NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: GASTROINTESTINAL SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

ESOPHAGEAL VARICES: life-threatening hemorrhage from tortuous dilated, thin-walled veins in submucosa of lower esophagus. May rupture when chemically or mechanically irritated, or when pressure is increased because of sneezing, coughing, use of the Valsalva maneuver, or excessive exercise.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: portal hypertension related to cirrhosis of the liver → distended branches of the azygos vein and inferior vena cava where they join the smaller vessels of the esophagus.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors for hemorrhage:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Exertion that increases abdominal pressure.
  • Trauma from ingestion of coarse foods.
  • Acid pepsin erosion.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Fear.

b. Dysphagia.

c. History: alcohol ingestion, liver dysfunction.

  • Objective data:

a. Hematemesis.

b. Hemorrhage: sudden, often fatal.

c. Decreased BP; increased pulse, respirations.

d. Melena (occult blood in stool).

e. Diagnostic endoscopy.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Fluid volume deficit related to blood loss.
  • Risk for injury related to hemorrhage.
  • Fear related to massive blood loss.
  • Ineffective individual coping related to complications of cirrhosis.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: provide safety measures related to hemorrhage.

a. Recognize signs of shock; vitals q15 min.

b. Assist with insertion of Sengstaken-Blakemore (or Minnesota) or Linton tube (tube is large and uncomfortable for client during insertion); explain procedure briefly to decrease fear and attempt to gain client’s cooperation.

c. While tube is in place, observe for respiratory distress; if present, deflate the balloon by releasing pressure; do not cut the tube.

d. Deflate the balloon as ordered to prevent necrosis.

e. NG tube to low gastric suction; monitor for amount of bright-red blood; irrigate only as ordered using tepid, not iced, solutions.

f. Vitamin K as ordered to control bleeding.

  • Goal: promote fluid balance.

a. IV fluids, expanders.

b. Fresh blood as ordered to avoid increased ammonia; aids in coagulation.

  • Goal: prevent complications of hepatic coma.

a. Saline cathartics as ordered to remove old blood from GI tract.

b. Antibiotics as ordered to prevent infection.

c. Reduce portal hypertension; give propranolol (Inderal), vasopressin (Pitressin).

  • Goal: provide emotional support.

a. Stay with client.

b. Calm atmosphere.

  •  Goal: health teaching.

a. Explain use of tube to client and family.

b. Bland diet instructions.

c. Recognize signs of bleeding.

d. Avoid straining at stool.

e. Avoid aspirin because of increased bleeding tendency.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Survives acute bleeding episode.
  • Further episodes prevented by avoiding irritants, especially alcohol.
  • Improves nutritional status.
  • Recognizes symptoms of complications (e.g., bleeding).
  • Demonstrates knowledge of medications by avoiding aspirin.

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DIAPHRAGMATIC (HIATAL) HERNIA: protrusion of part of stomach through diaphragm and into thoracic cavity (Hiatal hernia). Types: sliding (most common); paraesophageal “rolling.”

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: weakening of the musculature of the diaphragm, aggravated by increased intraabdominal pressure → protrusion of the abdominal organs through the esophageal hiatus → reflux of gastric contents → esophagitis.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Congenital abnormality.
  • Penetrating wound.
  • Age (middle-aged or elderly).
  • Women more than men.
  • Obesity.
  • Ascites.
  • Pregnancy.
  • History of constipation.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Pressure: substernal.

b. Pain: epigastric, burning.

c. Eructation, heartburn after eating.

d. Dysphagia.

e. Symptoms aggravated when recumbent.

  • Objective data:

a. Cough, dyspnea.

b. Tachycardia, palpitations.

c. Bleeding: hematemesis, melena, signs of anemia due to gastroesophageal irritation, ulceration, and bleeding.

d. Diagnostic tests:

(1) Chest x-rays, showing protrusion of abdominal organs into thoracic cavity.
(2) Barium swallow (upper GI series) to show presence of hernia.
(3) Endoscopy.

e. Symptoms parallel those of gastroesophageal reflux disease (GERD).

Physiological Integrity: Nursing Care of the Adult Client

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Pain related to irritation of lining of GI tract.
  • Altered nutrition, less than body requirements, related to dysphagia.
  • Sleep pattern disturbance related to increase in symptoms when recumbent.
  • Risk for aspiration related to reflux of gastric contents.
  • Activity intolerance related to dyspnea.
  • Anxiety related to palpitations.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Presurgical:

a. Goal: promote relief of symptoms.

(1) Diet:

(a) Small, frequent feedings of soft, bland foods, to reduce abdominal pressure and reflux.

(b)Fluid when swallowing solids may push food into stomach; hot fluid may work best.

(c) Avoid eating 2 hours before bedtime.

(d) High-protein, low-fat foods to decrease heartburn.

(2) Positioning: head elevated to increase movement of food into stomach. Symptoms may decrease if head of bed at home is elevated on 8-inch blocks.

(3) Weight reduction to decrease abdominal pressure.

(4) Medications as ordered:

(a) 30 mL antacid 1 hour after meals and at bedtime.

(b) Avoid anticholinergic drugs, which decrease gastric emptying.

  •  Postsurgical:

a. Goal: provide for postoperative safety needs.

(1) Respiratory: deep breathing, coughing, splint incision area.
(2) Nasogastric (NG) tube: check patency.

(a) Drainage: should be small amount.

(b) Color: dark brown 6 to 12 hours after surgery, changing to greenish-yellow.

(c) Do not disturb tube placement to avoid traction on suture line.

(3) Position: initially head of bed elevated slightly, then semi-Fowler’s; turn side to side frequently, to prevent pressure on diaphragm.

(4) Maintain closed chest drainage if indicated.

(5) Check for return of bowel sounds.

b. Goal: promote comfort and maintain nutrition.

(1) IVs for hydration and electrolytes.

(2) Initiate feeding through gastrostomy tube if present.

(a) Usually attached to intermittent, low suction after surgery.
(b) Aspirate gastric contents before feeding—delay if 75 mL or more is present; report these findings to physician.
(c) Feed in high Fowler’s or sitting position; keep head elevated for 30 minutes after eating.
(d) Warm feeding to room temperature; dilute with H2O if too thick.
(e) Give 50 mL H2O before feeding; 200 to 500 mL feeding by gravity over 10 to 15 minutes; follow with 50 mL H2O.
(f) Give frequent mouth care.

c. Goal: health teaching.

(1) Avoid constricting clothing and activities that increase intra-abdominal pressure (e.g., lifting, bending, straining at stool).

(2) Weight reduction.

(3) Dietary needs: small, frequent, soft, bland meals.

(4) Chew thoroughly.

(5) Upright position for at least 1 hour after meals.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Obtains relief from symptoms; is comfortable.
  • Receives adequate, balanced nutrition.
  • Describes dietary changes, recommended positioning, and activity limitations to prevent recurrence.

GASTROESOPHAGEAL REFLUX DISEASE (GERD): inappropriate relaxation of the lower esophageal sphincter (LES) in response to unknown stimulus.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: gastric volume or intraabdominal pressure elevated, or LES tone decreased → frequent episodes of acid reflux → breakdown of mucosal barrier → esophageal inflammation, hyperemia, and erosion → fibrotic tissue formation → esophageal stricture →impaired swallowing.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Hiatal hernia.
  • Diet—foods that lower pressure of LES (fatty foods, chocolate, cola, coffee, tea).
  • Smoking.
  • Drugs (calcium channel blockers, NSAIDs, theophylline).
  • Elevated intra-abdominal pressure (obesity, pregnancy, heavy lifting).

C. Assessment:

  • Subjective data:

a. Heartburn (pyrosis)—substernal or retrosternal; may mimic angina; 20 minutes to 2 hours after eating.

b. Regurgitation—sour or bitter taste not associated with belching or nausea.

c. Dysphagia or odynophagia (difficult or painful swallowing)—severe cases.

d. Belching, feeling bloated.

e. Nocturnal cough.

  • Objective data:

a. Hoarseness, wheezing.

b. Diagnostic tests: 24-hour pH monitoring; barium swallow with fluoroscopy; endoscopy.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Pain related to acid reflux and esophageal inflammation.
  • Knowledge deficit (learning need) related to modifications needed to control reflux.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: promote comfort and reduce reflux episodes.

a. Medications as ordered:

(1) Antacids to neutralize gastric acid.
(2) Histamine2 (H2) receptor antagonists (cimetidine, ranitidine, famotidine) to reduce gastric acid secretion and support tissue healing.
(3) Proton pump inhibitor (omeprazole [Prilosec]) to inhibit gastric enzymes and suppress gastric acid secretion.

b. Diet: avoid strong stimulants of acid secretion (caffeine, alcohol); avoid foods that reduce LES competence (fatty foods, onions, tomato-based foods); increase protein; restrict spicy, acidic foods until healing occurs.

c. Activity: avoid heavy lifting, straining, constrictive clothing, bending over.

d. Position: elevate head of bed 6 to 12 inches for sleeping. Reflux more likely on right side.

  • Goal: health teaching.

a. Weight reduction if indicated.

b. Smoking cessation.

c. Diet modification: avoid overeating—eat 4 to 6 small meals.

d. Medication administration.

e. Potential complications if uncontrolled (hemorrhage, aspiration).

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • No heartburn reported.
  • Changes diet as instructed.
  • No complications of continued reflux.

PEPTIC ULCER DISEASE: circumscribed loss of mucosa, submucosa, or muscle layer of the gastrointestinal tract caused by a decreased resistance of gastric mucosa to acid-pepsin injury. Peptic ulcer disease is a chronic disease and may occur in the distal esophagus, stomach, upper duodenum, or jejunum. Gastric ulcers, located on the lesser curvature of the stomach, are larger and deeper than duodenal ulcers and tend to become malignant. Duodenal ulcers are located on the first part of the duodenum and are more common than gastric ulcers. Esophageal ulcers occur in the esophagus. Stress ulcers, an acute problem, occur after a major insult to the body.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathology: failure of the body to regenerate mucous epithelium at a sufficient rate to counterbalance the damage to tissue during the breakdown of protein; decrease in the quantity and quality of the mucus; poor local mucosal blood flow, along with individual susceptibility to ulceration. A peptic ulcer is a hole in the lining
of the stomach, duodenum, or esophagus. This hole occurs when the lining of these organs is corroded by the acidic digestive juices secreted by the stomach cells. Excess acid is still considered to be significant in ulcer formation. The leading cause of ulcer disease is currently believed to be infection of the stomach by Helicobacter pylori (H. pylori). Another major cause of ulcers is chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs). Cigarette smoking is also an important cause of ulcers.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Gastric ulcers.

a. Infection with H. pylori.

b. Decreased resistance to acid-pepsin injury.

c. Increased histamine release → inflammatory reaction.

d. Ulcerogenic drugs (aggravate preexisting conditions).

e. Cigarette smoking.

f. Increased alcohol and caffeine use (aggravates preexisting conditions).

g. Gastric ulcer is thought to be a risk for gastric cancer.

h. Difficulty coping with stressful situations.

  • Duodenal ulcers.

a. Infection with H. pylori.

b. Elevated gastric acid secretory rate.

c. Elevated gastric acid levels postprandially (after eating).

d. Increased rate of gastric emptying → increased amount of acid in duodenum → irritation and breakdown of duodenal mucosa.

e. Ulcerogenic medication use (aggravates preexisting conditions).

f. Cigarette smoking.

g. Alcohol and caffeine use (aggravates preexisting condition).h. Difficulty coping with stressful situations.

  • Stress ulcers.

a. Severe trauma or major illness.

b. Severe burns (Curling’s ulcer); develop in 72 hours with majority of persons with burns over more than 35% of the body surface.

c. Head injuries or intracranial disease (Cushing’s ulcer).

d. Medications in large doses: corticosteroids, salicylates, ibuprofen, indomethacin, phenylbutazone (Butazolidin).

e. Shock.

f. Sepsis.

C. Assessment:

  • Subjective data:

a. Gastric ulcers.

(1) Pain:

(a) Type: gnawing, aching, burning.
(b) Location: epigastric, left of midline, localized.
(c) Occurrence: periodic pain, often 2 hours after eating.
(d) Relief: antacids; may be aggravated, not relieved, by food.
(e) Some clients report no discomfort at all.

(2) Weakness.

(3) History of risk factors as above.

b. Duodenal ulcers.

(1) Pain:

(a) Type: gnawing, aching, burning, hungerlike, boring.
(b) Location: right epigastric, localized; steady pain near midline of back may indicate perforation.
(c) Occurrence: 1 to 3 hours after eating, worse at end of day or during the night; initial attack occurs spring or fall; history of remissions and exacerbations.
(d) Relief: food, antacids, or both.
(e) Some clients report no discomfort at all.

(2) Nausea.

(3) History of risk factors.

c. Stress ulcers.

(1) Pain: often painless until serious complication (hemorrhage, perforation) occurs.

(2) History of risk factors as above.

  • Objective data:

a. Gastric ulcer.

(1) Vomiting blood (hematemesis).

(2) Melena (tarry stools).

(3) Weight loss.

(4) X-ray (upper GI series) confirms “crater” (punched-out appearance, clean base).

(5) Endoscopy confirms presence of ulcer; biopsy for cytology.

(6) Monitor for blood loss: CBC, stool for occult blood.

(7) Orthostatic hypotension.

(8) Laboratory data: positive for H. pylori.

b. Duodenal ulcer.

(1) Eructation.

(2) Vomiting blood (hematemesis).

(3) Regurgitation of sour liquid into back of mouth.

(4) Constipation.

(5) X-ray (upper GI series) confirms ulcer craters and niches, as well as outlet deformities: round or oval funnel-like lesion extending into musculature.

(6) Endoscopy for direct visualization.

(7) Monitor for blood loss: CBC, stool for occult blood.

(8) Orthostatic hypotension.

(9) Laboratory data: positive for H. pylori.

c. Stress ulcer.

(1) GI bleeding.

(2) Multiple, superficial erosions affecting large area of gastric mucosa.

D. Analysis/nursing diagnosis (all types):

  • Pain related to erosion of gastric lining.
  • Ineffective individual coping related to inability to change lifestyle.
  • Altered nutrition, less than body requirements, related to inadequate intake.
  • Knowledge deficit (learning need) regarding preventive measures.
  • Risk for injury related to possible hemorrhage or perforation.

E. Nursing care plan/implementation (all types):

  • Goal: promote comfort.

a. Medications as ordered to decrease pain sedatives to decrease anxiety.

b. Prepare for diagnostic tests.

(1) X-rays; upper GI series (barium swallow); lower GI (barium enema).
(2) Endoscopy.
(3) Gastric analysis, to determine amount of hydrochloric acid in GI tract.

  • Goal: prevent/recognize signs of complications.

a. Monitor vitals for shock.

b. Check stool for occult blood/ hemorrhage.

c. Palpate abdomen for perforation (rigid, boardlike); arterial bleeding.

  • Goal: provide emotional support.

a. Stress-management techniques.

b. Restful environment.

c. Prepare for surgery, if necessary.

  • 4. Goal: health teaching.

a. Medications:

(1) Antibiotics. Sometimes antibiotics work best if given in combination with omeprazole (Prilosec), H2 blockers, or bismuth (Pepto-Bismol). Caution: use of antibiotic treatment can cause allergic reactions, diarrhea, and severe antibioticinduced colitis.

(a) Tetracycline.
(b) Amoxicillin.
(c) Metronidazole (Flagyl).
(d) Clarithromycin (Biaxin).

(2) Histamine antagonists: given with meals/bedtime to block the action of histamine-stimulated gastric secretions (basal and stimulated); inhibit pepsin secretion and reduce the volume of gastric secretions.

(a) Cimetidine (Tagamet) inhibits gastrin release; can be given PO, IV, or IM; cannot be given within 1 hour of antacid therapy.
(b) Ranitidine (Zantac) has greater reduction of acid secretion, longer duration, less frequent administration (twice daily versus 4 times a day), and fewer side effects than cimetidine.
(c) Nizatidine (Axid).
(d) Famotidine (Pepcid).

(3) Proton pump inhibitors (gastric acid inhibitors): superior in treating esophageal ulcers; equal to other H2 receptors for gastric and duodenal ulcers.

(a) Omeprazole (Prilosec).
(b) Lansoprazole (Prevacid).
(c) Pantoprazole.

(4) Antiulcers: give 1 to 3 hours after meals and at bedtime to decrease pain by lowering acidity; monitor for:

(a) Diarrhea (seen most often with magnesium carbonate and magnesium oxide [Maalox, Mylanta]).
(b) Constipation (seen most often with calcium carbonate [Tums] or aluminum hydroxide [Amphojel]).
(c) Electrolyte imbalance (seen with systemic antacid, soda bicarbonate).
(d) Best 1 to 3 hours after meals.
(e) Liquids more effective than tablets; if taking tablets, chew slowly.

(5) Sucralfate (Carafate) and misoprostol (Cytotec): given 1 hour before meals and at bedtime.

(a) Locally active topical agent that forms a protective coat on mucosa, prevents further digestive action of both acid and pepsin.
(b) Must not be given within 30 minutes of antacids.

(6) Anticholinergic—when used, given before meals to decrease gastric acid secretion and delay gastric emptying.

(7) Important: avoid aspirin (could increase bleeding possibility).

b. Diet:

(1) Change diet only to relieve symptoms; diet may not influence ulcer formation.

(2) Avoid foods that increase acidity—caffeine and alcohol in moderation.

(3) Plan:

(a) Small, frequent meals (to prevent exacerbations of symptoms related to an empty stomach).
(b) Weight control.

c. Complications—signs and symptoms:

(1) Gastric ulcers may be premalignant.
(2) Perforation.
(3) Hemorrhage.
(4) Obstruction.

d. Lifestyle changes:

(1) Decrease:

(a) Smoking.
(b) Noise.
(c) Rush.
(d) Confusion.

(2) Increase:

(a) Communication.
(b) Mental/physical rest.
(c) Compliance with medical regimen.

F. Evaluation/outcome criteria:

  • Avoids foods/liquids that cause irritation.
  • Takes prescribed medications.
  • Pain decreases.
  • No complications.
  • States signs and symptoms of complications.
  • Participates in stress-reduction activities.
  • Stops smoking.

FURTHER READING/STUDY:

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