Nursing Management: Upper Gastrointestinal Problems

Chapter 42


Nursing Management


Upper Gastrointestinal Problems


Paula Cox-North




Learning Outcomes



1. Describe the etiology, complications, collaborative care, and nursing management of nausea and vomiting.


2. Describe the etiology, clinical manifestations, and treatment of common oral inflammations and infections.


3. Describe the etiology, clinical manifestations, complications, collaborative care, and nursing management of oral cancer.


4. Explain the types, pathophysiology, clinical manifestations, complications, and collaborative care (including surgical therapy and nursing management) of gastroesophageal reflux disease (GERD) and hiatal hernia.


5. Describe the pathophysiology, clinical manifestations, complications, and collaborative care of esophageal cancer, diverticula, achalasia, and esophageal strictures.


6. Differentiate between acute and chronic gastritis, including the etiology, pathophysiology, collaborative care, and nursing management.


7. Compare and contrast gastric and duodenal ulcers, including the etiology, pathophysiology, clinical manifestations, complications, collaborative care, and nursing management.


8. Describe the clinical manifestations, collaborative care, and nursing management of stomach cancer.


9. Explain the common etiologies, clinical manifestations, collaborative care, and nursing management of upper gastrointestinal bleeding.


10. Identify common types of foodborne illnesses and nursing responsibilities related to food poisoning.



Key Terms

















Reviewed by Marian Sawyier, RN, MSN, Staff Nurse, University of New Mexico Hospital, Albuquerque, New Mexico.




Nausea and Vomiting


Nausea and vomiting are the most common manifestations of gastrointestinal (GI) diseases. Although nausea and vomiting can occur independently, they are usually closely related and treated as one problem. Nausea is a feeling of discomfort in the epigastrium with a conscious desire to vomit. Vomiting is the forceful ejection of partially digested food and secretions (emesis) from the upper GI tract.


Vomiting is a complex act that requires the coordinated activities of several structures: closure of the glottis, deep inspiration with contraction of the diaphragm in the inspiratory position, closure of the pylorus, relaxation of the stomach and lower esophageal sphincter (LES), and contraction of the abdominal muscles with increasing intraabdominal pressure. These simultaneous activities force the stomach contents up through the esophagus, into the pharynx, and out the mouth.



image eNursing Care Plan 42-1   Patient With Nausea and Vomiting




Patient Goal


Reports minimal or no nausea and vomiting












Outcomes (NOC) Interventions (NIC) and Rationales




Nausea Management


• Perform complete assessment of nausea, including frequency, duration, severity, and precipitating factors, to identify etiologies and plan appropriate interventions.


• Reduce or eliminate personal factors that precipitate or increase the nausea (anxiety, fear, fatigue, and lack of knowledge) to avoid precipitating factors of nausea/vomiting.


• Use frequent oral hygiene, unless it stimulates nausea, to promote comfort.


• Ensure that effective antiemetic drugs are given when possible to prevent nausea and vomiting.


• Teach the use of nonpharmacologic techniques (e.g., relaxation, guided imagery, music therapy, distraction, acupressure) to manage nausea and vomiting.


• Inform other health care professionals and family members of any nonpharmacological strategies being used by the nauseated person to promote consistency of care.


• Monitor effects of nausea management throughout to evaluate effectiveness of interventions.



image





Patient Goal


Achieves normal fluid and electrolyte balance





Patient Goal


Maintains body weight with adequate intake of nutrients



BUN, Blood urea nitrogen.


*Nursing diagnoses listed in order of priority.



image eNursing Care Plan 42-2   Patient With Peptic Ulcer Disease




Patient Goal


Reports pain controlled without the use of analgesics





Patient Goals














Outcomes (NOC) Interventions (NIC) and Rationales






Teaching: Disease Process


• Review the patient’s knowledge about condition to determine if ineffective management is a knowledge problem.


• Explain the pathophysiology of the disease and how it relates to anatomy and physiology to foster understanding.


• Discuss therapy/treatment options.


• Describe rationale behind management/therapy/treatment recommendations to foster understanding of the therapy.


• Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process.


• Explore with patient what she or he has already done to manage the symptoms to confirm the patient has the ability to manage the disease.


• Instruct patient on which signs and symptoms to report to health care provider to ensure early initiation of treatment.




image




Collaborative Problems



Potential Complication


Hemorrhage secondary to eroded mucosal tissue




Potential Complication


Perforation secondary to ulcer penetration of the serosal surface



*Nursing diagnoses listed in order of priority.



Etiology and Pathophysiology


Nausea and vomiting occur in a wide variety of GI disorders and in conditions that are unrelated to GI disease. These include pregnancy; infection; central nervous system (CNS) disorders (e.g., meningitis, tumor); cardiovascular problems (e.g., myocardial infarction, heart failure); metabolic disorders (e.g., diabetes mellitus, Addison’s disease, renal failure); postoperatively after general anesthesia; side effects of drugs (e.g., chemotherapy, opioids, digitalis); psychologic factors (e.g., stress, fear); and conditions in which the GI tract becomes overly irritated, excited, or distended.


A vomiting center in the brainstem coordinates the multiple components involved in vomiting. This center receives input from various stimuli. Neural impulses reach the vomiting center via afferent pathways through branches of the autonomic nervous system. Receptors for these afferent fibers are located in the GI tract, kidneys, heart, and uterus. When stimulated, these receptors relay information to the vomiting center, which then initiates the vomiting reflex (Fig. 42-1).


image
FIG. 42-1 Stimuli involved in the act of vomiting. CTZ, Chemoreceptor trigger zone.

The chemoreceptor trigger zone (CTZ) located in the brainstem responds to chemical stimuli of drugs, toxins, and labyrinthine stimulation (e.g., motion sickness). Once stimulated, the CTZ transmits impulses directly to the vomiting center. This action activates the autonomic nervous system, resulting in both parasympathetic and sympathetic stimulation. Sympathetic activation produces tachycardia, tachypnea, and diaphoresis. Parasympathetic stimulation causes relaxation of the LES, an increase in gastric motility, and a pronounced increase in salivation.



Clinical Manifestations


Nausea is a subjective complaint. Anorexia (lack of appetite) usually accompanies nausea. When nausea and vomiting occur over a long period, dehydration can develop rapidly. Water and essential electrolytes (e.g., potassium, sodium, chloride, hydrogen) are lost. As vomiting persists, the patient may have severe electrolyte imbalances, loss of extracellular fluid volume, decreased plasma volume, and eventually circulatory failure.


Metabolic alkalosis can result from loss of gastric hydrochloric (HCl) acid. When contents of the small intestine are vomited, metabolic acidosis can occur. However, metabolic acidosis is less common than metabolic alkalosis. Weight loss resulting from fluid loss is evident in a short time when vomiting is severe.


The threat of pulmonary aspiration is a concern when vomiting occurs in older or unconscious patients or in patients with other conditions that impair the gag reflex. To prevent aspiration, put the patient who cannot adequately manage self-care in a semi-Fowler’s or side-lying position.



Collaborative Care


The goals of collaborative care are to determine and treat the underlying cause of the nausea and vomiting and to provide symptomatic relief. Assess the patient for precipitating factors, and describe the contents of the emesis. Women are more likely to suffer from nausea and vomiting associated with surgical procedures and motion sickness.1


It is important to differentiate among vomiting, regurgitation, and projectile vomiting. Regurgitation is an effortless process in which partially digested food slowly comes up from the stomach. Retching or vomiting rarely occurs before it. Projectile vomiting is a forceful expulsion of stomach contents without nausea and is characteristic of CNS (brain and spinal cord) tumors.


Emesis containing partially digested food several hours after a meal is indicative of gastric outlet obstruction or delayed gastric emptying. The presence of fecal odor and bile after prolonged vomiting suggests intestinal obstruction below the level of the pylorus. Bile in the emesis may suggest obstruction below the ampulla of Vater. The color of the emesis aids in identifying the presence and source of bleeding. Vomitus with a “coffee ground” appearance is related to gastric bleeding, where blood changes to dark brown as a result of its interaction with HCl acid. Bright red blood indicates active bleeding. This could be due to a Mallory-Weiss tear (disruption of the mucosal lining near the esophagogastric junction), esophageal varices, gastric or duodenal ulcer, or neoplasm. A Mallory-Weiss tear is most often related to severe retching and vomiting.


The time of day at which the vomiting occurs is often helpful in determining the cause. Early morning vomiting is common in pregnancy. Emotional stressors with no evident pathologic disorder may elicit vomiting during or immediately after eating.



Drug Therapy.

The use of drugs (Table 42-1) in the treatment of nausea and vomiting depends on the cause of the problem. Because the cause cannot always be readily determined, use drugs with caution. Using antiemetics before determining the cause can mask the underlying disease process and delay diagnosis and treatment. Many antiemetic drugs act in the CNS via the CTZ to block the neurochemicals that trigger nausea and vomiting.



TABLE 42-1


DRUG THERAPY
Nausea and Vomiting



















































Drug Mechanism of Action Side Effects
Phenothiazines
chlorpromazine (Thorazine)
perphenazine (Trilafon)
prochlorperazine (Compazine)
trifluoperazine (Stelazine)
promethazine (Phenergan)		 Act in the CNS level of the CTZ
Block dopamine receptors that trigger nausea and vomiting		 Dry mouth, hypotension, sedative effects, rashes, constipation
Antihistamines
meclizine (Bonine, Antivert)
dimenhydrinate (Dramamine)
hydroxyzine (Vistaril)
diphenhydramine (Benadryl)		 Block the histamine receptors that trigger nausea and vomiting Dry mouth, hypotension, sedative effects, rashes, constipation
Prokinetic Agents
domperidone (Motilium)
metoclopramide (Reglan)		 Inhibit action of dopamine
↑ Gastric motility and emptying		 CNS side effects ranging from anxiety to hallucinations
Extrapyramidal side effects, including tremor and dyskinesias (similar to Parkinson’s disease)
Serotonin (5-HT3) Antagonists
dolasetron (Anzemet)
granisetron (Kytril)
ondansetron (Zofran)
palonosetron (Aloxi)		 Block the action of serotonin (substance that causes nausea and vomiting) Constipation, diarrhea, headache, fatigue, malaise, elevated liver function tests
Anticholinergic (Antimuscarinic)
scopolamine transdermal Blocks the cholinergic pathways to the vomiting center Xerostomia, somnolence
Butyrophenone
droperidol (Inapsine) Blocks the neurochemicals that trigger nausea and vomiting Dry mouth, hypotension, sedative effects, rashes, constipation
Others
aprepitant (Emend)
dexamethasone (Decadron)
dronabinol (Marinol)
nabilone (Cesamet)
thiethylperazine (Torecan)
trimethobenzamide (Tigan)		    


image


CTZ, Chemoreceptor trigger zone.



Drug Alert


Promethazine Injection





Drug Alert


Metoclopramide (Reglan)




The serotonin (5-HT3) receptor antagonists are effective in reducing cancer chemotherapy–induced vomiting caused by delayed gastric emptying and also the nausea and vomiting related to migraine headache and anxiety.2 5-HT3 antagonists are also used in prevention and treatment of postoperative nausea and vomiting. Dexamethasone (Decadron) is used in the management of both acute and delayed cancer chemotherapy–induced emesis, usually in combination with other antiemetics such as ondansetron (Zofran). Aprepitant (Emend), a substance P/neurokinin-1 receptor antagonist, is used for the prevention of chemotherapy-induced and postoperative nausea and vomiting.


Dronabinol (Marinol) is an orally active cannabinoid that is used alone or in combination with other antiemetics for the prevention of chemotherapy-induced emesis. Because of the potential for abuse, as well as drowsiness and sedation, this drug is used only when other therapies are ineffective.



Nutritional Therapy.

The patient with severe vomiting requires IV fluid therapy with electrolyte and glucose replacement until able to tolerate oral intake. In some cases a nasogastric (NG) tube and suction are used to decompress the stomach. Start oral nutrition beginning with clear liquids once symptoms have subsided. Extremely hot or cold liquids are often difficult to tolerate. Carbonated beverages at room temperature and with the carbonation gone and warm tea are easier to tolerate. The addition of dry toast or crackers may be helpful. Water is the initial fluid of choice for rehydration by mouth. Sipping small amounts of fluid (5 to 15 mL) every 15 to 20 minutes is usually better tolerated than drinking large amounts less frequently. Broth and Gatorade are high in sodium, so administer them with caution.


As the patient’s condition improves, provide a diet high in carbohydrates and low in fat. Items such as a baked potato, plain gelatin, cereal, and hard candy are ideal. Coffee, spicy foods, highly acidic foods, and those with strong odors are often poorly tolerated. Tell the patient to eat food slowly and in small amounts to prevent overdistention of the stomach. Liquids taken between meals rather than with meals also reduce overdistention. Consult a dietitian regarding appropriate foods that have nutritional value and are well tolerated by the patient.



Nondrug Therapy.

For some patients, acupressure or acupuncture at specific points is effective in reducing postoperative nausea and vomiting.3 Some patients use herbs such as ginger and peppermint oil. Relaxation breathing exercises, changes in body position, or exercise may be helpful for some patients.



image Complementary & Alternative Therapies


Ginger




Source: Based on a systematic review of scientific literature. Retrieved from www.naturalstandard.com.



Nursing Management Nausea and Vomiting


Nursing Assessment


Each patient with a history of prolonged and persistent nausea or vomiting requires a thorough nursing assessment before you develop a specific plan of care. Although numerous conditions are associated with nausea and vomiting, you should have a basic understanding of the more common conditions and be able to identify the patient who is at high risk. Knowledge of the physiologic mechanisms involved in nausea and vomiting is important in the assessment process. Table 42-2 presents subjective and objective data to be obtained from a patient with nausea and vomiting.



TABLE 42-2


NURSING ASSESSMENT
Nausea and Vomiting










Subjective Data
Important Health Information

Related posts:

  1. Introduction
  2. Nursing Management: Sexually Transmitted Infections
  3. Nursing Assessment: Cardiovascular System
  4. Nursing Management: Musculoskeletal Problems

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Nov 17, 2016 | Posted by in NURSING | Comments Off on Nursing Management: Upper Gastrointestinal Problems

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