NURSING II Kathleen C. Ashton

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NURSING IIKathleen C. Ashton

• The Client With Alterations in Digestion

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Nutritional Assessment

• Digestion begins in mouth - mastecation
• Should chew our food at least 25 times
• Food Record used to determine type and amount
  over 3-7 days
• Consider IBW and UBW. Need ht. and wt.
• 24 hour recall - recalls previous days intake -
  measures total nutritive value of food compared
  with the RDA
• Limitations
• Previous day may not be typical (ask this
  question)
• Depends on memory (problem with elderly)

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Effects of Hospitalization

• metabolic changes due to illness or change in
  activity level (low albumin denotes low protein
  stores and negative nitrogen balance)
• necessity of NPO for diagnostic tests
• use of IVs or tube feeding without regard for
  exact needs of client
• institutional cooking vs. home cooking
• lack of normal mealtime atmosphere family, table
  and chairs, toilet tissue
• errors in delivery wrong person, wrong diet
• elderly effects of medications, anorexia
• antibiotics disturb normal flora, give yogurt
  when appropriate

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Diagnostic Tests

• Upper GI, Barium Swallow
• odorless, tasteless, insoluble
• NPO after midnight
• no smoking
• swallow barium under direct xray visualization
• will have white stool
• Gastric Analysis gives information on gastric
  acid secretion

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Diagnostics (Continued)

• Endoscopy
• uses fiberoptics and laser technology.
• can take color photos, biopsy, retrieve stones,
  reduce tumors (cannot remove them)
• check for gag reflex after gastroscopy, before
  giving fluids. Returns in 1 - 2 hours
• Lower GI, Barium Enema
• Direct visualization (scopes used tests
  sigmoidoscopy, proctoscopy, anoscopy, colonoscopy
  (also used to remove polyps)
• Virtual colonoscopy (half the cost, quick, not
  yet covered by insurance)
• Stool exam for ova and parasites, occult blood
• CAT scan, ultrasound, MRI (care with pacers)

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Considerations for Adolescents

• Calcium absorbed best during adolescence -
  negated by carbonated drinks high in phosphorous
• Eating disorders begin with disturbed body images
  - anorexia nervosa, bulemia
• Kate Moss type models send message that girls
  are fat
• Anabolic steroid use and misuse an issue with
  athletes

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Considerations for the elderly

• Tooth loss is not inevitable
• We are keeping our teeth longer due to better
  nutrition. Not true across the nation -
• Time magazine reports 48 of seniors in W.VA are
  toothless (highest in US)
• 13.9 of seniors in Hawaii are toothless
• Educate about careful fitting of dentures -
  should be refitted every 5 years or whenever
  there is a major change in weight
• Weight issues may necessitate a change in timing
  or amounts of food intake
• Eating six small meals starting with breakfast
  and ending before 7PM

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Cancer of the oral cavity

• Rare and carries a good prognosis if early
  detection
• Risk factors
• smoking snuff, chewing tobacco, pipes
• alcohol
• increased age
• exposure to elements
• affects more men than women
• Begins as painless sore, progresses to lymph
  involvement
• Large tumors (4cm) tend to recur

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Nursing Implications

• Early screening
• Body image is big issue
• Support needed as chemo or radiation begins
• Mouth care and fluids to prevent dryness
• Combat anorexia
• Address fears
• Communication - use paper and pencil or computer
  to facilitate communication

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Radical neck dissection

• Indicated for certain cancers
• Preoperative care is standard, main concern is
  airway maintenance and communication post
  operatively
• Wound care usually includes drains, may be
  connected to suction
• TPN may be indicated to maintain a positive
  nitrogen balance
• Diet orders later may include liquid, soft,
  puree or blenderized
• Complications hemorrhage, nerve injury

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Esophogeal conditions

• Esophagoscope used to remove foreign bodies
• Burns are common from accidental swallowing of
  caustic material
• Esophagectomy - may have blood-tinged drainage
  for 8-12 hours post op
• Surgery is difficult - esophagus lies behind
  trachea - thoracotomy needed

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GERD

• Highly acidic secretions escape from stomach into
  esophagus when LES relaxes
• Risk factors DM, obesity, hiatal hernia, ETOH,
  COPD, smoking, peppermint, hi fat, citrus or
  tomato-based foods, caffeine
• Can lead to Barretts esophagus, hemorrhaging,
  perforation, respiratory symptoms and cancer
• Treated with lifestyle change, antacids, H2
  receptor antagonists, proton pump inhibitors,
  surgery (fundoplication) to wrap the stomach
  around the esophagus

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Hiatal Hernia

• Common in US
• Types
• Sliding type stomach herniates into esophagus
• Paraesophogeal (less common) stomach herniates
  near esophagus
• Mimics cardiac and gi burning and pain
• Best advice maintain ideal weight, avoid
  activities that increase intra-abdominal pressure

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Gastrointestinal tubes

• Levin an orogastric or nasogastric single lumen
  tube
• removes gas and fluid from stomach (use
  intermittent suction)
• may be used to deliver feeding (short term)
• measure using NEX method
• check placement by 4 tests
• Maintain patency
• Salem sump double lumen tube with blue pigtail
• reduces force of suction against gastric mucosa
• uses continuous low suction to decompress stomach
• Keep vent above head do not irrigate through it
  
• Very common tube in hospitals

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Sengstaken-Blakemore tube

• Triple lumen tube to control bleeding esophageal
  varices (BEV)
• 2 balloons, one in stomach one in esophagus
• Third lumen for gastric lavage - monitors
  bleeding
• Inflated balloons and iced saline used to stop
  bleeding
• Minnesota tube permits suctioning, has 4 ports
• May use football helmet to provide counter
  traction and stabilize position

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Intestinal tubes

• Most common are
• Miller-Abbott
• Harris
• Cantor
• Double lumen tubes - one for aspiration and one
  for inflation or weight (mercury used)
• Inserted by physician, advanced by nurse or
  patient, usually one inch per hour
• Used to relieve obstructions

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Feeding tubes

• Dobhoff, Moss, Nutriflex, Keofeed, Interflex
• All are very flexible, may need stylet for
  insertion
• Irrigate q 4 hours, replace q 4 weeks
• Careful placement and careful monitoring!
• Provide oral and nasal care (intestinal tubes
  removed through the mouth)
• Ice chips with caution
• Irrigation 30-60cc NSS. Need MD order. Record
  carefully on IO.
• Tape gently but securely. Use holder if
  available. May clamp intermittently.

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Gastrostomy

• Percutaneous endoscopic gastrostomy (PEG) used
  almost exclusively now. Mushroom catheter
  threaded through mouth and out abdominal wall.
  Bumper used to keep in place.
• Flush bag between feedings to assure patency. Bag
  and tubing changed every 24 hours.
• Skin care vital - gastric juices may leak. Daily
  soap and water wash. Vaseline or stomahesive may
  be used for irritation
• Monitor for migration out of track

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Hyperalimentation (HAL or CHALcentral)

• May be the RN who first considers or suggests it
• Total parenteral nutrition (TPN) supplies
  nutrients to the body
• When protein intake less then protein use,
  negative nitrogen balance can occur (in as little
  as 24 hours)
• Average post-op adult requires 1500 calories per
  day to spare body protein
• Goals
• 1. Improve nutritional status and promote weight
  gain
• 2. Improve healing ability

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Solutions

• Prescribed solution prepared by pharmacist
• MD consults with pharmacist, nutritionist or CNS
  to determine best solution
• Prepared under filtered-air, laminar flow hood
• Basic solution is 25 glucose amino acids, ex.
  FreAmine provides 1000 cal 6 gm nitrogen/Liter
• Electrolytes added according to serum needs
• Commercial preparations Aminosol, Amigen
• TPN is irritating (highly concentrated), must use
  central line and discontinue gradually

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Administration of TPN

• Hickman single or double lumen, tubing hangs out
• Broviac pediatric use
• Groshong less popular
• Portacath placed under skin but must puncture
  skin with curved needle to gain access
• Care is specific for each device

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Gastritis

• Inflammation of stomach mucosa
• Caused by ingestion of infected or noxious food
  -sets up inflammatory process
• May be related to radiation or systemic infection
• Chronic gastritis - may be due to lack of
  intrinsic factor - Vitamin B12 not absorbed
• Anxiety is biggest nursing focus, also avoid
  smoking, alcohol, spices. Bland diet helps. Watch
  for dehydration hemorrhage
• Antacids (Peptobismol), anticholinergics
  (Donnatol) may provide relief

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GI Bleeding

• Frank red blood indicates active bleeding
• Coffee ground emesis may indicate older bleeding
• Melena - blood in stool - bleeding in lower GI
  tract
• Stabilized with iced saline lavage via NG tube
• Vasopressin used to provide constriction in GI
  tract
• Can occur with excessive ASA ingestion
• Treated with fluid replacement and blood
  transfusions

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Peptic Ulcers

• Helicobactor A pylori - becomes active in some
  people
• Risk factors
• smoking
• heredity (3X more have relative with ulcers)
• blood type O
• high anxiety, hurried lifestyle
• eating too fast
• affects more men then women
• may be associated with infection, tumors
• Duodenal ulcers more common than gastric

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Manifestations and management

• Worse in spring and fall
• Dull, gnawing pain usually relieved by food
• Heartburn, emesis, constipation, hemorrhage most
  common complication - also perforation
  obstruction
• Drugs Histamine receptor antagonists, Carafate
• Rest, reduce stress, no smoking or alcohol, avoid
  hot or cold foods, diet as tolerated, antibiotics
• Curlings ulcers occur after an acute medical
  crisis or head injury, also known as gastric
  erosion

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Gastric cancer

• Becoming less common each year
• Poor prognosis - defies early detection. May
  appear as an ulcer
• Progresses to indigestion, anorexia, pain, weight
  loss, anemia, NVD
• Requires complete gi workup with CAT, bone and
  liver scans
• Small frequent meals, may need B12, watch for
  obstruction, pain relief, emotional support.

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Surgical Procedures

• Gastrectomy removal of portion of stomach
• may require gastrostomy and liquids for life
• Whipple procedure removal of most of esophagus,
  stomach, intestines, pancreas.
• Only palliative
• Survival past 1 year is rare
• Vagotomy vagal nerve cut to reduce acid
  production
• Complications hemorrhage - lavage is performed
  with replacement of blood

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Dumping Syndrome

• Occurs in 10 - 15 of those who have had gastric
  surgery or vagotomy
• Rapid gastric emptying distends duodenum or
  jejunum
• N,V, pain, explosive diarrhea, borborygmus,
  tachycardia, vertigo
• Intervention
• 6 small meals/day
• low carbohydrate, high protein and fat
• rest for 1/2 to 1 hour postprandially
• drink between meals, not with meals