Caring for Clients with Disorders of the Upper Gastrointestinal Tract

Disorders that Affect Eating

AnorexiaLack of appetite; Malnutrition

Pathophysiology and EtiologyThe appetite center

Stimulates or suppresses appetite Location and function; Gluconeogenesis

Assessment Findings: Signs and SymptomsAbsence of hunger; Nausea; Hypovitaminosis

Assessment Findings: Diagnostic FindingsReduced hemoglobin level and blood cell counts

Anorexia nervosa

Is an eating disorder characterized by unrealistic fear of weight gain, self-starvation, and conspicuous distortion of body image. Two subtypes of anorexia nervosa—a restricting type, characterized by strict dieting and exercise without binge eating—binge-eating/purging type, marked by episodes of compulsive eating with or without self-induced vomiting and the use of laxatives or enemas.

Causes & Symptoms

Anorexia is a disorder that results from the interaction of cultural and interpersonal as well as biological factors. While the precise cause of the disease is not known, it has been linked to the following:Social Influences Occupational GoalsGenetic and Biological InfluencesPsychological Factors - Inability to interpret the body's hunger signals accurately due to early experiences of inappropriate feeding.

Diagnosis

Anorexics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea (failure to menstruate) in females, abdominal painConstipationlack of energyThe patient may feel chilly or have developed lanugo, a growth of downy body hair. If the patient has been vomiting, she may have eroded tooth enamel Weight loss - 15% below normal

Treatment

Nutritional TherapyAlternative treatments should serve as complementary to a conventional treatment program. Alternative therapies for anorexia nervosa include:Herbal therapy - may help reduce anxiety and depression which are often associated with this disorder:

chamomile (Matricaria recutita) lemon balm (Melissa officinalis)hydrotherapy

AromatherapyMedicationsMedications, including antidepressants, anti-anxiety drugs, selective serotonin reuptake inhibitors, and lithium carbonate. One study of Prozac showed it helped the patient maintain weight gained while in the hospital.

Bulimia nervosa

Is an eating disorder and psychological condition in which the subject engages in recurrent binge eating followed by feelings of guilt, depression, and self-condemnation and intentional purging to compensate for the excessive eating.Purging can take the form of vomiting, fasting, inappropriate use of laxatives, enemas, diuretics or other medication, or excessive physical exercise. The cycle damages bodily organs. Bulimia is common especially among young women of normal or nearly normal weight.

Diagnosis

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

Eating, in a fixed period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat.A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.

Types of Bulimia

Purging Type is the more common type of bulimia, and involves any of self-induced vomiting, laxatives, diuretics, enemas, or ipecac, to rapidly extricate the contents from their body.

Non-Purging Type occurs in only approximately 6%-8% of bulimia cases, as it is a less effective means of ridding the body of such a large number of calories. It involves doing excessive exercise or fasting after a binge, to counteract the large amount of calories previously ingested.

Causesof Bulimia

Bulimia is related to deep psychological issues and feelings of lack of control. Sufferers often use the destructive eating pattern to feel in control over their lives.They may hide or hoard food and overeat when stressed or upset. They may feel a loss of control during a binge, and consume great quantities of food (over 20,000 calories.There are higher rates of eating disorders in groups involved in activities that emphasize thinness and body type, such as gymnastics, dance and cheerleading, figure skating.

Treatment

Several residential treatment centers offer long term support, counseling, and symptom interruption. The most popular form of treatment involves therapy, often group psychotherapy or cognitive behavioral therapy. Anorexics and bulimics typically go through the same types of treatment and are members of these same treatment groups. Anti-depressants or anti-psychotics.

Disorders that Affect Eating: Anorexia

Medical and Surgical ManagementShort-term: No medical interventionVarious approaches for persistent anorexiaPsychological and psychiatric treatment

Nursing ManagementMonitoring weight dailyObtaining medical and allergy history Additional nursing measures for altered bowel patterns

Pathophysiology and EtiologyCommon causes and symptoms

Assessment Findings: Signs and Symptoms

Loss of appetite and dehydration Assessment Findings: Diagnostic Findings

Low levels of serum sodium and chlorideMedical and Surgical Management

IV fluids, electrolytes, and drug therapy Nursing Management

Assessing medical, allergy, and dietary history, and bowel patterns

Disorders that Affect Eating: Nausea and vomiting

AssessmentObtain medical, dietary, drug, and allergy history- details of food intake Monitoring signs of fluid volume deficit

Diagnosis, Planning, and InterventionsDeficient fluid volume Imbalanced nutrition

Evaluation of Expected OutcomesOral intake and output; Maintained weight, serum electrolyte levels and other laboratory test results

Nursing Process: The Client with Nausea and Vomiting

Obesity

Is an abnormal accumulation of body fat, usually 20% or more over an individual's ideal body weight. Obesity is associated with increased risk of illness, disability, and death

Causes of Obesity

Results from an excess of energy (caloric) intake over expenditure, but this statement does not explain why some individuals can eat as much as they like without gaining weight while others remain overweight despite constant dieting. Studies of genetically obese animals and those with damage to the part of the brain called the hypothalamus suggest that individuals may balance body weight around a “setpoint” that is maintained—without conscious control—by variations in metabolic rate in response to caloric intake. Variations in the prevalence of obesity among population groups suggest a genetic basis for the condition.

Treatment

Involve keeping a food diary and developing a better understanding of the nutritional value and fat content of foods. It may also involve changing grocery shopping habits (e.g. buying only what is on a prepared list and going only on a certain day), timing of meals (to prevent feelings of hunger, a person may plan frequent small meals), and actually slowing down the rate at which a person eats.Understanding what psychological issues underlie a person's eating habits. For example, one person may binge eat when under stress, while another may always use food as a reward. In recognizing these psychological triggers, an individual can develop alternate coping mechanisms that do not focus on food. How people spend their time. Making activity and exercise an integral part of everyday life is a key to achieving and maintaining weight loss. Starting slowly and building endurance keeps individuals from becoming discouraged. Varying routines and trying new activities also keeps interest high.

Other weight-loss medications available with a doctor's prescription include:Sibutramine (Meridia) Diethylpropion (Tenuate, Tenuate Dospan) Mazindol (Mazanor, Sanorex) Phendimetrazine (Bontril, Prelu-2) Phentermine (Adipex-P, Fastin, Ionamin, Oby-Cap)

Surgical Treatment

Lipectomy – liposuctionJaw wiringGastric Stapling ( Gastric Partitioning, Gastroplasty)Bypass Procedure

Cancer of the Oral CavityCancer cells; Effects on oral cavity

Pathophysiology and Etiology Causes for oral and lip cancer Consequences Squamous cell carcinoma

Assessment Findings: Signs and Symptoms

Early symptoms: Lesion; Lump; Changes; Pain; Soreness; Bleeding; Leukoplakia; Biopsy of the lesion

Disorders that Affect Eating

DISORDERS OF THE MOUTH

CARIES - Decay of a bone or tooth, especially dental caries. Candidiasis is an infection caused by a species of the yeast Candida, usually Candida albicans. Candida may cause mouth infections in people with reduced immune function, or in patients taking certain antibiotics.

Candidiasis

Treatment

Treatment of candidiasis is primarily accomplished through the use of antifungal drugs. Oral candidiasis is usually treated with prescription lozenges or mouthwashes. Some of the most-used prescriptions are nystatin mouthwashes (Nilstat or Nitrostat) and clotrimazole lozenges.

Medical and Surgical Management Transfusions and antianxiety agentsTumor excisionRadiation therapy and chemotherapy Tracheostomy and tube feedings

Nursing ManagementAddressing communication problemsPost-operative care after oral surgeryPromoting effective coping skillsNutritional management

Disorders that Affect Eating: Cancer of the Oral Cavity

Nursing Management (Cont’d) Gastrointestinal Intubation for Feedings or Medications

Reason Types of GI intubation Procedure Route of administration Selecting type of tube

Disorders that Affect Eating: Cancer of the Oral Cavity

Assessment Reason for tube feedingsEvaluating renal function and digestive issues

Diagnosis, Planning, and InterventionsClient receiving tube feedings and medications; Objectives; Fluid volume deficit – hydration; Infection Imbalanced nutrition: Dietary intake Aspiration and risk for Diarrhea

Nursing Process: The Client Receiving Tube Feedings

Evaluation of Expected Outcomes Maintains weight, clear lungs and normal bowel patterns

Gastrointestinal Intubation for decompression

Larger GI tube Gastric sump tube

Gastrostomy Tubes for Long-Term Feeding

Gastrostomy; Endoscopically

Nursing Process: The Client Receiving Tube Feedings

Fig. 51-1 Measuring length of nasogastric tube for placement into

stomach

Nursing Process: The Client Receiving Tube Feedings

Nursing Process: The Client Receiving Tube Feedings

Gastrostomy Tubes for Long-Term Feeding: General considerations

Surgical placement; Gastrostomy; Laparotomy; PEG – ProcedureGastric feedings; Passage of food into the small intestineGastrostomy feeding devices

Gastrostomy Tubes for Long-Term Feeding: Nursing Management

Precautions before and during PEG Preparation of client’s skinMonitor: Vital signs and client’s tolerance of the procedure

Disorders of the Esophagus

Gastroesophageal Reflux Disease Gastric contents flow upward

Pathophysiology and EtiologyInability of lower esophageal sphincter to close

Assessment Findings: Signs and Symptoms

Epigastric pain, burning sensation, and regurgitation

Disorders of the Esophagus: Gastroesophageal Reflux Disease

Assessment Findings: Diagnostic Findings Barium swallow findings; Upper endoscopy with biopsy; Capsule; Bronchoscopy

Medical and Surgical Management Conservative measures and medicationsFundoplication (tucking of fundus) and Stretta procedure

Nursing ManagementDietary management; Lifestyle changes Patient education

What is the Stretta Procedure?

Delivers precise radiofrequency (RF) waves to the gastro esophageal (GE) junction to restore lower esophageal sphincter function. Once the lower esophageal sphincter function is restored it will act as a barrier to prevent the upward flow of gastric contents into your esophagus.

Pathophysiology and Etiology Zenker’s diverticulum ( pharynx)Congenital or acquired weakness of esophageal wall

Assessment Findings: Signs and Symptoms

Foul breath and difficulty in swallowing

Barium swallow and esophagoscopy

Disorders of the Esophagus: Esophageal Diverticulum

Disorders of the Esophagus: Esophageal Diverticulum

Medical and Surgical ManagementDiet therapy: Bland; Soft; Semisoft; LiquidSurgical excision of the diverticulum

Nursing Management Educate about diet and lifestyle changes

Advise pregnant clients that symptoms of GERD usually resolve after delivery

Disorders of the Esophagus

Hiatal HerniaAxial or sliding and paraesophageal (A protrusion of a portion of the stomach)

Pathophysiology and Etiology Defect in diaphragmCongenital muscle weakness

Assessment Findings Heartburn, belching or pain after eating Barium swallow and esophagoscopy

Medical and Surgical ManagementNarrowed esophagus stretched endoscopically

Assessment Evaluate appetite, pain, weight and use of medications

Diagnosis, Planning, and Interventions Postoperative careImbalanced nutritionPain related to pressure or reflux of gastric secretions

Evaluation of Expected OutcomesConsumes adequate nutrientsRelief from epigastric pain

Nursing Process: The Client with an Esophageal Disorder

Pathophysiology and Etiology Affects men more often than women Tumor usually is squamous cell carcinoma Correlation with esophageal cancer, alcohol abuse, and cigarette smoking

Assessment FindingsBeginning and progressive symptoms Barium swallow, biopsy, EGD, bronchoscopy and endoscopic ultrasound or mediastinoscopy

Disorders of the Esophagus: Cancer of the Esophagus

Medical and Surgical Management Palliative measures, endoscopic laser surgery or esophageal dilatation Surgery

Nursing ManagementFocusing on nutritional needs Caring for client with tube feedings Postoperative care after surgeryPatient education

Disorders of the Esophagus: Cancer of the Esophagus

Pathophysiology and Etiology

Causes; Helicobacter pylori (Bacterium commonly infecting the gastric mucosa in patients with ulcers. Result of acid production

Assessment Findings Common symptomsSymptoms with bacterial or viral infection Complete blood count, stool test and gastroscopy

Gastric Disorders: Gastritis

Medical and Surgical Management Restricted eating and IV fluidsAvoidance of irritating substancesVarious drugs: Antiemetics; antibiotics

Nursing Management Evaluate response to dietary modifications and prescribed medicationsObserve color and characteristics of vomitus or stool Patient education

Gastric Disorders: Gastritis

FIG 51-4Gastric ulcer

Gastric Disorders: Peptic Ulcer Disease

Pathophysiology and Etiology Infection with Helicobacter pylori Family history and other risk factorsDevelopment of ulcers Chronic gastric inflammation

Assessment FindingsAbdominal pain and back painBleeding- hematemesis and melena

Gastric Disorders: Peptic Ulcer Disease

Assessment Findings: Diagnostic Findings Esophagogastroduodenoscopy Gastric washingLow Hemoglobin and RBC

Medical and Surgical Management Eradication therapy,Gastrectomy

Nursing Management Assessment of pain and dietary history Nutritional management; Bowel patterns

Assessment Information on current symptoms, past gastric problems and treatments or surgerySigns of abdominal pain, malnutrition, and dehydration

Diagnosis, Planning, and InterventionsRisk for deficient fluid volumeDeficient knowledge

Evaluation of Expected Outcomes Fluid intake and output; Nutritional intake

Nursing Process: The Client with a Gastric Disorder

Pathophysiology and Etiology Stomach malignanciesHeredity and chronic inflammation Achlorhydria and chronic ingestion of toxins

Assessment Findings Early symptoms: Stool contains occult bloodBarium swallow, CT scan, tissue biopsy, gastric analysis and ultrasonography

Gastric Disorders: Cancer of the Stomach

Medical and Surgical Management Subtotal or total gastrectomy ChemotherapyPalliative radiation

Nursing Management Client and family teachingInstructing high risk groupsSurgery for gastric cancer

Gastric Disorders: Cancer of the Stomach

General Nutritional Considerations Limiting high fat foods and liquidIntermittent cyclic and bolus tube feedings Use of medium-chain triglycerides (MCT)

General Pharmacologic Considerations H2 antagonists, antacids and sucralfate

Patient education Avoiding sodium bicarbonate

Nursing Management

General Gerontologic ConsiderationsFactors leading to anorexiaOropharyngeal dysphagia Modification of dietGreater risk for:

AspirationSuperficial gastritis and gastric ulcers Hiatal hernia

Pernicious anemia (inability to absorb vitamin B12)

Nursing Management

End of Presentation