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Alterations in Nutrition. Gastroesophageal Reflux Disease Peptic Ulcer Disease Cholecystitis/Gastric Surgery. Upper GI. Gastroesophageal Reflux Disease(GERD). Occurs when contents of the stomach including stomach juices (flow back) into the esophagus. Causes for GERD.

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alterations in nutrition

Alterations in Nutrition

Gastroesophageal Reflux Disease

Peptic Ulcer Disease

Cholecystitis/Gastric Surgery

gastroesophageal reflux disease gerd
Gastroesophageal Reflux Disease(GERD)
  • Occurs when contents of the stomach including stomach juices (flow back) into the esophagus
causes for gerd
Causes for GERD
  • Incompetent lower esophageal sphincter
  • Transient LES relaxation
  • Increased intragastric pressure
contributing factors to gerd
Contributing Factors to GERD
  • Smoking
  • Caffeine
  • ETOH
  • Fatty meals
  • Obesity
  • Increased gastric acid and pepsin production
signs and symptoms of gerd
Heartburn,indigestion

Chest pain

Regurgitation

Pain after eating

Dysphagia

Belching

Sore throat

Hoarseness

Pain is worsened when the patient bends over at the waist or reclines.

Signs and Symptoms of GERD
complications of gerd
Complications of GERD
  • Esophageal strictures
  • Ulcers
  • Erosions
barrette s esophagus
Barrette\'s Esophagus
  • Pre- malignant condition from irritation of gastric content on the normal cell epithelium of the esophagus. It may progress to adenocarcinoma.
diagnosing gerd
Diagnosing GERD
  • Barium swallow
  • Endoscopy (EGD)
  • Esophageal motility studies
  • Ambulatory pH monitoring
  • Esophageal manometry
treatment for gerd
Treatment for GERD
  • Practical changes in daily living
  • Pharmacology
  • Surgery
practical changes in life style
Practical changes in life style
  • Diet changes
    • loose weight and eat smaller meals
    • Refrain eating 3 hrs. after bed time and say upright 2 hours after a meal.
    • Limit the amount of citrus juices, coffee, chocolate, spicy foods alcohol and peppermint.
practical changes in life style21
Practical changes in life style
  • Stop smoking
  • Avoid tight clothing
  • Avoid bending
pharmacological treatments
Pharmacological treatments
  • H2 receptor antagonist (Cimetidine, Ranitidine, famotidine,nizatidine)
  • Proton Pump inhibitors (Prilosec, Prevacid)
  • Promotility agents (Cisapride=Propulsive)
pharmacological treatments23
Pharmacological treatments
  • Antacids-to neutralize acidity, increased LES pressure.
    • It is usually take 1-3hrs after a meal and at bed time.
surgery
Surgery
  • It is reserve for patients who can develop serious complication.
  • The must common surgery done is called
    • Nissen Fundoplication-This surgery involve wrapping the fundus of the stomach around the lower esophagus and suture the fundus to itself.
hiatal diaphragmatic hernia
Hiatal (diaphragmatic) Hernia
  • What is it?
  • Partial Stomach protrusion through the diaphragm.
what are the symptoms of hiatal hernia
Reflux

Chest pain

Occult bleeding

Regurgitation

Dysphasia

Belching

What are the symptoms of Hiatal Hernia ?
complications of hiatal hernia
Complications of Hiatal hernia
  • Incarcerated necrotic hernia
  • Hemorrhage
treatment for hiatal hernia
Treatment for Hiatal hernia
  • Pharmacological (same as GERD)
  • Changes in life style
  • Surgery (Nissen fundoplication)
esophageal spasm
Esophageal spasm
  • Pt. Experiences spastic contractions of the esophagus .
  • Symptoms: angina-like chest pains and dysphasia.
  • Treatment: Calcium channels blockers, nitrates and anticholinergics
achalasia
Achalasia
  • What is it ? Dilation and loss of tone in the esophagus with high gastroesophageal sphincter pressure.
  • Why does it happen? Cause unknown.
achalasia symptoms
Achalasia symptoms
  • Nocturnal cough
  • Chest pains
  • Dysphagia
  • Regurgitation
  • Weight loss
achalasia treatments
Achalasia treatments
  • Small frequent feedings of soft warm food and fluids.
    • Avoids hot spice food and ETOH
  • LES dilatation with a balloon dilator
    • Calcium channel blockers and nitrates
  • Surgical myotomy(opening LES )
cancer of the stomach
Cancer of the stomach
  • Is the second most common cancer in the world.
  • Every year 25,000 Americans develop gastric cancer.
    • 13,000 Americans died every year
  • Highest in Hispanic, African Americans, Asian Americans.
  • Men affected twice as much as women.
stomach cancer
Stomach cancer
  • Common location for the stomach cancer: distal portion of the stomach. A mayor factor for the development of gastric cancer is H. Pylori
risk factors for stomach cancer
Risk Factors for Stomach cancer
  • Genetic predisposition
  • Carcinogenic dietary
  • Pernicious anemia
  • Gastric polyps
  • Chronic H. Pyloric gastritis
  • Achlorhydria -lack of hydrochloric acid in the stomach.
cancer of the stomach43
Cancer of the stomach
  • Adenocarcinoma which involves the mucous producing cells is the most common form of gastric cancer.
  • These carcinomas may arise anywhere on the mucosa surface of the stomach but are more frequently found in the distal portions.
stomach cancer44
Stomach cancer
  • When the disease is limited to submucosa and mucosa; it is early gastric carcinoma.
  • Metastasis occur early due to rich blood supply of the area.
  • Symptoms are vague and usually the discovery is done when the disease is advance.
symptoms of gastric carcinoma
A general feeling of being tired or weak.

Bloating or indigestion soon after eating.

Vague pain in the upper abdomen.

Heartburn

Nausea/vomiting

Poor appetite

Blood in vomits or blood in the stool

Symptoms of gastric carcinoma
stomach cancer diagnostic studies
Stomach cancer diagnostic studies
  • Blood test will show presence iron deficient anemia or pernicious anemia.
  • Gastric analyses-may reveal deficiency of hydrochloric acid.
  • An upper GI X-ray study with barium swallow could identify lesions.
    • (the special x-rays of the esophagus and the stomach in which the pt. Drinks a solution containing barium. It shows up in x-rays and may outline a tumor or abnormality).
stomach cancer diagnostic studies48
Stomach cancer diagnostic studies
  • The stool may be tested for occult (hidden) blood.
  • Computerized Topography (CT) Scan of the abdomen may show tumor particularly when combined with a barium swallow.
  • Gastroscopy examination in which along thin tube is inserted down esophagus into stomach a small video camera at the other end pick up the image and displayed on monitor screen.
stomach cancer treatments
Stomach cancer treatments
  • If the gastric cancer is identified prior to the development of metastasis. Surgical intervention with total gastrectomy is the treatment of choice.
    • Radiation and chemotherapy may be used to eliminated any suspected metastasis.
    • If the disease is advanced, tx is palliative and includes surgery and chemotherapy.
gastric surgeries
Gastric Surgeries
  • Billroth I (gastroduodenostomy): removal of the distal half of the stomach and anastomosis to the duodenum. Vagotomy usually is done.
  • Billroth II (gastrojejunostomy): removal of the distal portion of the stomach with anastomosis to the proximal jejunum. Duodenal stump left intact so that bile can enter the intestines.
other gastric surgeries
Partial-gastrectomy:

removal of the distal 1/2 to 2/3 of the stomach.

Antrectomy:

Removal of the gastrin producing cells area of the stomach.

Pyloroplasty:

Surgical enlargement of an opening between stomach and duodenum to improve gastrin emptying.

Vagotomy severing all or part of the vagus nerve to significantly reduce the parietal cell acid secretion.

Other gastric surgeries:
complications of gastric surgery
Complications of gastric surgery.
  • Anemia (both iron deficiency and pernicious)
  • Dumping syndrome
  • Folic acid defiency
  • Decreased absorption of Vitamin D and calcium
disadvantages of the billroth i and billroth ii
Disadvantages of the Billroth I and Billroth II
  • Decreased size of the stomach reservoir causing absorption and emptying problems.
most common complication dumping syndrome
Most common complication:dumping syndrome.
  • Dumping syndrome is define as the rapid passage of food bolus into the duodenum or jejunum.
  • It usually occurs after gastric surgery when the pylorus has been resected or by passed.
dumping syndrome how does it happens
Dumping syndrome (how does it happens?)
  • A hypertonic, undigested food bolus may rapidly enter the duodenum or jejunum….
  • Then water is pulled into intestinal lumen...
  • Peristalsis is stimulated…..
  • Intestinal motility increased….
dumping syndrome with a closer look
Dumping syndrome with a closer look
  • It occurs 5-30 minutes after eating
  • Hyperosmolar chyme enter the jejunum: why?
  • Rapid rise in blood glucose: why?
  • Excessive amount of insulin are secreted and released: Why?
  • Hypoglycemia occurs 2-3 hours after a meal
  • why?
what might be the manifestation of dumping syndrome
Nausea

Vomiting

Epigastric pain with cramping.

Diarrhea

Loud, hyperactive bowel sounds (borborygmi)

Symptoms of hypovolemia and reflex sympathetic stimulation: dizziness flushing, Diaphoresis

tachycardia

What might be the manifestation of Dumping syndrome
how to treat or prevent gastric syndrome
How to treat or prevent gastric syndrome
  • Delay gastric emptying and allow smaller boluses of undigested food to enter the smaller intestine.
  • Give smaller and more frequent meals
  • Give liquids at a separate time from solids
how can we treat or prevent dumping syndrome
How can we treat or prevent Dumping Syndrome?
  • Increased protein and fats in the diet.
  • Reduce carbohydrates, especially simple sugars
  • After eating rest in a recumbent or a semirecumbent position for 30-60 minutes.
  • May give antispasmodics, anticholinergics, and sedatives.
peptic ulcer disease
Peptic Ulcer Disease
  • A break in the mucous lining of the GI tract where it comes in contact with gastric juice.
  • Can occur in the esophagus, stomach or duodenum.
  • Ulcers of the duodenum are 5 times more frequent.
peptic ulcer disease72
Peptic Ulcer Disease
  • About 20, 000 millions Americans develop at least one ulcer during their life time.
  • Each year 4,000,000 millions are affected by ulcers.
  • About 6,000 people die of ulcer related complications.
peptic ulcers and population at risk
Peptic ulcers and population at risk
  • People who smoke
  • People who use NSAIDS
  • People with chronic H. Pylori
  • People with hypersecretory states.
pathophysiology of peptic ulcers
Pathophysiology of Peptic ulcers
  • The gastric mucosa protects itself by creating a mucosal barrier make of mucosa gel and bicarbonate.
  • An ulcer or break down of the mucosa develops when the mucosal barrier is unable to protect the mucosa from damage by hydrochloric acid and pepsin.
pathophysiology of peptic ulcers76
Pathophysiology of Peptic ulcers
  • Mucosal barrier is maintained by:
    • Bicarbonate produced by the epithelial cells.
    • Mucous gel production stimulated by prostaglandins.
    • Adequate blood supply to the mucosa.
peptic ulcers
Peptic Ulcers
  • An imbalance between digestive juices (hydrochloric acid and pepsin) and the stomach’s ability to defend itself against these powerful substances result in ulcers
  • See the Table 14-1 on p.489 for the clinical features of ulcers of the stomach and duodenum.(could be test questions)
major causes of peptic ulcer disease pud
Major causes of Peptic ulcer disease (PUD)
  • **Non-steroidal anti-inflammatory drug use (NSAIDS).**Aspirin is the most ulcerogenic of the NSAIDS.
  • Chronic Helicobacter Pylori(H. Pylori) infection.(90 of ulcers cause by this)
  • Acid hypersecretory states with gastrin secreating tumor(Zollinger-Ellison syndrome)
manifestation of peptic ulcer disease
Classic:

Pain:gnawing,burning,aching or hunger like in the epigastric region

Pain occurs when the stomach is empty,2-3 hours after a meal or during the night.

May have heartburn, regurgitation or vomiting.

Manifestation of Peptic Ulcer Disease
older adult manifestation might be different
Older adult manifestation might be different
  • Vague, poorly localized discomfort
  • May have chest pain or dysphagia
  • May have weight loss or anemia
  • May present with GI hemorrhage or perforation of the stomach or duodenum.
lab and diagnostic testing used for peptic ulcer disease
Gastric analyses

H. Pylori

Stool for occult blood

Upper GI series less costly than gastroscopy and able to see 80% to 90% of ulcers (misses small and superficial ulcers)

Gastroscopy is definitive tool for diagnosis of PUD.

Lab and Diagnostic testing used for peptic ulcer disease
goals in the management of peptic ulcer disease
Goals in the management of Peptic ulcer disease
  • Symptoms relief
  • Healing of existing ulcers
  • Preventing complications
  • Preventing/reducing recurrences
management strategies
Management strategies
  • Behavior modification
  • Pharmacologic therapy
  • Surgical interventions
pharmacologic treatment
Pharmacologic treatment
  • Usually aims to eradicating H. Pylori and promoting healing.
  • Medications to treat PUD are :
    • agents that decreased gastric acid content.
    • agents that protect the mucosa
    • agents that eradicate H. Pylori
medications that decreased the gastric acid content in pud
Proton pump inhibitors such a Prevacid, Prilosec.

Proton pump binds the acid secreting enzyme (H+ K+ ATPase) that function as proton pump disabling it for 24hrs

H2- receptor antagonists which inhibits histamine binding to the receptors on the gastric parietal cell to reduce acid secretion.

Zantac, Pepcid, Tagamet and Axid

Medications that decreased the gastric acid content in PUD
agents that protect the mucosa in pud
Sulcrafate-bids to protein in the ulcer base forming a protective barrier.

Bismuth compounds stimulate mucosal bicarbonate and prostaglandin production.

Prostaglandin analogs promote healing by stimulating mucous and bicarbonate secretions and by inhibiting acid secretion (Misoprostol)

Antacid stimulate gastric mucosal defenses.

Agents that protect the mucosa in PUD
eradication of h pylori in pud
Usually two antibiotics with either bismuth or proton pump.

Tetracycline or (Amoxicillin)

Metronidazole

Bismuth subsalicylate

The regimen to treat H. Pylori is usually taking for 14 days.

NU 230 students are responsible for understanding the actions, nursing implications, adverse effects and drug interaction of the drug classes to treat PUD.

Eradication of H. Pylori in PUD
questions regarding the complications of pud
Questions regarding the complications of PUD.
  • Why would a patient with hemorrhage have orthostatic hypotension?
  • Why would a patient with perforation have rigid, boardlike abdomen, fever, and absence of bowel sounds.
complications of peptic ulcer disease
Complications of peptic ulcer disease
  • Hemorrhage
  • Obstruction
  • Perforation
  • *See LeMone text p.491 for signs and symptoms of complications.
hemorrhage
Hemorrhage
  • 10% -20% ulcer can cause ulceration and erosion into the blood vessel or gastric mucosa.
  • It occurs more commonly in older adults
hemorrhage in pud
Hemorrhage in PUD
  • Maintain adequate circulatory status.
    • By administering NS or Lactated Ringer’s to restore intravascular volume.
    • Blood transfusion with whole blood or RBC’s to restore hgb or hct.
    • NGT insertion and gastric lavage may be necessary.
hemorrhage in pud94
Hemorrhage in PUD
  • Additional measures to control bleeding.
    • Vasopressin (ADH) IV a potent vasoconstrictor agent.
    • Gastroscopy with direct injection of clotting or sclerosing agent into bleeding vessel.
    • Laser photocoagulation using light energy or electrocoagulation which use an electrical current to generate heat.
hemorrhage in pud95
Hemorrhage in PUD
  • Pt. Needs to be kept NPO
  • Antacids can be administer hourly via the NGT to protect the ulcer from gastric acid reflux.
obstruction as a complication for pud
Obstruction as a complication for PUD
  • Inflammation may cause obstruction.
  • Edema and poor ability to heal.
  • Scarring
  • Muscle spasm.
perforation peritonitis
Perforation/Peritonitis
  • Gastric or duodenal perforation result in contamination of the peritoneum with gastrointestinal contents require immediacy attention.
    • Prepare pt. for surgical intervention.
    • Give IV fluids and replace electrolytes.
    • NG to LIS
    • Pt. in Fowler’s and semi Fowler position.
    • Give antibiotics
if efforts to control bleeding fail surgery is indicated
If efforts to control bleeding fail surgery is indicated
  • Goals :
    • Decreased gastric secretions
    • Remove damage tissue
    • Promote gastric emptying
if efforts to control bleeding fail surgery is indicated104
If efforts to control bleeding fail surgery is indicated
  • The area to be removed depends were ulcer is located
stress ulcer
Stress ulcer
  • Acute onset as a result of a major physiologic stressor.
  • Examples of events which are followed by stress ulcer:
    • trauma
    • surgery involving the central nervous system or a head trauma(Cushing’s ulcer).
    • burns (Curling’s ulcers).
events that follow stress ulcers
Events that follow stress ulcers
  • Respiratory failure
  • Renal failure
  • Shock.
characteristics of stress ulcers
Multiple lesions

Superficial

Usually fundus

Not usually painful

Gastric bleeding 2 or more days after the stressor.

Bleeding typically minimal but may be massive.

High mortality rate.

Characteristics of stress ulcers:
why do stress ulcers occur
Why do stress ulcers occur?
  • Cause: ischemia of the gastric mucosa resulting from sympathetic vasoconstriction, and tissue injury from the gastric acid.
  • Maintaining the gastric pH greater than 3.5 and decreasing gastric acid secretions decreased possibility of having stress ulcers being form.
signs and symptoms of stress ulcers
Signs and symptoms of stress ulcers
  • Unlike other ulcers, stress ulcer are not typically associated with pain.
  • The first symptom is painless gastric bleeding occurring 2 or more days after the initial stress. The bleeding can be massive coming from multiple lesions.
zolliger ellison syndrome
Zolliger-Ellison Syndrome
  • Peptic ulcer disease caused by a gastrinoma or gastrin-secreating tumor of the pancreas, stomach or intestine.
  • 50% to 70% of the tumors are malignant.
  • Gastrin is a hormone that stimulate the secretion of pepsin and hydrochloric acid.
  • The increase gastrin levels cause ulcers.
zolliger ellison syndrome112
Zolliger-Ellison Syndrome
  • Characteristic ulcer like pain
  • Diarrhea
  • Steatorrhea(fat in the stool)
  • Electrolytes imbalance.
gastric ulcers
Gastric ulcers
  • Associated with gastric gland atrophy and decrease protection of gastric mucosa by the mucosal barrier rather than with increased secretion of hydrochloric acid.
  • Occur more commonly in older adults 60-70 years old.
gastric ulcers115
Gastric ulcers
  • Gastric ulcers are consider to be pre-malignant lesions because of the incident of gastric cancer.
  • Occur more common in the older adult above 60 years.
gastric ulcer signs and symptoms
Gastric ulcer signs and symptoms
  • Dull aching abdominal pains after eating.
  • Pain is exacerbated by food intake.
  • Vomiting is common as well.
nursing diagnosis for gerd pud disease
Nursing Diagnosis for GERD, PUD, Disease
  • Pain
  • Alteration in Nutrition: less than body requirements
  • Fluid Volume deficit
pain nursing interventions
Assess location, quality, acuity,frequency and duration.

Administer antiacids, H2-receptor antagonists, proton pump inhibitors or mucosal protective agents.

Provide adjunctive relief therapy such as distraction,relaxation (back rub, change position) and breathing exercises.

Teach life style management techniques.

Pain : nursing interventions
alteration in nutrition
Assess the patient current diet, including pattern of food intake, eating schedule, and food that precipitate pain.

Arrange a nutritional consult.

Monitor for symptoms of fullness, anorexia, nausea or vomiting.

Monitor lab values related to nutritional deficit.

Albumin

Iron studies

B12 levels

Alteration in nutrition
fluid volume deficit
Monitor vital signs closely.

Orthostatic blood pressure at the beginning of shift

Maintain Accurate I &O (foley may be needed)

Weigh QD

Monitor stool and gastric drainage for occult and overt blood.

Maintain IV therapy with fluid volume and electrolytes replacement.

Insert NGT and lavage if needed.

Fluid volume deficit
fluid volume deficit121
Monitor laboratory data for hemoglobin, hematocrit, and serum electrolytes.

Replace decreased HCT with whole blood or RBCS

Assess abdomen for distention, BS, and tenderness q4hrs and record.

Fluid volume deficit
gallbladder disorders
Gallbladder disorders
  • Cholelithiasis: stones or calculi
  • Cholecystitis: inflamed gallbladder with or without stones.
  • What are gallstones made of ? Cholesterol and bile pigments
pathophysiology of cholelithiasis disease
Pathophysiology of cholelithiasis disease
  • Gallstones are made of bile pigments or hardened cholesterol
  • Stone formation occur when the bile crystallizes.
    • Factors that contribute to stone formation
      • stasis of bile in the gallbladder
      • bile concentration
who is at risk for gallstones
Family History

Native American, Caucasian, Mexican American

Females(oral contraceptive use and pregnancy)

Patients on TPN

Certain disease (see text, p.512)

Who is at risk for gallstones?
cholethiasis
Stones in cystic duct

causes gallbladder to distend, result in in severe cramping , colicky pain.

Secondary infection combined with severe inflammation and edema result in duct blockage and abdominal pain.

Obstruction of the common bile duct.

May result in bile reflux into the liver producing jaundice, pain hepatic damage, pancretitis or sepsis

Cholethiasis
clinical manifestation of cholelithiasis
Epigastric pain

Heartburn

Right upper abdominal pain.

Jaundice

Intolerance to fat containing foods

Clinical manifestation of cholelithiasis
factors that increase the risk for cholelithiasis
Family history of gallbladder stones

Female gender

pregnancy

use of oral contraception

Hyperalimentation

Aging

Diseases or conditions

Native Americans

Caucasians

Mexican Americans

Factors that increase the risk for cholelithiasis
cholecystitis
Cholecystitis
  • It is an inflammation of the gallbladder.
  • It is commonly associate with stones in the cystic and common bile duct.
  • It is classified as acute or chronic.
acute cholecystitis signs and symptoms
Acute cholecystitis signs and symptoms
  • Severe spasmodic pains ( it usually happens after a high fat meal)
  • RUQ pain radiating to the mid line and posterior to the scapula region.
  • Frequent nausea and vomiting.
chronic cholecystitis signs and symptoms
Chronic cholecystitis signs and symptoms
  • Symptoms are not as severe and are more vague.
  • Long term intolerance to fatty food, increase flatulence.
signs and symptoms that might be present with cholecystitis
Fever

Increase WBCs

Abdominal muscle guarding with rebound tenderness and rigidity

Elevated bilirubin

Elevated Alkaline phosphatase

Elevated amylase

Signs and symptoms that might be present with cholecystitis
important lab test for cholecystitis
Important lab test for cholecystitis
  • CBC for elevated WBC
  • Serum amylase and lipase to see if pancretitis is present.
  • Serum bilirubin to see if there is an obstruction in the biliary system.
diagnosis studies in cholecystitis
Diagnosis studies in cholecystitis
  • Cholangiograms to check for stones
  • Ultrasound of the gallbladder(for non-obese clients)
  • HIDA scan done done in nuclear medicine to assess acute cholecystitis.
diagnosis studies in cholecystitis139
Complete blood count

Serum amylase and lipase to check for pancretitis.

Serum bilirubin

Gallbladder scans

oral cholecystogram

oral dye is use to assess the gallbladder’s ability to concentrate and excrete bile.

Diagnosis studies in cholecystitis
treatment of cholethiasis
Pharmacology with oral bile acids.

Diet therapy with low fat diet and weight loss.

Surgery: it depend on the stone location and severity of the complications

.

Treatment of cholethiasis
pharmacology
The major pharmacological interventions are aimed at curing gallstones involves a group of agents oral bile acid call dissolvers.

Urodeoxycholic (UDCA)

is for cholesterol stones less than 20mm in diameter.

Pt. Need to have hepatic enzymes monitor closely

watch for diarrhea

Pharmacology
pharmacology142
Chenodeoxycholic (Chenodiol) which work by decreasing cholesterol in the diet.

Other pharmacologic agents are use for palliative relief such as

Antibiotics -to decrease bacteria count and associate inflammation and edema.

Pain medications

Pharmacology
diet therapy
Dietary fats are a stimulus for gallbladder contraction

Patients need to be put on a low fat diet.

If bile flow is reduced because of obstruction fat soluble vitamins A, D, E, and K and bile salts needs to be replaced.

Examples of high fat food to avoid : deep fried foods, whole milk etc..

Diet therapy
surgery144
The type of surgical procedure performed for the client with gallstones depends on were the stones are located and severity of complications.

If the stones are located only in the Gallbladder a simple Cholecystectomy is performed.

Conventional surgical methods.

Laparascopic laser surgery

Surgery
surgery146
When stones are lodged within the ducts, a Cholecystectomy with common bile duct exploration and T- tube insertion may be indicated.Surgery
surgery147
Inserted after common bile duct exploration a T-tube maintain patency of the duct and promotes bile passage while the edema decreases.Surgery
surgical risk in cholecystitis
Surgical risk in cholecystitis.
  • For a poor surgical risk clients, a cholecystostomy (for drainage) or a choleduchostomy ( removal stones and T-tube placement) may be performed as opposed to surgical removal of the gallbladder.
treatment alternatives
Lithotrypsy or Percutaneous stone dissolution. With extracorporal shock wave lithotrypsy (ESWL). The physician uses ultrasound to align the stones with the source of shock waves and computerized lithotripter.

Percutaneous stone dissolution is a treatment option for patients who are a high risk for post surgical problems using a fluoroscopy the MD ,may position a catheter via the biliary system. Dissolution agents are then instill.

Treatment alternatives
students responsible for
Students responsible for :
  • Care of the patient with T-tube (Lemone p.517)
  • Possible complications of a patient with T-tube(Lemone p.517)
  • All readings and syllabus applications regarding the pharmacology and nutrition of GERD, PUD, cholecystitis, and gastric surgery.
nursing care of the client with a t tube
Nursing care of the client with a T-tube
  • Ensure that the tube is connected to sterile container; keep the tube below the surgical wound.
  • Monitor drainage for consistence, color, amount.
  • Place patient in semi-Fowler’s position
  • Assess skin around for bile leakage during dressing changes.
nursing care of the client with a t tube153
Nursing care of the client with a T-tube
  • Teach patient how to manage the tube when turning ambulating or doing activities.
  • When drainage subsides and stool returns to normal brown color clamp the tube for 1 to 2 hours after a meal.
nursing care for patients with cholelithiasis and cholecystitis
Nursing care for patients with cholelithiasis and cholecystitis
  • Frequent problems with these conditions:
    • Pains
    • Altered nutrition due to nausea, vomiting, and impaired fat metabolism.
    • Risk for impaired gas exchange/ risk for infection.
pain related to gallbladder problems
Teach clients to avoid fat in their diets

fat stimulate gallbladder contractions and is a stimulus for pain .

Administer prescribed medications such as Dicyclomine (Bentyl) used to decrease spasm and relax muscle.

If pain is not relieved by these methods administer prescribed narcotics

Check for elevation of temperature q4hrs.

Assist the patient to semi Fowler’s position.

Pain related to gallbladder problems
risk for impair gas exchange
Patients may have problems with effective breathing and gas exchange because of abdominal incision.

Institute a regiment of turning, deep breathing and coughing at least every 2 hrs.

Use incentive spirometer every hour while awake.

OOB ambulating as soon as possible.

Risk for impair gas exchange
risk for infection
Infections may arrive from various sources.

Asses for signs of systemic and localized infections during the post period.

Temperature q4hrs

Asses wound q4hrs

Performed abdominal assessment q4hrs.

Monitor labs QD

Administer prescribe antibiotics as order.

Use aseptic technique when doing invasive procedures,

Risk for infection
ad