GERD & GUD Assessment 4

Smoking _________ the effectiveness of Ranitidien & Famotidine?

*Decreases*

How long do H2-Blockers take to treat Duodenal ulcers vs Gastric Ulcers?

*Duodenal- 6 to 8 weeks* *Gastric- 12 weeks*

Nurse should immediately report what 4 signs reported by pt.?

*Fever* *Excess bruising* *Vomiting of blood* *Black colored stool*

Long term use of PPI could lead to?

*Osteoporosis* *Risk of infection (C-diff)*

How fast should the nurse administer Ranitidien & Famotidine via IV?

*Slowly over several minutes* To prevent *bradycardia & hypotension*

What 3 agents protect the stomach from gastric acids?

*Somostatatin* suppresses the secretion of gastrin *Bicarbonate ion* neutralizes the gastric acid on the mucosal surface *Prostaglandin E* stimulates the secretion of mucus and bicarbonate which promotes repair of damaged gastric mucosal cells

What is the initial treatment to *PUD*?

*Triple therapy* *Omeprazole (PPI), Clarithromycin (Biaxin) and metronidazole (flagyl)* A combination of antibiotics that are used to get rid of H. pylori that is involved in PUD while decreasing antibiotic resistance.

What vitamin deficiency may occur with Anti-ulcer drugs?

*Vitamin B12* because it is better absorbed in an acidic environment

The patient should report ________ immediately to HCP when taking PPIs? (6)

- GI bleed - Severe diarrhea - Abdominal pain - Nausea - Heartburn - Pain/blood with urination

What should nurse monitor in patient taking Ranitidien & Famotidine?

-Gastric pain using pain scale -Creatine & Bun levels -Elderly

Pharmacotherapy of GERD and PUD

-H2 receptor antagonists -Proton pump inhibitors -Antacids

What are risk factors associated with peptic ulcer disease? (7)

-infection with H. Pyloria -family history -drugs: corticosteroids, NSAIDS, platelet inhibitors (ASA) -blood group O -smoking tobacco -coffee -psychological stress

Bicarbonate antacids causes what 2 adverse effect?

1) *Metabolic alkalosis* (fatigue, mental status changes, twitching muscles & decreased RR) 2) *Bloating and belching*

What key factors are included when treating *Peptic ulcer*?

1) Change of lifestyle *-Eliminate smoking, stress, bad food, weight loss 2)*Eradicate H. Pylori* *Discontinue NSAIDS*

Omeprazole is prescribed for a client with gastroesophageal reflux disease. The nurse would monitor a *reduction* in which symptoms (4) to determine if the drug therapy is effective? Select all that apply? 1. dysphagia 2. dyspepsia 3. appetite 4. nausea 5. belching

1) Dysphagia 2) Dyspepsia 3) Nausea 4) Belching

2 common disorders of the *UPPER* digestive system include:

1) Peptic Ulcer 2) GERD

The nurse should monitor what levels when taking PPI?

1)BUN & CL 2)B12 & folic acid levels

What is the stomach's healthy acidity? (PH)

1-2

What is the PH of the gastric acid that is responsible for entering the esophageal resulting to *GERD* and *peptic ulcers*

1.5-3.5 Combined secretion of the chief and *parietal cells*

Because PPI has the ability to inactivate the proton pumps *irreversibly*...

They supress acid for 24 hours although their half lives are short (1.5 hours)

Because PPI has the ability to inactivate the proton pumps irreversibly...

They supress acid for 24 hours although their half lives are short (1.5 hours)

What 4 *common* adverse effects are associated with Ranitidien & Famotidine?

*Confusion in elderly* *Restlessness* *Hallucinations* *Depression*

Calcium antacids causes what 2 adverse effects?

*Constipation* *Aggravated kidney stones* (Renal failure)

What are two H2 receptor antagonist prototypes?

*-dine* Ranitidine (Zantac) Famotidine (Pepcid)

PPI prototypes

*-zole omeprazole (Prilosec) pantoprazole (Protonix)

Antacids should not be given within _______ of Ranitidien & Famotidine?

*2 hours before or after meals with a full glass of water*

What occurs if GERD goes untreated?

*Barrett's esophagus* occurs in 10% of those with GERD and is characterized by the normal tissue lining changing and resembles into the lining of the intestines which progresses to cancer

What 3 *serious* adverse effects are associated with Ranitidien & Famotidine?

*Blood dyscrasias neutropenia (decreased WBC)* *Thrombocytopenia (decreased platelets)* *Gynecomastia (enlarged breast in men), impotence (inability to have an erection), or loss of libido in MEN*

Which H2 receptor antagonist has the most drug interactions?

*Cimetidine* interacts with: warfarin, phenytoin, diazepam, theophylline

Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from all medications 2. Use of non steroidal anti inflammatory drugs (NSAIDs) 3. Any known allergies to drugs and environmental factors 4. Medical histories of at lease 3 generations

2. *Rationale* Use of NSAIDs places the client at risk for peptic ulcer and hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid.

A client with a gastric ulcer has a prescription for omezprazole 1 g PO QID. When should the nurse time her administration?

20-30 minutes before the first major daily meal (breakfast) Rationale: PPIs are activated by food so taking drug 20-30 minutes beforehand allows the drugs peak serum levels coinciede with when it is activated.

How should PPIs be taken with food?

20-30 minutes before the first major daily meal (breakfast) Rationale: PPIs are activated by food so taking drug 20-30 minutes beforehand allows the drugs peak serum levels coinciede with when it is activated. *Eat foods with beneficial bacteria*

OTC antihistamines such as Dramamine and prescribed scopolamine transdermal patch used for motion sickness are best taken

30 minutes before travel

What is GERD and why does it occur?

A condition that that is characterized with *persistent heartburn*. It is a result of when acidic stomach contents regurgitate back into the esophagus due to the *weakness/ relaxation* of the esophageal sphincter

What should GERD patient use at night time?

A foam wedge or risers under the head of the bed frame *Rationale* Acid reflux is more common when lying down because the gravity does not oppose the reflux as it does in an upright position. The reduced effect of gravity also allows the acidic content to stay in your food tube longer and reach the mouth easily.

Sulcralfate

A miscellaneous drug that treats *PUD*. The drug uses its ability to produce a thick protective barrier & binds/coats the ulcer, protecting it against further erosion from acid and pepsin. *consist of a aluminum antacid* *drug stimulates mucus, bicarbonate and prostaglandin secretion (enhance mucosal defenses)* *intended for short term therapy (8 weeks)* *not indicated for GERD or NSAID related GUD* *4x daily dosage (disadvantage)* *not taken with antacids within 2 hours*

During a home health visit, you are helping a patient develop a list of foods they should avoid due to GERD. Which items in the patient's pantry should be avoided? SELECT-ALL-THAT-APPLY: A. Hot and Spicy Pork Rinds B. Peppermint patties C. Green Beans D. Tomato Soup E. Chocolate Fondue F. Almonds G. Oranges

A, B, D, E, G. *Rationale* Patients with GERD should avoid foods that relax the lower esophageal sphincter such as greasy/fatty foods (Hot and Spicy Pork Rinds), peppermint (peppermint patties), acidic or citrus foods/juice (tomato soup and oranges), chocolate (chocolate fondue), along with coffee and soft drinks.

A patient reports frequent heartburn twice a week for the past 4 months. What other symptoms reported by the patient may indicate the patient has GERD? SELECT-ALL-THAT-APPLY: A. Bitter taste in mouth B. Dry cough C. Melena D. Difficulty swallowing E. Smooth, red tongue F. Murphy's Sign

A, B, D. *Rationale* These are signs and symptoms seen with GERD. Melena is seen with gastrointestinal bleeding as in peptic ulcer disease. Smooth, red tongue is seen with vitamin B12 deficiency, and Murphy's Signs is seen with cholecystitis.

Client comes in for her daily check up and reports that she was diagnosed with GERD a couple of months ago and takes antacids to relieve her heartburn. The nurse is most concerned with the following drugs listed in her charts. Select 4 that apply. A. Warfarin B. Amphetamines C. HCTZ D. NSAIDS E. Nitroglycerin F. Digoxin

A,B,D,F Warfarin, Amphetamines, NSAIDs, and Digoxins are all *acidic drugs* meaning that when taking it concurrently with an antacid, the other drugs therapeutic effects are *lessened*

A patient arrives to the clinic for evaluation of epigastric pain. The patient describes the pain to be relieved by food intake. In addition, the patient reports awaking in the middle of the night with a gnawing pain in the stomach. Based on the patient's description this appears to be what type of peptic ulcer? A. Duodenal B. Gastric C. Esophageal D. Refractory

A. *Rationale* The patient signs and symptoms describe a duodenal ulcer. Gastric ulcer tend to not cause pain in the middle of the night and epigastric pain in worst with food.

A patient is recovering from discomfort from a peptic ulcer. The doctor has ordered to advance the patient's diet to solid foods. The patient's lunch tray arrives. Which food should the patient avoid eating? A. Orange B. Milk C. White rice D. Banana

A. *Rationale* When an ulcer is actively causing signs and symptoms, the patient should avoid acidic foods like tomatoes or citric fruits/juices, chocolate, alcohol, fried foods and caffeine. These foods can irritate the ulcer site. Instead the patient should consume alkalotic or bland foods like milk, white rice or bananas.

A physician prescribes a Proton-Pump Inhibitor to a patient with a gastric ulcer. Which medication is considered a PPI? A. Omeprazole B. Famotidine C. Magnesium Hydroxide D. Metronidazole

A. Rationale Pantoprazole is the only PPI listed. Remember PPIs tend to end with the letters "prazole".

Which statement is INCORRECT about Histamine-receptor blockers? A. "H2 blockers block histamine which causes the chief cells to decrease the secretion of hydrochloric acid." B. "Ranitidine and Famotidine are two types of histamine-receptor blocker medications." C. "Antacids and H2 blockers should not be given together." D. All the statements are CORRECT.

A. Rationale This statement is false. H2 blockers block histamine which causes the PARTIETAL (not chief) cells to decrease the secretion of hydrochloric acid.

Antacids

Alkalines that neutralize stomach acid by: *-Neutralizes gastric acid *-Inactivates pepsin* *-Stimulating prostaglandins which increases LES tone reducing gastro refelex* This promotes relief from *heartburn* but does *NOT* promote ulcer healing or eliminate H. pylori It also does *NOT* coat the stomach

Peptic ulcer is a result of? (4)

An imbalance of: -protective mucus -bicarbonate ions -aggravating pepsin -gastric acids

The nurse who is caring for a client with gastroesophageal reflux disease should question the order for which drug? a. H2 receptor antagonist b. PPI c. Antibiotic d. Antacids

Antibiotics have no role in treating GERD although certain antibiotics are used for treating *PUD to eridicate H. pylori*

Helicobacter pylori can live in the stomach's acidic conditions because it secretes ___________ which neutralizes the acid. A. ammonia B. urease C. carbon dioxide D. bicarbonate

B. *Rationale* H. pylori can live in the acidic conditions of the stomach because it secretes urease which produces ammonia to neutralize the acid

After dinner time, during hourly rounding, a patient awakes to report they feel like "food is coming up" in the back of their throat and that there is a bitter taste in their mouth. What nursing intervention will you perform next? A. Perform deep suctioning B. Assist the patient into the Semi-Fowler's position C. Keep the patient NPO D. Instruct the patient to avoid milk products

B. *Rationale* The patient is experiencing regurgitation. The clues in this scenario are the patient signs and symptoms along with the time of day (after dinner time...the patient just ate a meal and is sleeping..we can assume they are lying down). If a patient has reflux disease, the lower esophageal sphincter is weak and after a meal when a person lies down to sleep the food can regurgitate into the throat which will cause the patient to feel like "food in coming up" in the back of the throat and bitter taste in the mouth. Placing the patient in semi-fowler's position will help alleviate this.

A patient with a peptic ulcer is suddenly vomiting dark coffee ground emesis. On assessment of the abdomen you find bloating and an epigastric mass in the abdomen. Which complication may this patient be experiencing? A. Obstruction of pylorus B. Upper gastrointestinal bleeding C. Perforation D. Peritonitis

B. *Rationale* This patient is most likely experiencing an upper GI bleeding. Signs and symptoms of a possible GI bleeding with a peptic ulcer include: vomiting coffee ground emesis along with bloating, and abdominal mass.

You're educating a group of patients at an outpatient clinic about peptic ulcer formation. Which statement is correct about how peptic ulcers form? A. "An increase in gastric acid is the sole cause of peptic ulcer formation." B. "Peptic ulcers can form when acid penetrates unprotected stomach mucosa. This causes histamine to be released which signals to the parietal cells to release more hydrochloric acid which erodes the stomach lining further." C. "Peptic ulcers form when acid penetrates unprotected stomach mucosa. This causes pepsin to be released which signals to the parietal cells to release more pepsinogen which erodes the stomach lining further." D. "The release of prostaglandins cause the stomach lining to breakdown which allows ulcers to form."

B. *Rationale* Ulcers form when acid penetrates unprotected stomach mucosa. This causes histamine to be released which signals to the parietal cells to release more hydrochloric acid which erodes the stomach lining further.. Option A is wrong because although peptic ulcers can from with increase gastric acid, this is not the sole cause of peptic ulcer formation. A breakdown in the defense mechanisms along with gastric acid leads to peptic ulcer formation. For example, h. pylori and regular NSAID usage leads to the breakdown of the stomach lining which allows stomach acid to penetrate and erode the lining. Option D is wrong because prostaglandins actually protect the stomach lining by causing the stomach cells to release mucous rich in bicarb, controls acid amounts via the parietal cells, and regulates perfusion to the stomach.

Pregnant woman taking PPIs should be monitored consistently with what labs?

B12 & Folic acid labs because omeprazole is optimal for vitamin B12 absorption.

Pregnant woman who are taking antiulcers should be monitored consistently with what labs?

B12 & Folic acid labs because omeprazole is optimal for vitamin B12 absorption.

Although patient reports that he is feeling better after 8 hours of taking PPI, nurse's best response would be...

Because not every proton pump is activated within the first dose, patient should continue to take for several days to achieve maximal acid inhibition.

What is the serious adverse effect with PPI?

Blood disorders that could lead to fatigue and weakness

Your patient, who is presenting with signs and symptoms of GERD, is scheduled to have a test that assesses the function of the esophagus' ability to squeeze food down into the stomach and the closer of the lower esophageal sphincter. The patient asks you, "What is the name of the test I'm having later today?" You tell the patient the name of the test is: A. Lower Esophageal Gastrointestinal Series B. Transesophageal echocardiogram C. Esophageal manometry D. Esophageal pH monitoring

C. *Rationale* An esophageal manometry assesses the function of the esophagus' ability to squeeze the food down and how the lower esophageal sphincter closes.

A patient is taking Bethanechol "Urecholine" for treatment of GERD. This is known as what type of drug? A. Proton-pump inhibitor B. Histamine receptor blocker C. Prokinetic D. Mucosal Healing Agent

C. *Rationale* This drug is known as a prokinetic drug. It prevents delayed gastric emptying by improving pressure in lower esophageal sphincter and improves peristalsis of the GI tract.

What does the gastric pH term-83have to be in order for the antacids to work? A. 2.8 B. 3.2 C. 3.5 D. 2.5

C. *3.5*

A client comes into the clinic with complaints of heart burn, chest pain, belching, difficulty swallowing and indigestion. The doctor ordered an esophageal pH test which came back and confirmed that she has GERD. What does the nurse suspect the pH was? A. 9.2 B. 6.3 C. 3.2 D. 5.0

C. 3.2 Rationale 7.0 is the neutral pH. A person with GERD or GUD would have a gastric/esophageal pH of 4 or less

Aluminum antacids causes what GI adverse effect?

Constipation

Sucralfates only possible adverse effect is _______?

Constipation

In the stomach lining, the parietal cells release _________ and the chief cells release __________ which both play a role in peptic ulcer disease A. pepsin, hydrochloric acid B. pepsinogen, pepsin C. pepsinogen, gastric acid D. hydrochloric acid, and pepsinogen

D) *Rationale* In the stomach lining, the parietal cells release HYDROCHLORIC ACID and the chief cells release PEPSINOGEN which both plays a role in peptic ulcer disease. Pepsinogen then mixes with the hydrochloric acid and turns into pepsin.

The physician orders a patient with a duodenal ulcer to take a UREA breath test. Which lab value will the test measure to determine if h. pylori is present? A. Ammonia B. Urea C. Hydrochloric acid D. Carbon dioxide

D. *Rationale* If h. pylori are present, the bacteria will release urease which produces ammonia and carbon dioxide. For the test, the patient will ingest a urea tablet and breath samples will be analyzed for carbon dioxide levels.

Which of the following does NOT play a role in the development of GERD? A. Pregnancy B. Hiatal hernia C. Usage of antihistamines or calcium channel blockers D. All the above play a role in GERD

D. *Rationale* All the options above play a role in the development of GERD. These options can weaken the lower esophageal sphincter and cause it to not close properly.

After providing education to a patient with GERD. You ask the patient to list 4 things they can do to prevent or alleviate signs and symptoms of GERD. Which statement is INCORRECT? A. "It is best to try to consume small meals throughout the day than eat 3 large ones." B. "I'm disappointed that I will have to limit my intake of peppermint and spearmint because I love eating those types of hard candies." C. "It is important I avoid eating right before bedtime." D. "I will try to lie down after eating a meal to help decrease pressure on the lower esophageal sphincter."

D. *Rationale* This statement is incorrect. The patient should have said I will AVOID lying down after eating a meal to help decrease pressure on the lower esophageal sphincter. It is important a patient does not immediately lie down after eating but wait for about 1 hour.

Magnesium antacids causes what GI adverse effect?

Diarrhea

Proton pump inhibitors

Drug of choice for GERD & GUD/DUD *Stops acid production completely by:* Irreversibly binding to the *H+,K+ ATPase enzyme* that secretes stomach HCL which is what leads to ulcer development

Antacids coat a peptic ulcer. Select one: True False

False

Sodium antacids causes what adverse effect and what 4 patients should not receive this medication?

Fluid retention

Patient that is taking PPIs should report what adverse effects to HCP?

GI bleeding, severe diarrhea, abdominal pain, nausea, vomiting, heartburn, pain/blood with urination

What are common adverse effects with PPI?

Headache Nausea Diarrhea Rash Abdominal pain

Sodium antacids should not be taken with patients that have?

Heart failure, HTN, or on a restricted sodium diet

Patient should report what when taking antacids?

Increase in abdominal pain, diarrhea or constipation

Decrease in stomach acid caused by Ranitidien & Famotidine can result in?

Increased growth of Candida and Bacteria in the stomach

Warfarin and PPI could lead to..

Induced likely hood of bleeding

Magnesium antacids shouldn't be taken with patients that have?

Kidney disease

Patient comes in and you see they've been using PPI for several of months. What is the nurses biggest concern?

Long term use could lead to increased risk for osteoporotic fractures.

The client has developed severe diarrhea following 4 days of self administration antacid prep. The nurse suspects that the diarrhea may be caused by which type of antacid? a. Al b. Mg c. Ca D. Na

Magnesium antacids cause diarrhea

Client comes in for her daily check up and reports that she was diagnosed with GERD a couple of months ago and takes antacids to relieve her heartburn. The nurse is most concerned with the following drugs listed under her charts. Select 4 that apply.

Morphine, antihistamines, tricyclic anti-depressants amphetamines, and quinidine are all *basic drugs* meaning that when taking it concurrently with an antacid, the other drugs therapeutic effects are have *greater* effects that may lead to *toxicity*

Should you take calcium antacids with milk or vitamin D?

NO! Could lead to *milk-alkali syndrome*. -headaches, urinary frequency, anorexia, nausea, fatigue and permanent renal damage

How long should patient take OTC Ranitidien & Famotidine?

Not longer than 2 weeks

When concurrently taking antacids and other PO medications, how would nurse give direction in doing so?

PO medication should be given at least *1 hour before* or *2 hours after* giving antacid

What is the significance of parietal cells?

Parietal cells! They have receptors for certain hormones: -gastrin -histamine 2 -AcH 1) When a person eats and stomach distends, it stimulates gastrin into the blood which bind to enteroendocrine cells in the gastric glands. 2) This does 2 things: -Signals the chief cells to secrete pepsin promoting the production of pancreatic enzymes which increases gastric blood flow roduces and secretes histamine 2) Histamine binds to H2 receptors on the parietal cells to stimulate acid secretion.

What is done before starting triple therapy?

Patient is to get tested for H. pylori because the therapy could worse condition if their PUD doesn't consist of H. pylori

What is the drug of choice when treating Gastric & Duodenal ulcers, GERD & Zollinger- Elliason Syndrome

Proton Pump Inhibitors

What directions should nurse teach client when administering antacid liquid or tablets?

Shake liquid preparation before drinking Chew thoroughly until wet before swallowing

Patients should avoid what when suffering from GERD or PUD?

Smoking Alcohol Caffeine Fatty foods such as: chocolates, fried foods, tomato sauce, alcohol, garlic, and onion

What is the purpose of gastric acid in our body?

The acidic environment it creates helps break down food and kill microbes that have been ingested

What is the mechanism of action of Ranitidien (Zantac) and Famotidine (Pepcid)?

They inhibit histamine action on H2-receptors, which are found on the gastric parietal cells and prevent gastrin secretion, thus decreasing acid production.

What are H2-Blockers used for? And give examples of two that are commonly used.

They *suppress gastric acid secretion* for patients with *peptic ulcer diseases*, heartburn, *GERD* and hyperacidity in GI tract

H2 blockers inhibit gastric acid secretion. Select one: True False

True

What is peptic ulcer disease?

When a lesion occurs in the stomach or duodenal that involves acute inflammation.

Should patient eat food with Ranitidien & Famotidine?

Yes or could be take immediately after meals.

Ideal dosing for antacids is: Select one: a. 1 hour after meals b. 1 hour before meals c. with meals

a. 1 hour after meals

J. M., a 22 year old Hispanic male is taking *Zantac (H2 antagonist)*, all of the following are potential side effects EXCEPT: Select one: a. headache b. nausea c. loss of libido

b. nausea

A client who has duodenal ulcers is receiving a long term therapy with ranitidine . The nurse includes in the care plan that the client should be monitored for which AE? a. photophobia & skin irritation b. neutropenia & thrombocytopenia c. dyspnea & productive coughing d. urinary hesitation & fluid retention

b. neutropenia & thrombocytopenia *Rationale* Blood dycrasias has been reported with long term

Which of the following drugs inhibits gastric acid secretions to a greater extent than histamine antagonists? Select one: a. Benadryl b. Zactac c. Prilosec d. Pepto-Bismuth

c. Prilosec (PPI)

Your client is diagnosed with H. pylori infection and PUD. Which discharge instructions should the nurse teach? Select one: a. Instruct the client to eat a soft, bland diet. b. Discuss elevating the head of the bed to prevent reflux. c. Take the combination of medications for 14 days as directed d. Teach to never use NSAID drugs again.

c. Take the combination of medications for 14 days as directed *Triple therapy*

Coadministration of omeprazole & __________ has been shown to increase both plasma levels

clarithomycin

The prescriber orders sucralfate for a client with PUD. The nurse should question the order if the client it concurrently taking: a. PPI b. Ca+ salt antacids c. H2 receptor antagonist d. Al+ salt antacids

d. Al+ antacids *Rationale* Taking concurrently could lead to Al+ toxicity