ATI 48-55 (Unit 1)

Histamine receptor antagonists: nursing considerations

use cautiously in clients who have kidney disease

Esophageal Manometry: what is it?

- 3 small tubes are swallowed - Records LES pressure, peristaltic activity, and pH levels

Liver function test

- A lab for esophageal varices - Indicates a liver disorder

endoscopic variceal ligation (EVL): nursing actions

- Administer preprocedure sedation - After procedure, monitor vital signs and take measures to prevent aspiration.

Laproscopic Nissen Fundoplication (LNF): compications

- Temporary dysphagia - Gas bloat syndrome - Atelectasis/pneumonia

TIPS: nursing actions

Monitor vital signs. Keep the head of the bed elevated.

Endoscopic Sclerotherapy: nursing actions

- Administer sedation preprocedure. - Monitor vitals and take measurements to prevent aspiration post procedure. - Antacids, H2-receptor blockers, or PPIs can be administered to protect the esophagus and prevent acid reflux after the procedure.

Peptic Ulcer: what is it?

- An erosion of the mucosal lining of the stomach, esophagus, or duodenum. - The most common site of occurrence is the duodenum. - Can erode to the point that the epithelium is exposed to gastric acid and pepsin, which can precipitate bleeding and perforation. - Perforation can lead to peritonitis. - Mostly caused by H. Pylori

CT scan w/ contrast: nursing actions

- Assess for iodine allergies if IV contrast is to be used - Encourage fluids following a procedure to promote dye excretion and minimize risk of renal injury - Monitor BUN/creatinine

Hiatal hernia: health promotion and prevention

- Avoid eating immediately before going to bed - Avoid foods/drinks that decrease LES pressure - Exercise regularly - Maintain a healthy weight - Elevate the head of the bed on 6-inch blocks - Avoid straining or excessive vigorous exercise - Avoid wearing clothing that is tight around the abdomen

Fundoplication: client education

- Avoid offending foods - Avoid large meals - Remain upright after eating - Avoid eating before bedtime - Consume 4-6 small meals throughout the day - Avoid clothing that is tight fitting around the abdomen - Lose weight, if applicable - Elevate the head of the bed 6 to 8 inches with blocks (15-20cm)

Endoscopic Sclerotherapy: complications

- Bleeding - Perforation of the esophagus - Aspiration pneumonia - Esophageal stricture

TIPS: complications

- Bleeding - Sepsis - Heart failure - Organ perforation - Liver failure

Esophagogastric balloon tamponade: nursing actions

- Check balloons for leaks prior to insertion - Monitor placement of the tube and observe for possible obstruction of airway - Monitor for aspiration into the lungs and secretions or blood from the esophagus - Provide oral suction as needed - Maintain balloon pressure as prescribed pressure for prescribed time to decrease the risk of esophageal or gastric necrosis from ischemia - Monitor the client who has decreased mentation or confusion and who might pull on the tube

Surgical Interventions for esophageal varices

- Considered a last resort - High morbidity and mortality rates associated with surgical interventions - Bypass procedures place a shut to bypass the liver and decrease portal hypertension - Common shunts: splenorenal, mesocaval, portacaval - Pts commonly have NG tube during surgical intervention to monitor for hemorrhage

Laproscopic Nissen Fundoplication (LNF): client education

- Consume a soft diet for the first week postop - Avoid carbonated beverages - Ambulate, but avoid heavy lifting

Peptic Ulcer Disease: health promotion and disease prevention

- Drink alcohol in moderation - Stop smoking and use of tobacco products - Use stress management techniques - Avoid NSAIDs - Limit caffeine-containing beverages - Consume a balanced diet - Engage regularly in exercise

Endoscopic Sclerotherapy

- During endoscopy, a sclerosing agent is injected into the varices resulting in thrombosis of the varicosity

Peptic Ulcer Disease: expected findings

- Dyspepsia - Heartburn - Bloating - N/V - Can be perceived as uncomfortable fullness or hunger - Dull, gnawing pain or burning sensation at the midepigastrium or the back - Pain or epigastric tenderness or abdominal distension - Bloody emesis (hematemesis) or tarry stools (melena) - Weight loss

Laproscopic Nissen Fundoplication (LNF): nursing considerations

- Elevate the head of the bed to promote lung expansion - Instruct the client to support the incision during movement and coughing to minimize strain on the suture line

esophageal varices: what do you do if suspected bleeding?

- Establish IV access with large bore needle - Monitor vital signs and hematocrit - Type and cross match for possible transfusion - Monitor for overt and occult bleeding

What foods relax the LES?

- Fatty foods - Fried foods - Chocolate - Caffeine - Peppermint - Spicy foods - Citrus fruits - Tomatoes - Alcohol

Peptic Ulcer Disease: risk factors

- H. Pylori infection - NSAID and corticosteriod use - Severe stress - Familial tendency - Hypersecretory states - Gastrin-secreting benign or malignant tumors of the pancreas - Type O blood - Excess alcohol consumption - Chronic pulmonary or kidney disease - Zollinger-Ellison syndrome (combination of peptic ulcers, hypersecretion of gastric acid, and gastrin-secreting tumors) - Pernicious anemia

Serum Ammonia Level

- Lab run for suspected esophageal varices - Elevated indicates an increased nitrogen load from the bleeding varices

Hemaglobin and Hematocrit Test

- Lab values run if suspected esophageal varices - indicates anemia secondary to occult bleeding or overt bleeding

esophageal varices: lab tests

- Liver function test - Hemoglobin and hematocrit tests - Elevated serum ammonia level

GERD: What are recommended lifestyle changes for health promotion/disease prevention?

- Maintain a weight below BMI of 30 - Stop smoking - Limit or avoid alcohol and tobacco use - Low fat diet - Avoid foods that lower LES pressure - Avoid eating or drinking 2 hours before bed - Avoid tight fitting clothes, especially around the abdomen - Elevate the head of the bed 6-8 inches

Surgical interventions for esophageal varices: nursing actions

- Monitor for an increase in liver dysfunction or encephalopathy - Monitor NG tube secretions for bleeding - Monitor PT, aPTT, platelets, and INR

Gastric Ulcer Pain

- Most commonly occurs 30 to 60 minutes after a meal - Less often experience pain at night (only in 30-40% of patients) - Pain is exacerbated by the ingestion of food - Malnourishment - Hematemesis

esophageal varices: what medications?

- Nonselective beta-blockers - Vasoconstrictiors

GERD: risk factors

- Obesity - Old age - Sleep apnea - NG tube

Esophageal varices: hypovolemic shock

- Observe for manifestations of hemorrhage and shock (tachycardia and hypotension) - Monitor vital signs, Hgb, Hct, and coagulation studies. - Replace losses and support therapeutic procedures to stop and control bleeding

Duodenal Ulcer Pain

- Pain occurs 1.5-3 hours after a meal - Patients are often awake with pain during the night - Pain is relieved by the ingestion of food or an antacid - Well-nourished - Melena (tarry colored stools)

Peptic Ulcers: patient care

- Patient should avoid foods that cause distress (coffee, tea, carbonated beverages) - Monitor for orthostatic changes in vital signs and tachycardia. These findings may suggest GI bleed or perforation - Administer saline lavage via NG tube - Administer medications as prescribed - Decrease environmental stress - Encourage rest periods - Encourage smoking cessation and avoiding alcohol consumption - Monitor lab results (hemoglobin, hematocrit, coagulation studies)

Esophagogastric balloon tamponade

- Rarely used - Temporarily controls bleeding until another measure can be implemented - Risks: tube migration, which can lead to airway obstruction or apsiritaion of gastric content into lungs. - Clients are often intubated to protect the airway - If left for an extended period of time, this can cause necrosis of the tissue. Balloon should be left in place for a maximum of 12 hours.

Esophageal pH monitoring: what is it?

- Small catheter through the nose into the distal esophagus - pH readings are taken in relation to food, position, and activity - 24 to 48 hours - MOST ACCURATE METHOD to dx GERD

Transjugular intrahepatic portosystemic shunt (TIPS)

- TIPS treats an acute epsiode of bleeding with EVL and pharmacological treatments are not controlling bleeding. - Rapidly lowers portal pressure - Very expensive. Only used when other procedures are not effective. - The Pt is under anesthesia or sedation when this is performed - A catheter is passed into the liver via the jugular vein. - A stent is placed between the portal and hepatic veins bypassing the liver. - Portal hypertension is subsequently relieved.

Barium Swallow: nursing actions

- Use cathartics to evacuate the barium - If left, barium can lead to fecal impaction

Vasoconstrictors: nursing considerations

- Vasopressin should not be given to clients who have CAD. Should not be used in conjunction with nitroglycerin IV. - Monitor for fluid retention and hyponatremia. This is because vasopressin has an antidiuretic effect.

Hiatal hernia: complications

- Volvulus: twisting of the esophagus and/or stomach - Obstruction (paraesophageal hernia): blockage of food in the herniated portion of the stomach - Strangulation (paraesophageal hernia): compression of the blood vessels to the herniated portion of the stomach - Iron-deficiency anemia (paraesophageal hernia): resulting from bleeding into the gastric mucosa due to obstruction

paraesophageal hiatal hernia expected findings

- Worse after a meal - Fullness after eating - Sense of breathlessness/suffocation - Chest pain - Worsening of symptoms with reclining - Pharyngitis - Inspiratory/expiratory wheeze

sliding hiatal hernia: expected findings

- Worse after a meal - Heartburn - Reflux - Chest pain - Dysphagia - Belching - Pharyngitis - Inspiratory/expiratory wheeze

esophageal varices: health promotion and disease prevention

- avoid heavy alcohol consumption - avoid heavy lifting - avoid straining with bowel movements - chew food completely, as poorly chewed foods can irritate the area - avoid salicylates and other medications that can irritate the esophagus

GERD: expected findings

- dyspepsia after eating offending food or fluid - regurgitation - radiating pain (neck, jaw, or back) - report of a feeling of having a heart attack - pyrosis (burning sensation in the esophagus) - dysphagia (pain on swallowing) - pain that worsens with position (bending, straining, laying down) - pain that occurs after eating and lasts 20mins-2hours - throat irritation - hypersalivation - bitter taste in mouth - increased flatus and eructation (burping) - pain is relieved by drinking water, sitting upright, or taking antacids - manifestations occur 4-5x weekly on a consistent basis - tooth erosion

esophageal varices: diagnostic procedure

- endoscopy

Fundoplication: what is it?

- for GERD Pts that fail to respond to other treatments. - treatment for hiatal hernia - fundus of stomach is wrapped around and behind the esophagus though a laparoscope - creates a physical barrier

GERD: Contributing factors

- ingestion of foods that relax LES - prolonged or frequent abdominal distension (from overeating or delayed emptying) - medications that relax the LES (theophylline, nitrates, ca channel blockers, anticholinergics, diazepam) - increased gastric acid (caused by NSAID use or stress) - hiatal hernia - debilitation resulting in decreased LES tone - laying flat

Nonselective beta-blockers

- lol drugs Propanolol Prescribed to decrease HR and consequently reduce hepatic venous pressure used prophylactically, not in the case of emergency hemorrhage

Laproscopic Nissen Fundoplication (LNF)

- minimally invasive with fewer complications compared to fundoplication

esophageal varices: risk factors

- portal hypertension (elevated BP in the vessels that carry blood from the intestines to the liver). This is the primary risk factor for developing esophageal varices. - alcoholic cirrhosis - viral hepatitis - older adult clients with depressed immune function, decreased liver function, and cardiac disorders that put them at risk for bleeding

endoscopic variceal ligation (EVL): complications

- superficial ulceration - dysphagia - temporary chest discomfort - esophageal strictures (though this is rare)

Histamine receptor antagonists: client education

- take with meals and at bedtime - separate dosages from antacids (1 hour before or after)

esophageal varices: expected findings

- there may be no manifestations until the varices begin to bleed - hematemesis - melena - general deterioration of physical and mental status - shock (when bleeding) - hypotension (when bleeding) - tachycardia (when bleeding) - cool clammy skin (when bleeding)

Histamine receptor antagonists What drugs are they? What do they do?

- tidine drugs Ranitidine, famotidine, nizatidine Reduce the secretion of acid

Barium Swallow: what is it?

- used to identify a hiatal hernia, strictures, or structural abnormalities (which could cause GERD)

esophageal varices: what precipitates bleeding?

- valsalva maneuver - lifting heavy objects - coughing - sneezing - alcohol consumption

esophagogastroduodenoscopy (EGD): what is it?

- visual examination of the esophagus, stomach, and duodenum - moderate sedation - observe for tissue damage and dilate stricture in the esophagus - dx GERD, hiatal hernia, peptic ulcers

GERD: what is it?

-gastroesophageal reflux disease -excessive backflow of gastric contents and enzymes into the esophagus.

Proton Pump Inhibitors (PPIs) What drugs are they? What do they do?

-prazole drugs Pantoprazole, Omeprazole, Esomeprazole, Rabeprazole, Lansoprazole. Reduce gastric acid by inhibiting the cellular pump of the gastric parietal cells

2 types of hiatal hernias?

1. Sliding: (more common) a portion of the stomach and the gastroesophageal junction move above the diaphragm 2. Paraesophageal (aka rolling): part of the fundus is above the diaphragm but the gastroesophageal junction is not

Antacids What drugs are they? What do they do?

Aluminum Hydroxide, Magnesium Hydroxide, Calcium Carbonate, Sodium Bicarbonate Neutralize excess acid, increase LES pressure

GERD: complications

Aspiration of gastric secretion (asthma exacerbations, upper respiratory infections, sinus or ear infections, aspiration pneumonia) Barrett's epithelium Esophageal adenocarcinoma

Nursing Considerations for Antacids

Check for contraindications with other meds. Evaluate kidney function if taking Magnesium Hydroxide.

Fundoplication: nursing considerations

Complications: Temporary dysphagia: monitor for aspiration Gas bloat syndrome: difficulty belching to relieve distension Atelectasis/pneumonia: monitor respiratory function

GERD: what is the primary treatment?

Diet and lifestyle changes and medication use (PPIs, antacids, H2 receptor agonists). Can progress to requiring surgery.

GERD: what causes it?

Due to any of the following: - incompetent LES (lower esophageal sphincter) - pyloric stenosis (narrowing of the pyloric muscle right before the intestines due to swelling and inflammation) - hiatal hernia - excessive intra-abdominal or intragastric pressure - motility problems

endoscopic variceal ligation (EVL)

EGL can be used for acute bleeding. During endoscopy, rubber bands are applied to the varices to cut off the circulation. Necrosis of the tissue occurs and there is eventual sloughing of the varix.

Peptic Ulcers: lab tests

H. Pylori testing Urea breath testing (also testing for the presence of H. Pylori) Stool sample test (also testing for H. Pylori by looking for the antigen) Hemoglobin and Hematocrit (looking for unusual findings which would be secondary to bleeding) Stool sample (for occult blood)

GERD: untreated, leads to what complications?

Inflammation, breakdown, and complications such as Barrett's esophagus or adenocarcinoma of the esophagus.

Esophageal pH monitoring: nursing actions

Instruct Pt to keep a journal of foods and beverages consumed , symptoms, and activity during the 24 hour test period

Prokinetics: client education

Instruct the Pt to report abnormal, involuntary movements

Client education for PPIs

Long-term use places the client at risk for fractures, especially in older adults.

esophageal varices: hemorrhage

Medical emergency High mortality rate

Prokinetics What drugs? What do they do?

Metoclopramide Increases the motility of the esophagus and stomach

Nursing Considerations for PPIs

Monitor for electrolyte imbalance and hypoglycemia in DM Pts Long-term use linked to c. diff infections and CAP

Prokinetics: nursing considerations

Monitor the client taking metepoclopramide for extrapyramidal side effects

Vasoconstrictors: what are they?

Octreotide (synthetic form of somatostatin). Decreases bleeding from the varices but does not decrease blood pressure. Vasopressin. Causes constriction of the esophageal and proximal gastric veins and reduces portal pressure.

esophagogastroduodenoscopy (EGD): nursing actions

Pt must be NPO 6-8 hours before procedure Verify gag-reflex has returned prior to providing PO foods, fluids, or meds. Monitor vital signs until sedation wears off. Monitor for manifestations of perforation (pain, bleeding, fever).

esophageal varices: what causes it?

Result of portal hypertension Usually as a result of cirrhosis of the liver

esophageal varices: what is it?

Swollen, fragile blood vessels that are generally found in the submucosa of the lower esophagus. Can develop higher in the esophagus or go lower into the stomach.

Client Education for Antacids

Take these when acid secretion is the highest (1-3 hours after eating and at bedtime). Separate from other medications by at least 1 hour.

Stretta procedure: what is it?

Treatment for GERD. Utilizes radiofrequency energy applied by an endoscope to decrease vagus nerve activity. So what? This causes the LES muscle tissue to contract and tighten

Endoscopy: nursing actions

administer pre-procedure sedation. after the procedure, monitor vital signs and take measures to prevent aspiration.

Hiatal hernia

protrusion of a part of the stomach upward through the opening in the diaphragm