1、1,Care of Patient with GERD & Peptic Ulcer,63-273,2,GERD: Background,Gastroesophageal reflux is a normal physiologic phenomenon in most people, particularly after a meal. Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the norma
2、l limit,3,Causes of GERD,4,GERD: Symptoms,Typical symptoms: Heartburn (Pyrosis): Most common Felt as a retrosternal sensation of burning or discomfort Occurs usually after eating or when lying down or bending over. Often relieved with milk or waterRegurgitation: Effortless return of gastric and/or e
3、sophageal contents into the pharynx. It can induce respiratory complications if gastric contents spill into the tracheobronchial tree. Atypical symptoms Cough, dyspnea, hoarseness, and chestpain,5,Diagnosis,Role out other potential causes for the heartburn: Cardiac Peptic ulcer EsophagitisEsophageal
4、 Endoscopy: The gold standard as a definitive diagnosisBarium swallow Not as definitive in mild cases,6,Collaborative Care,Lifestyle modificationsNutritional therapy Decrease high-fat foods, avoid milk products at night, and avoid late snacking or mealsDrug TherapySurgical therapyEndoscopic therapy,
5、7,GERD: Complications,Are related to HCl effect on the esophageal mucosa Esophagitis Can complicate to esophageal ulcerationBarretts esophagus (esophageal metaplasia) Pre-cancerous lesion,8,Nursing Management,Avoid factors that cause reflux Stop smoking Avoid acid or acid producing foodsElevate HOB
6、30Do not lie down 2 to 3 hours after eatingPatient teaching (see Table 40-10 in textbook)Drug therapy Evaluate effectiveness Observe for side effects,9,Peptic ulcer,Erosion or excavation of mucosal wall of the esophagus, stomach, pylorus, duodenum (most common). “Autodigestion”Requires acid environm
7、ent to developMucosal defenses impaired; cannot protect from effects of acid/pepsinResult from infection with H. pylori or Zollinger-Ellison syndromeRisk factors: Alcohol, smoking, and stress, medications,10,Three types of peptic ulcer,Gastric Duodenal Stress,11,Gastric ulcer,Most common in the less
8、er curvature of stomach near the pylorus Mucus and bicarb. generally protect mucosal barrier from acidH. pylori plays a roleBreak in gastric mucosal barrier allows HCl to damage epithelium via “back diffusion”Bile reflux from duodenum may break integrityDecreased blood flow,12,Duodenal ulcer,Results
9、 from excessive acid Associated with protein-rich meals, Ca+, and vagal stimulation)Rapid emptying of food from stomach large acid load in duodenumH. pylori infection plays key role in development produces substances that damage the mucosa, and contributes to higher acid concentrations,13,Stress ulc
10、er,Occurs after acute medical crisis, surgery, or traumaProximal portion of stomach and duodenum are most common sitesIschemia and elevated HCl contribute to evolution of erosions ulcerationsMay progress to hemorrhage,14,Duodenal versus Gastric ulcers,15,Diagnostic tests,Esphagogastroduodenoscopy Fi
11、beroptic endoscope allows direct visualization of esophagus, stomach and duodenum,16,Diagnostic tests: Upper GI series,Patients ingests barium, a thick, white, milkshake-like liquid, then multiple X-rays. Can detect structural disordersAfter the exam, provide plenty of liquids for 24 to 48 hours. Th
12、e barium may make the stool white for several days. If constipation occurs, the doctor may recommend a mild laxative.,17,Complications of ulcers: Hemorrhage,Manifested by: Orthostatic hypotension, BP, HR, cool, clammy skin overt bleedingHematemesis (bloody vomit) bright red or coffee ground (more li
13、kely with gastric ulcer)Melena (bloody or tarry black stool) more likely with duodenal ulcer Hgb, Hct,18,Remember: Management during Haemorrhage includes,Monitor S/S Determine rate amount of blood loss (Hct/hct), NGT Replace blood, fluid and electrolyte loss saline lavage via NGT NGT to low intermit
14、tent suction Prevents distension Assess amount/rate of bleeding, Medications, oxygen, possible surgery,19,Complications: Perforation,GI contents empty into peritoneal cavityManifested by: Sudden, sharp mid-epigastric pain which can shortly spread to all abdomen Rigid, tender, board-like abdomen Pati
15、ent assumes the fetal position to reduce tension on musclesCan lead to shockIt is a surgical emergency,20,Remember: Management during perforation includes,NGT to prevent additional spillage of GI contents in peritoneumReplace blood, fluid, electrolytesAntibioticsI & O, NPOSURGERY: Urgent,21,Complica
16、tions: Pyloric obstruction,Caused by inflammation or edema of the pylorus Stomach cannot empty abdominal bloating, N & VPersistent vomiting Hypokalemia and metabolic alkalosis,22,Medical Management of ulcers,Conservative therapy: Rest: Both physical and emotional Dietary modifications Elimination of
17、 smokingLong term follow up care,Pharmaceutical: Antibiotics To eradicate H. Pylori infections Recurrence of ulcer is 75-90% as high with infectionAntiacids Initial drugs of choice Histmaine H2 receptor antagonists Histamine is the final intracellular activator of HCL secretion Anticholinergic: Stop
18、 the cholinergic stimulation of HCl secretion and slow gastric motility Not commonly used, if used need to be used with caution in pts with Glaucoma,23,Surgical Management of ulcerations,Gastroduodenostomy (Billroth I) Removal of the lower portion of stomach and small portion of duodenum and connect
19、s remaining of stomach to duodenum,24,Surgical Management of ulcerations,Gastojejunostomy Removes lower stomach and small portion of duodenum. Reconnects stomach to jejunum. Subtotal gastrectomy - removal distal third of stomach, reconnecting to duodenum or jejunum Total gastrectomy removal of stoma
20、ch; connects esophagus to jejunum,25,Dumping syndrome,A complication of gastric surgeryS&S vertigo, sweating, palpitations, syncope, pallor, tachycardiaoccurs after eating D/t rapid emptying of hypertonic stomach contents into small intestine fluid shifts into gut abd. distention and cramps and S/S
21、of plasma volume. Later get rapid elevation of blood glucose followed by insulin secretion and hypoglycemiaManagement Small frequent meals fat, protein, CHO meals liquid between (not with) meals Lie down after meals,26,Nursing diagnoses,Pain r/t mucosal injuryAnxietyKnowledge deficitRisk for fluid v
22、olum deficit r/t hemorrhage or vomiting,27,Intervention: Pain,Medications Give antacids after meals and at bedtime to decrease gastric acidity; buffers the acid. Give H2 receptor antagonists as prescribed to decrease acid secretion Diet therapy Effectiveness controversial Avoid caffeinated beverages
23、 Exclude foods that cause discomfort Provide frequent, small, bland meals Avoid smoking, alcohol,28,Intervention: Anxiety & Knowledge deficit,Anxiety Provide emotional support Teach and provide relaxation techniques Identify and manage sources of stressKnowledge deficit Teach re diet, medications, Teach the risks associated with continued smoking Teach S/S of complications,
