Chapter 46: Management of Patients with Gastric and Duodenal Disorders

A nurse is admitting a patient diagnosed with late-stage gastric cancer. The patients family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor contributes to the fact that gastric cancer is often detected at a later stage?

The early symptoms of gastric cancer are usually not alarming or highly unusual. Feedback: Symptoms of early gastric cancer, such as pain relieved by antacids, resemble those of benign ulcers and are seldom definitive. Symptoms are rarely a cause for alarm or for detailed diagnostic testing. Symptoms precede metastasis, however, and do not include constipation.

A patient has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the patients level of anxiety. Which of the following actions is most likely to accomplish this?

The patient is encouraged to express fears openly. Feedback: Encouraging the patient to discuss his or her fears and anxieties is usually the best way to assess a patients anxiety. Presenting hypothetical situations is a surreptitious and possibly inaccurate way of assessing anxiety. Observing body language is part of assessment, but it is not the complete assessment. Presenting information may alleviate anxiety for some patients, but it is not an assessment.

A nurse is preparing to discharge a patient after recovery from gastric surgery. What is an appropriate discharge outcome for this patient?

The patient maintains or gains weight. Feedback: Expected outcomes for the patient following gastric surgery include ensuring that the patient is maintaining or gaining weight (patient should be weighed daily), experiencing no excessive diarrhea, and tolerating six small meals a day. Patients may require vitamin B12 supplementation by the intramuscular route and do not require a diet excessively rich in calcium.

A patient has come to the clinic complaining of pain just above her umbilicus. When assessing the patient, the nurse notes Sister Mary Josephs nodules. The nurse should refer the patient to the primary care provider to be assessed for what health problem?

A GI malignancy Feedback: Palpable nodules around the umbilicus, called Sister Mary Josephs nodules, are a sign of a GI malignancy, usually a gastric cancer. This would not be a sign of dumping syndrome, peptic ulcer disease, or esophageal/gastric obstruction.

A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medications therapeutic action?

A) This medication will reduce the amount of acid secreted in your stomach. Feedback: Proton pump inhibitors like Prilosec inhibit the synthesis of stomach acid. PPIs do not increase the durability of the stomach lining, relieve pain, or stimulate tissue repair.

A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcers?

Antibiotics, proton pump inhibitors, and bismuth salts Feedback: Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and bismuth salts that suppress or eradicate H. pylori. H2 receptor antagonists are used to treat NSAID-induced ulcers and other ulcers not associated with H. pylori infection, but they are not the drug of choice. Bicarbonate salts are not used. ZES is the Zollinger-Ellison syndrome and not a drug.

A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurses assessment should be planned in light of the possibility of what potential complications? Select all that apply.

Atelectasis, Pneumonia, Metabolic imbalances Feedback: After surgery, the nurse assesses the patient for complications secondary to the surgical intervention, such as pneumonia, atelectasis, or metabolic imbalances resulting from the GI disruption. Malignant hyperthermia is an intraoperative complication. Chronic gastritis is not a surgical complication.

A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide?

Avoid drinking alcohol while taking the drug. Feedback: Alcohol must be avoided when taking Flagyl and the medication should be taken with food. This drug does not cause drowsiness and the dose should not be adjusted by the patient.

A patient is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This patient should be informed that he may experience which of the following adverse effects associated with this procedure?

Diarrhea and feelings of fullness Feedback: Following a Billroth I, the patient may have problems with feelings of fullness, dumping syndrome, and diarrhea. Hunger and thirst, constipation, and gastric reflux are not adverse effects associated with this procedure.

A patient with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the patients continuing care in the home setting, what assessment question is most relevant?

Does anyone in your family have experience at giving injections? Feedback: Patients with malabsorption of vitamin B12 need information about lifelong vitamin B12injections; the nurse may instruct a family member or caregiver how to administer the injections or make arrangements for the patient to receive the injections from a health care provider. Questions addressing sun exposure, blood type and first aid are not directly relevant.

A nurse is caring for a patient who just has been diagnosed with a peptic ulcer. When teaching the patient about his new diagnosis, how should the nurse best describe a peptic ulcer?

Erosion of the lining of the stomach or intestine Feedback: A peptic ulcer is erosion of the lining of the stomach or intestine. Peptic ulcers are often accompanied by bleeding and inflammation, but these are not the definitive characteristics.

A nurse is providing patient education for a patient with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The patient has recently been prescribed misoprostol (Cytotec). What would the nurse be most accurate in informing the patient about the drug?

It protects the stomachs lining Feedback: Misoprostol is a synthetic prostaglandin that, like prostaglandin, protects the gastric mucosa. NSAIDs decrease prostaglandin production and predispose the patient to peptic ulceration. Misoprostol does not reduce gastric acidity, improve emptying of the stomach, or increase lower esophageal sphincter pressure.

A patient who is obese has been unable to lose weight successfully using lifestyle modifications and has mentioned the possibility of using weight-loss medications. What should the nurse teach the patient about pharmacologic interventions for the treatment of obesity?

Medications can be helpful, but few people achieve and maintain their desired weight loss with medications alone. Feedback: Though antiobesity drugs help some patients lose weight, their use rarely results in loss of more than 10% of total body weight. Patients are consequently unlikely to attain their desired weight through medication alone. They are not predicted to disappear from the market and results are not attributed to a placebo effect.

A patient who underwent gastric banding 3 days ago is having her diet progressed on a daily basis. Following her latest meal, the patient complains of dizziness and palpitations. Inspection reveals that the patient is diaphoretic. What is the nurses best action?

Monitor the patient closely for further signs of dumping syndrome. Feedback: The patients symptoms are characteristic of dumping syndrome, which results in a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. Aspiration is a less likely cause for the patients symptoms. Supine positioning will likely exacerbate the symptoms and insertion of an NG tube is contraindicated due to the nature of the patients surgery.

A nurse is caring for a patient who has a diagnosis of GI bleed. During shift assessment, the nurse finds the patient to betachycardic and hypotensive, and the patient has an episode of hematemesis while the nurse is in the room. In addition to monitoring the patients vital signs and level of conscious, what would be a priority nursing action for this patient?

Notify the physician. Feedback: The nurse must always be alert for any indicators of hemorrhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. If these occur, the physician is notified and the patients vital signs are monitored as the patients condition warrants. Putting the patient in a prone position could lead to aspiration. Giving ice water is contraindicated as it would stimulate more vomiting.

A patient has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the patient at this time?

Providing the patient with physical and emotional support Feedback: For acute gastritis, the nurse provides physical and emotional support and helps the patient manage the symptoms, which may include nausea, vomiting, heartburn, and fatigue. The scenario describes a newly diagnosed patient; teaching about the etiology of the disease, lifestyle modifications, or various treatment options would be best provided at a later time.

A nurse is presenting a class at a bariatric clinic about the different types of surgical procedures offered by the clinic. When describing the implications of different types of surgeries, the nurse should address which of the following topics? Select all that apply.

Specific lifestyle changes associated with each procedure, Implications of each procedure for eating habits, Effects of different surgeries on bowel function Feedback: Different bariatric surgical procedures entail different lifestyle modifications; patients must be well informed about the specific lifestyle changes, eating habits, and bowel habits that may result from a particular procedure. Bariatric surgeries do not influence the future use of immunizations or fertility, though pregnancy should be avoided for 18 months after bariatric surgery.

A nurse is completing a health history on a patient whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the patients health problem?

Smokes one pack of cigarettes daily. Feedback: Nicotine reduces secretion of pancreatic bicarbonate, which inhibits neutralization of gastric acid and can underlie gastritis. Protein drinks do not result in gastric inflammation. Antacid use is a response to experiencing symptoms of gastritis, not the etiology of gastritis. Alcohol ingestion can lead to gastritis; however, this generally occurs in patients with a history of consumption of alcohol on a daily basis.

A nurse is caring for a patient hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize?

Strategies for avoiding irritating foods and beverages Feedback: Measures to help relieve pain include instructing the patient to avoid foods and beverages that may be irritating to the gastric mucosa and instructing the patient about the correct use of medications to relieve chronic gastritis. An alkaline gastric environment is neither possible nor desirable. There is no plausible need for self-suctioning. Positioning does not have a significant effect on the presence or absence of gastric healing.

A patient who is obese is exploring bariatric surgery options and presented to a bariatric clinic for preliminary investigation. The nurse interviews the patient, analyzing and documenting the data. Which of the following nursing diagnoses may be a contraindication for bariatric surgery?

Deficient Knowledge Related to Risks and Expectations of Surgery Feedback: It is expected that patients seeking bariatric surgery may have challenges with body image and self- esteem related to their obesity. Anxiety is also expected when facing surgery. However, if the patients knowledge remains deficient regarding the risks and realistic expectations for surgery, this may show that the patient is not an appropriate surgical candidate.

A nurse caring for a patient who has had bariatric surgery is developing a teaching plan in anticipation of the patients discharge. Which of the following is essential to include?

Eat several small meals daily spaced at equal intervals. Feedback: Due to decreased stomach capacity, the patient must consume small meals at intervals to meet nutritional requirements while avoiding a feeling of fullness and complications such as dumping syndrome. The patient should not consume fluids with meals and low-Fowlers positioning is recommended during and after meals. Carbohydrates should be limited.

A nurse is performing the admission assessment of a patient whose high body mass index (BMI) corresponds to class III obesity. In order to ensure empathic and patient-centered care, the nurse should do which of the following?

Examine ones own attitudes towards obesity in general and the patient in particular. Feedback: Studies suggest that health care providers, including nurses, harbor negative attitudes towards obese patients. Nurses have a responsibility to examine these attitudes and change them accordingly. This is foundational to all other areas of assessing this patient.

A nurse is providing anticipator guidance to a patient who is preparing for bariatric surgery. The nurse learns that the patient is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the patients anxiety?

Facilitate the patients contact with a support group. Feedback: Support groups can be highly beneficial in relieving preoperative and postoperative anxiety and in promoting healthy coping. This is preferable to antianxiety medications. Downplaying the risks of surgery or focusing solely on the benefits is a simplistic and patronizing approach.

A community health nurse is preparing for an initial home visit to a patient discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include?

Monthly administration of injections of vitamin B12 Feedback: Since vitamin B12 is absorbed in the stomach, the patient requires vitamin B12 replacement to prevent pernicious anemia. A gastrectomy precludes the use of a G tube. Since the stomach is absent, a nasogastric tube would not be indicated. As well, this is not possible in the home setting. Since there is no stomach to act as a reservoir and fluids and nutrients are passing directly into the jejunum, distension is unlikely.

Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication?

Peritonitis Feedback: Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Chemical peritonitis develops within a few hours of perforation and is followed by bacterial peritonitis. Gastritis, reflux, and pancreatitis are not acute complications of a perforated ulcer.

A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patients condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence?

Tachycardia, hypotension, and tachypnea Feedback: Tachycardia, hypotension, and tachypnea are signs of recurrent bleeding. Patients who have had one GI bleed are at risk for recurrence. Tarry stools are expected short-term findings after a hemorrhage. Hemorrhage is not normally associated with sudden thirst or diaphoresis.

A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer?

The patient has a rigid, boardlike abdomen that is tender. Feedback: An extremely tender and rigid (boardlike) abdomen is suggestive of a perforated ulcer. None of the other listed signs and symptoms is suggestive of a perforated ulcer.

A patient has experienced symptoms of dumping syndrome following bariatric surgery. To what physiologic phenomenon does the nurse attribute this syndrome?

A sudden release of peptides Feedback: For many years, it had been theorized that the hypertonic gastric food boluses that quickly transit into the intestines drew extracellular fluid from the circulating blood volume into the small intestines to dilute the high concentration of electrolytes and sugars, resulting in symptoms. Now, it is thought that this rapid transit of the food bolus from the stomach into the small intestines instead causes a rapid and exuberant release of metabolic peptides that are responsible for the symptoms of dumping syndrome. It is not a result of phrenic nerve irritation, malabsorption, or bile reflux.

A patient comes to the bariatric clinic to obtain information about bariatric surgery. The nurse assesses the obese patient knowing that in addition to meeting the criterion of morbid obesity, a candidate for bariatric surgery must also demonstrate what?

Adequate understanding of required lifestyle changes Feedback: Patients seeking bariatric surgery should be free of serious mental disorders and motivated to comply with lifestyle changes related to eating patterns, dietary choices, and elimination. While assessment of knowledge about causes of obesity and its associated risks as well as insight into the reasons why previous diets have been ineffective are included in the clients plan of care, these do not predict positive client outcomes following bariatric surgery. Most obese patients have an impaired body image and alteration in self-esteem. An obese patient with a positive body image would be unlikely to seek this surgery unless he or she was experiencing significant comorbidities.

A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer?

Does your pain resolve when you have something to eat? Feedback: Pain relief after eating is associated with duodenal ulcers. The pain of peptic ulcers is generally unrelated to activity or bowel function and may or may not respond to analgesics.

A patient has received a diagnosis of gastric cancer and is awaiting a surgical date. During the preoperative period, the patient should adopt what dietary guidelines?

Eat small, frequent meals with high calorie and vitamin content. Feedback: The nurse encourages the patient to eat small, frequent portions of nonirritating foods to decrease gastric irritation. Food supplements should be high in calories, as well as vitamins A and C and iron, to enhance tissue repair.

A patient is one month postoperative following restrictive bariatric surgery. The patient tells the clinic nurse that he has been having trouble swallowing for the past few days. What recommendation should the nurse make?

Eating more slowly and chewing food more thoroughly Feedback: Dysphagia may be prevented by educating patients to eat slowly, to chew food thoroughly, and to avoid eating tough foods such as steak or dry chicken or doughy bread. After bariatric procedures, patients should normally not drink beverages with meals. Medications or chewing gum will not alleviate this problem.

A patient was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize?

Esophageal or pyloric obstruction related to scarring Feedback: A severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis (narrowing or tightening) or obstruction. Chronic referred pain to the lower abdomen is a symptom of peptic ulcer disease, but would not be an expected finding for a patient who has ingested a corrosive substance. Bacterial proliferation and hyperacidity would not occur.

A patient has been prescribed orlistat (Xenical) for the treatment of obesity. When providing relevant health education for this patient, the nurse should ensure the patient is aware of what potential adverse effect of treatment?

Flatus with oily discharge Feedback: Side effects of orlistat include increased frequency of bowel movements, gas with oily discharge, decreased food absorption, decreased bile flow, and decreased absorption of some vitamins. This drug does not cause bowel incontinence, abdominal pain, or heat intolerance.

A nurse in the postanesthesia care unit admits a patient following resection of a gastric tumor. Following immediate recovery, the patient should be placed in which position to facilitate patient comfort and gastric emptying?

Fowlers Feedback: Positioning the patient in a Fowlers position postoperatively promotes comfort and facilitates emptying of the stomach following gastric surgery. Any position that involves lying down delays stomach emptying and is not recommended for this type of patient. Supine positioning and the left lateral (left Sims) position do not achieve this goal.

A nurse is assessing a patient who has peptic ulcer disease. The patient requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the patient?

Infection typically occurs due to ingestion of contaminated food and water. Feedback: Most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water. The organism is endemic to all areas of the United States. Genetic factors have not been identified.

A patient presents to the walk-in clinic complaining of vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the physician is likely to order a diagnostic test to detect the presence of what?

Infection with Helicobacter pylori Feedback: H. pylori infection may be determined by endoscopy and histologic examination of a tissue specimen obtained by biopsy, or a rapid urease test of the biopsy specimen. Excessive stomach acid secretion leads to gastritis; however, peptic ulcers are caused by colonization of the stomach by H. pylori. Sphincter dysfunction and acidbase imbalances do not cause peptic ulcer disease.

A patient has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurses priority intervention?

Insertion of an NG tube for decompression Feedback: In treating the patient with gastric outlet obstruction, the first consideration is to insert an NG tube to decompress the stomach. This is a priority over fluid or medication administration.

A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient to first seek care?

Intermittent pain and bloody stool Feedback: When the patient is symptomatic from a tumor of the small intestine, benign tumors often present with intermittent pain. The next most common presentation is occult bleeding. The other listed signs and symptoms are not normally associated with the presentation of small intestinal tumors.

A patient is recovering in the hospital following gastrectomy. The nurse notes that the patient has become increasingly difficult to engage and has had several angry outbursts at various staff members in recent days. The nurses attempts at therapeutic dialogue have been rebuffed. What is the nurses most appropriate action?

Make appropriate referrals to services that provide psychosocial support. Feedback: The nurse should enlist the services of clergy, psychiatric clinical nurse specialists, psychologists, social workers, and psychiatrists, if needed. This is preferable to delegating care, since the patient has become angry with other care providers as well. It is impractical and inappropriate to expect the primary care provider to act as a liaison. It would be inappropriate and unsafe to simply limit contact with the patient.