Ch. 55 Care of Patients with Stomach Disorders

The nurse has placed a nasogastric (NG) tube in a patient with upper gastrointestinal (GI) bleeding to administer gastric lavage. The patient asks the nurse about the purpose of the NG tube for the procedure. What is the nurse's best response? "A fluid solution goes down the tube to help clean out your stomach." "The medication goes down the tube to help clean out your stomach." "The primary health care provider requested the tube to be placed just in case it was needed." "We'll start feeding you through it once your stomach is cleaned out."

"A fluid solution goes down the tube to help clean out your stomach." **The nurse's best response to the patient with upper GI bleeding about the purpose of a NG tube for gastric lavage is that fluid is put down the tube to clean out the stomach. Gastric lavage involves the instillation of a room-temperature solution of water or saline in volumes of 200 to 300 mL through an NG tube to clear out stomach contents and blood clots.Gastric lavage does not involve the instillation of medication. An NG tube is not typically placed in a patient without a particular purpose in mind. Gastric lavage does not involve enteral feeding.

The nurse is teaching a patient about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the patient indicates a need for further teaching? "I will need to avoid sweetened fruit juice beverages." "I can eat ice cream in moderation." "I cannot drink alcohol at all." "It is okay to have a serving of sugar-free pudding."

"I can eat ice cream in moderation." **A need for further teaching about dietary changes related to dumping syndrome is indicated when the patient says that ice cream can be eaten in moderation. Milk products such as ice cream must be eliminated from the diet of a patient with dumping syndrome.The patient with dumping syndrome can no longer consume sweetened drinks. Alcohol must also be eliminated from the diet. The patient can eat sugar-free pudding, custard, and gelatin but with caution.

The nurse is teaching a patient how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the patient demonstrates a correct understanding of the nurse's instruction? "It is okay to continue to drink coffee in the morning when I get to work." "I will need to take vitamin B12 shots for the rest of my life." "I should avoid alcohol and tobacco." "I should eat small meals about six times a day."

"I should avoid alcohol and tobacco." **The patient's statement that he/she needs to avoid alcohol and tobacco shows that the patient correctly understands the nurse's instructions. The patient with chronic gastritis should avoid alcohol and tobacco.The patient also needs to eliminate caffeine from the diet. The patient will need to take vitamin B12 shots only if he/she has pernicious anemia. The patient would also not eat six small meals daily. This practice may actually stimulate gastric acid secretion.

The nurse is teaching a patient with peptic ulcer disease (PUD) about the prescribed drug regimen. Which statement made by the patient indicates a need for further teaching before discharge? "Nizatidine (Axid) needs to be taken three times a day to be effective." "Taking ranitidine (Zantac) at bedtime should decrease acid production at night." "Sucralfate (Carafate) should be taken 1 hour before and 2 hours after meals." "Omeprazole (Prilosec) should be swallowed whole and not crushed."

"Nizatidine (Axid) needs to be taken three times a day to be effective." **Further discharge teaching is needed when the patient says that Nizatidine works best when taken three times a day. Nizatidine is most effective if administered once daily.A dose of ranitidine at bedtime would decrease acid production throughout the night. Sucralfate is taken 1 hour before and 2 hours after meals. Because omeprazole is a delayed-release capsule, it needs to be swallowed whole and not crushed.

A patient with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response? "No, they probably won't be useful. You should use only prescription medications in your treatment plan." "These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." "Yes, these are known to be effective in managing this disease but make sure you research the herbs thoroughly before taking them." "No, herbs are not useful for managing this disease. You can use any type of over-the-counter drugs though. They have been shown to be safe."

"These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." **The nurse's best response is that although licorice and slippery elm may be helpful in managing PUD, the patient must consult his or her primary health care provider before making a change in the treatment regimen.Alternative therapies may or may not be helpful in managing PUD. The patient must not use over-the-counter medications without first discussing it with his or her primary health care provider.

An older female patient is diagnosed with gastric cancer. Which statement made by the patient's family demonstrates a correct understanding of the disorder? "This may be related to her recurring ulcer disease." "This cancer is probably curable with surgery." "Gastric cancer has a strong genetic component." "Thank goodness she won't have to undergo surgery."

"This may be related to her recurring ulcer disease." **Correct understanding of a patient's diagnosis of gastric cancer is indicated when they family states that the diagnosis could be related to the patient's ulcer disease. Infection with Helicobacter pylori is the largest risk factor for gastric cancer because it carries the cytotoxin-associated antigen A (CagA) gene. Patients with chronic ulcers are probably infected with this organism.Surgery is often not curative because most gastric cancers do not present with symptoms until late in the disease and have a high fatality rate. There is no strong genetic predisposition to gastric cancer. Surgery is part of the treatment.

A patient has a long-term history of Crohn's disease and has recently developed acute gastritis. The patient asks the nurse whether Crohn's disease was a direct cause of the gastritis. What is the nurse's best response? "Yes, Crohn's disease is known to be a direct cause of the development of chronic gastritis." "We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop." "What has your doctor told you about how your gastritis developed?" "Yes, a familial tendency to inherit Crohn's disease and gastritis has been reported. Have your other family members been tested for Crohn's disease?"

"We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop." **The nurse's best response is that Crohn's disease may be an underlying disease process when chronic gastritis develops, but not when acute gastritis occurs. It is not known to be a direct cause of the disease.Although Crohn's disease tends to run in families, gastritis is a symptom of other disease processes. It is not a disease process in and of itself. Asking the patient what the doctor has said is an evasive response on the part of the nurse and does not help answer the patient's question.

Psychological Integrity

*Allow pts with gastric cancer to express feelings of grief, fear, and anxiety

Health Promotion and Maintenance

*Identify pts at risk for gastritis and PUD, especially those with H. pylori and older adults who take large amounts of NSAIDs *Teach pts to prevent PUD by avoiding excess consumption of caffeine, alcohol, coffee, aspirin, NSAIDs, and contaminated food and water by avoiding smoking *Teach pts to adhere to H. pylori treatment to prevent development of gastric cancer

Physiological Integrity

*Remember that pts with gastric ulcers may be malnourished and have pain that is worsened by ingestion of food; pts with duodenal ulcers are usually well nourished, have pain that is relieved by ingestion of food and awaken with pain during the night *Teach that hematemesis is a medical emergency and refer to emergency department for prompt treatment *Teach pt proper administration of antacids (1 or 2 after meals), reminding pts antacids can interfere with effectiveness of certain drugs, such as phenytoin (Dilantin) *Teach proper administration of H2 antagonists and explain that they should be taken at bedtime *Monitor pts with ulcers for s&s of upper GI bleeding *After an EGD, monitor vitals, heart rhythm, and oxygen saturation frequently until they return to baseline. Prevent aspiration by assessing the gag reflex and ensure it is intact before giving pt food or fluids *observe s&s of dumping syndrome after gastric surgery

Nurse is giving meds and recognizes which drugs contribute to signs and symptoms of gastritis?

-aspirin taken once daily to prevent cardiac concerns -naproxen taken once daily for joint pain associated with arthritis -prednisone tapered over a 14day period to decrease inflammation associated with acute sinus infection

The nurse finds a patient vomiting coffee-ground emesis. On assessment, the patient has a blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority? Administering a histamine2 (H2) antagonist Initiating enteral nutrition Administering intravenous (IV) fluids Administering antianxiety medication

Administering intravenous (IV) fluids **The nurse's first priority is to administer intravenous (IV) fluids. Administering IV fluids is necessary to treat the hypovolemia caused by acute gastrointestinal (GI) bleeding.Administration of an H2 antagonist will not treat the basic problem, which is upper GI bleeding. Enteral nutrition will not be part of the treatment plan for acute GI bleeding. Administration of antianxiety medication will not treat the acute confusion. The patient's change in mental status is due to hypovolemia caused by acute GI bleeding.

A patient with gastric cancer is scheduled to undergo surgery to remove the tumor once 5 pounds (2.3 kg) of body weight has been regained. The patient is not drinking the vanilla-flavored enteral supplements that have been prescribed. Which is the highest priority nursing intervention for this patient? Explain to the patient the importance of drinking the enteral supplements prescribed. Ask the patient's family to try to persuade the patient to drink the supplements. Inform the patient that a nasogastric tube may be necessary if he or she fails to comply. Ask the patient if a change in flavor would make the supplement more palatable.

Ask the patient if a change in flavor would make the supplement more palatable. **The highest priority nursing intervention for this patient is to ask the patient if a change in flavor would make the supplement more palatable. This action helps show that the nurse is attempting to determine why the patient is not drinking the supplements. Many patients don't like certain supplement flavors.The nurse would not assume that the patient does not understand the importance of drinking the supplements or that the patient requires persuasion to drink the supplements. The problem may be entirely different. Telling the patient that a nasogastric tube may be necessary could be construed as threatening the patient.

Surgery for PUD teaching

Avoid any OTC product containing aspirin or other NSAID Stress importance of following treatment regimen for H.pylori infection and healing of ulcer and keeping of follow-up appts Help pt identify situations that cause stress, describe feelings during stressful situations and develop a plan for coping with stressors

Peptic Ulcer Disease teaching

Avoid substances that increase gastric acid secretion (caffeine>>coffee, tea, cola) Seek immediate medical attention if experiencing any of these symptoms: -sharp sudden persistent and severe epigastric or abdominal pain -bloody or black stools Bloody vomit or vomit that looks like coffee grounds

The nurse is monitoring a patient with gastric cancer for signs and symptoms of upper gastrointestinal bleeding. Which change in vital signs is most indicative of bleeding? Respiratory rate from 24 to 20 breaths/min Apical pulse from 80 to 72 beats/min Temperature from 97.9° F to 98.9° F (36.6°C to 37.2°C) Blood pressure from 140/90 to 110/70 mm Hg

Blood pressure from 140/90 to 110/70 mm Hg **A decrease in blood pressure from 140/90 to 110/70 is the most indicative sign of bleeding.A slight decrease in respiratory rate, apical pulse, and temperature is not the primary indication of bleeding.

The nurse and the dietitian are planning sample diet menus for a patient who is experiencing dumping syndrome. Which sample meal is best for this patient? Chicken salad on whole wheat bread Liver and onions Chicken and rice Cobb salad with buttermilk ranch dressing

Chicken and rice **Chicken and rice is the best sample meal for this patient. It is the only selection suitable for the patient who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products.The patient with dumping syndrome would not be allowed to have mayonnaise, onions, or buttermilk ranch dressing. Buttermilk dressing is made from milk products. The patient can have whole wheat bread only in very limited amounts.

H.pylori infection in older adults

In older adults usually undiagnosed bc of vague symptoms associated with physiologic changes in aging and comorbidities that mask dyspepsia Teach older adults about symptoms of PUD and consider H.pylori screening Early detection and treatment can prevent PUD and gastric cancer

The admission assessment for a patient with acute gastric bleeding indicates blood pressure 82/40 mm Hg, pulse 124 beats/min, and respiratory rate 26 breaths/min. Which admission request does the nurse implement first? Type and crossmatch for 4 units of packed red blood cells. Infuse 0.9% normal saline solution at 200 mL/hr. Give pantoprazole (Protonix) 40 mg IV now and then daily. Insert a nasogastric tube and connect to low intermittent suction.

Infuse 0.9% normal saline solution at 200 mL/hr. **The nurse must first infuse 0.9% normal saline solution at 200 mL/hr for the patient with acute gastric bleeding and hypotension associated with volume loss. The most rapidly available volume expanders are crystalloids to treat hypovolemia.A type and crossmatch, administration of pantoprazole, and insertion of a nasogastric tube must all be done, but the nurse's immediate concern is correcting the patient's hypovolemia.

Priory care of upper GI bleeding

Maintain A: airway, B:breathing, C:circulation Provide oxygen and other ventilatory support, 2 large bore IV lines for replacing fluids and blood, monitoring vital signs, hematocrit and oxygen saturation

The nurse reviews a medication history for a patient newly diagnosed with peptic ulcer disease (PUD) who has a history of using ibuprofen (Advil) frequently for chronic knee pain. The nurse anticipates that the primary health care provider will request which medication for this patient? Bismuth subsalicylate (Pepto-Bismol) Magnesium hydroxide (Maalox) Metronidazole (Flagyl) Misoprostol (Cytotec)

Misoprostol (Cytotec) **The nurse expects that the primary health care provider will request that Misoprostol be given to the patient. Misoprostol is a prostaglandin analogue that protects against nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers.Bismuth subsalicylate is an antidiarrheal drug that contains salicylates, which can cause bleeding and would be avoided in patients who have PUD. Magnesium hydroxide is an antacid that may be used to neutralize stomach secretions but is not used specifically to help prevent NSAID-induced ulcers. Metronidazole is an antimicrobial agent used to treat Helicobacter pylori infection.

After EGD

Monitor vitals, heart rhythm, and oxygen saturation frequently until return to baseline Assess pt'a ability to swallow saliva Pt gag reflex may initially be absent after bc of numbing the throat with spray before procedure After procedure, DO NOT let pt have food or liquids until gag reflex is intact!!!!

The nurse is caring for an older adult male patient who reports stomach pain and heartburn. Which sign/symptom is most significant suggesting the patient's ulceration is duodenal in origin and not gastric? Pain occurs 1½ to 3 hours after a meal, usually at night. Pain is worsened by the ingestion of food. The patient has a malnourished appearance. The patient is a man older than 50 years.

Pain occurs 1½ to 3 hours after a meal, usually at night. **A key symptom of duodenal ulcers is that pain usually awakens the patient between 1:00 a.m. and 2:00 a.m. and occurs 1½ to 3 hours after a meal.Pain that is worsened with ingestion of food and a malnourished appearance are key features of gastric ulcers. A male over 50 years is a finding that could apply to either type of ulcer.

The nurse is reviewing admitting requests for a patient admitted to the intensive care unit with perforation of a duodenal ulcer. Which request does the nurse implement first? Apply antiembolism stockings. Place a nasogastric (NG) tube, and connect to suction. Insert an indwelling catheter, and check output hourly. Give famotidine (Pepcid) 20 mg IV every 12 hours.

Place a nasogastric (NG) tube, and connect to suction. **When caring for an ICU patient with a perforated duodenal ulcer, the nurse or primary care provider must first insert a nasogastric (NG) tube and connect it to suction. To decrease spillage of duodenal contents into the peritoneum, NG suction would be rapidly initiated. This will minimize the risk for peritonitis.Antiembolism stockings will need to be applied, monitoring urined output is important, and famotidine (Pepcid) will need to be administered, but these are done after the NG tube is inserted and connected to suction.

When caring for a pt. Who has just had an upper GI endoscopy, the nurse assesses that the pt has developed a temperature of 101.8 degrees. What's the approval nursing intervention?

Prompt asses the pt for potential perforation

A patient is scheduled to be discharged home after a gastrectomy and will need to perform daily dressing changes on the surgical wound. What is the nurse's highest priority intervention? Providing both oral and written instructions to the patient and his spouse on changing the dressing and on symptoms of infection that must be reported to the provider Asking the primary health care provider for a referral for home health services to assist with dressing changes Asking the spouse if any other family members are in the medical profession and could help change the dressing Offer literature on dressing changes and schedule follow-up phone calls with the patient and spouse to talk them through dressing changes when at home.

Providing both oral and written instructions to the patient and his spouse on changing the dressing and on symptoms of infection that must be reported to the provider **The nurse's highest priority intervention for a post-op gastrectomy patient about to be discharged with daily dressing changes is to provide the patient and spouse with both oral and written instructions on what to report to the provider, and how to perform the dressing changes. This will reinforce important points needed about what information to report to the provider as well as properly caring for the wound.Obtaining a referral and recruiting other family members prevents the patient and spouse from taking responsibility for the patient's care. Follow-up phone calls and written literature won't provide assurance that wound care is being done properly or that teaching was effective.

Which patient assessment information is correlated with a diagnosis of chronic gastritis? Anorexia, nausea, and vomiting Frequent use of corticosteroids Hematemesis and anorexia Radiation therapy, smoking, and excessive alcohol use

Radiation therapy, smoking, and excessive alcohol use **Treatment with radiation therapy, smoking, and alcohol use are known to be associated with the development of chronic gastritis.Anorexia, nausea, and vomiting are all signs and symptoms of acute gastritis. Corticosteroid use and hematemesis are also more likely to be signs and symptoms of acute gastritis.

Which nursing action is best for the charge nurse to delegate to an experienced LPN/LVN? Retape the nasogastric tube for a patient who has had a subtotal gastrectomy and vagotomy. Reinforce the teaching previously done by the RN about avoiding alcohol and caffeine for a patient with chronic gastritis. Document instructions for a patient with chronic gastritis about how to use "triple therapy." Assess the gag reflex for a patient who has arrived from the post anesthesia care unit after a laparoscopic gastrectomy.

Reinforce the teaching previously done by the RN about avoiding alcohol and caffeine for a patient with chronic gastritis. **The best nursing action to delegate to the experienced LPN/LVN is to reinforce patient teaching previously done by the RN to a patient with chronic gastritis about avoiding alcohol and caffeine. Reinforcement of teaching done by the RN is within the scope of practice for an LPN/LVN.Retaping the nasogastric tube for a patient who has had a subtotal gastrectomy and vagotomy is a complex task that would be done by the RN. Documenting instructions about how to use triple therapy are nursing functions that would be done by the RN. Assessment of a patient's gag reflex is also an RN nursing function.

A patient has been discharged home after surgery for gastric cancer, and a case manager will follow up with the patient. To ensure a smooth transition from the hospital to the home setting, which information provided by the hospital nurse to the case manager is given the highest priority? Schedule of the patient's follow-up examinations and diagnostic testing Information on family members' progress in learning how to perform dressing changes Copy of the diet plan prepared for the patient by the hospital dietitian Detailed account of what occurred during the patient's surgical procedure

Schedule of the patient's follow-up examinations and diagnostic testing **The highest priority information the hospital nurse would give to the home case manager is a schedule of the patient's follow-up exams and diagnostic testing. Because recurrence of gastric cancer is common, it is important for the patient to have follow-up examinations and x-rays so that a recurrence can be detected quickly.It may take family members a long time to become proficient at tasks such as dressing changes. Although the case manager must be aware of the diet, family members will likely be preparing the patient's daily diet, and they would be provided with this information. It is not necessary for the case manager to have details of the patient's surgical procedure unless a significant event occurred during the procedure.

A patient is experiencing bleeding related to peptic ulcer disease (PUD). Which nursing intervention is the highest priority? Starting a large-bore IV Administering IV pain medication Preparing equipment for intubation Monitoring the patient's anxiety level

Starting a large-bore IV **The nursing intervention that has the highest priority for a patient with a bleeding peptic ulcer is to start a large-bore IV. A large-bore IV is inserted so that blood products can be administered.IV pain medication is not a recommended treatment for gastrointestinal bleeding. Intubation is also not recommended. The mental status of the patient would be monitored, but it is not necessary to monitor the anxiety level of the patient.

Antacids

To achieve a therapeutic effect, must be ingested to neutralize hourly production of acid Optimal effect: take about 2hrs after meals to reduce hydrogen ion load in duodenum May be effective from 30min-3hrs after ingestion Do not take on empty stomach

The nurse working during the day shift on the medical unit has just received report. Which patient does the nurse plan to assess first? Young adult with epigastric pain, hiccups, and abdominal distention after having a total gastrectomy Adult who had a subtotal gastrectomy and is experiencing dizziness and diaphoresis after each meal Middle-aged patient with gastric cancer who needs to receive omeprazole (Prilosec) before breakfast Older adult with advanced gastric cancer who is scheduled to receive combination chemotherapy

Young adult with epigastric pain, hiccups, and abdominal distention after having a total gastrectomy **After receiving shift report, the nurse would first assess the post-op total gastrectomy young adult with epigastric pain, hiccups and abdominal pain. This patient is experiencing symptoms of acute gastric dilation, which can disrupt the suture line. The surgeon must be notified immediately because the nasogastric tube may need irrigation or repositioning.The patient who had a subtotal gastrectomy is not in a life-threatening situation and does not require immediate assessment. The patient with gastric cancer and the older adult with advanced gastric cancer are in stable condition and do not require immediate assessment.