Unit VIII GASTROINTESTINAL SYSTEM

Current Health Problems Severe epigastric pain when laying down What type of food does she eat and when does she need it, How long has she had the problem, What medications does she do to take regularly.

• From the information given, state in one sentence what she reports is her "chief complaint," or "current health problem." • Do you need to ask any other questions about her history? What else is a "need to know" vs a "nice to know?"

Acute Gastritis manifestations

• Rapid onset of epigastric pain/ discomfort •Nausea and vomiting • Hematemesis • Gastric hemorrhage • Dyspepsia (heartburn) • Anorexia

Mrs.E.E.'s teaching moment

•After the physician told EE that she had GERD, she asks the nurse to help her understand what the doctor just told her. So.... The nurse should teach

clinical manifestations (GERD)

•There are many clinical manifestations of GERD, which of these does Mrs. E.E. complain of: •Dyspepsia (heartburn) •Regurgitation •Hypersalivation or water brash •Dysphagia (difficulty swallowing) and odynophagia (painful swallowing) •Other manifestations: chronic cough, asthma, atypical chest pain, belching, flatulence, bloating, after eating, nausea, and vomiting GERD range from mild irritation to cancer-causing cellular changes. • Hemorrhage bleeding into the esophagus • Dental caries from the breakdown of the enamel on your teeth from the acid • Aspiration pneumonia • Morning hoarseness • Adult-onset asthma from the aspiration and the irritation to the lung, bronchial trees • Laryngitis • Pharyngitis • Bronchitis

Nursing Care for constipation

•What diagnoses would you give a patient with diarrhea? • The nursing diagnosis of Constipation is given to a patient with constipation, name 4 interventions for this dx • 1. Increase fluids •2. Increase fiber •3. Undiluted apple juice •4. Provide enema or laxatives as treatment

Patients will present with heartburn or indigestion, nausea, vomiting. Those are the most common clinical manifestations dyspepsia the heartburn may occur after ingestion of certain medications, especially NSAIDs or alcohol. acute gastritis- They're having the heartburn or indigestion, nausea, vomiting things that irritate the stomach meds foods, alcohol, smoking

•What does the patient with acute gastritis look like? •What can be causes of their disease? •What can we teach this patient about their own care?

Physical Assessment

(Hoffman, pages 1259 - 1266) Physical assessment for anyone experiencing a GI disorder could include a GI focused assessment of the following: •Mouth and pharynx - offers insight into gastrointestinal and oral health. With a bright light, assess the oral mucosa, gums, tongue, general repair of dentition, jaw strength, and the ability to swallow. -Bleeding or lesions on the underside of the mouth may indicate oral cancer. Lesions on the tongue can impair taste and appetite or impair the ability to swallow and may contribute to decreased nutritional status. Missing teeth or dental pain can lead to malnutrition. • Abdomen- skin over the abdomen can provide valuable information about the underlying structure. skin for color, striae, lesions, presence of superficial vessels, and scarring. Additionally, the contour and shape of the abdomen are noted; the abdomen should be slightly concave to round. It is important to assess for fullness at the sides. A rounded abdomen from obesity can be confused with abdominal distention and requires further assessment through percussion and palpation. - Bulging masses on the abdomen may indicate tumors or hernias (displacement or protrusion of a part of the intestine). Pulsatile masses may indicate aneurysms (enlargement or bulging of an artery usually associated with weakening of the vascular wall). Striae, commonly known as stretch marks, may be seen with a rapid change in weight. They may also indicate endocrine disorders. Yellow coloring (jaundice) of the skin, and perhaps of the sclera of the eyes, or superficial vessels indicate the presence of liver disease. Blue or purple coloring (Cullen's sign) around the periumbilical area is often associated with intra-abdominal bleeding. The presence of stomas (Box 55.1) should be noted, including their color and size. Visible swollen, protruding veins underlying the skin of the anus are indicative of hemorrhoids. • Patient preparation •Orderly assessment • Inspection: contour, shape • Auscultation- • • Bowel sounds- absent/ borborygmus- Hypoactive bowel sounds can be a later indicator of obstruction, whereas hyperactive bowel sounds can be an early indication of obstruction, diarrhea, or inflammatory bowel disorders. Absent bowel sounds may indicate paralytic ileus caused by mechanical or neurological dysfunction. Bruits can indicate an arterial obstruction. • Percussion - Tympany can be the predominant sound when abdominal gas is present. The presence of fluid can displace air, and dullness can be the dominant sound. This can also indicate constipation. • Palpation • • Light, deep, rebound tenderness - A rigid abdomen can indicate pain, guarding, or peritonitis, which is inflammation of the peritoneal cavity. A mass may indicate a tumor, aneurysm, or hernia.

Diagnostic Examinations

(Hoffman, pages 1266 - 1272) There are a multitude of diagnostic exams that can be used to determine the cause of a patient's gastrointestinal (GI) issue. Mrs. E.E.'s signs and symptoms lead her physician to suspect she has GERD, a common GI condition, experienced by 15-20% of adults. The physician can choose to do diagnostic tests to back up this diagnosis, including: 24 hour ambulatory pH monitoring, an endoscopy of esophagus and stomach, and esophageal manometry.

Laboratory Tests

(Hoffman, pages 1266) There are many tests that can be run for patients experiencing GI issues, these include: (Mrs. E.E.'s condition did not warrant such extensive tests, she had a CBC and BMP which had results WNL) • Blood tests • CBC - provides important information about potential blood loss through assessment of the red blood cell count, hemoglobin, and hematocrit, and the white blood cell count is indicated for evaluation of inflammatory or infectious processes. • Clotting- suspected liver disease, a prothrombin time is important to assess clotting because this test measures the time required for prothrombin to be converted to thrombin and may be prolonged because of impaired synthesis of clotting factors in the liver. • Electrolytes (BMP, Chemistry panel,etc) - electrolyte imbalances associated with impaired absorption or excretion. • Liver function studies - are evaluated with suspected hepatic dysfunction. • Serum amylase/ lipase • Bilirubin • Urine tests - Urine analysis is indicated in patients with suspected pancreatitis because urine amylase is elevated in this disorder • Amylase, urobilinogen • Stool tests - patients with complaints of changes in bowel pattern, stool samples are collected for occult blood. • Blood, parasites, Clostridium difficile

General Nutritional Disorders

(Hoffman-Chapter 68 pages 1571 - 1582) Morbid Obesity Obesity has reached epidemic levels in the United States. According to the CDC 20 states have an obesity rate of at least 30% so 30% of their population is morbidly obese. Huge health risk problems from being obese and medical costs it's projected that 42% of American adults will be obese by the year 2030 Obesity increases mortality and significantly increases morbidity. Obesity and obesity-associated conditions significantly increase hospital length of stay and overall healthcare costs. Medicare and Medicaid finance 42% of the total medical costs attributed to obesity. Annual hospital costs are $160 million higher in patients who are obese and undergo the most common nonbariatric surgical procedures compared with their normal-weight counterparts. • An excess of adipose tissue • More accurately defined by body mass index (BMI) Table 68.1/ pg.1572 • • An indirect measure of body fat/ adipose tissue • • BMI= weight (kg)/ height (m) squared • • BMI Below 18.5= Underweight • • BMI 18.5- 24.9= Normal weight • • BMI of 25-29.9 kg/m2= overweight • • BMI of 30.0-34.9 kg/m2 = obesity (class 1) • • BMI of 35.0-39.9 kg/m2= obesity (class 2) • • BMI of 40.0 kg/m2 or greater= obese

Answer d. Fatigue So when we break down intrinsic factor right that's critical for absorbing by 12 that can lead to pernicious anemia causing fatigue, so fatigue is going to be our huge concern here

(Take a moment to think about this one before answering) What is a major concern for the patient who has been diagnosed with chronic gastritis? a. Bleeding gastric lesions b. Sharp abdominal pain c. Nausea and vomiting d. Fatigue

Another way (easier way) for BMI:

(Weight (pounds)/ (Height (inches))2) X 703 • Example: • • Same 5' 3" and 125 lb. individual • • (125/ (63)2) x 703= (125/ 3,969) x703= • • 0.031 x 703= 22.14 • • BMI= 22.14- although not exact will keep you within range

Diarrhea

(page 1152 Funds book) An increase in the frequency, volume, and fluid content of stool • Due to either malabsorption or water secretion in the bowel • Manifestation rather than a primary disorder • Can be acute (< a week) or chronic (> 3-4 weeks) • • Chronic can be due to inflammatory bowel disease, malabsorption, or endocrine disorders

Gastritis

(pages 1310 - 1315) •Definition: Inflammation of the gastric mucosa •Can be scattered or localized •Can be acute or nonerosive (chronic) •Pathophysiology •A break in the protective mucosal barrier causing mucosal injury Acute or Chronic

Restrictive Procedures

- Adjustable gastric banding (AGB). Laparoscopic AGB involves placement of a silicone band around the fundus of the stomach, causing a restriction in the amount of food intake. - Restrictive procedures cause weight loss by reducing gastric capacity and include adjustable gastric banding (AGB), sleeve gastrectomy, and gastric plication. Laparoscopic AGB (Fig. 68.2) involves the placement of a silicone band around the fundus of the stomach, causing a restriction in the amount of food intake. The band can be adjusted by a healthcare provider to decrease or increase the amount of restriction by injecting saline through a subcutaneous port in the abdominal wall. During a sleeve gastrectomy, most of the greater curvature of the stomach is removed, creating a smaller, sleeve-like tube. The remaining stomach is approximately 25% of its original capacity. Gastric plication, a new procedure, is still considered investigational. This procedure involves infolding of the greater curvature of the stomach to create gastric restriction.

Malabsorptive Procedures

- Jejunoileal bypass procedure (JIB). A jejunoileal bypass is an end-to-end anastomosis of the jejunum to the terminal ileum, bypassing a large portion of the small intestine, causing malabsorption. - Biliopancreatic diversion (BPD). Biliopancreatic diversion involves a bypass of the majority of the small intestine and removal of a large portion of the stomach, causing malabsorption. - Although malabsorptive procedures are no longer commonly performed and account for only 2% of the surgeries performed worldwide, there are many patients who had these procedures in the past and require regular follow-up care. These procedures induce weight loss through decreased nutrient absorption; jejunoileal bypass and biliopancreatic diversion are examples of these procedures. Jejunoileal bypass (Fig. 68.3) is an end-to-end anastomosis (surgical connection between structures that were surgically removed) of the jejunum to the terminal ileum, bypassing a large portion of the small intestine, where the majority of nutrient absorption occurs. Biliopancreatic diversion (Fig. 68.4) involves a bypass of the majority of the small intestine and the removal of a large portion of the stomach, causing malabsorption.

Erosive Gastritis (stress induced)

- Sever form of gastritis a complication of other life-threatening conditions (shock, severe trauma, surgery, etc) that are causing intense physiological stress Tissue injury due to gastric acid - you need adequate mucosal blood flow, it is important to maintain the mucosal barrier and to buffer any back to fused hydrogen ions - when blood flow is an adequate these processes fail and the mucosal breakdown occurs. •Complication of conditions •Inadequate gastric mucosal blood flow during periods of intense physiological stress Result: Various degrees of mucosal necrosis and inflammatory reaction •Can recover completely, self limiting

Answer: B Rationale: Wound care is always a priority in morbidly obese patients due to skin folds. Wound infection can be a complication after all surgical procedures, and good skin care will help prevent this from occurring. Fluid deficit is more common than fluid overload in patients after bariatric surgery. Depression, while possible, is not a condition that the nurse can likely prevent. A leak at the anastomosis site is not a condition that the nurse can prevent.

A nurse is developing the care plan for a client after bariatric surgery for morbid obesity. The nurse includes which of the following on the care plan as the priority complication to prevent? A. Fluid overload B. Wound infection C. Depression D. Anastomosis leak

Answer: C Rationale: Hypoventilation is a concern after all surgeries, but is particularly concerning in patients with obesity. Signs of surgical site infection will not show up immediately following surgery and postoperative education would be better received when the patient has had time to recover from anesthesia. Repositioning the nasogastric tube in a bariatric surgery patient is never safe.

A patient undergoes bariatric surgery. Immediately following surgery in the post-anesthesia care unit, which intervention has the highest priority? A. Assessing the surgical site for signs of infection B. Educating the patient on postoperative dietary restrictions C. Monitoring respiratory status for signs of hypoventilation D. Repositioning the nasogastric tube for optimal drainage

Answer: C Rationale: Bariatric surgery has been shown to increase life expectancy in patients with obesity. The nurse should avoid offering their opinion that is not based in facts, or reflect value-based statements.

A patient with a BMI of 37 kg/m2 asks a nurse about whether or not to have bariatric surgery. Which statement by the nurse is best? A. "Bariatric surgery is an option for patients with a BMI of 25 kg/m2." B. "Many patients have terrible complications from bariatric surgery." C. "Bariatric surgery in obese patients has been shown to increase life expectancy." D. "If you are unable to lose weight by dieting, bariatric surgery is the easy way out."

Gastric Analysis

After a period of fasting, gastric fluid is obtained through a nasogastric tube or during endoscopic procedure. The fluid is used to: • Measure gastric acidity • Assess for presence of: • Blood • Bacteria • Medications Patients must be NPO from 8-12 hours Patients should refrain from caffeine and alcohol intake at 24 hours prior to test. Pretest: Patient education; Remove loose dentures before test' Assess patient medication intake Intratest: Monitor for patient distress during nasogastric insertion Posttest: Monitor vital signs after procedure; Patient education on reporting symptoms associated with postprocedural complications, further treatment, or lifestyle modification options Gastrinlevels: Increased levels can occur with duodenal ulcers, Zollinger-Ellison syndrome (ZES), hypersecretion of antral gastric cells, resection of small intestines Decreased levels can occur with adrenal insufficiency, rheumatoid arthritis, thyroid toxicosis, pernicious anemia, chronic renal failure, and atrophic gastritis Cultures should be negative for Mycobacterium

Liver function tests

Alanine aminotransferase (ALT) Normal value: Male: 13-40 units/L Female: 24-36 units/L Albumin Normal: 3.4-5.1 g/dL Patient education on rationale for test and specimen collection methods Patient education on rationale for test and specimen collection methods Collected in red-top tube Previous intramuscular injections may cause ↑ levels Collected in gold-, gray-, or red-top tube ↑levels: Hepatitis; Cirrhosis; Obstructive jaundice; Pancreatitis; Cholestasis; Severe burns; ↑levels Dehydration ↓levels: Malnutrition; Thyroid disorders; Liver disorders; Hypervolemia; Genetic hypoalbuminemia

Answer •C. Pantoprazole (Protonix)

Another question about meds: The physician decides to prescribe Mrs.E.E. a proton pump inhibitor. Which drug is included in this classification? •A. Famotidine (Pepcid) •B. Mylanta •C. Pantoprazole (Protonix) •D. Ranitidine (Zantac)

Pathophysiology of Constipation

Can be a primary problem or manifestation of another disease/condition • Acute: Often caused by an organic process • Persistent change: May be due to a tumor or bowel obstruction • Chronic: problem with impaired storage, transport, and/or evacuation mechanisms> all impeding normal stool passage •See Table 47-1 page 1152(Fundamentals book) for causes of constipation

Constipation

Definition: Includes 2 of the following symptoms for at least 12 weeks in the past 12 months: • Fewer than 3 BMs/ week • Straining • Hard Stools • Incomplete evacuation • Manual evacuation required for 25% of BMs

Treatment of Constipation

Diagnosis: • • Barium enema, sigmoid/ colonoscopy, CT • Medications • • Laxatives, enemas • • Know when not to give, which conditions • Nutrition • • High fiber, fluids, ensure adequate intake of food and fluids in elderly

Alterations in Bowel Patterns

Diarrhea Constipation

Health History of the Gastrointestinal System

Dietary practices- Who prepares the food in your home? Do you fast for cultural or religious reasons? Do you have any dietary restrictions due to religious or cultural practices? How often do you eat? What do you consider to be healthy or unhealthy foods? Do you use food to treat illnesses? Any food intolerances? Any food allergies? Nutrition - Do you take vitamins? Any history of vitamin deficiencies? Completion of a food frequency questionnaire. Completion of nutritional screening tool. (MUST, Figure 55-11) Oral health - Do you see a dentist? How often per year? Do you have a history of dental caries or cavities? Do you wear dentures? Do you have gum disease? Have you been treated for oral candidiasis or oral cancer? Do you have difficulty swallowing or suffer with chronic hoarseness? Preventive health - What are your exercise habits? Have you had Hepatitis vaccines? Have you had a colonoscopy or sigmoidoscopy? What were the results? Weight changes - Have you had any unexplained weight loss or weight gain? Do you diet frequently? Any binging or purging? Do you ever make yourself vomit? Any hematemesis (blood in emesis) /hemoptysis (blood in sputum)? Calculate body mass index (BMI)? Appetite changes - Have you had increased hunger or thirst? Any early feeling of fullness? Stool changes - How often do you have a bowel movement? When was your last bowel movement? Have you noticed any changes in color, consistency, or odor? Have you noticed any bright red blood? Have you noticed undigested food? Any laxative use? Frequent flatus? Pain - Where is the pain? How often do you have pain? When do you have pain? What have you done to relieve the pain? What are the characteristics of your pain? Do you experience pain before or after eating meals? Do you experience pain with defecation?

Answer •C. Gastroscopy Gastroscopy, we put a scope down there. We can look at the lining. We can look at our stomach, we can look at that LES and that's going to help us to determine what's going on. CBC and BMP are blood work right not going to show us a cause it's just going to show us you know what our blood. You know, maybe our h&h was low, because we've had continuous slow bleeding in our esophagus that we didn't know about A barium swallow was showing structures but not cause

Ensuring the diagnosis of GERD •A diagnosis of GERD can be made based upon a patient's history and signs and symptoms. To ensure the diagnosis and seek a cause the physician can order which test? •A. CBC •B. BMP •C. Gastroscopy •D. Barium Swallow

Answer: A Rationale: Orlistat inhibits pancreatic lipase, thereby reducing dietary fat absorption. Lorcaserin affects chemicals in the brain that help to regulate appetite and increase the feeling of fullness after eating so less food is eaten. Phentermine is approved by the Food and Drug Administration to suppress appetite for up to 12 weeks.

In administering orlistat to a patient for weight loss, the nurse recognizes which as the mechanism of action of this medication? A. Reducing fat absorption B. Suppressing appetite C. Increasing satiety D Accelerating metabolic rate

Answer: B, C, and D Rationale: The assessment of a stoma includes the surrounding skins that should be consistent with the rest of the abdomen. The stoma itself should be pink and moist. The consistency of the stool is dependent upon the area of the stoma, and in the patient with an ileostomy, the stool is semi-liquid

In assessing the patient with an ileostomy, the nurse focuses on which "three Ss"? (Select all that apply.) A. Sensation B. Skin C. Stoma D. Stool E. Size

Answer: A Rationale: Automation makes the availability of food more convenient and requires less energy expenditure to both procure and prepare food. Increased appetite is considered a genetic factor and is also associated with function of the hypothalamus. Obesity is also associated with inheritance, with an increased chance of obesity in families. Growth hormone abnormalities are considered secondary factors to obesity.

In correlating contributing factors to the pathophysiology of obesity, which factor is considered environmental? A. Increased appetite B. Automation C. Growth hormone deficiency D. Obese family members

24 hour ambulatory pH monitoring

Involves continuous monitoring of gastric pH by monitoring and recording the pH of the stomach through a catheter placed in the nose so (down the nose), terminates in the distal esophagus (goes down to the distal esophagus) and then just continuous monitoring of the pH of the area; the patient keeps a diary of symptoms and activities and then pH monitoring is useful diagnostic tool used in patients with a typical symptoms, not something that they do often because a lot of times they patients have very typical symptoms with GERD

Physical Assessment Mrs. EE

Mrs. E.E.'s physical assessment shows: She is well nourished, and appears her stated age of 62. She is 5'6" and weighs 138lbs and her vital signs are: 120/82, 82, 16, 98.4. An exam of her mouth show some redness and irritation. Upon palpating her upper abdomen (the epigastric area) she expresses some discomfort. She states that at times the discomfort is so severe, she thinks she is having a heart attack (although she says the pain states right in her chest and feels like it is burning).

MRS.E.E.COMESTO THE CLINIC:

Mrs.E. E. is a 62-year-old female, retired teacher who presents today c/o severe epigastric pain when she lies down to sleep. She states that she has never had stomach problems prior to this. The pain usually is present shortly after meals and as she lies down to sleep or if she bends over and tries to clean house or do work in the garden. She often wakes up with burning in her throat and epigastric area, and sometimes has an unpleasant bile taste in her mouth.

Answer: D Rationale: Ms. Wiley does qualify for surgery based on BMI alone, but BMI is only a consideration for surgery. A and C provide inaccurate information. B is incorrect because the nurse should not impose personal beliefs on the patient.

Ms. Wiley asks if she qualifies for bariatric surgery. What is the best response by the nurse? A. "No. You are healthy and therefore do not qualify for bariatric surgery." B. "Yes. You meet the BMI criteria, but I would not recommend bariatric surgery for someone so young. I know someone who died from it." C. "No. You do not meet the BMI criteria for bariatric surgery." D. "Yes. You meet the BMI, but there are several other factors that determine whether someone should have bariatric surgery."

Answer: C Rationale: BMI is calculated by dividing weight in kilograms by height in meters squared.

Ms. Wiley is 5 ft 6 in. tall and weighs 256 lb. The nurse calculates her BMI to be which value? A. 19 kg/m2 B. 34 kg/m2 C. 41 kg/m2 D. 49 kg/m2

Answer: B Rationale: Roux-en-Y is a combination of a restrictive surgery and a malabsorptive surgery. While A is true, it does not factually answer the patient's question.

Ms. Wiley wants to know the key difference between the Roux-en-Y and adjustable gastric banding. Which explanation by the nurse is most accurate? A. "Some surgeons just prefer one over the other." B. "Roux-en-Y is a combination of a restrictive surgery and a malabsorptive surgery." C. "Adjustable gastric banding is designed to be temporary." D. "Roux-en-Y is a type of adjustable gastric banding."

GERD-Treating Mrs. E.E.

Much of what can be done for Mrs. E.E. is some simple changes in lifestyle and medication to ease the symptoms. Her GERD is simply a relaxing of the LES, here is what can help relieve her distress: • Nonsurgical Management • • Diet therapy • • Avoid or eliminate acidic foods • • Fatty foods, chocolate, peppermint, alcohol relax LES/ or delay gastric emptying • • caffeine, carbonated beverages, acidic foods, certain medications (if possible), such as calcium channel blockers, anticholinergic medications, and smooth muscle relaxers; Avoid NSAIDs and aspirin - These foods, substances, and medications are associated with decreasing LES pressure, which allows gastric reflux from the stomach into the esophagus. Both NSAIDs and aspirin can irritate the lining of the esophagus. • • Smaller, frequent meals- Eating large meals causes delayed gastric emptying and leads to gastric reflux; Eating three larger meals per day increases pressure in the stomach and delays gastric emptying. Eating four to six smaller meals decreases pressure. • Client education • Lifestyle changes: • • elevate HOB 6 inches for sleep (Lying on the right side promotes gastric emptying, and elevating the HOB promotes peristalsis and uses gravity to return gastric refluxate from the esophagus to the stomach. Sleeping in this position also decreases reflux at night) • • sleep in right lateral recumbent (where you're laying on your right side; it helps so that the acid stays in the fundus of the stomach and not up the esophagus • • stop smoking/ alcohol consumption (Both smoking and alcohol may lead to a decrease in LES pressure, increasing the risk of reflux) • • reduce weight (Obesity increases intra-abdominal pressure, increasing the hiatal hernia and GERD), • • wear nonbinding clothing(Tight clothing causes an increase in intra-abdominal pressure, which weakens the LES and contributes to GERD) • • refrain from lifting heavy objects, straining, or working in a bent over posture (especially after eating)

Aspartate aminotransferase (AST)

Normal value: Male: 20-40 units/L Female: 15-35 units/L Patient education on rationale for test and specimen collection methods ↑levels: Hepatitis; Cirrhosis; Liver cancer; Skeletal muscle trauma/diseases; Severe burns; Acute pancreatitis; Acute hemolytic anemia ↓levels: Acute renal disease; Beriberi; Chronic renal dialysis; Diabetic ketoacidosis

Bilirubin

Normal: Total bilirubin: 0.3-1 mg/dL Indirect bilirubin: 0.2-0.8 mg/dL Direct bilirubin: 0.1-0.3 mg/dL Patient education on rationale for test and specimen collection methods ↑levels (conjugated): Gallstones; Extrahepatic duct obstruction; Dubin-Johnson syndrome ↑levels (unconjugated): Hemolytic jaundice; Large-volume blood transfusion; Sepsis; Hemolytic anemia; Pernicious anemia; Sickle cell anemia; Transfusion reaction

Pathophysiology obesity

Obesity causes a marked decrease in life expectancy Obesity is linked to numerous chronic health conditions, and there is a strong association between obesity and its major comorbidities. Type 2 diabetes mellitus (DM) is the most prevalent, with the overlap between type 2 DM and obesity being about 50% Hypertension, dyslipidemia, heart diseases such as heart failure, a fib coronary is more common in patients with obesity, increase risk of stroke and sleep apnea, GI conditions such as GERD, gallbladder issues, non alcoholic fatty liver, osteoarthritis, kidney failure, reproductive issues, increased risk of cancer and increase the likelihood of dying from cancer. all kinds of health issues that go along with Obesity • Obesity occurs when excess calories are stored as fat • Can be a result of excess energy intake, decreased energy expenditure, or a combination of both • Regulated by a complex interaction between endocrine and neural systems Obesity is a complex disease in which genetic, environmental, biochemical, and behavioral factors intertwine, and most patients with obesity have more than one factor contributing to their disease. Genetic factors are well documented and contribute to more than 50% of variations in BMI. Genetic polymorphisms have been linked to obesity in several populations. The discovery of these mutations has led to increased understanding of the powerful biological nature of appetite and has resulted in obesity being seen as a medical condition as opposed to a moral failing. • If we didn't have any external influences: • • When weight loss occurs: our regulatory systems ↑ appetite and ↓ energy expenditure • • After overeating the opposite occurs • Appetite is regulated by CNS (Fig. 68.1 pg 1573) • • Hunger center is in hypothalamus: stimulated by hypoglycemia and peptides produced in the gut • • Nutrient levels rise the hypothalamus again (in the satiety center) stimulated to stop eating • • GI filling and hormones also stimulate satiety • • Also know that appetite isn't the only regulator: people eat to various reasons: anxiety/depression...

Answer: C Rationale: The function of the large intestine is fluid and electrolyte reabsorption and elimination.

Patients experiencing diarrhea are at risk for which alteration in absorption? A. Decreased chyme absorption B. Increased chyme absorption C. Decreased potassium absorption D. Increased potassium absorption

Medications to treat obesity

Pharmacotherapy should be considered in patients with a BMI greater than or equal to 30 kg/m2 or with a BMI greater than or equal to 27 kg/m2 with one or more obesity-associated comorbidities whose weight-loss attempts have been unsuccessful in the past. It should be employed only in the presence of diet, exercise, and behavioral therapy and requires close observations by a healthcare provider. The potential risks of medication treatment should be weighed against the benefits, and a thorough health examination should take place prior to starting any pharmacotherapy. The majority of weight loss occurs within the first 6 months of starting a medication. Several medications currently available for the long-term treatment of obesity include orlistat; lorcaserin; phentermine-topiramate extended release; bupropion-naltrexone extended-release tablet; and liraglutide, a daily injectable.

Answer •D. "It speeds up the emptying of food from your stomach."

Question about meds •Mrs. E.E. has been prescribed Metoclopramide, Mrs. E.E. asks you how this medication is going to help her. What is your best response? • A. "It decreases the amount of acid in your stomach." •B. "It decreases the acidity in your stomach so it doesn't damage your esophagus." •C. "It stops the production of acid in your stomach." •D. "It speeds up the emptying of food from your stomach."

Combination Procedures

Roux-en-Y gastric bypass (RYGB). - Roux-en-Y gastric bypass is a combination procedure that involves the creation of a restrictive 30-mL gastric pouch and bypass of a portion of the small intestine, causing mild malabsorption. - Combination approaches induce weight loss primarily through restriction but also create a component of malabsorption. The Roux-en-Y gastric bypass (RYGB; Fig. 68.5) is a combination procedure that involves the creation of a restrictive 30-mL gastric pouch and bypass of a portion of the small intestine, causing mild malabsorption. The Roux-en-Y gastric bypass is the most commonly performed (46.6%) bariatric surgery worldwide.

Questions to Assess the Gastrointestinal System

Social history - Do you smoke? Do you use street drugs? Do you use prescription or over-the-counter (OTC) medications? Do you use herbals? Do you drink alcohol? Recent antibiotic use? Any recent international travel? Medical history - Do you have a history of previous heart attacks, chest pain? Parkinson's disease, sickle cell disease? Sjögren's syndrome? Do you have a history of diabetes, multiple sclerosis? Crohn's disease? Irritable bowel disorder? Gastroesophageal reflux disease (GERD)? Do you have a history of anorexia nervosa? Bulimia? Depression? Familial adenomatous polyposis? Celiac disease? Surgical history - Any history of previous abdominal surgeries?

Stool analysis

Stool is collected to assess for presence of: • Blood (gross and occult) • Fecal leukocytes • Bacteria (Clostridium difficile) • Mucus • Parasites • Fat Patient education on rationale for test and specimen collection methods Pretest: Analysis and studies should be done prior to the administration of antibiotics, antidiarrheal medications, laxatives. Stool specimen should not be collected from the toilet. Patient education on specimen collection. Posttest: Patient education on contact isolation if C. difficile cultures are positive. Presence of blood may indicate gastrointestinal cancer, inflammatory disorders, or hemorrhoids. Presence of C. difficile is an indication of pseudomembranous colitis. Presence of mucus Bloody (colon cancer and inflammatory disorders) Clear (spastic constipation) Increased fat (steatorrhea) may indicate malabsorption or pancreatic disorders.

Answer: D Both A and B are correct A. Producing mucus to lubricate and protect the mucosal layer of the GI tract wall B. Secretion of fluids and enzymes to aid in digestion and absorption of nutrients

The basic functions of the secretory glands of the gastrointestinal tract include which of the following? A. Producing mucus to lubricate and protect the mucosal layer of the GI tract wall B. Secretion of fluids and enzymes to aid in digestion and absorption of nutrients C. To promote absorption of proteins, fats, and carbohydrates in the stomach D. Both A and B are correct

Answer: D Rationale: No special preparation is needed for the blood test for H pylori. Answer A is incorrect because the patient is not NPO before the test. Answer B is incorrect because glucose is not administered before the test. Answer C is incorrect because it refers to preparation for the breath test.

The healthcare provider has ordered a blood test for H pylori. How does the nurse prepare the patient for this diagnostic test? A. Instructing the patient not to consume food or liquids after midnight B. Giving an oral suspension of glucose 1 hour before the test C. Explaining that a small dose of radioactive isotope will be used D. Telling the patient that no special preparation is needed

Answer: B Rationale: H. pylori infections can remain active for life, if not treated appropriately. Elimination of this organism allows ulcers to heal more rapidly and remain in remission longer. Two or more antibiotics are given concurrently to increase the effectiveness of therapy and to lower the potential for bacterial resistance. The antibiotics are also combined with a proton pump inhibitor or an H2-receptor antagonist.

The healthcare provider prescribes a combination of antibiotics for a patient with a peptic ulcer. The patient asks you why these types of medications are being given. What is the nurse's best response? A. "It will increase mucus production in your stomach." B. "The combination of antibiotics will help to rid the stomach of the H. pylori bacteria." C. "This medication will help buffer the gastric acid in your stomach." D. "It is used only as a prophylactic to prevent colonization of bacteria in the stomach."

Answer: A, D, and E Rationale: Rapid emptying of the stomach into the intestine leads to nausea, vomiting, abdominal cramping, and pain, diarrhea, bloating, belching, and fatigue. With loss of fluids, the patient will demonstrate signs of fluid depletion including decreased urine output, decreased blood pressure, and tachycardia.

The nurse assesses for which clinical manifestations of dumping syndrome in the patient after bariatric surgery? (Select all that apply.) A. Nausea B. Increased urine output C. Hypoglycemia D. Diarrhea E. Abdominal cramping

Answer: C Rationale: Parietal cells secrete intrinsic factor, a chemical needed for the absorption of vitamin B12, an important component of hemoglobin synthesis; they secrete hydrochloric acid. Mucous cells secrete mucus, which protects the stomach lining. Chief cells secrete gastric lipase, and enteroendocrine cells secrete hormones needed for digestion.

The nurse correlates a disorder of which type of cell in the patient with vitamin B12 deficiency? A. Mucous cells B. Chief cells C. Parietal cells D. Enteroendocrine cells

Answer: B Rationale: Amylase is an enzyme responsible for digestion of carbohydrates, and it is produced in the pancreas. When the pancreas is inflamed, amylase is released in the blood.

The nurse correlates an increase in which laboratory value to the diagnosis of acute pancreatitis? A. Serum sodium B. Serum amylase C. Serum potassium D. Serum creatinine

Answer: C Rationale: The mechanical breakdown of ingested protein occurs through the process of mastication (chewing).

The nurse correlates poor dentition in patients to which digestive disorder? A. Chemical digestion of protein B. Mechanical digestion of chyme C. Mechanical digestion of protein D. Chemical breakdown of carbohydrates to simple sugars

Answer: C Rationale: Due to decreased peristalsis in the older adult, constipation is a risk factor.

The nurse correlates which clinical manifestation as a normal age-related variant in an older adult? A. Diarrhea B. Melena C. Constipation D. Anorexia

Answer: A, C, and D Rationale: Increased waist circumference is associated with increased abdominal fat. Binge and compulsive eating are manifestations of behavioral changes associated with obesity. Joint pain increases as the BMI and weight increases. The basal metabolic rate is typically decreased in obese patients. Yellowish color changes are associated with hepatic disorders and not directly with obesity.

The nurse correlates which clinical manifestations to the pathophysiology of obesity? (Select all that apply.) A. Increased waist circumference B. Increased basal metabolic rate C. Binge eating D. Joint pain E. Yellowish skin

Answer: D Rationale: Patients are NPO and have a bowel prep before bariatric surgery. There should be no food in the stomach. A small amount of gastric acid tinged with blood is normal since the stomach and intestinal lumen has been cut. The nurse should never remove or reposition a NGT in a bariatric surgery patient.

The nurse is caring for Ms. Wiley in the post-anesthesia recovery unit. The patient is 2 hours post-gastric bypass surgery and has a nasogastric tube (NGT). The orders state the NGT should be hooked up to low continuous suction. There is scant blood-tinged drainage coming from the tube. What action should the nurse take? A. Call the surgeon right away B. Reposition the NGT C. Discontinue the NGT D. Document the findings

Answer: C Rationale: The nurse should respond to the patient request by holding her hand and then employing active listening skills when a patient expresses a concern. Patting the patient on the shoulder rather than holding her hand as she requested would seem to diminish the patient's concern and seem patronizing. The nurse should not diminish the patient's concern by stating facts. Oral anxiety meds would be inappropriate in a patient preparing for gastric surgery

The nurse is caring for Ms. Wiley in the presurgical suite. The patient asks, "Will you hold my hand? I am getting nervous. My mom told me this morning that I could die from this surgery." Which action by the nurse is best? A. Patting the patient on the shoulder and covering her up B. Asking her if she would like some alprazolam (Xanax) to calm her down C. Holding her hand and listening to her concerns D. Explaining that the percentage of people who die from bariatric surgery is small

Answer: C Rationale: Support groups have been show to help patients after weight loss surgery. AGG does not cause malabsorption. The intestinal lumen is not cut, so there is not anastomosis. The patient will not be injecting into their own port.

The nurse is providing a patient with postoperative instructions following an adjustable gastric banding. Which information should be included in the education? A. Importance of vitamins due to malabsorption B. Small meals to prevent anastomosis leak C. Date and location of support group D. Instructions for injecting saline into the port

Answer: C Rationale: Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a patient with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Rabeprazole sodium is a proton pump inhibitor used in treating gastrointestinal disorders such as GERD and duodenal ulcers. Propranolol (Inderal) is a β-adrenergic blocker. Furosemide and propranolol are not contraindicated in patients with gastric disorders.

The nurse is reviewing the medication record regarding Mrs. Taylor's PUD. Which medication, if noted on the patient's record, will the nurse question? A. Rabeprazole sodium (AcipHex) B. Furosemide (Lasix) C. Indomethacin (Indocin) D. Propranolol hydrochloride (Inderal)

Answer: B Rationale: Frequent ingestion of the nonsteroidal antiinflammatory agents (NSAIDS), such as indomethacin and ibuprofen, is associated with acute gastritis. NSAIDS inhibit prostaglandin synthesis and diffuse rapidly into the gastric mucosa, causing mucosal injury

The nurse is screening patients for their risk of developing acute gastritis. The nurse should consider which patient at greatest risk? A. A 25-year-old woman who has a vegan diet B. A 32-year-old man who takes ibuprofen daily C. A 77-year-old man who smokes D. An 80-year-old woman who takes low-dose aspirin daily for atrial fibrillation

Answer: D Rationale: When the barium is not properly eliminated, it can harden and cause constipation.

The nurse monitors for which complication in the patient who has undergone a barium enema? A. Fluid overload B. Dehydration C. Diarrhea D. Constipation

Answer: C Rationale: Skin breakdown is a preventable complication. Hypoventilation is more common in obese patients. Hypertension is a long-term condition that does not commonly worsen due to hospitalization. Tachycardia can be a sign of complications and should be investigated.

The nurse monitors for which preventable complication in a patient hospitalized for treatment of obesity? A. Hyperventilation B. Tachycardia C. Skin breakdown D. Hypertension

Answer: D Rationale: Patients should be supine with arms relaxed at the sides and bent knees in order to promote relaxation of the abdomen.

The nurse places the patient in which position for a gastrointestinal assessment to promote relaxation of the abdominal muscles? A. Sitting upright with arms relaxed in the lap and feet on the floor B. Semirecumbent with knees extended and arms at the sides C. Side lying with arms above the head and knees flexed D. Supine with arms at the side and knees flexed

Answer: B Rationale: The cranial nerves involved in effective swallowing include CN V (trigeminal), CN VII (facial), CN IX (glossopharyngeal), and CN XII (hypoglossal). The trochlear, CN IV, involves movement of the eye; CN XI, accessory, controls contraction of the neck and shoulder muscles; and CN X (vagus) affects peristalsis.

The nurse recognizes that an impairment of which CN makes a patient at risk for aspiration due to ineffective swallowing? A. Trochlear B. Trigeminal C. Vagus D. Accessory

Answer: A and C Rationale: There are various treatment regimens for H. pylori eradication and most include the combination of a proton pump inhibitor (PPI) with two antibiotics for 7 to 14 days. H. pylori release a toxin that promotes mucosal inflammation and ulceration, stimulating the release of cytokines and other mediators of inflammation that contribute to mucosal damage. Damage to gastroduodenal mucosa allows for decreased resistance to bacteria, and thus infection from H. pylori bacteria may occur.

The nurse recognizes that the treatment of H. pylori includes which medications? (Select all that apply.) A. PPIs B. Antiemetics C. Antibiotics D. NSAIDs E. Antacids

Answer: A Rationale: Erosive or stress-induced gastritis is a severe form of acute gastritis that is a complication of conditions such as shock, severe trauma, or major surgery most likely due to inadequate gastric mucosal blood flow during periods of intense physiologic stress. Adequate mucosal blood flow is important to maintain the mucosal barrier and to buffer any back-diffused hydrogen ions. When blood flow is inadequate, these processes fail and mucosal breakdown occurs.

The nurse recognizes which gastric disorder as a complication of inadequate mucosal perfusion secondary to intense physiological stress? A. Erosive gastritis B. Chronic gastritis C. Duodenal ulcers D. Esophageal reflux

Answer: B B. Absorption

The process through which nutrients enter the bloodstream through the intestinal wall is called: A. Diffusion B. Absorption C. Mucositis D. Motility

x-ray of the abdomen

This diagnostic study may reveal abnormal masses, obstruction, or strictures. The presence of air in the abdomen is consistent with an obstruction and requires further assessment because perforation can occur with increasing pressure behind the obstruction. Routine plain x-rays require no preparation except an explanation. In the patient with severe, acute abdominal pain, positioning may be difficult because the patient may experience increased pain secondary to peritoneal irritation when placed in a supine position.

Quadruple Therapy

Treatment Regimen: Bismuth subsalicylate 525 mg four times daily plus, Metronidazole 250 mg orally four times daily plus, Tetracycline 500 mg orally four times daily plus, PPI twice daily (or ranitidine 150 mg orally twice daily) for 10-14 days Eradication Rates (%): 75-90 Comments: Usually used as second-line therapy in patients who fail to respond to triple therapy

Sequential Therapy

Treatment Regimen: PPI twice daily plus, Amoxicillin 1 g twice daily for the first 5 days followed by PPI twice daily plus, Clarithromycin 500 mg twice daily and tinidazole 500 mg twice daily for the next 5 days Eradication Rates (%): 83-98 Comments: Overall eradication rate greater than 90%; recommended for second-line or rescue therapy but may also be considered for initial therapy

Levofloxacin-Based Triple Therapy

Treatment Regimen: PPI twice daily plus, Levofloxacin 250-500 mg twice daily plus, Amoxicillin 1 g twice daily for 10 days Eradication Rates (%): 60-80 Comments: Often recommended for second-line or rescue therapy

Triple Therapy

Treatment Regimen: Proton pump inhibitor (PPI) plus, Clarithromycin 500 mg twice daily or metronidazole 500 mg twice daily, plus, Amoxicillin 1 g twice daily for 7-14 days Eradication Rates (%): 73-86 Comments: Often used as first-line therapy; in the United States, recommendation is to treat for at least 10 days OR Treatment Regimen: PPI plus, Clarithromycin 500 mg twice daily, plus, Metronidazole 500 mg twice daily for 7-14 days Eradication Rates (%): 70-85 Comments: May be used as first-line therapy in penicillin-allergic patients

Interventions Gastritis

Treatment depends upon severity and cause: • Acute gastritis usually resolves itself • • Drug therapy • • • H2-receptor antagonists (Ranitidine, famotidine, nizatidine), Mucosal barriers (Carafate, Sulcrate), Antacids, Proton-pump inhibitors (Prilosec, Nexium), may need Vitamin B12 supplements, antibiotic for H.Pylori, • • • Look at meds that might be causative (corticosteroids, NSAIDs, erythromycin, etc.) • • Identify cause and eliminate cause (H.pylori) •Chronic gastritis • • H.pylori treated with combo of antibiotics • Diet therapy • • Limit foods and spices that cause distress • Stress reduction • • Progressive relaxation, guided imagery, distraction • Surgical Management • • Partial gastrectomy (removal of the stomach) • • Pyloroplasty (enlarging of the pylorus opening) • • Total gastrectomy (those w/ erosive gastritis and major bleeding)

Answer: B Rationale: According to the NIH Classification system, patients with BMI of 18.5 to 24.9 are normal weight, BMI of 25.0 to 29.9 are overweight, BMI of 30.0 to 34.9 have class 1 obesity, BMI of 35.0 to 39.9 have class 2 obesity, and BMI greater than 40.0 are categorized with extreme obesity.

Using the NIH classification for BMI, the nurse identifies the patient with a BMI of 32 kg/m2 as which category? A. Overweight B. Class 1 obesity C. Class 2 obesity D. Extreme obesity

The GI Assessment

We need a nursing history for Mrs. E.E. that is pertinent to her care and can include any of the following: • Demographic data • Family history • Personal history • Diet history • Socioeconomic status What we have currently gathered from her is: She has HTN and hypothyroidism. Current medications include Lopressor 50mg per day, and Synthroid daily. Edna states she sometimes has anglass of wine with her meal and smokes 1/2 to 1 pack of cigarettes per day. She is retired teacher and lives by herself in her home (which you see from the address is in a middle-class section of town)

BMI Example

What is the BMI of a person who is 5'3" and is 125 lbs: • Multiply the weight in pounds by 0.45 (metric conversion factor) •125 X 0.45= 56.25 kg •Multiply the height in inches by 0.025 (metric conversion factor) •63 x 0.025 = 1.575 m •Square the answer from 2nd step •1.575 X 1.575= 2.480625 •Divide the answer from step 1 by answer from step 3 •56.25/ 2.480625= 22.7 BMI

Answer: A Rationale: The purpose of auscultation is to indirectly assess bowel sounds and vascular integrity of the arteries. In the assessment process, percussion and palpation usually occur prior to auscultation, but manipulation of the abdomen can result in inaccurate interpretation of bowel sounds as being hyperactive, so auscultation is completed prior to percussion and palpation.

When a physical assessment of gastrointestinal function is completed, which procedure follows inspection? A. Auscultation B. Percussion C. Light palpation D. Deep palpation

Answer: C Rationale: In patients with physical characteristic of Cushing's disease, 24-hour urine collection for urinary free cortisol excretion should be performed. Growth hormone deficiency is a secondary disorder associated with hypothalamic dysfunction. Changes in secretion of thyroid stimulating hormone are associated with primary or secondary hypothyroidism. Hemoglobin A1c provides data on glucose regulation over a period of time.

Which diagnostic result does the nurse assess in the patient with obesity to evaluate for concomitant Cushing's disease? A. Growth hormone B. Thyroid-stimulating hormone C. Urine cortisol excretion D. Hemoglobin A1c

Answer C. Both can be treated and the damage repaired and reversed The patient can recover in approximately 1 day because of the ability of gastric mucosa to repair itself. The patient's appetite may be diminished for approximately 2 to 3 days. Patients with gastritis can achieve full recovery by complying with the prescribed therapy and avoiding irritating substances such as caffeine, alcohol, and NSAIDs. Expected outcomes include vital signs within normal limits, decreased pain, report of less anxiety, and compliance with the therapeutic regimen. The patient and family should be knowledgeable of the signs of gastritis and what clinical manifestations should reported to their healthcare provider.

Which is true about chronic and acute gastritis? A. Both are treated with antibiotics B. The primary cause of both is H.pylori C. Both can be treated and the damage repaired and reversed D. Chronic gastritis is unrelated to acute gastritis

Answer: B B. Gastrointestinal hormones stimulate glands that will directly secrete enzymes into the digestive tract.

Which of the following statements is true regarding digestion and absorption? A. Gastrointestinal hormones function in the digestive tract to facilitate the absorption of essential nutrients. B. Gastrointestinal hormones stimulate glands that will directly secrete enzymes into the digestive tract. C. The regulation of secreted enzymes is controlled by the hypothalamus via trophic hormones. D. Pepsin, an enzyme that mediates protein digestion, is secreted by the salivary glands.

Answer: B Rationale: The most common contributing factor to acute stress gastritis is the disruption of the integrity of the gastric lining by gastric irritants such as aspirin and/or NSAIDs. A period of gastric rest followed by a slow progression to regular dietary intake is advised.

Which patient statement indicates effective teaching related to acute gastritis? A. "I will eat a diet rich in milk and cream to decrease the secretion of hydrochloric acid." B. "I need to avoid using aspirin or nonsteroidal medications for routine pain relief." C. "I will need to return for yearly upper endoscopy examinations." D. "I will need to fully cook all meat, poultry, and egg products."

Answer: B Rationale: Obesity Hypoventilation Syndrome is worsened when patients are supine or prone. Elevating 30 to 45 degrees optimizes diaphragmatic excursion and minimizes pressure of abdominal contents on the thoracic cavity

Which position does the nurse place the patient in to minimize complications in the patient with OHS? A. Prone with hips elevated B. Head of bed elevated 30 to 45 degrees C. Side lying with head flat D. Head of bed elevated 90 degrees

Answer: D Rationale: Due to the decreased size of the stomach, fluids should be consumed between meals. Multivitamins may be needed due to decreased absorption of fat soluble vitamins, including A, D, E, and K. The patient is at increased of risk of constipation due to possible dietary restrictions and use of opioids for pain. Lifting is limited postoperatively to decrease strain on the surgical site.

Which statement by the patient being discharged after gastric bypass surgery indicates the need for further teaching? A. "I may need to take a multivitamin every day." B. "I may develop constipation while I am taking pain medications." C. "I should not lift anything heavy until cleared by the surgeon." D. "I should drink at least one cup of fluids with every meal."

Answer: D Rationale: There is no need to increase fiber after the test as it does not include barium that could cause constipation. The patient is maintained NPO after the EGD until the gag returns, and then the diet is advanced to fluids. The patient can return to their normal dietary intake upon discharge.

Which statement by the patient scheduled for an EGD indicates the need for further teaching? A. "I will not be able to eat 8 to 10 hours before the test." B. "My throat will be anesthetized so the provider can pass the tube." C. "I will probably have a sore throat after the test." D. "It is important that I eat extra fiber after the test."

Barium Studies

a series of x-rays and are ordered to examine the integrity and patency of the gastrointestinal tract; these studies can be diagnostic or therapeutic.Preparation for barium studies typically requires the patient to follow a special diet the day before the test (clear liquids) and then nothing by mouth after midnight. A laxative or enema may also be prescribed for the night before the study. Patients are typically given barium, a radiographic opaque liquid, to drink. However, if there is a concern about possible perforations anywhere along the gastrointestinal tract, a water-soluble liquid, gastrografin, is administered. With the use of fluoroscopy, patients are then taken through a series of time-sensitive x-rays. There are several studies that can be performed: an upper gastrointestinal series, which visualizes the esophagus, stomach, and duodenum; a small bowel series, which visualizes the small intestine; and lastly, the barium enema, which visualizes the colon. Regardless of the type of barium study performed, the nursing interventions are similar

Lorcaserin (Belviq)

affects chemicals in the brain that help to regulate appetite and increase the feeling of fullness after eating so that less food is eaten. Lorcaserin is taken twice daily, and the expected weight loss is 3% to 5% of an individual's weight. Common side effects include headache, dizziness, nausea, fatigue, constipation, and dry mouth. Lorcaserin is contraindicated in patients with severe depression and cardiac or valvular disease.

Phendimetrazine (Bontril PDM), diethylpropion (Tenuate), benzphetamine (Regimex), and phentermine (Adipex-P, Lomaira)

are available for short-term treatment of up to 12 weeks for obesity. They decrease appetite, also known as an anorexigenic effect. They may also increase satiety, and through these mechanisms, patients may experience weight loss. Because of their sympathomimetic effects, these medications should be used with caution in patients with hypertension and are contraindicated in patients with cardiovascular disease, hyperthyroidism, arrhythmias, agitation, insomnia, or glaucoma. Common side effects include insomnia, headache, dry mouth, and irritability. Because of the chronic nature of obesity, these medications are not strongly supported by treatment guidelines. Patients often develop tolerance within several weeks.

Ultrasonography

can detect any size and structural abnormalities of the underlying abdominal cavity organs and vessels. The abdominal cavity is also evaluated for the presence of ascites. The liver and pancreas can be visualized to detect cysts, tumors, or masses. The gallbladder and kidneys can be further visualized for stones. As a therapeutic intervention, ultrasonography can be utilized to place stents in obstructed areas. Ultrasonography is the preferred method of visualization of abdominal structures in patients who cannot tolerate contrast dye

Endoscopy

general term used to describe the procedure in which a fiberoptic scope is used to visualize the gastrointestinal tract. Endoscopic studies can serve three purposes: diagnostic, curative, or palliative. Patients are sedated with a narcotic and a sedative. The pre- and postprocedural nursing interventions are similar and are outlined in Table 55.8 1272

GERD

http://www.youtube.com/watch?v=o8iShP84HP4&feature=BF&playnext=1&list=QL&index=2

Orlistat (Xenical, Alli)

inhibits pancreatic lipase, thereby reducing dietary fat absorption. The prescription brand of orlistat (Xenical) is supplied in a 120-mg capsule and should be taken three times per day with any meal that contains fat. The over-the-counter version of orlistat (Alli) is supplied in a 60-mg capsule. Orlistat causes a modest increase in weight loss of 5 to 7 pounds over a year period. Persons who take the medication may also report the lowering of blood pressure and are less likely to develop type 2 diabetes. Common side effects of the medication include significant gastrointestinal symptoms, including increased flatus, loose and oily stools, abdominal cramping, and nausea. Rare cases of liver injury, a serious side effect, have been reported, and symptoms include dark urine, itching, light-colored stools, loss of appetite, or jaundice. Because of the mechanism of action, it may also decrease the absorption of fat-soluble vitamins (A, D, E, and K) and beta-carotene. Patients are instructed to take a multivitamin 2 hours before or after taking orlistat. It is contraindicated in patients with cholelithiasis, hepatic disease, pancreatic disease, or malabsorption syndrome.

Bupropion-naltrexone (Contrave)

is a combination medication typically used as a second option in the treatment of obesity. It was approved by the FDA in September 2014 as an adjunct to diet and exercise in patients with a BMI of greater than 30 kg or greater than 27 kg in the presence of at least one weight-related comorbidity. The initial dose is one tablet daily for 1 week, which is then increased to two tablets twice daily by week 4. It is approved for up to 12 weeks and results in the loss of approximately 5% to 6% of body weight. Common side effects are headache, insomnia, vomiting, dizziness, and dry mouth. It can raise blood pressure, and cardiovascular effects have not been yet established. It contains bupropion, an antidepressant, and the FDA recommends counseling in patients aged 18 to 24 for risks of suicidal ideations.

Phentermine/topiramate-extended release (Qsymia)

is a combination medication. Phentermine is approved by the U.S. Food and Drug Administration (FDA) to suppress appetite for up to 12 weeks. Topiramate is approved for the treatment of seizures and migraines, and weight loss was observed to be a side effect associated with decreased appetite and enhanced satiety. Phentermine/topiramate is taken once daily and produces the most weight loss, as much as 9% of initial weight. To minimize side effects, the combination of phentermine/topiramate contains lower dosages of each medication than if used alone. Common side effects include altered taste, numbness, tingling, insomnia, dizziness, and anxiety. Because phentermine/topiramate may cause birth defects, females must use a reliable form of birth control and receive pregnancy tests on a monthly basis during treatment.

Liraglutide (Saxenda)

is the only FDA-approved injectable medication for weight loss. It is an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a BMI of greater than 30 kg or greater than 27 kg with at least one weight-related comorbid condition. Dosing is done through daily injection, with the initial dosing titrated up by weekly increments to the target dose of 3 mg to reduce the gastrointestinal (GI) side effects of nausea and vomiting. The mechanism of action is via slowing gastric emptying. It is contraindicated in patients with medullary thyroid cancer (MTC). Common side effects of liraglutide include headache, nausea, diarrhea, and an increase in the resting heart rate.

GERD - Gastroesophageal Reflux Disease

pg 1285 •Backward flow (reflux) of GI contents into the esophagus •Reflux esophagitis characterized by acute symptoms of inflammation Pathophysiology •Esophageal reflux occurs when gastric volume or intraabdominal pressure is elevated, the sphincter tone of the lower esophageal sphincter is decreased, or it is inappropriately relaxed Etiology •Most common cause of GERD= inappropriate relaxation of LES= esophageal exposure to gastric contents •Gastric distention w/ ingestion of large meals or conditions that cause delayed emptying Refluxed material in the esophagus normally returns to the stomach with the help of gravity, peristalsis, and saliva. When the esophagus is inflamed or injured, the ability of the esophagus to clear refluxed material becomes slower, resulting in an extended period of exposure of the esophagus to refluxed material from the stomach. Each episode of acid reflux results in hyperemia (increased blood flow), erosion (ulceration), and possible minor bleeding to the esophagus. During reflux, other gastric substances such as pepsin and bile may be present. These substances, like acid, are caustic to the esophageal epithelium.

Nursing Actions

pg 1287 • Medication management: • Antacids Neutralize or buffer stomach acid • Histamine receptor agonists Acid production is decreased (see Table 56.2). • Proton pump inhibitors Acid production is blocked (see Table 56.2). • Prokinetic medications Gastric emptying is increased with prokinetic medications such as Reglan. Long-term use is not recommended because of the possibility of psychotropic or neurological side effects such as tardive dyskinesia. • Position the patient on the right side with the HOB elevated 6 to 12 inches. Lying on the right side promotes gastric emptying, and elevating the HOB promotes peristalsis and uses gravity to return gastric refluxate from the esophagus to the stomach. Sleeping in this position also decreases reflux at night. • Provide 4-6 meals per day. Eating three larger meals per day increases pressure in the stomach and delays gastric emptying. Eating four to six smaller meals decreases pressure.

Nursing Assessments (GERD)

pg 1287 • Respiratory symptoms: aspiration pneumonia, chronic cough, morning hoarseness, night-time wheezing, adult-onset asthma, laryngitis, pharyngitis, bronchitis with long-term regurgitation Respiratory symptoms occur with aspiration of acid reflux into the tracheobronchial tree, larynx, pharynx, nose, and mouth (especially when supine). Gastroesophageal reflux disease is a causative factor in the development of adult-onset asthma. • Regurgitation Occurs when acid reflux reaches the level of the pharynx, leaving a sour taste in the mouth. If the patient is supine, regurgitation can lead to aspiration. • Severe atypical chest pain Caused by esophageal spasms or stimulation of esophageal pain receptors. Pain may be so severe that it lasts for 2 hours, and it can radiate to the neck. Pain increases when supine, bending, or performing a Valsalva. The etiology of chest pain needs to be determined to rule out cardiac causes. • Hemorrhage Associated with erosion and necrosis of the esophagus from chronic acid reflux • CBC Chronic erosion of the esophageal tissue may lead to bleeding that results in decreased hematocrit and hemoglobin. • Dyspepsia Reflux of gastric contents into the esophagus occurs most often as a result of excessive relaxation of the LES, leading to inflammation and ulceration of the esophagus. Minor bleeding from capillaries may occur with erosion. • Dysphagia and odynophagia The damage from the refluxate causes inflammation and ulcerations in the esophagus. When healing occurs, scarring occurs with the development of strictures or rings, causing esophageal stenosis and difficulty swallowing. • Signs of Barrett's esophagus Metaplasia of columnar epithelium from squamous cells in the lower third of the esophagus results from chronic acid reflux into the esophagus. Columnar cells, like the cells found in the stomach, are resistant to the damaging effects of stomach acid; however, these cells, not normally seen in the esophagus, have a propensity for dysplasia, thus becoming adenocarcinomas. • Dental caries Eructation of acid reflux into the oral cavity leads to the destruction of tooth enamel and decay. • Water brash A production of excessive saliva in response to reflux, leading to the sense of fluid in the throat, is termed water brash. There is no sour taste, and acid is not present. Patients who exhibit water brash may or may not have esophageal injury. • Eructation, flatulence, or bloating Occurs when eating a large meal and with abdominal distention, causing increased intra-abdominal pressure. The LES pressure decreases and allows gastric refluxate to enter the esophagus. • Nausea Nausea occurs as a result of stomach acid and bile that reflux into the esophagus from the stomach, usually after eating. • Globus (sensation that there is a lump in the throat) Gastric refluxate into the larynx and pharynx resulting from GERD • pH of gastric aspirate Acid refluxate from the stomach has a pH of 1.5 to 2.0, whereas the normal pH of the esophagus is 6.0 to 7.0.

Nursing Teaching

pg 1288 • Educate the patient to limit the following foods and substances: spicy/fatty foods, caffeine, chocolate, carbonated beverages, acidic foods, peppermint, alcohol, and certain medications (if possible), such as calcium channel blockers, anticholinergic medications, and smooth muscle relaxers. These foods, substances, and medications are associated with decreasing LES pressure, which allows gastric reflux from the stomach into the esophagus. • Avoid smoking and alcohol. Both smoking and alcohol may lead to a decrease in LES pressure, increasing the risk of reflux. • Avoid NSAIDs and aspirin. Both NSAIDs and aspirin can irritate the lining of the esophagus. • Encourage the patient to eat meals 2 hours before lying supine. Eating large meals causes delayed gastric emptying and leads to gastric reflux. • Educate the patient to wear nonrestrictive clothing Tight clothing causes an increase in intra-abdominal pressure, which weakens the LES and contributes to GERD. • Educate the patient and family about maintaining ideal body weight. Obesity increases intra-abdominal pressure, increasing the hiatal hernia and GERD.

Treatments surgery (obesity)

pg 1577 - 1578 Types Bariatric surgical procedures include restrictive, malabsorptive, and combination techniques. Most procedures are performed openly or laparoscopically, dependent on the surgeon's expertise and the patient's history of abdominal surgery, degree of obesity, and other medical conditions. More than 90% of the procedures are performed laparoscopically. Pic

Additional Diagnosis following surgery

pg 1579 • Deficient fluid volume related to malabsorption secondary to surgical procedure • Imbalanced nutrition: less than body requirements related to poor nutrition prior to surgery and postoperative restriction • Impaired physical mobility related to body habitus and postoperative pain • Acute pain related to surgical incisions • Disturbed body image related to obesity and failed attempts to lose weight • Anxiety related to the surgical procedure

GERD Epidemiology

results from the backward flow of gastroduodenal contents (refluxate) into the esophagus and/or adjacent organs, producing a variety of clinical manifestations that may or may not cause tissue damage. Chronic in nature, GERD is a highly prevalent disorder in Western countries, with about 10% to 20% affected, whereas the prevalence in Asian countries is 5%. Sanitation practices and chlorination of the water supply have influenced the low prevalence of Helicobacter pylori (HP) in Western countries. The lower prevalence of GERD in undeveloped countries is thought to be related to lifestyle, dietary habits, and the presence of HP, a gram-negative bacterium commonly associated with gastric ulcers and stomach cancer. Helicobacter pylori has been found to decrease gastric acid secretion, but because it is a class 1 carcinogen, steps have been taken to eradicate this organism.

esophagogastroduodenoscopy (EGD)

test evaluates esophagitis and monitors Barrett's esophagitis. During this test, biopsy samples can be taken and strictures can be dilated. Strictures occur as a result of fibrosis and scarring related to injury from acid exposure. Over time, strictures can lead to dysphagia.

Esophageal manometry or motility

testing is the gold standard for the assessment and measurement of esophageal motor activity. During this test, catheters filled with water are inserted into the nose or mouth and withdrawn slowly while readings of LES pressure and peristalsis are taken. Esophageal manometry is used infrequently to diagnose GERD, and when used for this purpose, it is inconclusive except when used in conjunction with patient history, barium radiology, or endoscopy.

Etiology of diarrhea

varies • Increased water content • • Osmotic or secretory processes (feces contain osmotically active molecules) • • • Stool softeners/ laxatives • • • Foods not broken down or absorbed (lactose) • • • Microorganisms • Inflammation or disease of the colon • • Inflammatory bowel disease causes plasma, proteins, blood and mucous to accumulate and increases fluidity • Disruption of normal flora • • Loss of normal flora affects food digestion> diarrhea • • Can also lead to overgrowth of bacteria- C.difficle

Diagnostic Assessment

• Acute Gastritis- Can be dx by history and clinical presentation • Chronic Gastritis-May require more extensive diagnostic testing: • Testing for H.pylori infection (Urea breath testing) • Gastric analysis- assess HCL secretion • CBC- to check for anemia • Serum Vitamin B12 • Upper Endoscopy- can look for bleeding, changes in mucosal lining, take biopsies of tissue The diagnosis of gastritis cannot be based exclusively on clinical manifestations. The gross endoscopic diagnosis of gastritis correlates poorly with histological findings and is somewhat useless as a diagnosis without confirmatory biopsy. Additionally, there is poor correlation between clinical presentation and histological gastritis. An upper GI x-ray series or endoscopy and histological examination of a tissue specimen obtained by biopsy may be useful for ruling out disorders that can suggest gastritis, such as gastric polyps and gastric neoplasms. If hemorrhage is suspected, stools may be tested until they are negative for occult (hidden) blood. Fecal occult blood can be detected by simple tests (e.g., guaiac, Hematest, Hemoccult) that cause color changes in samples of feces in the presence of blood. Urea breath testing can be used to detect active infection with H pylori. A baseline breath test is first obtained. The patient then drinks a urea solution that contains a special carbon atom. Helicobacter pylori secretes an enzyme, urease, which breaks down the urea, releasing the carbon. Blood carries the carbon dioxide (CO2) to the lungs, and it is expelled in the breath. The amount of CO2 is compared to the baseline sample. A positive urea breath test reveals low levels of exhaled carbon-13. Other tests for H pylori infection include serological testing and fecal antigen testing.

Nursing interventions Actions gastritis

• Administer IV fluids as prescribed Fluid replacement is prescribed in patients with severe fluid loss. If nausea and vomiting threaten fluid and electrolyte balance, IV fluids and electrolytes are ordered. • Administer H2-receptor antagonists as prescribed H2-receptor antagonists block gastric secretions. • Administer antacids as prescribed Antacids are used as buffering agents to correct the pH balance of the acidic gastric environment. • Administer PPIs as prescribed Antisecretory agents (PPIs) can be used to suppress gastric acid secretion.

Meds and other treatments (GERD)

• Drug Therapy (pg. 1287) • Chronic disorder - requires long term treatment • Antacids elevate the pH level of the gastric contents • • Maalox, Mylanta, Gaviscon • Histamine receptor antagonists decrease acid production • • Cimetidine (Tagamet), Famotidine (Pepcid), Ranitidine (Zantac) • Proton pump inhibitors provide effective, long-acting inhibition of gastric acid secretion • • Pantoprazole (Protonix), Lansoprazole (Prevacid) • Prokinetic drugs increase motility • • Metoclopramide (Reglan)

Behavioral Modification Techniques

• Eat only while sitting down at kitchen/ dining room table- Do not eat while watching TV, reading, cooking, talking on the phone, standing at the refrigerator or working on the computer • Keep tempting foods out of the house- don't buy them • Plan for healthy snacks and bring them with you • Use smaller plates, bowls and glasses • Politely refuse second helping • Replace eating with another activity, that isn't associated with food •Wait 20 minutes before eating something you are craving • Drink a large glass of water or diet soda before eating • Do not shop when hungry or tired • Chew a piece of gum while cooking meals •Write down everything you eat and it's associated calories

Normal Biological Changes of the Gastrointestinal System in the Geriatric Population

• Esophageal stiffening • Decreased peristaltic movement of the esophagus • Decreased gastric emptying Subjective data: Ask about chest pain, eructation, heartburn, indigestion, early satiety, over-the-counter GERD treatment, weight loss Objective data: Weight • Decreased bile synthesis • Widened common bile duct • Increased cholecystokinin secretion Subjective data: Ask about right upper quadrant pain, early satiety, decreased appetite Objective data: Inspection of the skin. Palpation of the abdomen • Distention and dilation of pancreatic ducts • Decreased weight of the pancreas • Decreased sensitivity of pancreatic B cells to glucose • Decreased lipase production Subjective data: Ask about diabetes symptoms: Thirst? Frequent urination? Increased appetite? Right upper quadrant or right shoulder pain. Color and consistency of stool. Objective data: Weight (loss); serum blood glucose levels • Decrease in number and size of hepatic cells • Decrease in liver enzyme activity and cholesterol synthesis Subjective data: Ask about medications (prescribed, OTC, and herbals), alcohol intake Objective data: Percuss and palpate abdomen • Decreased peristalsis • Decreased mucus secretion in the large intestine • Decreased elasticity of the rectal wall • Decreased sensation of rectal wall distention • Decreased percentage of water weight Subjective data: Ask about frequency of bowel movements. Bloating? Urgency or straining? Incontinence? Laxative use? Medication use? Dietary practices? Objective data: Auscultate bowel sounds, percuss and palpate abdomen, assess rectal area for hemorrhoids

Diagnosis obesity

• Hx and physical exam • BMI • Anthropometry- is the scientific study of the measurements in proportion of the human body; common and through pro metric measurements include height, weight, tricep skin folds, subscapularis skin folds, arm circumference, abdominal circumference, calf circumference • Underwater weighing- to measure body fat- submerge entire body and measure displaced water, most accurate • Bioelectrical impedance= % of body fat; analysis is commonly used method for estimation, a body composition in particular body fat and muscle mass. The bio electrical impedance analysis is a week electrical current that flows through the body and the voltage is major measured in order to calculate impedance of the body. Most of our body water is stored in our muscles so they can get the percentage of body fat and your muscle mass. • Waist circumference • Thyroid panel • Serum glucose/ Lipid panel/ ECG diagnostic tests us to evaluate for obesity co-morbidities sleep studies for sleep apnea ultrasounds, EKGs Most CTS MRIs or x ray tables have weight limits of 350 pounds up to 450; A lot of tests used to diagnose other things are very difficult on obese patients just because they don't fit on the tables. A lot of places don't have open MRI that accommodate heavier people and also the excessive abdominal adipose obscures organs in traditional landmarks that you know radiologist used to diagnose things it makes diagnosis of conditions really difficult.

Nursing interventions Teaching gastritis

• Immediately report hematemesis (vomiting of blood) Hemorrhagic gastritis may lead to vomiting of blood. The vomited blood can be bright red or can have a dark "coffee grounds" appearance. Immediate correction of blood loss may be required to prevent hemorrhagic shock and is dependent on the amount of blood loss and the rate of bleeding. • Take medications as prescribed It is important to take medications as prescribed, even if the symptoms are relieved, until discontinued by the prescriber. Teach patients not to take other over-the-counter medications if they are taking related prescribed medications, and it is best to review these medications with their healthcare provider. • Avoid medications and other irritants that are associated with gastric episodes Read all over-the-counter drug labels that may contain NSAIDs or aspirin. Limit intake of food and spices that cause gastric episodes, such as caffeine, citrus juices, or hot spices. A bland, nonspicy diet combined with smaller, more frequent meals may prevent distress. • Follow prescribed dietary teaching regarding types of foods and how to introduce back into the diet. Gastrointestinal rest should be provided by 6 to 12 hours of NPO status, then slow reintroduction of clear liquids, followed by ingestion of heavier liquids, and finally a gradual reintroduction of solid food. It is also important to eliminate irritating foods such as caffeine and spicy foods.

Nursing Interventions Teaching obesity

• Incentive spirometry, coughing, and deep-breathing exercises Decrease risk of pneumonia and atelectasis • Sequential compression devices Decrease risk of venous thromboembolism • Ambulation Decreases risk of pneumonia, atelectasis, and venous thromboembolism • Postoperative lifting restrictions Decrease hernia development or suture disruption • Postoperative and recovery activity Exercise should begin in the immediate postoperative period to decrease the risk of operative complications and to begin lifelong healthy weight-management practices. • Postoperative dietary restrictions Decrease risk of dehydration, suture disruption, and vomiting • Medication side effects Pain medications may cause drowsiness and constipation. Patients should not drive, drink alcohol, or operate machinery while taking opioid pain medications. Patients should be taught about the increased risk of constipation as a side effect of opioid medications. • Care of wounds/drains Wounds should be kept clean, dry, and covered. Jackson-Pratt drains should be emptied when they are half-full to decrease pull on the surgical site and should be kept clean to prevent infection. • Signs and symptoms to report to the healthcare provider Shortness of breath, tachycardia, severe abdominal pain, fever, rigors, purulent discharge or redness at wounds, and hypotension can be indicative of life-threatening complications, such as pulmonary embolism, anastomosis leak, or infection, and need to be immediately reported to the healthcare provider. • Signs of dumping syndrome Symptoms include nausea, vomiting, diarrhea, diaphoresis, tachycardia, salivation, fatigue, and dizziness, and this complication places the patient at risk of fluid and electrolyte disorders. • Available support groups Patients who attend support groups are more likely to have better outcomes.

Chronic

• Initial changes > Superficial changes in gastric mucosa and ↓ in mucus. Eventually, gastric glands mucous destroyed > inflammatory process in deep portions of mucosa causing thinning & atrophy =loss of parietal cells and source of intrinsic factor is lost. • Most common cause H. pylori • • Increases in people over 60 • • Transmission likely person to person • • Inadequately treated water or food not washed well or cooked properly Vaccines are under development to prevent or even cure H pylori infection. To help prevent infection, it is advised that people wash their hands with soap and water after using the bathroom and before eating, eat food that has been washed well and cooked properly, and drink water from a clean, safe source •Presence of antibodies to parietal cells and intrinsic factor The intrinsic factor is critical for absorption of vitamin B12. When body stores of vitamin B12 are depleted, hemoglobin cannot be synthesized and pernicious anemia results.

Treatments for obesity

• Medications: Recommendation is to consider meds when BMI> 30 or >27 with comorbidty • • Used in combo w/ diet, exercise, behavioral modification, Behavioral Therapy (Self-monitoring via food logs, stimulus control, social support, and cognitive restructuring is encouraged.) • • Orlistat (lipase inhibitor), Lorcaserin (setotonin activator), Osymia (phentermine/topiramate) (combo med- suppresses appetite and increases feelings of fullness) • Exercise • Nutrition • Behavior Modification ( behavior therapy)

Nursing Interventions Actions obesity

• Obtain appropriately sized equipment for care (gowns, bed, chair, bedside commode, stretcher, wheelchairs, etc.). Properly sized bariatric gowns are needed to provide patient dignity. A bariatric bed should be large enough to ensure the patient can turn and reposition. Skin should not be in contact with bed rails because this can lead to pressure injury. Bariatric chairs, bedside commodes, and wheelchairs/stretchers increase patient mobility, prevent injury, and allow safe patient transport. • Elevate head of bed 30 to 45 degrees if no contraindications Obesity hypoventilation syndrome is worsened when patients are supine or prone. Elevating the head of the bed 30 to 45 degrees optimizes diaphragmatic excursion and minimizes the pressure of abdominal contents on the thoracic cavity. • Encourage use of incentive spirometer Promotes increased lung expansion and decreases risk of atelectasis and pneumonia • Apply sequential compressive devices as ordered. The risk for venous thromboembolism is increased in patients with obesity. • Encourage self-care and mobility as appropriate. Early ambulation and mobility decrease the risk of venous thromboembolism and other complications associated with decreased mobility (atelectasis, pressure injury, constipation, etc.). • Turn patients with decreased mobility frequently, a minimum of every 2 hours, using additional staff as needed. Skin injury is common in hospitalized patients who are obese and have decreased mobility, in part because of the difficulty in achieving rotational pressure relief for all body surfaces. • Use slide and transfer assistance devices as appropriate. Proper equipment is essential for the safety of the patient and nursing staff when repositioning or transferring patients who are obese. Skin shearing and back injuries can be prevented. • Assist patient with skin care. Patients with obesity commonly have difficulty with toileting and bathing, which, along with increased skinfolds, makes patients more prone to skin breakdown and infection. • Administer pain medication. Pain management improves early ambulation and the use of the incentive spirometry. Intravenous patient-controlled analgesia is the suggested method of pain control in the first 24 to 48 hours after surgery or until the patient can transition to oral pain management. • Do not reposition a nasogastric tube (NGT); monitor the NGT for patency if applicable. Repositioning or insertion of an NGT can perforate the new gastric staple or suture lines. • Introduce clear liquids as ordered. Dehydration is common after bariatric surgery, so introducing and encouraging small sips of clear liquids as ordered decreases the risk of a fluid volume deficit. • Inform transportation and other departments of weight prior to transport. Hospital equipment is often not properly sized for patients who are obese or overweight. In addition, some tests may not be able to be performed on certain equipment, and accommodations may need to be made before the patient arrives. Alerting staff early to bring proper equipment or prepare for the patient decreases patient embarrassment and decreases the risk of injury. • Collaborate with appropriate members of the healthcare team: wound ostomy care nurse for skin assessment and specialty bed recommendation; physical therapy and occupational therapy; respiratory therapy; social services; clinical pharmacist; nutrition services. Obesity is a complex disease, and proper care of this patient population requires a collaborative approach with other healthcare experts.

Acute

• Protective layer broken> Injury compounded by histamine release and vagal nerve stimulation> HCL acid potentially diffuses into mucosa and damages vessels> results in edema, hemorrhage, and erosion of stomach lining. an acute mucosal inflammatory process; may include a thickened, reddened mucous membrane with extrusive rugae, or longitudinal folds. Various degrees of mucosal necrosis and inflammatory reaction occur in acute gastritis, and in severe cases, sloughing of the surface mucosa may lead to acute GI bleeding •Cause: Chronic ingestion of irritating foods and alcohol • Over use of aspirin and other NSAID use •Complications of acute illness •Endotoxins form bacteria (staph, E. Coli, Salmonella) Acute gastritis may be caused by chronic ingestion of irritating foods and alcohol or a complication of acute illnesses including traumatic injuries, such as burns, severe infection, hepatic, renal, or respiratory failure, or major surgery. Endotoxins released from infecting bacteria such as staphylococci, Escherichia coli, and Salmonella can lead to gastritis by immune cell infiltration and cytokine production. Bacterial and viral infections are often considered food poisoning because contaminated food is the usual route of entry. Overuse of aspirin and other NSAIDs is a high risk factor for acute gastritis, with risk factors including alcohol, cytotoxic agents, caffeine, corticosteroids, and antimetabolites. Acute gastritis is also caused by local irritation from radiation therapy and ingestion of poisons (e.g., dichlorodiphenyltrichloroethane [DDT], ammonia, mercury, and carbon tetrachloride).

Nursing interventions Assessments gastritis

• Vital signs Increased heart rate and decreased blood pressure are caused by fluid volume deficit from vomiting or blood loss. • History of presenting signs and symptoms Heartburn, indigestion, and nausea and/or vomiting are clinical manifestations of gastritis. Dyspepsia (heartburn) may occur after ingestion of certain medications (aspirin/NSAIDs) or alcohol. Gastritis caused by endotoxins (food poisoning) has an abrupt onset. • Laboratory assessment for H pylori Breath and stool analyses are non-invasive ways to test for H pylori. Carbon-13 urea breath test determines the presence of bacteria. Enzyme-linked immunosorbent assay (ELISA) stool testing can detect the H pylori antigen in a fresh stool specimen. • Serum electrolytes In the patient with vomiting, the serum potassium may be low due to loss in the vomitus. With fluid deficit, the serum sodium may be elevated. • Intake and output Pain and decreased appetite may limit the patient's intake of food and fluid, and fluid loss may lead to dizziness, tachycardia, and hypotension.

Nursing Interventions Assessment obesity

• Vital signs, using appropriately sized equipment Body temperature, heart rate, respiratory rate, and blood pressure can point to early complications such as infection or bleeding. Elevated heart rate and decreased blood pressure may be secondary to hypovolemia, hemorrhage, or infection. Bariatric-sized blood pressure cuffs are essential to obtain proper readings in patients who are obese. • Oxygen saturation Decreased ventilation due to obesity hypoventilation syndrome (OHS) and opioid analgesics can result in lower oxygen saturation. • Electrolytes The patient is at risk for fluid and electrolyte disturbances, particularly with dumping syndrome. • Daily weight and intake and output Dehydration and fluid overload are common in postoperative patients and can be identified through changes in weight and monitoring of intake and output. • Skin using a pressure-injury-prevention protocol Increased weight and decreased mobility increase the risk of skin breakdown due to pressure as well as increased moisture. • Skinfolds (breast, groin, neck, abdomen, perianal) for irritation/fungal infections Patients with obesity have increased skinfolds, which are prone to skin irritation and infection. • Incisions and drains Signs of bleeding, anastomosis leak, and infection may be observed in incisional drainage and drains. • Pain Postoperative pain not only decreases ventilation and mobility, but it can also be a sign of infection and other complications.

Activity Intolerance (Nursing Diagnosis obesity)

• • Assess current activity level and activity tolerance • • After medical clearance, assist client in planning a program of regular, progressive exercise program

BMI levels

• • BMI= weight (kg)/ height (m) squared • • BMI Below 18.5= Underweight • • BMI 18.5- 24.9= Normal weight • • BMI of 25-29.9 kg/m2= overweight • • BMI of 30.0-34.9 kg/m2 = obesity (class 1) • • BMI of 35.0-39.9 kg/m2= obesity (class 2) • • BMI of 40.0 kg/m2 or greater= obese

Ineffective Therapeutic Regimen Management (Nursing Diagnosis obesity)

• • Discuss ability/ willingness to incorporate changes into daily life • • Help identify behavioral modification strategies for weight loss/ maintenance • • Help establish strategies for "stress eating" and interruptions in the establish regimen

Imbalanced Nutrition: More than Body Requirements (Nursing Diagnosis obesity)

• • Help identify factors contributing to increased intake • • Establish realistic goals • • Assess patient's knowledge of diet plans • • Discuss behavior modification strategies • • Monitor weight loss, BP, labs

Manifestations of Gastritis

•Acute Gastritis • Rapid onset of epigastric pain/ discomfort •Nausea and vomiting • Hematemesis • Gastric hemorrhage • Dyspepsia (heartburn) • Anorexia •Chronic Gastritis •Often asymptomatic until atrophy is so advanced as to interfere w/ digestion and gastric emptying • Vague complaint of epigastric pain (relieved by food) • Anorexia •Nausea and vomiting • Intolerance of fatty or spicy foods • Pernicious anemia

Nursing Diagnoses Gastritis

•Acute Pain or Chronic Pain r/t physical injury •Nausea r/t gastric irritation •Deficient Fluid Volume r/t nausea, vomiting, or abdominal distress •Imbalanced Nutrition: Less Than Body Requirements r/t reduced food intake

Answer: •A. Acute pain r/t physical injury (esophageal irritation) So remember prayer highest priority, something that we can treat right now. These all problems with GERD. The first thing we want to do is stop the pain from the esophageal and those are things that we can do with medication right now. Impaired swallowing related to strictures that's going to be a long term, they're going to have to go in, they're going to have to dilate it. There's nothing that we can do right now about that. Risk respiration, always a concern, but it's not an actual problem. It's something that could happen. So just precautionary we would be doing things setting them up not laying down after they eat. The highest priority is always, you know, ABC, we don't have really an ABC right here. So we're going to look at something that we can you know take care of immediately and the acute pain is going to be causing her is the problem right now.

•After the assessment, nursing diagnoses can be chosen for the patient r/t to their response to the medical diagnosis. Which of these diagnoses would be the highest priority for Mrs. EE? •A. Acute pain r/t physical injury (esophageal irritation) •B. Chronic pain •C. Risk for Aspiration r/t incompetent LES •D. Impaired Swallowing r/t stricture or inflammation

Treatment of diarrhea

•Identify cause • • Stool analysis/ Sigmoidoscopy/ Biopsy • Medications • • Depends upon cause (antidiarrheals, antibiotics ....) • Nutritional Replacement • • Fluid and Electrolyte replacement • • Food often held for 24 hours after diarrhea (BRAT diet may be recommended: Bananas, rice, applesauce, and toast) • Alternative Therapy • • Herbal or homeopathic therapies • • Fecal Bacteriotherapy (used w/ C.difficle very effective)

Facts about Obesity

•More than 30% of adults in US are obese •1 in 20 have BMI > 40 kg/m2 •2/3 of all adults in US are overweight •Associated with many other disease processes: CAD, DM, Gallstones, Stroke ... •Contributes to poor health-related quality of life to a greater extent than smoking, excess alcohol use, or poverty. •Associated with increased risk for death, particularly in adults < 65 years of age

Chronic Gastritis manifestations

•Often asymptomatic until atrophy is so advanced as to interfere w/ digestion and gastric emptying • Vague complaint of epigastric pain (relieved by food) • Anorexia •Nausea and vomiting • Intolerance of fatty or spicy foods • Pernicious anemia