Nutritional Patterns Part IIA

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Nutritional Patterns Part II-A

• Terry Moorman, RN, MSN

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Two Forms Of Gastritis

• Acute gastritis
• Lasts several hours to a few days
• Often due to a dietary indiscretion
• Also due to overuse of NSAIDS, ASA, or excessive
  ETOH use
• Scarring can occur

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• Chronic gastritis
• There is prolonged inflammation
• Often due to benign or malignant ulcers,
  Helicobacter pylori (H-pylori), autoimmune
  disorders
• Also due to dietary factors, overuse of NSAIDS,
  ASA, steroids, ETOH, smoking

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Clinical Manifestations Gastritis

• Epigastric discomfort, dyspepsia
• Eructation
• Anorexia, nausea, vomiting
• Hematemesis

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Diagnostic Testing For Gastritis

• Upper GI series
• EGD with biopsy
• Serologic testing for H-pylori antibodies
• Breath test for H-pylori

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Complications Of Gastritis

• Bleeding
• Pernicious anemia
• Peptic ulcer
• Gastric cancer

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Medical Management Of Gastritis

• Remove cause
• Refrain from food and fluids until signs and
  symptoms subside
• Treat H-pylori
• Amoxicillin
• Biaxin - clarithromycin
• Flagyl - metronidazol
• Prilosec - omeprazole
• Bismuth subsalicylate

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• Protect stomach mucosa
• Prostaglandin E1 analog (PGE1) - Cytotec
  (misoprostol)
• Carafate (sucralfate)
• Treat symptoms
• H2 blocker - Pepcid (famotidine)
• Proton pump inhibitor (PPI) - Prilosec
  (omeprazole)
• Antacids - liquid Mylanta, Riopan, Maalox
• Phenothiazines - Phenergan
• Anticholinergics - Bentyl (dicyclomine)
• Promote rest and reduce stress

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Imbalanced nutrition, less than body requirements
r/t inadequate intake

• Help manage symptoms
• Foods with-held as per order
• Gradually resume intake after symptoms subside
• Discourage use of ETOH, nicotine and caffeine

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Risk for fluid volume deficit r/t insufficient
intake and N/V

• Intake and output
• Monitor for manifestations of dehydration
• Administer and monitor IV fluids as ordered
• Monitor for manifestations of hemorrhagic
  gastritis

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Knowledge deficit regarding management of
condition

• Instruct on avoidance of ETOH, nicotine, spicy
  foods, caffeine
• Instruct on medications
• Instruct on stress relief

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Characteristics Of Duodenal Ulcers

• Located 1/4 - 1 from pylorus in duodenum
• Age of onset is 30-60 years
• Gastric acid and pepsin secretion are increased
• Pain occurs 2-3 hours after eating and in the
  middle of the night dull or gnawing

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• Pain relieved by food or antacids
• Bleeding pattern is less likely but will be
  melena if present
• Predisposing factors stress, smoking, ETOH,
  H-pylori
• Malignancy potential is rare

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Characteristics Of Gastric Ulcers

• Located in the antrum or junction of fundus and
  pylorus
• Age of onset is 50 years and older
• Normal or hyposecretion of gastric acid
• Breakdown in the normally protective epithelial
  lining

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• Pain occurs 1/2 to 1 hour after eating - may be
  relieved by vomiting
• Malignancy potential is 10
• Bleeding pattern - hematemesis more common
• Predisposing factors gastritis, ETOH, NSAIDS,
  H-pylori

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Risk Factors That Contribute to PUD

• H-Pylori
• Chronic use of ASA, NSAIDS, steroids
• ETOH ingestion
• Smoking
• Excessive caffeine
• Milk ingestion
• Zollinger-Ellison syndrome (ZES)
• Stress

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Stress Ulcers

• Initiated by conditions physiologically stressful
• Usually gastric in origin
• Hemorrhage frequently first sign
• Types
• Curlings ulcers
• Cushings ulcers
• Stress ulcers

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Assessment And Diagnostic Findings With PUD

• Epigastric tenderness or abdominal distention on
  assessment
• Upper GI - may or may not show ulcer
• EGD - preferred diagnostic procedure
• Hemoccult stools - may be positive
• Gastric secretory studies
• Serologic studies for H-pylori

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Medical Management Of PUD

• Eliminate H-pylori if present
• Reduce gastric secretions and pain
• H2 receptor antagonists
• Proton pump inhibitors
• Antacids
• Anticholinergics

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• Strengthen mucosal barrier
• Prostaglandin E1 analog
• Sucralfate
• Modify diet
• Smoking cessation
• Treat complications
• Hemorrhage
• Perforation
• Pyloric obstruction

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Surgical Treatment Of PUD

• Selective vagotomy
• Antrectomy
• Gastrectomy
• Pyloroplasty

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Dumping Syndrome

• Common complication after gastric surgeries
• Rapid passage of food into jejunum
• Jejunum dilates
• Hypertonic food contents draw fluid from blood

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Clinical Manifestations Of Dumping Syndrome

• Weakness, faintness, dizziness
• Diaphoresis
• Feeling of fullness or discomfort
• Occasional diarrhea
• Palpitations, tachycardia
• Rapid increase in glucose level then hypoglycemia

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Management of Dumping Syndrome

• Assume low Fowlers during mealtime and lie down
  20-30 min after eating
• Antispasmodics
• Drink fluids 1 hr before or 1 hr after meals
• Foods should be low CHO, high protein, high fat
  and contain more dry items
• Eat smaller more frequent meals

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Potential Complication Hemorrhage

• Monitor vital signs and for symptoms of shock
• Insert peripheral IV line
• Monitor O2 saturation and administer O2
• Insert NG tube as ordered

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• Insert urinary cath and monitor output
• Place client in left lateral recumbent position
• Administer Vasopressin as ordered
• Monitor HH and stools for blood
• Administer blood as ordered

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Potential Complication Perforation and
Penetration

• Monitor for signs and symptoms of perforation
• Sudden, severe upper abdominal pain
• Vomiting
• Tender and rigid abdomen
• Hypotension and tachycardia
• Administer antibiotics as ordered
• Monitor labs

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Potential Complication Pyloric Obstruction

• Monitor for N/V, epigastric fullness, anorexia
• Monitor for constipation
• Insert NG tube as ordered
• Administer IV fluids as ordered
• Monitor lytes

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Post-operative Nursing Care

• Monitor vital signs
• Turn, cough, deep breathe
• Monitor NG drainage
• Position patient in Fowlers or semi-Fowlers
  position
• Relieve pain

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• As a nursing instructor, I remember a critically
  ill patient we were monitoring closely. The
  student was caring for her and I instructed her
  to check the patients Is Os every hour.
  Later in the day I returned to review her
  charting, finding an hourly description of
  changes in her EYES watery, blinking and NOSE
  runny.

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Discharge Teaching

• Gradual increase of food intake
• Daily monitoring of weight
• Signs and symptoms to report to physician

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• Methods to control symptoms associated with
  Dumping Syndrome
• Avoid concentrated sweets or CHO
• Consume 6 small, dry meals daily
• No fluids with meals
• Assume recumbent position for 1/2 hr after meals
• Antispasmodics as prescribed
• Dietary supplements
• Vitamin B12 injections

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Risk Factors For Gastric Cancer

• Diet
• Chronic gastritis and gastric ulcers
• Pernicious anemia
• Presence of H-pylori
• Heredity

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Late Clinical Manifestations Of Gastric Cancer

• Dyspepsia or indigestion
• N/V, anorexia
• Weight loss
• Constipation
• Abdominal pain
• Anemia

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Diagnostic Tests For Gastric Cancer

• Upper GI series
• EGD with biopsies is the gold standard
• CT scan
• Bone scan

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Treatment For Gastric Cancer

• Surgery
• Chemotherapy
• Radiation therapy

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• Malabsorption inability of the digestive system
  to absorb one or more vitamins, minerals or
  nutrients

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Causes Of Malabsorption

• Mucosal disorders
• Infectious diseases
• Postoperative malabsorption
• Disorders that cause malabsorption of specific
  nutrients
• Medical disorders

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Clinical Manifestations Of Malabsorption

• Diarrhea
• Bulky, foul smelling stools
• May be gray in color
• Flatulence
• Weight loss
• Malnutrition

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Diagnostic Testing For Malabsorption

• Lactose tolerance
• Schilling test
• Biopsy of mucosa of small intestine
• Fecal analysis
• CBC
• Hydrogen breath test

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Medical Treatment Of Malabsorption

• Avoid agent that aggravates condition
• Supplemental vitamins and minerals
• Antibiotics
• Antidiarrheal agents
• Parenteral fluids for hydration

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Nursing Management of Malabsorption

• Monitor for fluid and electrolyte imbalance
• Monitor nutritional status
• Educate patient and family

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Irritable Bowel Syndrome (IBS)

• Results from a functional disorder of GI motility
• Spastic contractions
• No evidence of inflammation

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Risk Factors For Irritable Bowel Syndrome

• Heredity
• Psychological stress or illness
• Diets high in fat or irritating foods
• ETOH consumption
• Smoking
• Lactose intolerance

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Clinical Manifestations Of Irritable Bowel
Syndrome

• Alteration in bowel function
• Abdominal pain
• Bloating and abdominal distention
• Flatulence

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Diagnostic Tests For IBS

• BaE
• Colonoscopy
• R/O other diseases

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Medical Treatment Of Irritable Bowel Syndrome

• Well balanced, high fiber diet
• Hydrophilic colloids and anti-diarrheal agents
• Anticholinergics and calcium channel blockers
• Zelnorm
• Antidepressants
• Exercise
• Stress reduction

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Nursing Management

• Educate patient
• Well balanced, high fiber diet
• Adequate fluid
• Avoid ETOH and smoking
• Get adequate rest and exercise
• Medications

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Clinical Manifestations Of Appendicitis

• Low grade fever
• Nausea and sometimes vomiting
• Right lower quadrant pain
• Rovsings sign
• Rebound tenderness
• Guarding
• Legs drawn up
• Constipation

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Diagnostic Findings With Appendicitis

• WBC
• Ultrasound
• CT scan

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Medical Treatment Of Appendicitis

• Appendectomy
• Antibiotics
• IV fluids
• Analgesics

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Complications With Appendicitis

• Perforation
• Peritonitis
• Abscess formation

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Nursing Diagnoses With Appendicitis
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Post-operative Nursing Interventions

• Monitor vital signs
• Assess dressing and drains
• Place client in semi-Fowlers position
• Administer analgesics
• Oral fluids given when tolerated
• Administer antibiotics as ordered
• Monitor for peritonitis

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Discharge Teaching For The Appendectomy Client

• Follow-up appointment
• Instruct on incision care
• Activity restrictions
• Signs and symptoms of complications to inform
  physician of