Chapter 41: Upper Gastrointestinal Problems

Which statement by a patient with chronic atrophic gastritis indicates that the nurse's teaching regarding cobalamin injections has been effective?

. "The cobalamin injections will prevent me from becoming anemic." Cobalamin supplementation prevents the development of pernicious anemia. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer

Which patient statement indicates that the nurse's postoperative teaching after a gastroduodenostomy has been effective?

. "Vitamin supplements may prevent anemia."

Which patient should the nurse assess first after receiving change-of-shift report?

. A patient with esophageal varices who has a rapid heart rate

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. What should the nurse teach the patient to take?

. Antacids after meals and sucralfate 30 minutes before meals

Which patient is at highest risk for developing oral candidiasis?

A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks. Rationale: Oral candidiasis is caused by prolonged antibiotic treatment (e.g., ciprofloxacin) or high doses of corticosteroids. Amphotericin B is used to treat candidiasis. Vitamin B and C deficiencies may lead to Vincent's infection. Use of tobacco products leads to stomatitis, not candidiasis.

The patient with chronic gastritis is being put on a combination of medications to eradicate Helicobacter pylori. Which drugs does the nurse know will probably be used?

Antibiotic(s), proton pump inhibitor, and bismuth Rationale: To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.

The nurse is caring for a postoperative patient who has just vomited yellow-green liquid. Which action would be an appropriate nursing intervention?

Apply a cool washcloth to the forehead and provide mouth care. Rationale: Cleansing the face and hands with a cool washcloth and providing mouth care are appropriate comfort interventions for nausea and vomiting. Ginseng is not used to treat postoperative nausea and vomiting. Unnecessary activity should be avoided. The patient should rest in a quiet environment. Medications may be temporarily held until the acute phase is over, but the medications should not be discontinued without consultation with the health care provider.

After administering a dose of promethazine to a patient with nausea and vomiting, what medication side effect does the nurse explain is common and expected?

Drowsiness Rationale: Although being given to this patient as an antiemetic, promethazine also has sedative and amnesic properties. For this reason, the patient is likely to experience drowsiness as an adverse effect of the medication. Tinnitus, reduced hearing, and loss of balance are not side effects of promethazine.

The nurse is caring for a patient being treated with IV fluid therapy for severe vomiting. As the patient recovers and begins to tolerate oral intake, which food choice would be most appropriate?

Dry toast Rationale: Dry toast or crackers may alleviate the feeling of nausea and prevent further vomiting. Water is the initial fluid of choice. Extremely hot or cold liquids and fatty foods are generally not well tolerated.

The nurse determines a patient has experienced the beneficial effects of famotidine when which symptom is relieved?

Epigastric pain Rationale: Famotidine is an H2-receptor antagonist that inhibits parietal cell output of HCl acid and minimizes damage to gastric mucosa related to hyperacidity, thus relieving epigastric pain. It is not indicated for nausea, belching, and dysphagia.

Barium Swallow

Fluoroscopic x-ray study using contrast medium. Used to diagnose structural abnormalities of esophagus, stomach, and duodenum. Before: Explain procedure, including the need to drink contrast medium and assume various positions on x-ray table. Keep patient NPO for at least 8 hr. Tell patient to avoid smoking after midnight. After: Take measures to prevent contrast medium impaction (fluids, laxatives). Tell patient that stool may be white for up to 72 hr.

he patient is having an esophagoenterostomy with anastomosis of a segment of the colon to replace the resected portion. What initial postoperative care should the nurse expect when this patient returns to the nursing unit?

NG will have bloody drainage and it should not be repositioned. Rationale: The patient will have bloody drainage from the nasogastric (NG) tube for 8 to 12 hours, and it should not be repositioned or reinserted without contacting the surgeon. Deep breathing and spirometry will be done every 2 hours. Coughing would put too much pressure in the area and should not be done. Because the patient will have the NG tube, the patient will not be eating yet. The patient should be kept in a semi-Fowler's or Fowler's position, not supine, to prevent reflux and aspiration of secretions.

Which action should the nurse in the emergency department anticipate for a young adult patient who has had several acute episodes of bloody diarrheaa.

Obtain a stool specimen for culture Patients with bloody diarrhea should have a stool culture for Escherichia coli O157:H7. Antidiarrheal medications are usually avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications. Acetaminophen does not cause bloody diarrhea.

The patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication?

Ondansetron Rationale: Ondansetron is a 5-HT3 receptor antagonist antiemetic that is especially effective in reducing cancer chemotherapy-induced nausea and vomiting. Morphine sulfate may cause nausea and vomiting. Zolpidem does not relieve nausea and vomiting. Dexamethasone is usually used in combination with ondansetron for acute and chemotherapy-induced emesis.

After receiving a dose of metoclopramide, which patient assessment finding would indicate the medication was effective?

Relief of nausea and vomiting Rationale: Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient's nausea and vomiting should resolve. Metoclopramide does not affect blood pressure, muscle tremors, or diarrhea.

A patient was admitted with epigastric pain because of a gastric ulcer. Which patient assessment warrants an urgent change in the nursing plan of care?

Rigid abdomen and vomiting following indigestion Rationale: A rigid abdomen with vomiting in a patient who has a gastric ulcer indicates a perforation of the ulcer, especially if the manifestations of perforation appear suddenly. Midepigastric pain is relieved by eating, drinking water, or antacids with duodenal ulcers, not gastric ulcers. Back pain 3 to 4 hours after a meal is more likely to occur with a duodenal ulcer. Burning epigastric pain 1 to 2 hours after a meal is an expected manifestation of a gastric ulcer related to increased gastric secretions and does not cause an urgent change in the nursing plan of care.

A patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. What should the nurse teach the patient to avoid?

Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Stressful situations, abdominal distention, and use of H2 blockers are not associated with an increased incidence of stomach cancer.

A patient reporting nausea receives a dose of metoclopramide. Which potential adverse effect should the nurse tell the patient to report?

Tremors Rationale: Extrapyramidal side effects, including tremors and tardive dyskinesias, may occur with metoclopramide administration. Constipation, double vision, and numbness in fingers and toes are not adverse effects of metoclopramide.

• The 3 major complications of chronic PUD

are hemorrhage, perforation, and gastric outlet obstruction

A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed?

b. "I eat small meals and have a bedtime snack."

Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy?

b. Elevate the head of the bed to at least 30 degrees Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started.

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider?

b. The patient's lungs have crackles audible to the midchest

A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient?

c. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec)

A young adult has been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)?

c. Assist the patient with oral care.

A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), what should the nurse plan to assess more frequently than is routine?

c. Breath sounds Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective?

c. Cherry gelatin with fruit Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. What should the nurse teach the patient to do?

c. Lie down for about 30 minutes after eating

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately?

c. The patient has no breath sounds in the left anterior chest.

A patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse?

c. The patient is lethargic and difficult to arouse.

A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. What should the nurse ask the patient about to determine possible risk factors for gastritis?

c. Use of nonsteroidal antiinflammatory drugs Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

An 80-yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration?

d. Metoclopramide (Reglan)

What should the nurse anticipate teaching a patient with a new report of heartburn?

d. Proton pump inhibitors Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

Which assessment should the nurse perform first for a patient who just vomited bright red blood?

d. Taking the blood pressure (BP) and pulse ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume

• Peptic ulcer disease (PUD

is a condition characterized by erosion of the GI mucosa from the digestive action of hydrochloric acid and pepsin

Gastroesophageal reflux disease (GERD)

is a syndrome, not a disease, in which there are chronic symptoms or mucosal damage resulting from reflux of gastric contents into the lower esophagus.

• Hiatal hernia

is the herniation of a portion of the stomach into the esophagus through an opening in the diaphragm.

The use of drugs to treat nausea and vomiting depends on the problem. Commonly used drugs include serotonin receptor antagonists

ondansetron [Zofran]), substance P/neurokinin-1 receptor antagonists, phenothiazines, and metoclopramide (Reglan). Dexamethasone and cannabinoids are given with other antiemetics to manage chemotherapy-induced nausea and vomiting

A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), what should the nurse plan to assess more frequently than is routine?

. Breath sounds Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago reports increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. What is the highest priority action by the nurse?

. Contact the surgeon. Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion or return to surgery are needed (or both). Because the NG is draining, there is no indication that irrigation is needed. Continuing to monitor the NG drainage is not an adequate response. The patient may need morphine, but this is not the highest priority action.

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider?

. Temperature 102.1° F (38.9° C) An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery and do not require any urgent action.

A patient who had a gastroduodenostomy (Billroth I operation) for stomach cancer reports generalized weakness, sweating, palpitations, and dizziness 15 to 30 minutes after eating. What long-term complication does the nurse suspect is occurring?

Dumping syndrome Rationale: After a Billroth I operation, dumping syndrome may occur 15 to 30 minutes after eating because of the hypertonic fluid going to the intestine and additional fluid being drawn into the bowel. Malnutrition may occur but does not cause these symptoms. Bile reflux gastritis cannot happen when the stomach has been removed. Postprandial hypoglycemia occurs with similar symptoms, but 2 hours after eating.

A patient is seeking emergency care after choking on a piece of steak. The nursing assessment reveals a history of alcohol use, cigarette smoking, and hemoptysis. Which diagnostic study is most likely to be performed on this patient?

Endoscopic biopsy Rationale: Because of this patient's history of alcohol use, smoking, and hemoptysis and the current choking episode, cancer may be present. A biopsy is necessary to make a definitive diagnosis of cancer, so an endoscope will be used to obtain a biopsy and observe other abnormalities as well. A barium swallow may show narrowing of the esophagus, but it is more diagnostic for achalasia. An endoscopic ultrasonography may be used to stage esophageal cancer. Capsule endoscopy can show esophageal problems but is more often used for small intestine problems. A barium swallow, capsule endoscopy, and endoscopic ultrasonography cannot provide a definitive diagnosis for cancer.

A patient has a sliding hiatal hernia. What priority nursing intervention will reduce the symptoms of heartburn and dyspepsia?

Having the patient eat 4 to 6 smaller meals each day Rationale: Eating smaller meals during the day will decrease the gastric pressure and symptoms of hiatal hernia. Keeping the patient NPO or in a Trendelenburg position is not safe or realistic for a long period of time for any patient. Varying antacids will only be done with the health care provider's prescription, so this is not a nursing intervention.

The patient with a history of irritable bowel disease and gastroesophageal reflux disease (GERD) is admitted with a diagnosis of diverticulitis and has received a dose of Mylanta 30 mL PO. The nurse will determine the medication was effective when which symptom has been resolved?

Heartburn Rationale: Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of gastrointestinal discomfort, such as heartburn associated with GERD. Mylanta can cause both diarrhea and constipation as a side effect. Mylanta does not affect lower abdominal pain.

The results of a patient's recent endoscopy indicate the presence of peptic ulcer disease (PUD). Which teaching point should the nurse provide to the patient based on this new diagnosis?

It would be beneficial for you to stop drinking alcohol." Rationale: Alcohol increases the amount of stomach acid produced, so it should be avoided. Although there is no specific recommended dietary modification for PUD, most patients find it necessary to make some dietary modifications to minimize symptoms. Milk may worsen PUD.

The nurse is caring for a patient who reports abdominal pain and hematemesis. Which new assessment finding(s) would indicate the patient's condition is declining?

Pallor and diaphoresis Rationale: A patient with hematemesis has some degree of bleeding from an unknown source. Guaiac-positive diarrhea stools would be an expected finding. When monitoring the patient for stability, the nurse observes for signs of hypovolemic shock such as tachycardia, tachypnea, hypotension, altered level of consciousness, pallor, and cool and clammy skin. A reddened peripheral IV site will require assessment to determine the need for reinsertion. Access would be critical in the immediate treatment of shock, but the IV site does not represent a decline in condition.

A patient with a history of peptic ulcer disease presents to the emergency department with severe abdominal pain and a rigid, boardlike abdomen. The health care provider suspects a perforated ulcer. Which interventions should the nurse anticipate?

Providing IV fluids and inserting a nasogastric (NG) tube Rationale: A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis, and parenteral nutrition is not a priority in the short term.

A patient with oral cancer is not eating. A small-bore feeding tube was inserted, and the patient started on enteral feedings. Which patient goal would best indicate improvement?

Weight gain of 1 kg in 1 week Rationale: The best goal for a patient with oral cancer that is not eating would be to note weight gain rather than loss. Consuming 50% of the clear liquid tray is not a realistic goal. The absence of nausea and proper tube placement, while desired, do not indicate nutritional improvement.

What diagnostic test should the nurse anticipate for an older patient who is vomiting "coffee-ground" emesis?

a. Endoscopy Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding.

A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed?

b. "I eat small meals and have a bedtime snack." GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). What should the nurse explain about the action of the medication?

b. "It inhibits development of stress ulcers." Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

Which information will the nurse provide for a patient with newly diagnosed gastroesophageal reflux disease (GERD)?

b. "Keep the head of your bed elevated on blocks." Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)?

b. "Ranitidine decreases gastric acid secretion Ranitidine is a histamine-2 (H2) receptor blocker that decreases the secretion of gastric acid. Ranitidine does not constrict the blood vessels, absorb the gastric acid, or cover the ulcer.

A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take?

b. Check the vital signs. The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.

A 49-yr-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which prescribed action will the nurse implement first?

b. Infuse normal saline at 250 mL/hr

An adult with E. coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which prescribed action will the nurse question?

c. Administer loperamide (Imodium) after each stool Use of antidiarrheal agents is avoided with this type of food poisoning. IV fluids, clear oral fluids, and monitoring renal function are appropriate for dehydration.

How should the nurse explain esomeprazole (Nexium) to a patient with recurring heartburn?

d. "It treats gastroesophageal reflux disease by decreasing stomach acid production." ANS: D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

A patient who takes a nonsteroidal antiinflammatory drug (NSAID) daily for the management of severe rheumatoid arthritis has recently developed melena. What should the nurse anticipate teaching the patient?

d. Misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa

A 73-yr-old patient is diagnosed with stomach cancer after an unintended 20-lb weight loss. Which nursing action will be included in the plan of care?

d. Offer supplemental feedings between meals. ANS: D The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving the response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions.