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Phases of swallowing

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oral preparatory oral pharyngeal esophageal

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upper esophageal sphincter

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closed at rest to prevent air from entering the esophagus during respiration

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lower esophageal sphincter

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closed at rest to prevent reflux of gastric contents into the esophagus

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structure of the stomach

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digestive and endocrine organ located in the midline and LUQ

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Pancreas

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decreased lipase level result in small, frequent feedings, assess for diarrhea

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liver

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decreased enzyme activity depresses drug metabolism which leans to accumulation of drugs. assess all clients for adverse effects of drugs

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GI change in elderly-stomach

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atrophy of gastric mucosa. Note a decreased hydrochloric acid level. may see decreased iron absorption.encourage bland foods high in vitamins and iron. assess for epigastric pain

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GI change in elderly-large intestine

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peristalsis decreases and nerve impulses are dulled. May see constipation and impaction. encourage activity, fiber and fluids

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Stomatitis

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ulcer in mouth from inflammation referred to as canker sores, causes pain, possible bleeding and infection

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Stomatitis primary classifications

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noninfectious, herpes simplex, and traumatic ulcers

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stomatitis secondary classifications

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results from infection by opportunistic viruses, fungi, or bacteria candidiasis-a fungal infection resulting from an overgrowth of normal flora

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stomatitis etiology

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may result from infection, allergy, vitamin deficiency, systemic disease, irritants, chemotherapy, or radiation

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noninfectious stomatitis

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most common oral lesion; may affect 30% of population

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stomatitis clinical manifestations

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range from dry, painful mouth to open ulcerations; occur most often commonly on buccal mucosa, soft palate, oropharyngeal mucosa, and tongue

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stomatitis labs

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tests not usually needed serum albumin iron level CBC culture if sores drain vitamin B 12 and folate

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stomatitis drug therapy

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usually antimicrobials (biotin or oracle), anti fungal, symptomatic topical and complementary therapies

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premalignant lesions

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leukoplakia and erythroplakia

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more than 90% of oral cancers are...

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squamous cell carcinomas

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Basal cell carcinoma

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occurs primarily on lips. lesion evolves to have a raised pearly border. they do not metastasize

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Kaposi's sarcoma

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malignant lesion that arises in blood vessels.appears as raised purple nodule.most common in mouth: hard palate. most often seen with AIDS

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Nursing care of oral cancers-CM

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unusual lumps or thickening of buccal mucosa or red/white patches appearing on the gums, tongue or oral mucous membranes

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nursing care of oral cancers-testing

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CT, biopsy, toluidine blue

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impaired oral mucous membrane

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goal-intact and functional mucous membrane interventions-oral care, radiation, chemotherapy

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Oral surgical management

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excision, cryotherapy

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Oral surgical management-preop

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temporary teach loss of speech NPO and possibilities of drains

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classical radical neck dissection

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sternocleidomastoid and smaller muscles are removed, all tissue is removed, from the rams of the jaw to the clavicle, jugular vein is also removed

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functional neck dissection

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preserves the sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve

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Staphylococcal infection

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food poisoning caused by contaminated meats and dairy transmitted by human carriers abrupt vomiting and diarrhea with no fever symptoms occur 2-4 hours after ingestion may need parenteral fluid report if epidemic occurs

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E. coli infection

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food poisoning caused by meat contaminated with animal feces causes abrupt vomiting, diarrhea, abdominal cramping and fever may needs IV fluids and antibiotics report if epidemic occurs

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Botulism

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food poisoning commonly associated with improperly canned foods, especially fruits and veggies diagnosed by stool culture N/V, diarrhea, weakness progressing to paralysis diplopia, dysphagia, dysarthria treatment with trivalent botulism antitoxin may need vent support do not use punctured cans sterile containers for home-canned foods all cases need to be reported

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Salmonellosis

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caused by contaminated food ro drink but can be transmitted by the 5 F's- flies, food, fingers, feces, fomites fever, N/V, diarrhea, and abd cramping for 3-5 days may need antibiotics wash hands before eating and after defecating all cases need to be reported

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GERD

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most common GI disorder backward flow of GI contents into the esophagus caused by inappropriate relaxation of the LES, irritation of the reflux material, delayed gastric emptying abnormal esophageal clearance

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Esophageal reflux can occur with?

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elevated gastric volume decreased sphincter tone of LES inappropriate relaxation of the LES

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healing process of GERD

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the body may substitute a columnar epithelium for the normal squamous cell epithelium and this can be considered premalignant. increase risk of cancer

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uncontrolled esophageal reflux can create a risk for?

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hemorrhage, ulceration and aspiration pneumonia

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GERd may cause adult-onset

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asthma, laryngitis, and dental deterioration

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GERD etiology

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can be caused by pregnancy and obesity more common after 45 yo

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what to avoid to lower LES pressure?

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fatty foods, caffeinated drinks, chocolate, citrus fruits, tomatoes, nicotine, calcium channel blockers, nitrates, peppermint, alcohol, anticholinergic drugs, high levels of estrogen and progesterone, NG tube placement

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GERD Clinical manifestations

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feeling of fullness and discomfort after eating dyspepsia, regurgitation, coughing, water brash, painful swallowing, epigastric pain, belching, flatulence, bloating and dental caries

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GERD diagnostic tets

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24-hour ambulatory pH monitoring endoscopy barium swallow or upper Gi series esophageal manometry

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endoscopy

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used to evaluate bleeding, ulceration, inflammation, assess, tumors, and cancerous lesions

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EGD

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exam of esophagus, stomach and duodenum NPO local anestetic to inactive gag reflux-spray remove dentures position left lateral with basin and bite blockers after monitor VS, NPO until gag return, monitor for signs of perforation

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GERD teaching

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eat 4-6 small meals limit alcohol and tobacco no PM snack eat slowly sit up after meal for hour teach about possibility of aspiration never sleep flat in bed-6-8 inches elevated lose weight don't eat 3 hours before sleep do not wear constrictive clothes sleep on left side teach about medications

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types of acid controlling agents

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antacids h2 antagonists proton pump inhibitors

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the stomach secretes

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HCL bicarbonate pepsinogen intrinsic factor mucus prostaglandins

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stomach glands

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cardiac pyloric gastric

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cell of the gastric gland

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parietal chief mucoid endocrine enterchromaffin

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parietal cells

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produce and secrete HCL primary site of action for many acid-controller drugs

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chief cells

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secrete pepsinogen, a proenzyme pepsinogen become pepsin when activated by exposure to acid pepsin breaks down proteins

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mucoid cells

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mucus-secreting cells provide a protective mucous coat protect against self-digestion by HCL

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HCL

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secreted by the parietal cells when stimulated by food maintain stomach pH of 1-4 secretion also stimulated by: large fatty meals, excessive amounts of alcohol, emotional stress

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acid related diseases

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caused by imbalance of the three cells of the gastric glad and their secretions most common: hyperacidity lay terms for overprotective of HCL by the parietal cells -indigestion, sour stomach, heart burn, and stomach

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Helicobacter pylori

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bacterium found in GI tract of 90% of patients with duodenal ulcers and 70% of those with gastric ulcers antibiotics are used to eradicate the disease

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antacids-mechanism of action

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promote gastric mucosal defense mechanisms secretion of: mucous, bicarbonate, prostaglandins do not revert the overproduction of acid do neutralize the acid once its in the stomach

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antacid drug effects

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reduction of pain associated with acid-related disorders -raise gastric pH from 1.3 to 1.6 neutralizes 50% of the gastric acid -raise gastric pH 1 point(1.3 to 2.3) neutralized 90% of the gastric acid -reduce acidity reduces pain

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antacids

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OTC formulations available as: capsules and tablets. powders, chewable tablets, suspensions, effervescent granules and tablets used alone or in combination-aluminum salts =m magnesium salts, calcium salts, sodium bicarbonate

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aluminum salts

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forms carbonate and hydroxide used to treat hyperphosphatemia can reduce effects of tetracycline,warfarin, digoxin, and phosphate caution in HTN and HF clients may have constipation-use magnesium to help

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magnesium salts

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forms carbonate, hydroxide, oxide, triplicate S/E diarrhea dangerous when used with renal failure contraindicated in clients with intestinal obstruction, appendicitis and undiagnosed ab pain

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calcium salts

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forms carbonate rapid acting and release Co2 in the stomach, causing belching and flatulence S/E constipation may result in kidney stones long durations could cause increased gastric acid secretion extra source of dietary calcium ex. tums

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sodium bicarbonate

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rapid onset, releases carbon dioxide, increase intra-ab pressure, promotes flatulence caution with patients with HTN and HF can cause systemic alkalosis in clients with renal impairment useful to treat acidosis and elevating urinary pH to promote excretion of acidic medications following overdose

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antacids and antiflatulents

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used to relieve the painful symptoms associated with gas several agents are used to bind or after intestinal gas and are often added to antacid combination products OTC antiflatulents activated charcoal simethicone -alter elasticity of mucus coated bubbles,causing them to break -used often, but there are limited data to support effectiveness

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antacids drug interactions

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Absorption of other drugs to antacids Reduces the ability of the other drug to be absorbed into the body Chelation Chemical binding, or inactivation, of another drug Produces insoluble complexes Result: reduced drug absorption Increased stomach pH Increased absorption of basic drugs Decreased absorption of acidic drugs Increased urinary pH Increased excretion of acidic drugs Decreased excretion of basic drugs

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Antacids: Nursing Implications

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Assess for allergies and preexisting conditions that may restrict the use of antacids, such as: Fluid imbalances - Renal disease - HF Pregnancy - GI obstruction Patients with HF or hypertension should use low-sodium antacids such as Riopan, Maalox, or Mylanta II Use with caution with other medications due to the many drug interactions Most medications should be given 1 to 2 hours after giving an antacid Antacids may cause premature dissolving of enteric-coated medications, resulting in stomach upset

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what aggravates the underlying GI condition

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Caffeine, alcohol, harsh spices, and black pepper

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antacids S/E

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Nausea, vomiting, abdominal pain, diarrhea With calcium-containing products: constipation, acid rebound

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H2 Antagonists

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Reduce acid secretion All available OTC in lower dosage forms Most popular drugs for treatment of acid-related disorders cimetidine (Tagamet) - nizatidine famotidine (Pepcid) (Axid) ranitidine (Zantac)

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H2 Antagonists: Mechanism of Action

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Block histamine (H2) at the receptors of acid-producing parietal cells Production of hydrogen ions is reduced, resulting in decreased production of HCl

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H2 Antagonists: Side Effects

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Overall, less than 3% incidence of side effects Cimetidine (Tagamet) may induce impotence and gynecomastia May see: Headaches, lethargy, confusion, diarrhea, urticaria, sweating, flushing, other effects

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H2 Antagonists: Drug Interactions

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cimetidine Binds with P-450 microsomal oxidase system in the liver, resulting in inhibited oxidation of many drugs and increased drug levels All H2 antagonists may inhibit the absorption of drugs that require an acidic GI environment for absorption SMOKING has been shown to decrease the effectiveness of H2 blockers

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H2 Antagonists: Nursing Implications

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Assess for allergies and impaired renal or liver function Use with caution in patients who are confused, disoriented, or elderly Take 1 hour before or after antacids For intravenous doses, follow administration guidelines

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proton pump

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The parietal cells release positive hydrogen ions (protons) during HCl production This process is called the "proton pump" H2 blockers and antihistamines do not stop the action of this pump

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Proton Pump Inhibitors: Mechanism of Action

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Irreversibly bind to H+/K+ ATPase enzyme This bond prevents the movement of hydrogen ions from the parietal cell into the stomach Result: achlorhydria—ALL gastric acid secretion is blocked In order to return to normal acid secretion, the parietal cell must synthesize new H+/K+ ATPase

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Proton Pump Inhibitors: Drug Effect

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Total inhibition of gastric acid secretion lansoprazole (Prevacid) omeprazole (Prilosec)* rabeprazole (Aciphex) pantoprazole (Protonix) esomeprazole (Nexium) *The first in this new class of drugs

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Proton Pump Inhibitors: Indications

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GERD maintenance therapy Erosive esophagitis Short-term treatment of active duodenal and benign gastric ulcers Zollinger-Ellison syndrome Treatment of H. pylori-induced ulcers

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Proton Pump Inhibitors: Side Effects

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Constipation, heart burn, anxiety, diarrhea, ab. Pain, hepato-cellular damage, pancreatitis, gastroenteritis, tinnitus, vertigo, confusion, headache, blurred vision, hypokinesia, chest pain, dyspnea

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Proton Pump Inhibitors: Nursing Implications

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Assess for allergies and history of liver disease pantoprazole is the only proton pump inhibitor available for parenteral administration, and can be used for patients who are unable to take oral medications May increase serum levels of diazepam, phenytoin, and cause increased chance for bleeding with warfarin Instruct the patient taking omeprazole: It should be taken before meals The capsule should be swallowed whole, not crushed, opened, or chewed It may be given with antacids Emphasize that the treatment will be short term

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ucosal Healing Agents: Sucralfate (Carafate)

answer

Cytoprotective agent Used for stress ulcers, erosions, PUD Attracted to and binds to the base of ulcers and erosions, forming a protective barrier over these areas Protects these areas from pepsin, which normally breaks down proteins (making ulcers worse) Little absorption from the gut May cause constipation, nausea, and dry mouth May impair absorption of other drugs, especially tetracycline, phenytoin, digoxin, and cimetidine Binds with phosphate; may be used in chronic renal failure to reduce phosphate levels Do not administer with other medications Antacids interfere with absorption Take at least 1 hour before meals

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Misoprostol (Cytotec)

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Synthetic prostaglandin analog Prostaglandins have cytoprotective activity Protect gastric mucosa from injury by enhancing local production of mucus or bicarbonate Promote local cell regeneration Help to maintain mucosal blood flow Used for prevention of NSAID-induced gastric ulcers Doses that are therapeutic enough to treat duodenal ulcers often produce abdominal cramps, diarrhea

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Other Therapies for GERD

answer

Metoclopramide (Reglan) Increases gastric emptying and improves LES pressure and esophageal paristalsis Does not affect gastric acid secretion or heal Take before meals Observe for neurologic or psychotropic side effects Stretta procedure: MD applies radiofrequency energy through needles placed near the gastroesophageal junction. The RF energy inhibits the activity of vagus nerve, thus reducing discomfort

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GERD Surgical Management

answer

Laparoscopic Nissen fundoplication Encouraged to continue following the basic antireflux regimens of antiacids and diet therapy because the rate of recurrence is significant

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Post-op teaching for LNF

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Soft diet for 1 wk Antireflux meds as prescribed No driving for a week Walk daily; no heavy lifting Remove gauze dressings at 2 days, leave steri-strips for 10 days Clean incision with soap and water Report fever, N/V or uncontrollable bloating or pain Follow-up in 3-4 wks with surgeon

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