1 Care of Patient with GERD & Peptic Ulcer 63-273.
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Transcript of 1 Care of Patient with GERD & Peptic Ulcer 63-273.
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GERD: BackgroundGERD: Background
Gastroesophageal reflux is a normal Gastroesophageal reflux is a normal physiologic phenomenon in most physiologic phenomenon in most people, particularly after a meal. people, particularly after a meal.
Gastroesophageal reflux disease Gastroesophageal reflux disease (GERD) occurs when the amount of (GERD) occurs when the amount of gastric juice that refluxes into the gastric juice that refluxes into the esophagus exceeds the normal limitesophagus exceeds the normal limit
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GERD: SymptomsGERD: Symptoms Typical symptoms:Typical symptoms:
Heartburn (Pyrosis):Heartburn (Pyrosis): Most commonMost common Felt as a retrosternal sensation of burning or discomfortFelt as a retrosternal sensation of burning or discomfort Occurs usually after eating or when lying down or Occurs usually after eating or when lying down or
bending over.bending over. Often relieved with milk or waterOften relieved with milk or water
Regurgitation: Regurgitation: Effortless return of gastric and/or esophageal contents Effortless return of gastric and/or esophageal contents
into the pharynx. into the pharynx. It can induce respiratory complications if gastric contents It can induce respiratory complications if gastric contents
spill into the tracheobronchial tree. spill into the tracheobronchial tree.
Atypical symptomsAtypical symptoms Cough, dyspnea, hoarseness, and chestpain Cough, dyspnea, hoarseness, and chestpain
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DiagnosisDiagnosis Role out other potential causes for the heartburn:Role out other potential causes for the heartburn:
CardiacCardiac Peptic ulcerPeptic ulcer EsophagitisEsophagitis
Esophageal Endoscopy:Esophageal Endoscopy: The gold standard as a definitive diagnosisThe gold standard as a definitive diagnosis
Barium swallowBarium swallow Not as definitive in mild casesNot as definitive in mild cases
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Collaborative CareCollaborative Care
Lifestyle modificationsLifestyle modifications
Nutritional therapyNutritional therapy Decrease high-fat foods, avoid milk products Decrease high-fat foods, avoid milk products
at night, and avoid late snacking or mealsat night, and avoid late snacking or meals
Drug TherapyDrug Therapy
Surgical therapySurgical therapy
Endoscopic therapyEndoscopic therapy
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GERD: ComplicationsGERD: Complications
Are related to HCl effect on the Are related to HCl effect on the esophageal mucosa esophageal mucosa EsophagitisEsophagitis
Can complicate to esophageal ulcerationCan complicate to esophageal ulceration
Barrett’s esophagus (esophageal Barrett’s esophagus (esophageal metaplasia)metaplasia)Pre-cancerous lesionPre-cancerous lesion
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Nursing ManagementNursing Management Avoid factors that cause refluxAvoid factors that cause reflux
Stop smokingStop smoking Avoid acid or acid producing foodsAvoid acid or acid producing foods
Elevate HOB ~30°Elevate HOB ~30°
Do not lie down 2 to 3 hours after eatingDo not lie down 2 to 3 hours after eating
Patient teaching (see Table 40-10 in textbook)Patient teaching (see Table 40-10 in textbook)
Drug therapyDrug therapy Evaluate effectivenessEvaluate effectiveness Observe for side effectsObserve for side effects
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Peptic ulcerPeptic ulcer Erosion or excavation of mucosal wall of the Erosion or excavation of mucosal wall of the
esophagus, stomach, pylorus, duodenum esophagus, stomach, pylorus, duodenum
(most common). “Autodigestion”(most common). “Autodigestion”
Requires acid environment to developRequires acid environment to develop
Mucosal defenses impaired; cannot protect from Mucosal defenses impaired; cannot protect from effects of acid/pepsineffects of acid/pepsin
Result from infection with Result from infection with H. pyloriH. pylori or Zollinger- or Zollinger-Ellison syndromeEllison syndrome
Risk factors:Risk factors: Alcohol, smoking, and stress, medicationsAlcohol, smoking, and stress, medications
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Three types of peptic Three types of peptic ulcerulcer
GastricGastric DuodenalDuodenal StressStress
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Gastric ulcerGastric ulcer Most common in the lesser curvature of Most common in the lesser curvature of
stomach near the pylorus stomach near the pylorus
Mucus and bicarb. generally protect Mucus and bicarb. generally protect mucosal barrier from acidmucosal barrier from acid
H. pyloriH. pylori plays a role plays a role
Break in gastric mucosal barrier allows Break in gastric mucosal barrier allows HCl to damage epithelium via “back HCl to damage epithelium via “back diffusion”diffusion”
Bile reflux from duodenum may break Bile reflux from duodenum may break integrityintegrity
Decreased blood flowDecreased blood flow
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Duodenal ulcerDuodenal ulcer
Results from excessive acidResults from excessive acid Associated with protein-rich meals, Ca++, and Associated with protein-rich meals, Ca++, and
vagal stimulation)vagal stimulation)
Rapid emptying of food from stomach Rapid emptying of food from stomach large acid load in duodenumlarge acid load in duodenum
H. pyloriH. pylori infection plays key role in infection plays key role in developmentdevelopment produces substances that damage the mucosa, produces substances that damage the mucosa,
and contributes to higher acid concentrationsand contributes to higher acid concentrations
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Stress ulcerStress ulcer
Occurs after acute medical crisis, surgery, Occurs after acute medical crisis, surgery, or traumaor trauma
Proximal portion of stomach and duodenum Proximal portion of stomach and duodenum are most common sitesare most common sites
Ischemia and elevated HCl contribute to Ischemia and elevated HCl contribute to evolution of erosions evolution of erosions ulcerations ulcerations
May progress to hemorrhageMay progress to hemorrhage
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Duodenal versus Gastric Duodenal versus Gastric ulcersulcers
Gastric Duodenal Normal/hypo-secretion of gastric acid
Hyper-secretion
Pain 1-2 hrs pc meals Pain 2-4 hrs pc meals Food aggravates pain Food may relieve pain Vomiting common Vomiting not common More likely to hemorrhage – manifests as hematemesis
Less likely to hemorrhage, but if occurs, likely to manifest as melena
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Diagnostic testsDiagnostic tests
EsphagogastroduodenoEsphagogastroduodenoscopyscopy Fiberoptic endoscope Fiberoptic endoscope
allows direct allows direct visualization of visualization of esophagus, stomach and esophagus, stomach and duodenum duodenum
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Diagnostic tests: Upper GI Diagnostic tests: Upper GI seriesseries
Patients ingests Patients ingests barium, a barium, a thick, white, milkshake-like thick, white, milkshake-like liquid, liquid, then multiple X-rays. then multiple X-rays. Can detect structural Can detect structural disordersdisorders
After the exam, provide After the exam, provide plenty of liquids for 24 to 48 plenty of liquids for 24 to 48 hours. hours.
The barium may make the The barium may make the stool white for several days. stool white for several days.
If constipation occurs, the If constipation occurs, the doctor may recommend a doctor may recommend a mild laxative. mild laxative.
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Complications of ulcers: Complications of ulcers: HemorrhageHemorrhage
Manifested by:Manifested by: Orthostatic hypotension, Orthostatic hypotension, BP, BP, HR, cool, HR, cool,
clammy skin overt bleedingclammy skin overt bleeding
Hematemesis (bloody vomit) – bright red or Hematemesis (bloody vomit) – bright red or coffee ground (more likely with gastric coffee ground (more likely with gastric ulcer)ulcer)
Melena (bloody or tarry [black] stool) – more Melena (bloody or tarry [black] stool) – more likely with duodenal ulcerlikely with duodenal ulcer
Hgb, Hgb, Hct Hct
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Remember: Management during Remember: Management during Haemorrhage includesHaemorrhage includes
Monitor S/SMonitor S/S
Determine rate amount of blood loss (Hct/hct), Determine rate amount of blood loss (Hct/hct),
NGTNGT
Replace blood, fluid and electrolyte lossReplace blood, fluid and electrolyte loss
saline lavage via NGTsaline lavage via NGT
NGT to low intermittent suctionNGT to low intermittent suction Prevents distensionPrevents distension
Assess amount/rate of bleeding, Assess amount/rate of bleeding,
Medications, oxygen, possible surgeryMedications, oxygen, possible surgery
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Complications: Complications: PerforationPerforation
GI contents empty into peritoneal cavityGI contents empty into peritoneal cavity
Manifested by:Manifested by: Sudden, sharp mid-epigastric pain which can Sudden, sharp mid-epigastric pain which can
shortly spread to all abdomenshortly spread to all abdomen Rigid, tender, board-like abdomenRigid, tender, board-like abdomen Patient assumes the fetal position to reduce Patient assumes the fetal position to reduce
tension on musclestension on muscles
Can lead to shockCan lead to shock
It is a surgical emergencyIt is a surgical emergency
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Remember: Management during Remember: Management during perforation includesperforation includes
NGT to prevent additional spillage of GI NGT to prevent additional spillage of GI contents in peritoneumcontents in peritoneum
Replace blood, fluid, electrolytesReplace blood, fluid, electrolytes
AntibioticsAntibiotics
I & O, NPOI & O, NPO
SURGERY: UrgentSURGERY: Urgent
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Complications: Complications: Pyloric Pyloric obstructionobstruction
Caused by inflammation or edema of Caused by inflammation or edema of the pylorus the pylorus
Stomach cannot empty Stomach cannot empty abdominal abdominal bloating, N & Vbloating, N & V
Persistent vomiting Persistent vomiting Hypokalemia Hypokalemia and metabolic alkalosis and metabolic alkalosis
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Medical Management of Medical Management of ulcersulcers
Conservative Conservative therapy:therapy: Rest: Both physical Rest: Both physical
and emotionaland emotional Dietary Dietary
modificationsmodifications Elimination of Elimination of
smokingsmoking Long term follow Long term follow
up careup care
Pharmaceutical:Pharmaceutical: AntibioticsAntibiotics
To eradicate To eradicate H. PyloriH. Pylori infections infections Recurrence of ulcer is 75-90% as Recurrence of ulcer is 75-90% as
high with infectionhigh with infection
AntiacidsAntiacids Initial drugs of choiceInitial drugs of choice
Histmaine H2 receptor Histmaine H2 receptor antagonistsantagonists
Histamine is the final intracellular Histamine is the final intracellular activator of HCL secretion activator of HCL secretion
Anticholinergic:Anticholinergic: Stop the cholinergic stimulation of Stop the cholinergic stimulation of
HCl secretion and slow gastric HCl secretion and slow gastric motilitymotility
Not commonly used, if used need to Not commonly used, if used need to be used with caution in pts with be used with caution in pts with GlaucomaGlaucoma
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Surgical Management of Surgical Management of ulcerationsulcerations
GastroduodenosGastroduodenostomy (Billroth I) tomy (Billroth I) Removal of the Removal of the
lower portion of lower portion of stomach and small stomach and small portion of portion of duodenum and duodenum and connects connects remaining of remaining of stomach to stomach to duodenumduodenum
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Surgical Management of Surgical Management of ulcerationsulcerations
GastojejunostomyGastojejunostomy Removes lower stomach and Removes lower stomach and
small portion of duodenum.small portion of duodenum. Reconnects stomach to Reconnects stomach to
jejunum.jejunum. Subtotal gastrectomySubtotal gastrectomy - removal distal third of - removal distal third of
stomach, reconnecting to stomach, reconnecting to duodenum or jejunumduodenum or jejunum
Total gastrectomyTotal gastrectomy removal of stomach; removal of stomach;
connects esophagus to connects esophagus to jejunumjejunum
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Dumping syndromeDumping syndrome A complication of gastric surgeryA complication of gastric surgery
S&SS&S vertigo, sweating, palpitations, syncope, pallor, vertigo, sweating, palpitations, syncope, pallor,
tachycardiatachycardia
occurs after eatingoccurs after eating D/t rapid emptying of hypertonic stomach contents into D/t rapid emptying of hypertonic stomach contents into
small intestine small intestine fluid shifts into gut fluid shifts into gut abd. distention abd. distention and cramps and S/S of and cramps and S/S of plasma volume. plasma volume.
Later get rapid elevation of blood glucose followed by Later get rapid elevation of blood glucose followed by insulin secretion and hypoglycemiainsulin secretion and hypoglycemia
ManagementManagement Small frequent mealsSmall frequent meals fat, fat, protein, protein, CHO meals CHO meals liquid between (not with) mealsliquid between (not with) meals Lie down after mealsLie down after meals
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Nursing diagnosesNursing diagnoses
Pain r/t mucosal injuryPain r/t mucosal injury
AnxietyAnxiety
Knowledge deficitKnowledge deficit
Risk for fluid volum deficit r/t Risk for fluid volum deficit r/t hemorrhage or vomitinghemorrhage or vomiting
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Intervention: PainIntervention: Pain MedicationsMedications
Give antacids after meals and at bedtime to decrease Give antacids after meals and at bedtime to decrease gastric acidity; buffers the acid. gastric acidity; buffers the acid.
Give H2 receptor antagonists as prescribed to decrease acid Give H2 receptor antagonists as prescribed to decrease acid secretion secretion
Diet therapyDiet therapy Effectiveness controversialEffectiveness controversial Avoid caffeinated beveragesAvoid caffeinated beverages Exclude foods that cause discomfortExclude foods that cause discomfort Provide frequent, small, bland mealsProvide frequent, small, bland meals Avoid smoking, alcoholAvoid smoking, alcohol
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Intervention: Anxiety & Intervention: Anxiety & Knowledge deficitKnowledge deficit
AnxietyAnxiety Provide emotional supportProvide emotional support Teach and provide relaxation techniquesTeach and provide relaxation techniques Identify and manage sources of stressIdentify and manage sources of stress
Knowledge deficitKnowledge deficit Teach re diet, medications, Teach re diet, medications, Teach the risks associated with continued Teach the risks associated with continued
smokingsmoking Teach S/S of complicationsTeach S/S of complications