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Promoting Optimal Nutrition
The nurse encourages the patient to eat small, frequent portions of
nonirritating foods to decrease gastric irritation. Food supplements should
be high in calories, as well as vitamins A and C and iron, to enhance tissue
repair. Because the patient may develop dumping syndrome when enteral
feeding resumes after gastric resection, the nurse explains ways to prevent
and manage it and informs the patient that symptoms often resolve after
several months.
Management of dumping syndrome includes encouraging 6 small feedings
daily that are low in carbohydrates and sugar and the consumption of fluids
between meals rather than with meals. If a total gastrectomy is performed,
an injection of vitamin B12 will be required for life, because an intrinsic
factor, secreted by parietal cells in the stomach, binds to vitamin B12 so
that it may be absorbed in the ileum. This deficiency in vitamin B12
metabolism can result in decreased production of red blood cells, or
pernicious anemia. If the patient is unable to eat adequately prior
to surgery to meet nutritional requirements, parenteral nutrition may be
necessary. Weight loss is a common occurrence in the postoperative
period following gastric surgery; research findings suggest that
individualizing dietary interventions based on patient preferences can
improve outcomes (Kim, Suh, Lee, et al., 2014) (see Chart 46-3). The
nurse monitors the IV therapy and nutritional status and records intake,
output, and daily weights to ensure that the patient is maintaining or gaining
weight. The nurse assesses for signs of dehydration (thirst, dry mucous
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membranes, poor skin turgor, tachycardia, decreased urine output) and
reviews the results of daily laboratory studies to note any metabolic
abnormalities (sodium, potassium, glucose, BUN). Antiemetic agents are
given as prescribed.
NEXIUM
Nexium Teaching 1316
Nexium is indicated for the treatment of heartburn and other symptoms
associated with GERD.
Nexium Teaching 1317
Nexium should be taken at least one hour before meals.
Nexium Teaching 1318
The most common adverse reactions to Nexium are headache, diarrhea,
and abdominal pain.
Take each dose with a full glass (8 ounces) of water. Esomeprazole should
be taken at least one hour before a meal. Swallow the capsule whole and
do not crush, chew, break, or open it.
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H-PYLORI
Helicobacter pylori (H. pylori): a spiral-shaped Gram-negative bacterium
that colonizes the gastric mucosa; is involved in most cases of peptic ulcer
disease
Medical Management
Once the diagnosis is established, the patient is informed that the condition
can be managed. Recurrence may develop; however, peptic ulcers treated
with antibiotics to eradicate H. pylori have a lower recurrence rate than
those not treated with antibiotics. The goals are to eradicate H. pylori as
indicated and to manage gastric acidity. Methods used include
medications, lifestyle changes, and surgical intervention.
Pharmacologic Therapy
Currently, the most commonly used therapy for peptic ulcers is a
combination of antibiotics, proton pump inhibitors, and sometimes bismuth
salts that suppress or eradicate H. pylori. Recommended combination drug
therapy is typically prescribed for 10 to 14 days and may include triple
therapy with two antibiotics (e.g., metronidazole [Flagyl] or amoxicillin
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[Amoxil] and clarithromycin [Biaxin]) plus a proton pump inhibitor (e.g.,
lansoprazole [Prevacid], omeprazole [Prilosec], or rabeprazole [AcipHex]),
or quadruple therapy with two antibiotics (metronidazole and tetracycline)
plus a proton pump inhibitor and bismuth salts (Pepto-Bismol).
H2 blockers and proton pump inhibitors that reduce gastric acid secretion
are used to treat ulcers not associated with H. pylori infection. Table 46-3
provides information about the medication regimens for peptic ulcer
disease.
The patient is advised to adhere to and complete the medication regimen to
ensure complete healing of the ulcer. The patient is advised to avoid the
use of aspirin and other NSAIDs. Because most patients become
symptom-free within a week, the nurse stresses to the patient the
importance of following the prescribed regimen so that the healing process
can continue uninterrupted and the return of chronic ulcer symptoms can
be prevented. Maintenance dosages of H2 blockers are usually
recommended for 1 year.
H. pylori infection Triple therapy with a PPI bid, plus clarithromycin 500 mg
bid, plus amoxicillin 1000 mg bid (or metronidazole 500 mg bid) for 10–14
days. Quadruple therapy with bismuth subsalicylate 525 mg qid, plus
tetracycline 500 mg qid, plus metronidazole 250 mg qid, plus a PPI daily for
10–14 days Efficacy of therapy is approximately 85% qid dosing may
decrease ad
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ULCERS
Clinical Manifestations Symptoms of peptic ulcer disease may last for a few
days, weeks, or months and may disappear only to reappear, often without
an identifiable cause. Many patients with peptic ulcers have no signs or
symptoms. These silent peptic ulcers most commonly occur in older adults
and those taking aspirin and other NSAIDs (Anand, 2015). As a rule, the
patient with an ulcer complains of dull, gnawing pain or a burning sensation
in the mid epigastrium or the back. Few clinical manifestations differentiate
gastric ulcers from duodenal ulcers; however, classically, the pain
associated with gastric ulcers most commonly occurs immediately after
eating, whereas the pain associated with duodenal ulcers most commonly
occurs 2 to 3 hours after meals. In addition, approximately 50% to 80% of
patients with duodenal ulcers awake with pain during the night, whereas
30% to 40% of patients with gastric ulcers voice this type of complaint.
Patients with duodenal ulcers are more likely to express the relief of pain
after eating or after taking an antacid than patients with gastric ulcers
(Anand, 2015). Other nonspecific symptoms of either gastric ulcers or
duodenal ulcers may include pyrosis vomiting, constipation or diarrhea, and
bleeding. These symptoms are often accompanied by sour eructation
(burping), which is common when the patient’s stomach is empty. Although
vomiting is rare in an uncomplicated peptic ulcer, it may be a symptom of a
complication of an ulcer. It results from gastric outlet obstruction, caused by
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either muscular spasm of the pylorus or mechanical obstruction from
scarring or acute swelling of the inflamed mucous membrane adjacent to
the ulcer. Vomiting may or may not be preceded by nausea; usually, it
follows a bout of severe pain and bloating, which is relieved by vomiting.
Emesis may contain undigested food eaten many hours earlier.
Constipation or diarrhea may occur, probably as a result of diet and
medications. The patient with bleeding peptic ulcers may present with
evidence of GI bleeding, such as hematemesis (vomiting blood) or the
passage of melena (black, tarry stools) (Anand, 2015). Between 30% and
50% of patients with bleeding peptic ulcers do not experience abdominal
pain at the time of diagnosis (Gururatsakul, Holloway, Bellon, et al., 2014).
Peptic ulcer perforation results in the sudden onset of signs and symptoms.
The patient often reports severe, sharp upper abdominal pain, which may
be referred to the shoulder; extreme abdominal tenderness; and nausea or
vomiting. Hypotension and tachycardia may occur, indicating the onset of
shock (Anand, 2015; Dimou & Velanovich, 2015). Assessment and
Diagnostic Findings A physical examination may reveal pain, epigastric
tenderness, or abdominal distention. Upper endoscopy is the preferred
diagnostic procedure because it allows direct visualization of
inflammatory changes, ulcers, and lesions. Through endoscopy, a biopsy of
the gastric mucosa and any suspicious lesions can be obtained.
Endoscopy may reveal lesions that, because of their size or location, are
not evident in x-ray studies. H. pylori infection may be determined by
endoscopy and histologic examination of a tissue specimen obtained by
biopsy, or a rapid urease test of the biopsy specimen. Other less invasive
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diagnostic measures for detecting H. pylori include serologic testing for
antibodies against the H. pylori antigen, stool antigen test, and urea breath
test (Anand, 2015). The patient who has a bleeding peptic ulcer may
require periodic CBCs to determine the extent of blood loss and whether or
not blood transfusions are advisable (see Chapter 32). Stools may be
tested periodically until they are negative for occult blood. Gastric secretory
studies are of value in diagnosing ZES and achlorhydria (lack of
hydrochloric acid [HCl], hypochlorhydria (low levels of HCl), or
hyperchlorhydria (high levels of HCl).
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