Assessment of the Gastrointestinal System

Overview of the Gastrointestinal Tract Structure Function Nerve supply Blood supply Oral cavity Esophagus Stomach

(Continued)

Overview of the Gastrointestinal Tract

(Continued)

Pancreas Liver and gallbladder Intestines

Assessment Techniques

History Demographic data Family history and genetic risk Personal history Diet history

Anorexia Dyspepsia

Current Health Problems

Pattern of bowel movements Color and consistency of the feces Occurrence of diarrhea or constipation Effective action taken to relieve

diarrhea or constipation Presence of frank blood or tarry stools Presence of abdominal distention or

gas

Skin Changes Related to Gastrointestinal Disorders

Skin discolorations or rashes Itching Jaundice Increased susceptibility to bruising Increased tendency to bleed

Physical Assessment

Mouth and pharynx Abdomen and extremities

Inspection (Cullen’s sign) Auscultation, look for borborygmus Percussion Palpation

Laboratory Tests Complete blood count Clotting factors Electrolytes Assays of liver enzymes—aspartate

and alanine aminotransferase Serum amylase and lipase Bilirubin: the primary pigment in bile

(Continued)

Laboratory Tests (Continued)

Evaluation of oncofetal antigens CA 19-9 and CEA

Urine tests—amylase, urine urobilinogen

Stool tests—fecal occult blood test, ova parasites, Clostridium difficile infection

Radiographic examinations

Upper Gastrointestinal Series and Small Bowel Series

Before test: Maintain NPO for 8 hr. Withhold analgesics and

anticholinergics for 24 hr. Client drinks 16 ounces of barium. Rotate examination table.

(Continued)

Barium Enema

Barium enema enhances radiographic visualization of the large intestine.

Only clear liquids are given 12 to 24 hr before the test; NPO the night before; bowel cleansing is done.

After the test, expel the barium: drink plenty of fluids; stool is chalky white for 24 to 72 hr.

Upper Gastrointestinal Series and Small Bowel Series (Continued)

After the test: Give plenty of fluids. Administer mild laxative or stool

softener; stools may be chalky white for 24 to 72 hr.

Percutaneous Transhepatic Cholangiography

X-ray study of the biliary duct system Laxative before the procedure NPO for 12 hr before test Coagulation tests, intravenous infusion Bedrest for several hours after

procedure Assessment of vital signs

(Continued)

Percutaneous Transhepatic Cholangiography (Continued)

Client positioned on right side with a firm pillow or sandbag placed against the lower ribs and abdomen

Other Tests

Computed tomography Endoscopy: direct visualization of

the gastrointestinal tract by means of a flexible fiberoptic endoscope

Esophagogastroduodenoscopy

Visual examination of the esophagus, stomach, and duodenum

NPO for 6 to 8 hr before the procedure Conscious sedation After the test, assessment of vital

signs every 30 min NPO until gag reflex returns Throat discomfort possible for several

days

Endoscopic Retrograde Cholangiopancreatography

Visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas

NPO for 6 to 8 hr before test Access for intravenous sedation After the test, assessment of vital

signs every 15 min(Continued)

Endoscopic Retrograde Cholangiopancreatography

(Continued)

Return of gag reflex checked Assessment for pain Colicky abdominal pain

Small Bowel Capsule Enteroscopy

Visualization of the small intestine Only water for 8 to 10 hr before test NPO for first 2 hr of the testing Application of belt with sensors

Colonoscopy Endoscopic examination of the entire

large bowel Liquid diet for 12 to 24 hr before

procedure, NPO for 6 to 8 hr before procedure

Bowel cleansing routine Assessment of vital signs every 15 min If polypectomy or tissue biopsy, blood

possible in stool

Proctosigmoidoscopy Endoscopic examination of the rectum

and sigmoid colon Liquid diet 24 hr before procedure Cleansing enema, laxative Position client on left side in the knee-

chest posture.

(Continued)

Proctosigmoidoscopy

(Continued)

Mild gas pain and flatulence from air instilled into the rectum during the examination

If biopsy was done, a small amount of bleeding possible

Gastric Analysis

Measurement of the hydrochloric acid and pepsin content for evaluation of aggressive gastric and duodenal disorders (Zollinger-Ellison syndrome)

Basal gastric secretion and gastric acid stimulation test

NPO for 12 hr before test Nasogastric tube insertion

Other Tests Ultrasonography Endoscopic ultrasonography Liver-spleen scan

Gasrointestinal Intubation

To remove gas and fluids from the stomach or intestines (decompression).

To diagnose GI motility and to obtain gastric secretions for analysis.

To relieve and treat obstructions or bleeding within the GI tract.

Gastrointestinal Intubation cont……

To provide a means for nutrition ( gavage feeding), hydration, and medication when the oral route is not possible or is contraindicated.

To promote healing after esophageal, gastric, or intestinal surgery by preventing distension of the GI tract and strain on the suture lines.

Gastrointestinal Intubation cont….

To remove toxic toxic substances (lavage) that have been ingested either accidentally or intentionally and to provide for irrigation.

General Nursing Care

Assessing tube placement must be assessed after insertion and maintenance. Assessing tube placement is essential to prevent complications or death from incorrect tube placement.

Nasogastric tube placement must be assessed after insertion and then intermittently to ensure that it is in the correct position and not in the lungs (most common), esophagus, pleural space, or brain.

Interventions for Clients with Oral Cavity Problems

Stomatitis

Painful, single or multiple ulcerations of the oral mucosa that appear as inflammation and denudation of the oral mucosa, impairing the protective lining of the mouth

Primary stomatitis Secondry stomatitis Candidiasis

Clinical Manifestations

Dry, painful mouth, open ulcerations, predisposing the client to infection

Commonly found on the buccal mucosa, soft palate, oropharyngeal mucosa, and lateral and ventral areas of the tongue

If candidiasis, white plaquelike lesions on the tongue; when wiped away, red sore tissue appears

Oral Hygiene

Soft-bristled toothbrush or disposable foam swabs to stimulate gums and clean the oral cavity are recommended.

Frequent rinsing of the mouth with solution, not commercial mouthwash

Mouth care every 2 hr and twice during the night, if stomatitis is not controlled

Drug Therapy

Antibiotics such as tetracycline syrup and minocycline (swish and swallow)

Antifungals such as nystatin oral suspension (swish and swallow)

Intravenous acyclovir for immunocompromised clients with herpes simplex stomatitis

(Continued)

Drug Therapy (Continued)

Anti-inflammatory agents and immune modulators

Symptomatic topical agents such as gargle or mouthwash

Leukoplakia Slowly developing changes in the oral

mucous membranes characterized by thickened, white, firmly attached patches that are slightly raised and sharply circumscribed.

Most common oral lesion among adults

(Continued)

Leukoplakia (Continued)

Oral hairy leukoplakia is an early manifestation of HIV infection and is highly correlated with the progression from HIV to AIDS.

Erythroplakia

Red, velvety mucosal lesions on the surface of the oral mucosa

Higher degree of malignant transformation in erythroplakia than in leukoplakia

Commonly found on the floor of the mouth, tongue, palate, and mandibular mucosa

Squamous Cell Carcinoma

Most common oral malignancy: can be found on the lips, tongue, buccal mucosa, and oropharynx

Highly associated with aging, tobacco use, and alcohol ingestion

Tumor, node, metastasis classification system for tumors of the lips and oral cavity

Basal Cell Carcinoma

Occurs primarily on the lips Lesion is asymptomatic and

resembles a raised scab; evolves into ulcer with a raised pearly border

Aggressively involves the skin of the face, but does not metastasize

Major etiologic factor is exposure to sunlight

Kaposi’s Sarcoma

Malignant lesion arising in blood vessels

Usually painless Raised purple nodule or plaque Found on the hard palate, gums,

tongue, or tonsils Most often associated with AIDS

Risk for Ineffective Airway Clearance

Interventions include: Excessive tumor involvement and

tenacious secretions can inhibit airway patency.

Nursing measures for maintaining airway patency is primary focus.

Assessment should focus on client’s dyspnea, inability to cough effectively, or inability to swallow.

Nonsurgical Management

Airway management Cough management Aspiration precautions

Surgical Management

Tracheostomy Decannulation accomplished after

postoperative edema resolves

Impaired Oral Mucous Membrane

Oral cavity lesions can be treated by surgical excision, by nonsurgical treatments such as radiation or chemotherapy, or by a combination of treatments (multimodal therapy)

Nonsurgical Management

Oral care Radiation therapy Chemotherapy

Surgical Management

Preoperative care Operative procedure Postoperative care

Maintaining airway patency Protecting the operative area Relieving pain Promoting nutrition

Acute Sialadenitis Inflammation of a salivary gland,

caused by infectious agents, irradiation, or immunologic disorders

Interventions Hydration Application of warm compresses Massage of the gland Use of saliva substitute Use of sialagogues

Postirradiation Sialadenitis Xerostomia results in very dry mouth

caused by severe reduction in the flow of saliva.

Little can be done during the course of radiation, but frequent sips of water and frequent mouth care, especially before meals, are the most effective interventions.

(Continued)

Postirradiation Sialadenitis (Continued)

Saliva substitutes can be used after the course of radiation therapy is complete.

Salivary Gland Tumors

Relatively rare among oral tumors Often associated with radiation of the

head and neck areas Assessment: ability to wrinkle brow,

raise eyebrows, squeeze eyes shut, wrinkle nose, pucker lips, puff out cheeks, and grimace or smile

Treatment of choice: surgical excision of the parotid gland

Interventions for Clients with Esophageal Problems

Gastroesophageal Reflux Disease

Occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus

Reflux esophagitis characterized by acute symptoms of inflammation

(Continued)

Gastroesophageal Reflux Disease (Continued)

Esophageal reflux occurs when gastric volume or intra-abdominal pressure is elevated, the sphincter tone of the lower esophageal sphincter is decreased, or it is inappropriately relaxed.

Clinical Manifestations

Dyspepsia Regurgitation Hypersalivation or water brash Dysphagia and odynophagia Others manifestations: chronic cough,

asthma, atypical chest pain, eructation (belching), flatulence, bloating, after eating, nausea and vomiting

Diagnostic Assessment

24-hr ambulatory pH monitoring Endoscopy Esophageal manometry

Nonsurgical Management

Diet therapy Client education Lifestyle changes: elevate head of bed 6

in. for sleep, sleep in left lateral decubitus position; stop smoking and alcohol consumption; reduce weight; wear nonbinding clothing; refrain from lifting heavy objects, straining, or working in a bent-over posture

Drug Therapy Antacids elevate the level of the

gastric contents. Histamine receptor antagonists

decrease acid production. Proton pump inhibitors provide

effective, long-acting inhibition of gastric acid secretion.

Prokinetic drugs increase gastric emptying and improve lower esophageal sphincter pressure and esophageal peristalsis.

Other Treatments

Endoscopic therapies Surgical therapies

Hiatal Hernia Protrusion of the stomach through the

esophageal hiatus of the diaphragm into the thorax

Sliding hernia most common, occurring when esophagogastric junction and a portion of the fundus of the stomach slide upward through the esophageal hiatus into the thorax

Rolling hernia: fundus rolls into the thorax beside the esophagus

Assessment

Heartburn Regurgitation Pain Dysphagia Belching Worsening symptoms after eating

or when in recumbent position

Nonsurgical Management Drug therapy: antacids, histamine

receptor antagonists Diet therapy: avoid eating in the late

evening and avoid foods associated with reflux

Weight reduction

(Continued)

Nonsurgical Management

(Continued)

Elevate head of bed 6 -12 in. for sleep, remain upright for several hours after eating, avoid straining and vigorous exercise, avoid nonbinding clothing.

Surgical Management

Laparoscopic Nissen Fundoplication (LNF) – is the most common surg proc. – the stomach fundus is wrapped around the lower part of the esophagus and then sutured onto itself to hold it in place.

Surgical Management

Preoperative care Operative procedures Postoperative care

Respiratory care Nasogastric tube management Nutritional care for complications of

surgery including gas bloat syndrome and aerophagia (air swallowing)

Achalasia

Esophageal motility disorder believed to result from esophageal denervation characterized by chronic and progressive dysphagia

Primary symptoms: dysphagia and regurgitation of solids, liquids, or both

Drug and Diet Therapy Calcium channel blockers Nitrates Direct injection of botulinum toxin into

the lower esophageal muscle Semisoft foods Arching the back while swallowing Avoidance of restrictive clothing

Esophageal Dilation Passage of progressively larger sizes of

esophageal bougies using polyurethane balloons on a catheter

Metal stents used to keep the esophagus open for longer durations

Complications: bleeding, signs of perforation, chest and shoulder pain, elevated temperature, subcutaneous emphysema, hemoptysis

Esophagomyotomy

Surgical procedure for achalasia is done to facilitate the passage of food.

Laparoscopic approach is most common.

For long-term refractory achalasia, the surgeon may attempt excising the affected portion of the esophagus with or without replacement of a segment of colon or jejunum.

Esophageal Tumors

Esophageal tumors can be benign or malignant.

Barrett’s esophagus is ultimately malignant.

Clinical manifestations include dysphagia, odynophagia, regurgitation, vomiting, foul breath, chronic hiccups, pulmonary complications, chronic cough, and hoarseness.

Imbalanced Nutrition: Less Than Body Requirements

Interventions include: Nonsurgical management

Nutrition therapy Swallowing therapy Chemotherapy Radiation therapy

(Continued)

Imbalanced Nutrition: Less Than Body Requirements

(Continued)

Photodynamic therapy Esophageal dilation Endoscopic therapies Surgical removal of the tumor

Surgical Management

Esophagectomy: the removal of all or part of the esophagus

Esophagogastrostomy: the removal of part of the esophagus and proximal stomach

Minimally invasive esophagectomy Extensive preoperative care Operative procedures

Postoperative Care

Highest postoperative priority: respiratory care

Cardiovascular care Wound management Nasogastric tube management Nutritional care Discharge planning

Diverticula

Sacs resulting from the herniation of esophageal mucosa and submucosa into surrounding tissue

Zenker’s diverticulum most common Diet therapy for size and frequency

of meals Surgical management

Esophageal Trauma

Trauma to the esophagus can result from blunt injuries, chemical burns, surgery or endoscopy, or stress of protracted vomiting.

Nothing is administered by mouth; broad-spectrum antibiotics are given.

Surgical management requires resection of part of the esophagus with a gastric pull-through and repositioning or replacement by a bowel segment.

Interventions for Clients with Stomach Disorders

Gastritis Gastritis is defined as inflammation of

the gastric mucosa; two types: Acute gastritis Chronic gastritis

Type A gastritis Type B gastritis Atrophic gastritis

Helicobacter pylori, Escherichia coli can cause gastritis.

Clinical Manifestations

Abdominal tenderness Bloating Hematemesis Melena Intravascular depletion and shock

Nonsurgical Management

Primary treatment: identification and elimination of causative factors

Drug therapy H2-receptor antagonists Antacids Antisecretory agents Vitamin B12

Triple therapy for H. pylori infection

Other Therapies

Diet therapy Limit intake of foods and spices that

cause distress (tea, coffee, cola, chocolate, mustard, paprika, cloves, pepper, and hot spices), as well as tobacco and alcohol.

Stress reduction

Surgical Management

Partial gastrectomy Pyloroplasty Vagotomy Total gastrectomy

Peptic Ulcer Disease

PUD is a mucosal lesion of the stomach or duodenum as a result of gastric mucosal defenses impaired and no longer able to protect the epithelium from the effects of acid and pepsin.

Acid, pepsin, and Helicobacter pylori infection play an important role in the development of gastric ulcers.

Duodenal Ulcers

Most duodenal ulcers occur in the first portion of the duodenum.

Duodenal ulcers present as deep, sharply demarcated lesions that penetrate through the mucosa and submucosa into the muscularis propria.

Stress Ulcers

Acute gastric mucosa lesions occurring after an acute medical crisis or trauma

Associated with head injury, major surgery, burns, respiratory failure, shock, and sepsis.

Principal manifestation: bleeding caused by gastric erosion

Complications of Ulcers Hemorrhage—hematemesis Perforation—a surgical emergency Pyloric obstruction—manifested by

vomiting caused by stasis and gastric dilation

Intractable disease—the client no longer responds to conservative management, or recurrences of symptoms interfere with ADLs

Clinical Manifestations

Epigastric tenderness usually located at the midline between the umbilicus and the xiphoid process

Dyspepsia Typically described as sharp,

burning, or gnawing pain Sensation of abdominal pressure or

of fullness or hunger

Acute or Chronic Pain One of the primary purposes for

employing drug therapy is to eliminate or reduce pain.

Analgesics are not the mainstay of pain relief for PUD.

Ulcer drug regimen itself promotes relief of pain by eradicating H. pylori infection and promoting healing of the gastric mucosa.

Drug Therapy

Four primary goals for drug therapy: Provide pain relief Eradicate H. pylori infection Heal ulcerations Prevent recurrence

Hyposecretory Drugs

Hyposecretory drugs produce a reduction in gastric acid secretion. Antisecretory agents H2-receptor antagonists Prostaglandin analogues

Antisecretory Agents

Antisecretory agents, also called proton pump inhibitors, include: Prilosec Prevacid Aciphex Protonix Nexium

H2-Receptor Antagonists Drugs that block histamine-stimulated

gastric secretion May be used for indigestion and

heartburn Block the action of the H2-receptors of

the parietal cells, thus inhibiting gastric acid secretion

The most common: Zantac, Pepcid, and Axid

Prostaglandin Analogues

These agents reduce gastric acid secretion and enhance gastric mucosal resistance to tissue injury.

Misoprostol (Cytotec) helps prevent NSAID-induced ulcers.

Uterine contraction is a significant adverse effect of misoprostol.

Antacids

Antacids buffer gastric acid and prevent the formation of pepsin; they are effective in accelerating the healing of duodenal ulcers.

The most widely used preparations are mixtures of aluminum hydroxide and magnesium hydroxide, such as Mylanta or Maalox.

(Continued)

Antacids (Continued)

For optimal effect, take about 2 hr after meals.

Antacids can interact with certain drugs and interfere with their effectiveness.

Mucosal Barrier Fortifiers

Sucralfate (Carafate) is a sulfonated disaccharide that forms complexes with proteins at the base of a peptic ulcer; this protective coat prevents further digestive action of both acid and pepsin.

(Continued)

Mucosal Barrier Fortifiers (Continued)

Sucralfate binds bile acids and pepsins, reducing injury from these substances.

The main side effect of sucralfate is constipation.

Diet Therapy

Diet therapy may be directed toward neutralizing acid and reducing hypermotility.

A bland, nonirritating diet is recommended during the acute symptomatic phase.

Avoid bedtime snacks. Avoid alcohol and tobacco.

Complementary and Alternative Therapies

Kundalini yoga techniques are being studied to see how they can help manage gastrointestinal disorders.

Certain herbs are thought to heal inflamed tissue and increase blood flow to the gastric mucosa.

Other substances include zinc, vitamin C, essential fatty acids, acidophilus, vitamins E and A, and glutamine.

Potential for Gastrointestinal Bleeding

Interventions include: Monitoring and early recognition of

complications (critical to the successful management of PUD).

Preventing and/or managing bleeding, perforation, and gastric outlet obstruction.

Possible surgical treatment.

Hypovolemia Management

Monitor vital signs and observe for fluid loss from bleeding and vomiting.

Monitor serum electrolytes. Insert two large-bore peripheral IV

catheters to replace both fluids and blood lost.

(Continued)

Hypovolemia Management

(Continued)

Volume replacement with isotonic crystalloid solutions should be started immediately.

Blood products may be ordered to expand volume and correct abnormalities in the CBC.

Orthostatic hypotension is common in clients with decreased fluid volume.

Bleeding Reduction: Gastrointestinal

Endoscopic therapy can assist in achieving hemostasis.

Acid-suppressive agents are used to stabilize the clot by raising the pH level of gastric contents.

Upper gastrointestinal bleeding may require the health care provider to insert nasogastric tube.

Saline lavage requires the insertion of a large-bore nasogastric tube.

Nonsurgical Management

Perforation is managed by immediately replacing fluid, blood, and electrolytes. Administering antibiotics Keeping the client NPO

Pyloric obstruction related to edema, and spasm generally responds to medical therapy.

Surgical Management Preoperative care: insertion of a

nasogastric tube. Operative procedure

A simple gastroenterostomy permits neutralization of gastric acid.

(Continued)

Surgical Management

(Continued)

Vagotomy eliminates the acid-secreting stimulus to gastric cells and decreases the response of parietal cells.

Pyloroplasty facilitates emptying of stomach contents.

Postoperative Care Monitor the nasogastric tube. Monitor for postoperative

complications: Dumping syndrome (constellation of

vasomotor symptoms after eating) Reflux gastropathy

(Continued)

Postoperative Care (Continued)

Delayed gastric emptying (usually resolved within 1 week)

Afferent loop syndrome may occur after a Billroth II resection.

Recurrent ulceration occurs in about 5% of clients.

Nutritional Management

Deficiencies of vitamin B12, folic acid, and iron; impaired calcium metabolism; and reduced absorption of calcium and vitamin D develop as a result of partial removal of the stomach.

These problems are caused by a shortage of intrinsic factor.

Monitor CBC for signs of megaloblastic anemia and leukopenia.

Zollinger-Ellison Syndrome

Zollinger-Ellison syndrome is manifested by upper gastrointestinal tract ulceration, increased gastric acid secretion, and the presence of a non–beta cell islet tumor of the pancreas, called a gastrinoma.

Clients may complain of peptic ulcer disease symptoms and may have diarrhea and/or steatorrhea.

Interventions

The aim of therapy is to suppress acid secretion to control the client’s symptoms.

Drugs of choice are: Prevacid Prilosec Zantac

(Continued)

Interventions (Continued)

If medical therapy fails, a vagotomy and pyloroplasty to supplement pharmacologic means of controlling hypersecretion may be performed.

Gastric Carcinoma

Gastric carcinoma refers to malignant neoplasms in the stomach.

Clinical manifestations: early gastric cancer may be asymptomatic, but indigestion and abdominal discomfort are the most common symptoms.

(Continued)

Gastric Carcinoma (Continued)

Signs of distant metastasis include: Virchow's nodes Sister Mary Joseph nodes Blumer's shelf Krukenberg's tumor

Nonsurgical Management

Drug therapy The role of chemotherapy in gastric

cancer remains uncertain. Radiation therapy

The use of this treatment is limited because the disease is often widely disseminated.

Surgical Management Preoperative care is similar to that

provided for general anesthesia and abdominal surgery.

Operative procedures include subtotal and total gastrectomy.

Postoperative complications: Pneumonia Anastomotic leak

(Continued)

Surgical Management

(Continued)

Hemorrhage Reflux aspiration Wound infection Sepsis Reflux gastritis Paralytic Ileus Bowel obstruction Dumping syndrome

Interventions for Clients with Malnutrition and Obesity

Nutritional Standards to Promote Health

Dietary recommendations, food guide pyramids for adequate nutrition

Nutritional assessment includes: Diet history Anthropometric measurements Measurement of height and weight Assessment of body fat (body mass

index)

Malnutrition

Protein-calorie malnutrition Marasmus calorie malnutrition, in

which body fat and protein are wasted, serum proteins are often preserved

Kwashiorkor Marasmic-kwashiorkor

Laboratory Assessment

Hematology Protein studies Serum cholesterol Other laboratory tests

Imbalanced Nutrition: Less Than Body Requirements

Interventions include: Drug therapy Partial enteral nutrition Total enteral nutrition Candidates for total enteral nutrition

Enteral Nutrition Types of enteral products for nutrients Methods of administration of total

enteral nutrition Types of tubes Types of feedings Complications of total enteral

nutrition: Aspiration, fluid excess, increased

osmolarity, dehydration, electrolyte imbalances

Parenteral Nutrition

Partial parenteral nutrition Total parenteral nutrition Complications include:

Fluid imbalances Electrolyte imbalances Glucose imbalances Infection

Obesity

Overweight: increase in body weight for height compared to standard

Obesity: at least 20% above upper limit of normal range for ideal body weight

Morbid obesity: severe negative effect on health

Obesity Complications

Diabetes mellitus Hypertension Hyperlipidemia CAD Obstructive sleep apnea Obesity hypoventilation syndrome Depression and other mental

health/behavioral health problems(Continued)

Obesity Complications (Continued)

Urinary incontinence Cholelithiasis Chronic back pain Early osteoarthritis Decreased wound healing Increased susceptibility to infection

Obesity and Health Promotion

Health promotion/illness prevention Teach the potential consequences and

complications. Teach the importance of eating a

healthy diet. Teach that foods eaten away from home

tend to be higher in fat, cholesterol, and salt, and lower in calcium.

(Continued)

Obesity and Health Promotion (Continued)

Reinforce need for regular moderate activity for at least 30 min per day.

Educate regarding diet and activity for children and adolescents, and continuing throughout adulthood.

Nonsurgical Management

Fasting Very low-calorie diets of 200 to 800

calories per day Balanced and unbalanced low-energy

diets Novelty diets Diet therapy Exercise program

(Continued)

Nonsurgical Management

(Continued)

Drug therapy Complementary and alternative

therapies and treatments

Surgical Management Liposuction Panniculectomy Bariatric surgery Preoperative care Operative procedures

Vertical banded gastroplasty Circumgastric banding Gastric bypass Roux-en-Y gastric bypass

Postoperative Care

Analgesia Skin care Nasogastric tube placement Diet Prevention of postoperative complications Observe dumping syndrome signs such

as tachycardia, nausea, diarrhea, and abdominal cramping

Gastrointestinal Intubation

To remove gas and fluids from the stomach or intestines (decompression).

To diagnose GI motility and to obtain gastric secretions for anaysis