PrepU Chapter 40: Management of Patients with Gastric and Duodenal Disorders

Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?

Mental confusion

The nurse advises the patient who has just been diagnosed with acute gastritis to:

Refrain from food until the GI symptoms subside.

Which of the following is the most successful treatment for gastric cancer?

Removal of the tumor -There is no successful treatment for gastric carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient may be cured. If the tumor has spread beyond the area that can be excised, cure is less likely.

A health care provider counsels a client about bariatric surgery and recommends the Roux-en-Y gastric bypass. What is the best response by the nurse to further explain this procedure to the client?

Separation of the jejunum with an anastomosis -The Roux-en-Y gastric bypass is recommended for long-term weight loss because it uses a combined restrictive and malabsorptive procedure.

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?

Six small meals daily with 120 mL fluid between meals

A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client?

Take the medication 2 hours before or after other medications

A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen?

10 to 14 days -Recommended therapy for 10 to 14 days includes triple therapy with two antibiotics (e.g., metronidazole [Flagyl] or amoxicillin [Amoxil] and clarithromycin [Biaxin]) plus a proton pump inhibitor (e.g., lansoprazole [Prevacid], omeprazole [Prilosec], or rabeprazole [Aciphex]), or quadruple therapy with two antibiotics (metronidazole and tetracycline) plus a proton pump inhibitor and bismuth salts (Pepto-Bismol).

The nurse is evaluating a client's ulcer symptoms to differentiate ulcer as duodenal or gastric. Which symptom should the nurse at attribute to a duodenal ulcer?

Awakening in pain

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description?

Black and tarry -Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.

The nurse is providing preoperative care for a client with gastric cancer who is having a resection. What is the nursing management priority for this client?

Correcting nutritional deficits

Which medication is classified as a histamine-2 receptor antagonist?

Famotidine

A client has been taking famotidine at home. What teaching should the nurse include with the client?

Famotidine will inhibit gastric acid secretions. -Famotidine is useful for treating and preventing ulcers and managing gastroesophageal reflux disease. It functions by inhibiting the action of histamine at the H-2 receptor site located in the gastric parietal cells, thus inhibiting gastric acid secretion. Famotidine will not neutralize acid in the stomach, but inhibits acid secretion. Famotidine will not shorten digestion time and will not improve food mixing with gastric secretions.

Nizatidine, cimetidine, and famotidine are classified as

H2 receptor antagonists.

The nurse in the ED admits a client with suspected gastric outlet obstruction. The client's symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which order?

Nasogastric tube insertion -The nurse anticipates an order for nasogastric tube insertion to decompress the stomach.

During a home visit the nurse notes that a client recovering from peptic ulcer disease is experiencing cool clammy skin and has a heart rate of 96 beats a minute. Which action will the nurse take?

Notify the primary health care provider.

The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition?

Peptic ulcers -Chronic gastritis caused by Helicobacter pylori is implicated in the development of peptic ulcers. Chronic gastritis is sometimes associated with autoimmune disease, such as pernicious anemia, but not as a cause of the anemia. Chronic gastritis is not implicated in system infections and/or colostomies.

A client is in the hospital for the treatment of peptic ulcer disease. The client reports vomiting and a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate?

Perforation of the peptic ulcer -Signs and symptoms of perforation include the following: Sudden, severe upper abdominal pain (persisting and increasing in intensity), which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock.

The nurse is teaching a client with peptic ulcer disease who has been prescribed misoprostol. What information from the nurse would be most accurate about misoprostol?

Prevents ulceration in clients taking nonsteroidal anti-inflammatory drugs (NSAIDs)

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect?

Vasomotor symptoms associated with dumping syndrome

A client recovering from a total gastrectomy has a low red blood cell count. Which medication will the nurse expect to be prescribed for this client?

Vitamin B12 injections -Intrinsic factor is secreted by the parietal cells in the stomach, which binds to vitamin B12 so it can be absorbed in the ileum. With the loss of some parietal cells, there is a deficiency in vitamin B12, which leads to a decreased production of red blood cells or pernicious anemia. Treatment would be vitamin B12 injections for life. Oral iron tablets would be prescribed for iron deficiency anemia. Erythropoietin injections would be prescribed for anemia caused by kidney disease. The client is not actively bleeding and would not need transfusions of packed RBCs.

Signs of hemorrhage following surgery include

cool skin, confusion, increased heart rate, labored breathing, and blood in the stool.

The nurse recognizes that the client diagnosed with a duodenal ulcer will likely experience

pain 2 to 3 hours after a meal. -The client with a duodenal ulcer often awakens between 1 and 2 with pain, and ingestion of food brings relief. Vomiting is uncommon in the client with duodenal ulcer. Hemorrhage is less likely in the client with duodenal ulcer than in the client with gastric ulcer. The client with a duodenal ulcer may experience weight gain.

Dehiscence of the surgical wound is characterized by

pain and a pulling or popping feeling at the surgical site.

Omeprazole is classified as a

proton pump inhibitor

Lansoprazole and esomeprazole are

proton pump inhibitors (PPIs).

Peritonitis presents with a

rigid, board-like abdomen, tenderness, and fever.

Signs of penetration and perforation are

severe abdominal pain, rigid and tender abdomen, vomiting, elevated temperature, and increased heart rate.

A healthcare provider prescribes a combination of drugs to treat reoccurring peptic ulcer disease, and the client asks the nurse the reason for all the medications. What teaching should the nurse review with the client?

The bismuth salts, antibiotics, and proton pump inhibitors will work together to suppress or eradicate H. pylori.

Signs of bleeding include

tachycardia, tachypnea, hypotension, mental confusion, thirst, and oliguria.

A client diagnosed with a peptic ulcer says, "Now I have something else I have to worry about." Which actions will the nurse take to help reduce the client's anxiety? Select all that apply.

- Interact with the client in a relaxed manner. - Help identify the client's current stressors. - Discuss potential coping techniques with the client. - Offer information about relaxation methods.

A client is prescribed a histamine (H2)-receptor antagonist. The nurse understands that this might include which medication(s)? Select all that apply.

- Nizatidine - Famotidine - Cimetidine

The nurse is caring for a client with chronic gastritis. Which interventions will the nurse add to this client's plan of care? Select all that apply.

- Remind to avoid alcohol intake. - Review actions to reduce stress. - Provide omeprazole as prescribed. - Instruct to avoid foods that aggravate the condition.

Which of the following are characteristics associated with the Zollinger-Ellison syndrome (ZES)? Select all that apply.

- Severe peptic ulcers - Extreme gastric hyperacidity - Gastrin-secreting tumors of the pancreas

A nursing student is preparing a teaching plan about peptic ulcer disease. The student knows to include teaching about the percentage of clients with peptic ulcers who experience bleeding. The percentage is

15%

A client weighing 165 lb. (75 kg) is being treated for acute gastritis. Which amount of urine output for 4 hours would indicate an adequate fluid balance if the output should be 1 mL/kg/hour?

300

The nurse practitioner suspects that a patient may have a gastric ulcer after completing a history and physical exam. Select an indicator that can be used to help establish the distinction between gastric and duodenal ulcers.

Amount of hydrochloric acid (HCL) secretion in the stomach -A duodenal ulcer is characterized by hypersecretion of stomach acid, whereas a gastric ulcer shows evidence of hyposecretion of stomach acid. The other three choices have similar characteristics in both types of ulcers.

A client with peptic ulcer disease has a blood pressure of 88/40 mm Hg, dizziness, and nausea. Which complication will the nurse suspect is occurring with this client?

Bleeding from the ulcer - Bleeding peptic ulcers account for 27% to 40% of all upper GI bleeds and it may be manifested by hematemesis or melena. Faintness or dizziness and nausea may precede or accompany bleeding. A low blood pressure could indicate active bleeding. The client's symptoms do not indicate evidence of the ulcer healing. It is unlikely that the client's symptoms are adverse effects or allergic responses to the medications.

A client who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the client reported cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the nurse educate the client about regarding this event?

Dumping syndrome -Dumping syndrome is an unpleasant set of vasomotor and GI symptoms that occur in up to 76% of patients who have had bariatric surgery. Early symptoms include a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. These symptoms resolve once the intestine has been evacuated (i.e., with defecation).

Clients with Type O blood are at higher risk for which of the following GI disorders?

Duodenal ulcers -Familial tendency also may be a significant predisposing factor. People with blood type O are more susceptible to peptic ulcers than are those with blood type A, B, or AB. Blood type is not a predisposing factor for gastric cancer, esophageal varices, and diverticulitis.

A health care provider suspects that a client has peptic ulcer disease. With which diagnostic procedure would the nurse most likely prepare to assist?

Endoscopy -Barium study of the upper GI tract may show an ulcer; however, endoscopy is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. Through endoscopy, a biopsy of the gastric mucosa and of any suspicious lesions can be obtained. Endoscopy may reveal lesions that, because of their size or location, are not evident on x-ray studies. Less invasive diagnostic measures for detecting H. pylori include serologic testing for antibodies against the H. pylori antigen, stool antigen test, and urea breath test.

A Billroth I procedure involves removal of

the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. A vagotomy severs the vagus nerve; a Billroth I procedure may be performed in conjunction with a vagotomy. If the remaining part of the stomach is anastomosed to the jejunum, the procedure is a Billroth II.

Metronidazole is an

antibiotic.

A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which explanation from the nurse would be most accurate?

"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."

A client has recently been diagnosed with gastric cancer. On palpation, the nurse would note what two signs that confirm metastasis to the liver? Select all that apply.

- Ascites - Hepatomegaly

The nurse is caring for a client who has developed dumping syndrome while recovering from a gastrectomy. What recommendation should the nurse make to the client?

Eat several small meals daily spaced at equal intervals. -The client with dumping syndrome should consume small meals at intervals to reduce symptoms. The client should not consume fluids with meals. Carbohydrates should be limited and sitting upright does not relieve the symptoms.

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

Eat small, frequent meals with high calorie and vitamin content. -The nurse encourages the client 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 client is preparing for discharge to home following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal?

Slows gastric emptying -Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful. Promoting rest after a major surgery is helpful in recovery but not the reason for resting after meals. Following this type of surgery, clients will have a need for vitamin B12 supplementation due to absence of production of intrinsic factor in the stomach. Resting does not increase absorption of B12 or remove tension on suture line.

A 66-year-old African-American client has recently visited a physician to confirm a diagnosis of gastric cancer. The client has a history of tobacco use and was diagnosed 10 years ago with pernicious anemia. He and his family are shocked about the possibility of cancer because he was asymptomatic prior to recent complaints of pain and multiple gastrointestinal symptoms. On the basis of knowledge of disease progression, the nurse assumes that organs adjacent to the stomach are also affected. Which of the following organs may be affected? Choose all that apply.

- Liver - Pancreas - Duodenum

Early manifestations of dumping syndrome occur

15 to 30 minutes after eating. - Signs and symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, diarrhea, nausea, and the desire to lie down.

Signs and symptoms of perforation includes

sudden, severe upper abdominal pain (persisting and increasing in intensity); pain may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm.

A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?

"I will have to take vitamin B12 shots up to 1 year after surgery." -After a total gastrectomy, a client will need to take vitamin B12 shots for life. Dietary B12 is absorbed in the stomach, and the inability to absorb it could lead to pernicious anemia. Visiting clergy for emotional support is normal after receiving a cancer diagnosis. This action should be encouraged by the nurse. It's appropriate for the client to call the physician if he experiences signs and symptoms of intestinal blockage or obstruction, such as abdominal pain. Because a client with a total gastrectomy will receive enteral feedings or parenteral feedings, he should weigh himself each day and keep a record of the weights.

A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems?

Acute gastritis -A client with acute gastritis may have a rapid onset of symptoms, including abdominal discomfort, headache, lassitude, nausea, anorexia, vomiting, and hiccupping, which can last from a few hours to a few days. Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. A client with a duodenal ulcer will present with heartburn, nausea, excessive gas and vomiting. A client with gastric cancer will have persistent symptoms of nausea and vomiting, not sudden symptoms. A client with a gastric ulcer will have bloating, nausea, and vomiting, but not necessarily hiccups.

A client with a peptic ulcer is diagnosed with Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole, omeprazole, and clarithromycin. Which statement by the client indicates the best understanding of the medication regimen?

"The medications will kill the bacteria and stop the acid production."

A client being treated for a peptic ulcer seeks medical attention for vomiting blood. Which statement indicates to the nurse the reason for the client developing hematemesis?

"The pain stopped so I stopped taking the medications." -The client should be instructed to adhere to and complete the medication regimen to ensure complete healing of the peptic ulcer. Because most clients become symptom free within a week, it should be stressed to the client the importance of following the prescribed regimen so that the healing process can continue uninterrupted and the return of symptoms can be prevented. Since the client stopped taking the medication, the ulcer was not healed and became worse. The statements about soda, being nauseated, and eating only one meal would not explain the reason for the client's new onset of hematemesis during treatment for a peptic ulcer.

A client with gastric cancer is scheduled to undergo a Billroth II procedure. The client's spouse asks how much of the client's stomach will be removed. What would be the most accurate response from the nurse?

Approximately 75% -The Billroth II is a wide resection that involves removing approximately 75% of the stomach and decreases the possibility of lymph node spread or metastatic recurrence.

A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply.

- Ingestion of strong acids - Irritating foods - Overuse of aspirin

Which ulcer is associated with extensive burn injury?

Curling ulcer -Curling ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum.

A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer.

Omeprazole -Omeprazole (Prilosec) is a proton pump inhibitor that, if used according to the health care provider's directions, will result in healing in 90% of patients. The other drugs are H2 receptor antagonists that need to be used for 6 weeks.

A client is prescribed tetracycline to treat peptic ulcer disease. Which instruction would the nurse give the client?

"Be sure to wear sunscreen while taking this medicine."

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:

drink liquids only between meals. -A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.

Famotidine is a

histamine-2 receptor antagonist.

The spouse of a client recovering from a partial gastrectomy for cancer is concerned about the client's nutrition once discharged home. Which response will the nurse make?

"I can ask a dietitian to talk with you about foods and meal preparation."

The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client makes which statement?

"I have learned some relaxation strategies that decrease my stress."

A client with an H. pylori infection asks why bismuth subsalicylate is prescribed. Which response will the nurse make?

"It aids in the healing of the stomach lining." -Bismuth subsalicylate suppresses H. pylori bacteria in the gastric mucosa and assists with healing of mucosal ulcers. It does not affect digestion, enhance the function of the pyloric sphincter, or propel food from the stomach into the duodenum.

A nurse is teaching a client who has experienced an episode of acute gastritis. The nurse knows further education is necessary when the client makes which statement?

"My appetite should come back tomorrow." -The gastric mucosa is capable of repairing itself after an episode of gastritis. As a rule, the client recovers in about 1 day, although the appetite may be diminished for an additional 2 or 3 days. Acute gastritis is also managed by instructing the client to refrain from alcohol and food until symptoms subside. When the client can take nourishment by mouth, a nonirritating diet is recommended.

A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.)

- "It can be caused by ingestion of strong acids." - "You may have ingested some irritating foods." - "Is it possible that you are overusing aspirin."

A client recovering from surgery for gastric cancer develops dumping syndrome. Which teachings will the nurse provide to reduce the symptoms of this condition? Select all that apply.

- Ingest 6 small meals a day. - Eat foods low in carbohydrates.

A young adult client is prescribed misoprostol to prevent gastric ulcers caused by frequent use of nonsteroidal anti-inflammatory agents for an autoimmune disorder. For which reason will the nurse question giving the client a dose of this medication?

Awaiting the results of a pregnancy test -Misoprostol is a synthetic prostaglandin that protects the gastric mucosa from agents that cause ulcers, and also increases mucus production and bicarbonate levels. It is a pregnancy category X medication and should not be taken by a pregnant client as it can soften the cervix and result in miscarriage or premature labor. This medication does not cause constipation. Sucralfate needs to be taken without food. Misoprostol can cause diarrhea and cramping; however, this is not the reason to question giving the client a dose of the medication.

The nurse is assessing a client with advanced gastric cancer. The nurse anticipates that the assessment will reveal which finding?

Bloating after meals -Symptoms of progressive disease include bloating after meals, weight loss, abdominal pain above the umbilicus, loss or decrease in appetite, and nausea or vomiting.

Which of the following clients is at highest risk for peptic ulcer disease?

Client with blood type O

The nursing student approaches his instructor to discuss the plan of care for his client diagnosed with peptic ulcer disease. The student asks what is the most common site for peptic ulcer formation? The instructor would state which one of the following?

Duodenum -Peptic ulcers occur mainly in the gastroduodenal mucosa because this tissue cannot withstand the digestive action of gastric acid (HCl) and pepsin.

The nurse visits the home of a client recovering from acute gastritis. Which observation indicates that teaching about the disorder was effective?

Medications placed in a pillbox -The client with acute gastritis should be instructed on methods of keeping track of medications such as placing the doses into a pillbox. The client should also be instructed about foods and substances that may cause gastritis, including nicotine, spicy seasoned foods, and caffeine. Cigarettes in the ashtray, tomato sauce, and caffeinated coffee indicate that additional teaching is required.

Which medication classification represents a proton (gastric acid) pump inhibitor?

Omeprazole -Omeprazole decreases gastric acid by slowing the hydrogen-potassium adenosine triphosphatase pump on the surface of the parietal cells. Sucralfate is a cytoprotective drug. Famotidine is a histamine-2 receptor antagonist. Metronidazole is an antibiotic, specifically an amebicide.

When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain in the right shoulder. What is the initial appropriate action by the nurse?

Assess the client's abdomen and vital signs.

Indicators of pyloric obstruction are

nausea, vomiting, distended abdomen, and abdominal pain.

The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage?

Hematemesis

Which of the following medications is classified as a proton pump inhibitor (PPI)?

Omeprazole

A client with gastric ulcers caused by H. pylori is prescribed metronidazole. Which client statement indicates to the nurse that teaching about this medication was effective?

"It might cause a metallic taste in my mouth." -Metronidazole is a synthetic antibacterial and antiprotozoal agent that assists with eradicating H. pylori bacteria in the gastric mucosa when given with other antibiotics and proton pump inhibitors. This medication may cause a metallic taste in the mouth. It should not be taken with anticoagulants as it will increase the blood thinning effects of warfarin. Alcohol should be avoided while taking this medication. This medication may cause anorexia and not an increased appetite.

A client with a peptic ulcer asks, "How does something that goes into my lungs, like smoking, affect my stomach?" Which response by the nurse is most appropriate?

"Smoking reduces the amount of bicarbonate needed to buffer stomach acid."

A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed?

A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum.

A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, labored breathing, and appears to be confused. Which complication has the client most likely developed?

Hemorrhage

A client sustained second- and third-degree burns over 30% of the body surface area approximately 72 hours ago. What type of ulcer should the nurse be alert for while caring for this client?

Curling's ulcer -Curling's ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum. Peptic, esophageal, and Meckel's ulcers are not related to burn injuries.