunt with the use of a
metallic stent
• The shunt is between the portal and
systemic venous system within the liver and
is aimed at relieving portal hypertension
DESCRIPTION
• Ulcerative and inflammatory disease of the
bowel that results in poor absorption of
nutrients
• Commonly begins in the rectum and
spreads upward toward the cecum
• Characterized by various periods of
remissions and exacerbations
• The colon becomes edematous and may
develop bleeding lesions and ulcers; the
ulcers may lead to perforation
 DESCRIPTION
• Scar tissue develops and causes loss of
elasticity and loss of ability to absorb
nutrients
• Acute ulcerative colitis results in vascular
congestion, hemorrhage, edema, and
ulceration of the bowel mucosa
• Chronic ulcerative colitis causes muscular
hypertrophy; fat deposits; and fibrous tissue
with bowel thickening, shortening, and
narrowing
DESCRIPTION
• Surgical intervention involves creation of an
ostomy; the ostomy can be created within the
ileum or at various sites within the large bowel
• An ileostomy is the surgical creation of an
opening into the ileum or small intestine that
allows for drainage of fecal matter from the
ileum to the outside of the body
• A colostomy is the surgical creation of an
opening into the colon that allows for drainage
of fecal matter from the colon to the outside of
the body
From Rosai J: Ackerman’s surgical pathology, ed. 8, St. Louis, 1996, Mosby.
From Damjanov I, Linder J, editors: Anderson’s pathology, ed. 10, St. Louis, 1996, Mosby.
ASSESSMENT
• Anorexia
• Weight loss
• Malaise
• Abdominal tenderness and cramping
• Severe diarrhea that may contain blood and
mucus
• Dehydration and electrolyte imbalances
• Anemia
• Vitamin K deficiency
IMPLEMENTATION
• Acute phase: Maintain NPO status,
administer IVs and electrolytes, or total
parenteral nutrition (TPN) as prescribed
• Restrict the client’s activity to reduce
intestinal activity
• Monitor bowel sounds and for abdominal
tenderness and cramping
• Monitor stools, noting color, consistency,
and the presence or absence of blood
 IMPLEMENTATION
• Monitor for perforation, peritonitis, and hemorrhage
• Following the acute phase, the diet progresses from
clear liquids to low-residue as tolerated
• Instruct client to consume a low-residue, high-
protein diet; vitamins and iron supplements may be
prescribed
• Instruct client to avoid gas-forming foods and milk
products and foods such as whole-wheat breads,
nuts, raw fruits and vegetables, pepper, alcohol, and
caffeine-containing products
IMPLEMENTATION
• Instruct the client to avoid smoking
• Administer bulk-forming agents such as
bran, psyllium, or methylcellulose, to
decrease diarrhea and relieve symptoms
• Administer antimicrobial, corticosteroids,
and immunosuppressants as prescribed to
prevent infection and reduce inflammation
TOTALPROCTOCOLECTOMY WITH
PERMANENT ILEOSTOMY
• Curative and involves the removal of the
entire colon (colon, rectum, and anus with
anal closure)
• The end of the terminal ileum forms the
stoma, which is located in the right lower
quadrant
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical
thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
KOCK ILEOSTOMY (CONTINENT
ILEOSTOMY)
• An intra-abdominal pouch (stores the feces)
is constructed from the terminal ileum
• The pouch is connected to the stoma with a
nipple-like valve constructed from a portion
of the ileum; the stoma is flush with the skin
• A catheter is used to empty the pouch, and
a small dressing or adhesive bandage is
worn over the stoma between emptyings
From Beare, P. & Myers, J. (1998). Adult health nursing, ed 3, St Louis: Mosby.
ILEOANAL RESERVOIR
• A two-stage procedure that involves the
excision of the rectal mucosa, an abdominal
colectomy, construction of a reservoir to the
anal canal, and a temporary loop ileostomy
• The ileostomy is closed in approximately 3
to 4 months after the capacity of the
reservoir is increased
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.
ILEOANAL ANASTOMOSIS
(ILEORECTOSTOMY)
• Does not require an ileostomy
• A 12- to 15-cm rectal stump is left after the
colon is removed and the small intestine is
inserted into this rectal sleeve and
anastomosed
• Requires a large, compliant rectum
From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts and clinical practice,
ed. 6, St. Louis, 1999, Mosby.
Consult with enterostomal therapist to assist in
identifying optimal placement of the ostomy
Instruct the client to eat a low-residue diet for a
day or two prior to surgery as prescribed
Administer intestinal antiseptics and antibiotics as
prescribed to cleanse the bowel and to decrease
the bacterial content of the colon
Administer laxatives and enemas as prescribed
 Place a petrolatum gauze over the stoma
as prescribed to keep it moist, followed
by a dry sterile dressing if a pouch
(external) system is not in place
 Place a pouch system on the stoma as
soon as possible
 Monitor the stoma for size, unusual
bleeding, or necrotic tissue
 Monitor for color changes in the stoma
 The normal stoma color is pink to bright red
and shiny, indicating high vascularity
 A pale pink stoma indicates low hemoglobin
and hematocrit levels
 A purple-black stoma indicates compromised
circulation, requiring physician notification
 Assess the functioning of the colostomy
 Expect that stool is liquid in the
immediate postoperative period, but
becomes more solid depending on the
area of the colostomy
• Ascending colon - liquid
• Transverse colon - loose to semi-formed
• Descending colon - close to normal
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative
care, ed 4, Philadelphia: W.B. Saunders.
Monitor the pouch system for proper
fit and signs of leakage
Empty the pouch when it is one-third
full
Fecal matter should not be allowed to
remain on the skin
Administer analgesics and antibiotics
as prescribed