Care of the Patient With a Gastrointestinal Disorder

Organs of the Digestive System and Their Functions

Box 5-1 lists various organs of the digestive system and the accessory organs involved in digestion.

Stomach. 

The stomach is in the left upper quadrant of the abdomen, directly inferior to the diaphragm (Figure 5-2). A filled stomach is the size of a football and can hold a volume of approximately 1 to 1.5 L. The stomach entrance is at the cardiac sphincter (so named because it is close to the heart); the exit is at the pyloric sphincter. As food leaves the esophagus, it enters the stomach through the relaxed cardiac sphincter. The sphincter then contracts, preventing reflux (splashing or return flow), which can be irritating to the esophagus.

Once the bolus has entered the stomach, the muscular layers of the stomach churn and contract to mix and compress the contents with the gastric juices and water. The gastric juices are secretions released by the gastric glands. Digestion of protein begins in the stomach. Hydrochloric acid softens the connective tissue of meats, kills bacteria, and activates pepsin (the chief enzyme of gastric juices that converts proteins into proteoses and peptones). Mucin is released to protect the stomach lining. Intrinsic factor (a substance secreted by the gastric mucosa) is produced to allow absorption of vitamin B₁₂. The stomach breaks the food down into a viscous semiliquid substance called chyme. The chyme passes through the pyloric sphincter into the duodenum for the next phase of digestion.

Small intestine.

The small intestine (Figure 5-3) is a tube that is 6 meters (20 feet) long and 2.5 cm (1 inch) in diameter. It begins at the pyloric sphincter, ends at the ileocecal valve, and is divided into three major sections: duodenum, jejunum, and ileum. Up to 90% of digestion takes place in the small intestine. The intestinal juices finish the metabolism of carbohydrates and proteins. Bile and pancreatic juices enter the duodenum. Bile from the liver breaks molecules into smaller droplets, which enables the digestive juices to complete their process. Pancreatic juices contain water, protein, inorganic salts, and enzymes. Pancreatic juices are essential in breaking down proteins into their amino acid components, in reducing dietary fats to glycerol and fatty acids, and in converting starch to simple sugars.

The inner surface of the small intestine contains millions of tiny fingerlike projections called villi, which are clustered over the entire mucous membrane surface. The villi aid in the digestive process by absorbing the products of digestion into the bloodstream. They increase the absorption area of the small intestine by about 600 times. Inside each villus is a rich capillary bed, along with modified lymph capillaries called lacteals. The primary function of the lacteals is to absorb metabolized fats.

Large intestine.

Once the small intestine has completed its tasks of digestion, the ileocecal valve opens and releases the contents of digestion into the large intestine. The large intestine is a tube that is larger in diameter (6 cm, or 2 inches), but shorter at 1.5 to 1.8 meters (5 to 6 feet), than the small intestine. The large intestine consists of the cecum; appendix; ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and sigmoid colon; rectum; and anus (Figure 5-4). This is the terminal portion of the digestive tract, where the process of digestion is completed. The large intestine has four major functions: (1) completion of absorption of water, (2) manufacture of certain vitamins (such as vitamins K and B₇), (3) formation of feces, and (4) expulsion of feces.

Just inferior to the ileocecal valve is the cecum, a blind pouch approximately 2 to 3 inches long. The vermiform appendix, a small wormlike, tubular structure, dangles from the cecum. Research has revealed that the appendix functions as an area where nonpathologic bacteria live safely until they are needed for digestion. In addition, the appendix houses immune system cells and tissue (Duke University Medical Center, 2007). The open end of the cecum connects to the ascending colon, which continues upward on the right side of the abdomen to the inferior area of the liver. The ascending colon then becomes the transverse colon. It crosses to the left side of the abdomen, where it becomes the descending colon. When the descending colon reaches the level of the iliac crest, the sigmoid colon begins and continues toward the midline to the level of the third sacral vertebra.

Bacteria in the large intestine change the chyme into fecal material by releasing the remaining nutrients. The bacteria are also responsible for the synthesis of vitamin K, which is needed for normal blood clotting, and the production of some of the B-complex vitamins. As the fecal material continues its journey, the remaining water and vitamins are absorbed into the bloodstream by osmosis.

Gallbladder

The gallbladder is a pear-shaped organ measuring approximately 7 to 10 cm (3 to 4 inches) long. Areolar connective tissue connects it to the underside of the liver. The gallbladder can store 30 to 50 mL of bile and its primary function is to store and eject bile into the duodenum for digestion of fats.

Pancreas

The pancreas is an elongated gland, approximately 12 to 15 cm (6 to 9 inches) long, that lies posterior to the stomach (see Figure 5-4). It is involved in both endocrine and exocrine duties. In this chapter, discussion of the pancreas is limited to its exocrine activities.

Each day the pancreas produces 1000 to 1500 mL of pancreatic juice to aid in digestion. This pancreatic juice contains the digestive enzymes protease (trypsin), lipase (steapsin), and amylase (amylopsin). These enzymes are important because they digest the three major components of chyme: proteins, fats, and carbohydrates. The enzymes are transported through an excretory duct to the duodenum. This pancreatic duct connects to the common bile duct from the liver and gallbladder and empties through a small orifice in the duodenum called the major duodenal papilla. In addition, the pancreas contains an alkaline substance, sodium bicarbonate, which neutralizes hydrochloric acid in the gastric juices that enter the small intestine from the stomach.

Nursing Interventions

The patient should take nothing by mouth (NPO) and avoid smoking after midnight the night before the study. Explain the importance of rectally expelling all the barium after the examination. Feces (stools) will be light in color until all the barium is expelled (up to 72 hours after the test). Eventual absorption of fecal water may cause a hardened barium impaction. The patient should be instructed to increase his fluid intake in order to help in expelling the barium, thus preventing constipation or blockage. The health care provider may order a laxative to be given in addition to increasing fluid intake.

Nursing Interventions

The patient should receive no anticholinergic medications for 24 hours before the test and should maintain NPO status after midnight to avoid altering the rate of gastric acid secretion. The patient should also be instructed that smoking is prohibited before the test because nicotine stimulates the flow of gastric secretions.

The nurse or radiology personnel inserts a nasogastric (NG) tube into the stomach to aspirate gastric content. Specimens are properly labeled and sent to the laboratory immediately. The NG tube is removed and the patient may eat and drink without restrictions unless otherwise ordered.

Nursing Interventions

The patient should maintain NPO status after midnight prior to the test, and an informed consent form must be signed. The patient is usually given a preprocedure intravenous (IV) sedative such as midazolam (Versed), and the patient's pharynx is anesthetized by spraying it with lidocaine hydrochloride (Xylocaine). Following the procedure the patient will not be allowed to eat or drink until the gag reflex returns, which is usually soon after the procedure and can be assessed by placing a tongue blade to the back of the pharynx. The patient's vital signs and oxygen saturation are monitored after the procedure, as well as assessing for any signs and symptoms of perforation, including abdominal pain and tenderness, guarding, oral bleeding, melena (tarlike, fetid-smelling stool containing undigested blood), and hypovolemic shock.

Nursing Interventions

The patient will be NPO for approximately 10 hours prior to the test and should not smoke for 24 hours prior to the test. The patient swallows the video capsule and is usually kept NPO until 4 to 6 hours later. The procedure is comfortable for most patients. Eight hours after swallowing the capsule, the patient returns to have the monitoring device removed. Peristalsis causes passage of the disposable capsule with a bowel movement, usually in 2 to 3 days. The pill camera does not need to be retrieved (American Gastroenterological Association, 2010).

Nursing Interventions

The patient is NPO after midnight. Food and fluid in the stomach prevent barium from accurately outlining the GI tract, and the radiographic results may be misleading. Explain the importance of rectally expelling all barium. Stools will be light in color until this occurs. Eventual absorption of fecal water may cause a hardened barium impaction. The patient should be instructed to increase his or her fluid intake to help in expelling the barium, thus preventing constipation or blockage. The health care provider may order a laxative to be given in addition to increasing fluid intake.

Nursing Interventions

The patient is NPO for 8 hours before the examination, and any medications that may interfere with the production of acid, such as antacids and analgesics, are withheld. An NG tube is inserted and mild hydrochloric acid is instilled followed by saline. The patient will be asked if any pain or discomfort is felt during instillation of the hydrochloric acid.

Nursing Interventions

The patient is instructed to keep the stool specimen free of urine or toilet paper, since either can alter the test results. The nurse or patient should don gloves and use tongue blades or an appropriate specimen collection device for stool to transfer the stool to the proper receptacle. The patient should not eat any organ meat for 24 to 48 hours before a guaiac test. A specimen slide and developer are used by the nurse to test the stool for occult blood. The health care provider sometimes orders that three consecutive stools be tested for occult blood.

Nursing Interventions

The patient should maintain NPO status after midnight prior to the test and an informed consent form must be signed. The specific bowel preparation is determined by the health care provider performing the procedure, usually a gastroenterologist, and usually consists of laxatives, enemas, or a combination of both. After the examination, the patient should be observed for evidence of bowel perforation (abdominal pain, tenderness, distention, and bleeding), and should be instructed to watch for these symptoms at home.

Nursing Interventions

The evening before the BE, cathartics such as magnesium citrate, or other cathartics designated by facility policy, are administered. A cleansing enema the evening before or the morning of the BE is administered if directed by the health care provider's order or facility policy. Fluids should be encouraged and a laxative may be ordered after the BE to stimulate evacuation of the barium.

After the BE study, the nurse should assess the patient for complete evacuation of the barium, or instruct the patient to monitor stools at home. Patients typically expel most of the barium prior to leaving the radiology department. Retained barium may cause constipation or a hardened impaction. Stool will be light in color until all the barium has been expelled.

Nursing Interventions

Informed consent is necessary for a colonoscopy to be performed. Dietary restrictions include a clear liquid diet for 1 to 3 days before the procedure in order to decrease the residue in the bowel, and then NPO status is maintained for 8 hours before the procedure. Laxatives and/or enemas, and premedication, such as a stool softener, are ordered to cleanse the bowel. The bowel preparation will depend on the health care provider's preference and the patient's condition.

After the colonoscopy, the patient must be monitored for evidence of bowel perforation (abdominal pain, guarding, distention, tenderness, excessive rectal bleeding, or blood clots) and the stools should be examined for gross blood. The patient should also be monitored for hypovolemic shock.

Nursing Interventions

If an enema must be administered to collect specimens, only normal saline or tap water is used. Soapsuds or any other substance could affect the viability of the organisms collected.

Stool samples for O&P are obtained before barium examinations. The nurse must be sure that urine is not mixed with feces in the sample. Gloves are worn for sample collection and the specimen is taken to the laboratory within 30 minutes of collection in a specified container.

Nursing Interventions

For adequate visualization, the nurse must ensure that this study is scheduled before any barium studies.

Medical Management

Dental caries are treated by removal of affected areas of the tooth and replacement with some form of dental material. Treatment of periodontal disease centers on removal of plaque from the teeth. If the disease is advanced, surgical interventions on the gingivae and alveolar bone may be necessary.

Nursing Interventions and Patient Teaching

Proper technique for brushing and flossing the teeth at least twice a day is the primary focus for teaching patients. Plaque forms continuously and must be removed periodically through regular visits to the dentist. The importance of prevention through continual care should be stressed. Because carbohydrates create an environment in which caries develop and plaque accumulates more easily, proper nutrition should be included in patient teaching. When the patient is ill, the mouth's normal cleansing action is impaired. Illnesses, drugs, and irradiation all interfere with the normal action of saliva. If the patient is unable to manage oral hygiene, the nurse must assume this responsibility.

Nursing diagnoses and interventions for the patient with dental plaque and caries include but are not limited to the following:

The prevention and elimination of dental plaque and caries are directly related to oral hygiene, dental care, nutrition, and heredity. All but heredity are controllable factors. The prognosis is more favorable for people who brush, floss, regularly visit the dentist for removal of affected areas, eat low-carbohydrate foods, and drink fluoridated water.

Clinical Manifestations

Candidiasis appears as pearly, bluish white “milk-curd” membranous lesions on the mucous membranes of the mouth, tongue, and larynx. One or more lesions may be on the mucosa, depending on the duration of the infection (see Chapter 16, Figure 16-4 for illustration). If the patch or plaque is removed, painful bleeding can occur.

Assessment

Assessment of the patient with oral candidiasis may reveal subjective complaints of soreness, and difficulty swallowing. Angular cheilitis (cracks at the corners of the mouth) is an objective sign of oral candidiasis. Failure to eat is an objective sign of candidiasis of the GI tract that is seen in infants and adults who are unable to communicate (CDC, 2012).

Medical Management

Nystatin or amphotericin B (an oral suspension) or buccal tablets of fluconazole (Diflucan), one-third–strength hydrogen peroxide, and saline mouth rinses may provide some relief. In addition, eating unsweetened yogurt or taking acidophilus capsules or liquid can restore normal bacterial flora (NLM, 2012b).

Nursing Interventions

Meticulous hand hygiene should be used to prevent spread of the infection. For infants, hand hygiene, care of feeding equipment, and cleanliness of the mother's nipples are important to prevent spread. The infant's mouth should be assessed regularly.

For adults, the patient should be encouraged to use a soft-bristled toothbrush, and avoid hot, cold, spicy, fried, or citrus foods. A topical anesthetic such as lidocaine or benzocaine may be ordered to be administered to the mouth 1 hour before meals (Mayo Clinic, 2011).

Prognosis

If the host has a strong defense system and medical treatment is initiated early in the course of the disease, the prognosis is good.

Clinical Manifestations

Leukoplakia (a white, firmly attached patch on the mouth or tongue mucosa) may appear on the lips and buccal mucosa. These nonsloughing lesions cannot be rubbed off by simple mechanical force. They can be benign or malignant. A small percentage develop into squamous cell carcinomas, and biopsy is recommended if the lesions persist for longer than 2 weeks.

Assessment

Collection of subjective data includes understanding that malignant lesions of the mouth may be asymptomatic. The patient may feel only a roughened area with the tongue. As the disease progresses, the first complaints may be (1) difficulty in chewing, swallowing, or speaking; (2) edema, numbness, or loss of feeling in any part of the mouth; and (3) earache, facial pain, and toothache, which may become constant. Cancer of the lip is associated with discomfort and irritation caused by a nonhealing lesion, which may be raised or ulcerated. Malignancy at the base of the tongue produces less obvious symptoms: slight dysphagia (difficulty in swallowing), sore throat, and salivation. Most oral cancers occur in males over the age of 60, but it is important for the nurse to not overlook symptoms based on age and gender.

Diagnostic Tests

Direct and indirect laryngoscopy are important diagnostic tests for examination of the soft tissue. This procedure allows direct visualization of the oral cavity and both can be performed in the health care provider's office. If necessary, panendoscopy—a more invasive form of laryngoscopy—may be performed with an endoscope. Radiographic evaluation of the mandibular structures is another essential part of the head and neck examination to rule out cancer. Excisional biopsy is the most accurate method for making a definitive diagnosis. Oral exfoliative cytology, in which a scraping of a lesion provides cells for cytologic examination, is used to screen intraoral lesions (ACS, 2013c).

Medical Management

Treatment depends on the location and staging of the malignant tumor. Stage I oral cancers are treated by surgery or radiation. Stage II and III cancers require both surgery and radiation. Chemotherapy may also be used when surgery and radiation therapy fail or as the initial therapy for smaller tumors. Treatment for stage IV cancer may include all three treatment modalities, or treatment may be palliative if metastasis is extensive. The 5-year survival rate for patients with oral cancers that have metastasized averages less than 50% (National Cancer Institute, n.d.b.).

Small, accessible tumors can be excised surgically. Surgical options include a glossectomy, removal of the tongue; hemiglossectomy, removal of part of the tongue; mandibulectomy, removal of the mandible; and total or supraglottic laryngectomy, removal of the entire larynx or the portion above the true vocal cords.

Large tumors usually require more extensive and traumatic surgery. In a functional neck dissection of neck cancer with no growth in the lymph nodes, the surgeon removes the lymph nodes but preserves the jugular vein, the sternocleidomastoid muscle, and the spinal accessory nerve. In radical neck dissection, all these structures are removed and reconstructive surgery is necessary after tissue resection. Patients may have drains in the incision sites that are connected to suction to aid healing and reduce hematomas. A tracheostomy may also be performed, depending on the degree of tumor invasion.

Because of the location of the surgery, complications can occur. These include airway obstruction, hemorrhage, tracheal aspiration, facial edema, formation of fistulas (abnormal passages connecting internal organs, or to the surface of the body), and necrosis of the skin flaps. If the patient has difficulty swallowing, a percutaneous endoscopic gastrostomy (PEG) tube may be inserted to allow for adequate nutritional intake. Neurologic complications can occur because of nerves being severed and manipulated during surgery.

Radiation therapy may involve (1) external radiation beam radiation therapy or (2) internal radiation by means of needles or seeds. The purpose of radiation therapy is to shrink the tumor. It can be given preoperatively or postoperatively, depending on the health care provider's preference and the patient's disease process. In more advanced cases, chemotherapy may be combined with radiation postoperatively to make the patient more comfortable. Other treatment options include laser excision.

Nursing Interventions and Patient Teaching

A holistic approach to patient care includes awareness of the patient's level of knowledge regarding the disease, emotional response and coping abilities, and spiritual needs. Nursing interventions must be individualized to the patient—beginning with the preoperative stage, continuing through the postoperative stage, and ending after the patient's rehabilitation in the home environment. Family members, hospice workers, close friends, social workers, and pastoral care staff may provide information and support during this potentially fatal disease.

Nursing diagnoses and interventions for the patient with oral cancer include but are not limited to the following:

Prevention is the key to successful treatment or cure for cancer of the oral cavity, and should include education on avoiding excess exposure to sun and wind on the lips, eliminating smoking or chewing tobacco, eliminating plaque and caries through good oral and dental care, and decreasing the intake of excessive amounts of alcohol. Individuals infected with HPV should also be monitored for the development of oral cavity cancer. Early detection of oral cancer can increase the patient's chance of survival. Any person with a mouth lesion that does not heal within 2 to 3 weeks is urged to seek medical care.

The nurse should provide instruction regarding preoperative and postoperative care, with full explanations regarding potential speech loss and alternative methods of nutritional intake if warranted by the extent of cancer or anticipated surgical procedure. Explanation of tracheostomy care and other tubes the patient may have on discharge helps reduce anxiety and increase the patient's sense of control over the situation.

Prognosis

Staging and biologic characterization of the neoplasm provide prognostic information. The prognosis of carcinoma in the oral cavity is directly related to the size of the primary tumor, the involvement of regional lymph nodes, and the presence or absence of metastasis. The patient's immunologic response and general condition also influence the prognosis and the choice of therapy.

Carcinomas of the lip can generally be detected early by the patient, the health care provider, or the dentist during examination, and the prognosis for cure is good. If the carcinoma is difficult to detect, as on the anterior tongue and the floor of the mouth, it is often in a more advanced stage when detected, making the prognosis poor.

Clinical Manifestations

The clinical manifestations of GERD are consistent, but vary substantially in severity. The irritation of chronic reflux produces the primary symptom, which is heartburn (pyrosis). Heartburn is often described as a substernal or retrosternal burning sensation that tends to radiate upward and may involve the neck, the jaw, or the back. Heartburn is usually experienced after eating. An atypical pain pattern that closely mimics angina may also occur and must be carefully differentiated from true cardiac disease. The second major symptom of GERD is regurgitation. The individual experiences a feeling of warm fluid moving up the throat and may experience a sour taste in the mouth (Mayo Clinic, 2012b; Livestrong, 2010).

GERD can produce symptoms such as dysphagia or odynophagia (painful swallowing), dry cough, hoarseness, and a sore throat. Eructation (belching) and a feeling of flatulence are other common complaints. The frequency and severity of reflux episodes usually determine the severity of the symptoms.

Assessment

Subjective data include heartburn, a substernal or retrosternal burning sensation that may radiate to the back or jaw (in some cases the pain may mimic angina); and regurgitation, which causes a sour or bitter taste in the pharynx. Frequent eructation, flatulence, and dysphagia or odynophagia usually occur only in severe cases.

Objective data include nocturnal cough, wheezing, and hoarseness.

Diagnostic Tests

When a mild case of GERD is suspected, treatment is initiated on the basis of the presumptive diagnosis. More involved cases may require other screening tools such as esophageal pH test. In this test the patient is fitted with a small nasogastric tube that remains in place and is connected to a small computer that may be worn on the belt or on a shoulder strap. The probe, in the esophagus, monitors acid levels for 24 to 48 hours. An esophageal motility test and Bernstein test can be performed in conjunction with pH monitoring to evaluate LES competence and the response of the esophagus to acid infusion. The barium swallow with fluoroscopy is widely used to document the presence of hiatal hernia. Endoscopy is routinely performed to evaluate for LES competence, potential scarring and strictures, and the presence and severity of esophagitis, and to rule out malignancy (Kahrilas, 2012).

Medical Management

In its simplest form, GERD produces mild symptoms that occur infrequently (twice a week or less). In these cases, encouraging the patient to avoid problem foods or beverages, stopping smoking, elevating the head of the bed, or losing weight may solve the problem. Medication therapy for GERD focuses on improving LES function, increasing esophageal clearance, decreasing volume and acidity of reflux, and protecting the esophageal mucosa. Treatment with antacids or acid-blocking medications called H₂ receptor antagonists—such as cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), or nizatidine (Axid)—may also be used. More severe and frequent episodes of GERD can trigger asthma attacks, cause severe chest pain, result in bleeding, or promote a narrowing (stricture) or chronic irritation of the esophagus. In these cases, more powerful inhibitors of stomach acid production called proton pump inhibitors (PPIs), such as omeprazole (Prilosec), esomeprazole (Nexium), pantoprazole (Protonix), rabeprazole (Aciphex), and lansoprazole (Prevacid), may be added to the treatment prescribed. Sucralfate (Carafate) is an antiulcer drug that may be used in patients with GERD for its protective properties by forming a complex that adheres to an ulcer. Metoclopramide (Reglan) is used in moderate to severe cases of GERD. It is in a class of drugs called promotility agents, which increase peristalsis and therefore promote gastric emptying and reduce the risk of gastric acid reflux.

If conventional treatments fail, the health care provider may suggest a surgical procedure to treat the condition. Nissen fundoplication is one surgical procedure that can be performed to strengthen the sphincter. The procedure involves wrapping a layer of the upper stomach wall (fundus) around the sphincter and terminal esophagus to lessen the possibility of acid reflux (see Figure 5-14). Surgery may also be performed to create a barrier that will prevent the backup of gastric acid. A device called an EsophyX folds the tissue at the base of the stomach, acting as a sphincter valve. Another surgical approach is the Stretta procedure. This procedure uses electrodes to heat the tissue in the esophagus in order to create scar tissue that strengthens the esophagus. The LINX is another surgical device that is used to treat GERD; it consists of a band of titanium beads with magnetic cores that, when implanted around the LES, strengthens it by closing the sphincter when necessary. If GERD is left untreated, serious pathologic (precancerous) changes in the esophageal lining may develop—a condition called Barrett's esophagus (esophageal metaplasia). In Barrett's esophagus the normal squamous epithelium of the esophagus is replaced by columnar epithelium. Because patients with Barrett's esophagus are at higher risk for esophageal cancer, they may need to be monitored regularly (every 1 to 3 years) by endoscopy and biopsy (Mayo Clinic, 2012b).

Nursing Interventions and Patient Teaching

Nursing interventions involve educating the patient about diet and lifestyle modifications that may alleviate symptoms of GERD.

Dietary instructions include: (1) eat four to six small meals daily; (2) follow a low-fat, adequate-protein diet; (3) reduce intake of chocolate, tea, and other foods and beverages that contain caffeine; (4) limit or eliminate alcohol intake; (5) eat slowly, and chew food thoroughly; (6) avoid evening snacking, and do not eat for 2 to 3 hours before bedtime; (7) remain upright for 1 to 2 hours after meals when possible, and never eat in bed; (8) avoid any food that directly produces heartburn; and (9) reduce overall body weight if needed.

Numerous lifestyle changes are also indicated in the treatment of GERD. Patients who smoke should be encouraged to stop. Cigarette smoking has been associated with decreased acid clearance from the lower esophagus. Patients should be advised to avoid constrictive clothing over the abdomen, and should avoid activities that involve straining, heavy lifting, or working in a bent-over position. Also, patients should be instructed never to sleep flat in bed. They should elevate the head of the bed at least 6 to 8 inches for sleep, using wooden blocks or a thick foam wedge.

Prognosis

If GERD is not successfully controlled, it can progress to serious and even life-threatening problems. Esophageal ulceration and hemorrhage may result from severe erosion, and chronic nighttime reflux is accompanied by a significant risk of aspiration. Adenocarcinoma can develop from the premalignant tissue (termed Barrett's epithelium). Gradual or repeated scarring can permanently damage esophageal tissue and produce strictures (American College of Gastroenterology, 2013).

Clinical Manifestations

The most common clinical symptom is progressive dysphagia over a 6-month period. The patient may have a substernal feeling, as though food is not passing through the esophagus.

Assessment

Collection of subjective data includes noting that initially the patient may have difficulty swallowing when eating bulky foods such as meat; later the difficulty occurs with soft foods and finally with liquids and even saliva. Another symptom is odynophagia (painful swallowing). Pain is a late symptom and indicates local extension of the malignancy. Additional subjective symptoms include chest pain, pressure, or burning; indigestion; heartburn; and fatigue.

Collection of objective data includes observing the patient for regurgitation (backward flowing or casting up of undigested food), vomiting, hoarseness, chronic cough, choking, and iron deficiency anemia. Weight loss may be directly related to the cancer itself or to the difficulty in swallowing. Hemorrhage may occur if the cancer erodes through the esophagus. Esophageal perforation may result in the formation of a tracheoesophageal fistula (an abnormal passage between two internal organs), causing the patient to cough when swallowing anything, including saliva. Esophageal tumors may enlarge enough to cause esophageal obstruction, causing increased dysphagia. The cancer spreads via the lymph system, with the liver and lung being common sites of metastasis.

Diagnostic Tests

A barium swallow examination with fluoroscopy and endoscopy is used to detect esophageal cancer. An endoscopy with biopsy and cytologic examination provides a highly accurate diagnosis. Endoscopic ultrasonography is an important tool used to stage esophageal cancer. Computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) also are used to assess the extent of the disease.

Medical Management

The treatment of esophageal cancer depends on the tumor's location and whether invasion or metastasis has occurred. Tumor staging must be determined to guide patient management. In advanced cases, surgery is palliative to relieve dysphagia and restore continuity of the alimentary tract. An aggressive approach provides excellent palliation (therapy designed to relieve or reduce intensity of uncomfortable symptoms but not to produce a cure), increased longevity, and a chance for a cure. Standard resection seems to give as good a result as a radical procedure (Mayo Clinic, 2011b).

Radiation therapy may be curative or palliative. Problems associated with radiation therapy include the development of a tracheoesophageal fistula, and burning. The burning that occurs may result in sunburned-like skin when external radiation is used, or damage to nearby organs such as the lungs and heart if internal radiation therapy is used. Aspiration from the fistula and edema from the radiation are common as well. Chemotherapeutic agents cisplatin (Platinol), paclitaxel (Taxol), and fluorouracil (5-FU) are currently used, as well as other chemotherapy agents, in combination with radiation before and/or after surgery (ACS, 2012b). Because of the extreme toxicity of these drugs, the nurse should expect the patient to experience side effects of respiratory and liver dysfunction, nausea and vomiting, leukopenia, and sepsis. If the tumor is in the upper third of the esophagus, radiation is indicated. A tumor in the lower third is usually resected surgically.

The following four types of surgical procedures can be performed:

Nursing Interventions and Patient Teaching

Nursing diagnoses and interventions for the patient with esophageal carcinoma include but are not limited to the following:

The nurse should discuss with the patient and family all aspects of care, including surgery, radiation, and chemotherapy. Psychological adjustment of the patient who cannot ingest food orally, whether temporary or permanent, is difficult. Thorough explanations of all diagnostic tests, medications, procedures, and the treatment plan will help relieve the patient's anxiety. Support is given to the patient with this serious diagnosis by allowing time for questions.

Prognosis

In carcinoma of the esophagus, the disease is often well advanced by the time symptoms appear. The delay between the onset of early symptoms and when the patient seeks medical advice may be extensive. High mortality rates among these patients are affected by the following issues: (1) the patient is generally older; (2) the tumor has usually invaded surrounding structures by the time diagnosis is made; (3) the malignancy tends to spread to nearby lymph nodes; and (4) the esophagus is close to the heart and lungs, making these organs accessible to tumor extension.

The esophagus has an extensive lymphatic network, which facilitates the rapid spread of malignant cells to various local and distant sites. As discussed earlier in this section, the stage of the disease when diagnosed directly impacts the survival rate.

Collection of objective data includes observing for premalignant lesions, including leukoplakia. Unusual bleeding in the mouth, some blood-tinged sputum, lumps or edema in the neck, and hoarseness may be observed.

Clinical Manifestations

The primary symptom of achalasia is dysphagia. The patient has a sensation of food sticking in the lower portion of the esophagus. As the condition progresses, the patient complains of regurgitation of food, which relieves prolonged distention of the esophagus. The patient may also have substernal chest pain.

Assessment

The nurse should observe for loss of weight, poor skin turgor, and weakness.

Diagnostic Tests

Radiologic studies show esophageal dilation above the narrowing at the cardioesophageal junction. The diagnosis is confirmed by manometry, which shows the absence of primary peristalsis. Esophagoscopy is also used to confirm the diagnosis.

Medical Management

Conservative treatment of achalasia includes drug therapy and forceful dilation of the narrowed area of the esophagus. Anticholinergics, nitrates, and calcium channel blockers reduce pressure in the lower esophageal sphincter.

Dilation is done by first emptying the esophagus. Then a dilator with a deflated balloon is passed down to the sphincter. The balloon is inflated and remains so for 1 minute; it may need to be reinflated once or twice.

The preferred surgical approach is a cardiomyotomy. The muscular layer is incised longitudinally down to but not through the mucosa. Two thirds of the incision is in the esophagus, and the remaining one third is in the stomach; this permits the mucosa to expand so that food can pass easily into the stomach.

Nursing Interventions and Patient Teaching

Nursing interventions for esophageal surgery are presented in Box 5-2.

Nursing diagnoses and interventions for the patient with achalasia include but are not limited to the following:

Discuss home care and follow-up care in preparation for dismissal. Include a family member or support person if possible, and involve the patient as an active participant in the planning. Explain the need to eat high-calorie, high-protein foods, and provide printed material in support of such a diet. Explain the need to sleep with the head elevated and to avoid bending over and stooping. Discuss medications if prescribed (including name, dose, time of administration, purpose, and side effects). Discuss ways to avoid constipation by eating high-fiber foods (if tolerated) and natural laxatives. Explain the importance of follow-up care with the health care provider. Finally, discuss symptoms of recurrence or progression of disease and the need to report these to the health care provider.

Prognosis

Surgical separation, in addition to bag dilation, permits the return of normal peristalsis in approximately 10% of patients with achalasia.

Clinical Manifestations

If the condition is acute, the patient may experience fever, epigastric pain, nausea, vomiting, headache, coating of the tongue, and loss of appetite. If the condition results from ingestion of contaminated food, the intestines are usually affected and diarrhea may occur. Some patients with gastritis have no symptoms.

Assessment

Collection of subjective data includes observing for anorexia, nausea, discomfort after eating, and pain.

Collection of objective data includes observing for vomiting, hematemesis (vomiting blood), and melena caused by gastric bleeding.

Diagnostic Tests

Diagnosis is based on testing the stools for occult blood, noting white blood cell (WBC) differential increases related to certain bacteria, evaluating serum electrolytes, and observing for elevated hematocrit related to dehydration.

Medical Management

If medical treatment is required, an antiemetic—such as prochlorperazine (Compazine), promethazine (Phenergan), or trimethobenzamide (Tigan)—may be prescribed. Antacids and cimetidine (Tagamet) or ranitidine (Zantac) may be given in combination. Antibiotics are given if the cause is a bacterial agent. IV fluids are used to correct fluid and electrolyte imbalances. Patients who experience GI bleeding from hemorrhagic gastritis require fluid and blood replacement and NG lavage.

Nursing Interventions and Patient Teaching

The patient's I&O should be monitored and recorded. Foods and fluids are withheld orally as prescribed until signs and symptoms of gastritis subside. Tolerance to oral feedings is monitored and IV feedings are administered as prescribed. Clear liquids are increased to a diet as tolerated when the patient's symptoms improve.

A nursing diagnosis and interventions for the patient with gastritis include but are not limited to the following:

Patient education includes explanations of (1) the effects of stress on the mucosal lining of the stomach; (2) how salicylates, nonsteroidal antiinflammatory drugs (NSAIDs), and particular foods may be irritating; and (3) how lifestyles that include alcohol and tobacco may be harmful. Assist the patient in locating self-help groups in the community to deal with these behaviors.

Prognosis

Because of the many classifications and causes of gastritis, prognosis is variable. In general, the prognosis is good for individuals who are willing to change their lifestyles and follow a medical regimen.

Etiology and Pathophysiology

Peptic ulcers are ulcerations of the mucous membrane or deeper structures of the GI tract. They most commonly occur in the stomach (gastric ulcer) and duodenum (duodenal ulcer). The term peptic ulcer refers to acid in the digestive tract eroding the mucosal lining of the stomach, esophagus, or duodenum. Peptic ulcer disease (PUD) is most common in persons between the ages of 55 and 65 years (NDDIC, 2012b).

The stomach is normally protected from autodigestion by the gastric mucosal barrier. The GI tract has a high cell turnover rate, and the stomach's surface mucosa is renewed about every 3 days. As a result, the mucosa continuously repairs itself except in extreme instances when cell breakdown surpasses the cell renewal rate. In such cases, peptic ulcers can occur. The most common causes of peptic ulcer disease include the presence of Helicobacter pylori (H. pylori) bacteria in the stomach, regularly taking NSAIDs, smoking or chewing tobacco, excessive alcohol intake, and physical or emotional stress (NLM, 2011a).

Understanding of the factors that contribute to ulcer formation is developing rapidly. The discovery of the bacterium H. pylori provided new insight to ulcer formation. H. pylori has been identified in more than 80% of patients with gastric ulcers and 90% of those with duodenal ulcers. In Western cultures, half of all people over age 50 harbor H. pylori, yet most do not develop peptic ulcer disease. Scientists still need to determine what triggers ulcers in those with H. pylori (Johns Hopkins University, n.d.c).

Physiologic stress ulcer or stress-related mucosal disease is an acute ulcer that develops after a major physiologic insult such as trauma or surgery (Rohan, 2011). A stress ulcer is a form of erosive gastritis. It is believed that the gastric mucosa of the stomach undergoes a period of transient ischemia in association with hypotension, severe injury, extensive burns, and complicated surgery. The ischemia is due to decreased capillary blood flow as blood is shunted away from the GI tract, so that blood flow bypasses the gastric mucosa. This occurs as a compensatory mechanism in hypotension or shock. The decrease in blood flow produces an imbalance between the destructive properties of hydrochloric acid and pepsin and protective factors of the stomach's mucosal barrier, especially in the fundus portion. Multiple superficial erosions result, and these may bleed. Because of the possibility of development of physiologic stress ulcers and high morbidity, patients at risk receive prophylaxis with antisecretory agents, including H₂ receptor blockers and proton pump inhibitors.

Clinical Manifestations

Both gastric and duodenal ulcers may have similar symptoms but may differ in timing, degree, or factors that worsen or alleviate the symptoms. Pain is the characteristic symptom and is described as dull, burning, or gnawing; it is located in the epigastric region.

Assessment

Collection of subjective data requires awareness that in patients with gastric ulcers, the pain is closely associated with food intake and usually does not awaken the patient at night or when the stomach is empty, as does the pain experienced by those with duodenal ulcers. Nausea, weight loss, eructation (belching), and distention are also common complaints made by patients with PUD. These additional vague feelings of epigastric discomfort are sometimes referred to as dyspepsia. All these subjective symptoms intensify if perforation and obstruction occur (NDDIC, 2012b).

Collection of objective data includes observing for signs of complications of PUD. Hemorrhage is a potential complication.

Diagnostic Tests

Fiberoptic endoscopy can detect both gastric and duodenal ulcers. This is called esophagogastroduodenoscopy (EGD). Fiberoptic endoscopy is more reliable than barium contrast studies because of the maneuverability of fiberoptic scopes and direct visualization of the entire esophagus and gastric and duodenal mucosa. This procedure also can be used to determine the degree of ulcer healing after treatment. During endoscopy, specimens can be obtained for identification of H. pylori or tissue specimens for biopsy. The patient is sedated but remains conscious throughout the endoscopy procedure. Local anesthetics in the throat are used to decrease the gag reflex and minimize pain during the procedure. No liquids or food are allowed following the procedure until the patient's gag reflex returns.

A noninvasive test used for diagnostic purposes is a breath test to detect H. pylori. The test calls for the patient to drink a solution containing carbon 13–enriched urea, a natural, nonradioactive substance. If H. pylori infection is present, it breaks down the compound and releases carbon-13 dioxide (¹³CO₂). Thirty minutes after drinking the solution, the patient exhales into a collection bag, which is sent to the manufacturer for analysis. A finding of ¹³CO₂ confirms H. pylori infection. The test may prove especially useful in determining whether antibiotic therapy eradicated an H. pylori infection. A fecal assay antigen test for H. pylori is another test that is especially useful to determine eradication of the bacteria after antibiotic treatment. An additional noninvasive way to confirm H. pylori infection is a serum or whole blood antibody test, in particular, immunoglobulin G. This test is approximately 90% to 95% sensitive for H. pylori infection but cannot distinguish active from recently treated disease (Johns Hopkins, n.d.b).

Barium contrast studies (UGI) are not as accurate as endoscopy, especially for small lesions, but are still occasionally used. Testing of feces for occult blood in the intestinal tract is also used for diagnosis.

Medical Management

The health care provider may order insertion of an NG tube to remove gastric contents and blood. Surgery is usually indicated for complications of perforation, penetration, or obstruction, or for PUD that is no longer responding to medical management.

Scar tissue builds up with repeat episodes of ulceration and healing, causing obstruction, particularly at the pylorus. The patient may experience gastric dilation, vomiting, and distention. When fluid and electrolyte balance are achieved, surgical intervention is possible.

The primary treatment for peptic ulcers is to reduce signs and symptoms by decreasing or neutralizing normal gastric acidity with drug therapy. The types of drugs most commonly used include the following (Table 5-1):

Antibiotic therapy eradicates H. pylori. The drugs used include metronidazole (Flagyl), tetracycline, amoxicillin, and clarithromycin (Biaxin). Treatment is typically combined in a therapeutic regimen with other medications, such as bismuth or omeprazole. Another weapon that has entered the battle against H. pylori is a combination of bismuth, metronidazole, and tetracycline. Marketed under the brand name Helidac, the medication kit contains a 14-day supply of the three drugs, with each daily dose packaged on a blister card to improve patient compliance.

Among patients whose H. pylori is treated with antibiotics, the peptic ulcer recurrence may be as low as 10%. Patients who do not receive antibiotics have a relapse rate of 75% to 90%.

Dietary modification may be necessary to avoid foods and beverages that irritate the ulcer. There is considerable controversy over the therapeutic benefits of a bland diet, since the rationale is not supported by scientific evidence. Therefore, it is recommended that the patient eat smaller meals more frequently throughout the day to decrease the degree of gastric motor activity.

Smoking has an irritating effect on the mucosa, increases gastric motility, and delays mucosal healing. Smoking should be eliminated completely or severely reduced. The combination of adequate rest and cessation of smoking accelerates ulcer healing. Because caffeinated and decaffeinated coffee, tobacco, alcohol, and aspirin aggravate the mucosal lining of the stomach and duodenum, educate patients with ulcers about the need for lifestyle change.

Surgical intervention has decreased drastically with more effective diagnosis and medical treatment with antisecretory agents and antibiotics. Approximately 20% of patients with ulcers require surgical intervention. These are patients who are unresponsive to medical management, raising concerns about gastric cancer; patients whose ulcers are drug induced but who cannot be withdrawn from the drugs (e.g., patients with rheumatoid arthritis); or patients who develop complications. Surgical procedures that may be performed are the same as those listed for cancer of the stomach.

Nursing Interventions and Patient Teaching

NG or intestinal tube insertion, irrigation, and intermittent suctioning are often performed while the patient is feeling ill and uncomfortable from PUD. In addition to being skilled and knowledgeable in performing these procedures, the nurse is responsible for easing the patient's fears and anxieties. Patient cooperation not only makes the procedures easier but also reduces patient discomfort.

Helping patients through the experience of GI intubation requires understanding of the following points:

An NG tube is inserted through the nose, pharynx, and esophagus into the stomach. Various tubes are available, depending on the purpose (Table 5-2).

Nursing interventions depend on the stage of the ulcer disease. The emphasis in patient care should always be on prevention and early detection of pain in the epigastric region, hematemesis, melena, or tenderness and rigidity of the abdomen (see Communication box and Nursing Care Plan 5-1).

Nursing diagnoses and interventions for the specific stages of ulcer care include but are not limited to the following:

It is necessary to form a trusting relationship with the patient with an ulcer because of the severity of the condition and the need for long-term treatment. Include the family in patient education sessions to increase understanding and support, and involve the patient in goal setting to increase compliance (see Home Care Considerations box).

Instruct the patient to seek medical attention immediately if severe and sudden pain occurs. Assist the patient in describing signs and symptoms of weakness, anorexia, nausea, diarrhea, constipation, anxiety, or restlessness. When medications are prescribed, the patient must fully understand (1) the purpose of taking antibiotic therapy to eradicate H. pylori; (2) the importance of taking all medications such as H₂ receptor antagonists, antiulcer drugs, prostaglandin E analog, and proton pump inhibitors as prescribed; (3) why the antacids are taken in specific dosages and at the specific times ordered; and (4) the known side effects (diarrhea and constipation). Preventive teaching includes identifying high-risk behaviors, such as the use of tobacco, caffeine, and alcohol. Emphasize that the patient should eat six smaller meals daily and avoid any foods that cause noticeable stomach discomfort.

If surgery is required, explain the procedures thoroughly, including the reasons for them. Explain immediate postoperative care, including deep breathing; coughing; position changes; frequent monitoring of vital signs; IV tubing, NG tubing, catheters, and other drainage tubes; and the use of patient-controlled analgesia (PCA) or other medications for pain relief. The patient's ability to eat normally after healing depends on the type of surgery and when peristalsis returns. Help the patient realize that symptoms often recur and he or she should seek medical care if they do.

Prognosis for Peptic Ulcers

Recurrence of an ulcer may happen within 2 years in about one third of all patients. Among patients whose H. pylori is treated with antibiotics, the peptic ulcer recurrence drops to 20%. Patients who do not receive antibiotics have a relapse rate of 75% to 90%. The likelihood of recurrence is lessened by eliminating foods that aggravate the condition and following prescribed therapies such as taking proton pump inhibitors and avoiding NSAIDs. If symptoms recur, the prognosis is better in patients who seek immediate medical treatment and comply with the prescribed regimen (Best Practice, 2012).

Clinical Manifestations

The patient may be asymptomatic in early stages of the disease. Stomach cancer often spreads to adjacent organs before any distressing symptoms occur. With more advanced disease, the patient may appear pale and lethargic if anemia is present. With a poor appetite and significant weight loss, the patient may appear cachectic (weak and emaciated).

Assessment

Subjective data include complaints of vague epigastric discomfort or indigestion, early satiety, and postprandial (after meal) fullness. Some patients complain of an ulcer-like pain that does not respond to therapy. Anorexia and weakness are also common.

Objective data include weight loss, bleeding in the stools, hematemesis, and vomiting after drinking or eating. Anemia is common. It is caused by chronic blood loss as the lesion erodes through the mucosa or as a direct result of pernicious anemia, which develops when intrinsic factor is lost. The presence of ascites is a poor prognostic sign.

Diagnostic Tests

The tumor is diagnosed by radiographic barium studies (GI series). Endoscopic or gastroscopic examinations with biopsy remain the best diagnostic tool. The stomach can be distended with air during the procedure to stretch mucosal folds. Tissue samples for the growth-promoting protein, HER2/neu, can be obtained during endoscopic examination. Findings of increased levels are seen in gastric adenocarcinoma. Endoscopic ultrasound and CT and PET scans can be used to stage the disease. Stool examination provides evidence of occult or gross bleeding. Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 tumor markers are usually elevated in advanced gastric cancer. Serum tumor markers correlate with the degree of invasion, liver metastasis, and cure rate. Laboratory studies of RBCs, hemoglobin, hematocrit, and serum B₁₂ assist in the detection of anemia and determination of severity (ACS, 2013d).

Medical Management

The most therapeutic management of stomach cancer is surgical removal. Surgery may be done as an exploratory celiotomy to determine involvement. The surgical interventions used in treating gastric cancer are typically the same procedures used for peptic ulcer disease. A partial or total gastric resection is the treatment of choice for an extensive lesion. Surgery for advanced gastric cancer carries high morbidity and mortality rates (Mayo Clinic, 2013). Types of surgical procedures include the following:

• Antrectomy: Removal of the entire antrum, the gastric-producing portion of the lower stomach, to eliminate the main stimulus to acid production.

• Gastroduodenostomy (Billroth I) (Figure 5-7, A): Direct anastomosis of the fundus of the stomach to the duodenum; used to remove ulcers or cancer located in the antrum of the stomach.

• Gastrojejunostomy (Billroth II) (Figure 5-7, B): Closure of the duodenum, and anastomosis of the fundus of the stomach into the jejunum; used to remove ulcers or cancer located in the body of the fundus.

• Total gastrectomy: Removal of the entire stomach; rarely used for patients with gastric cancer.

• Vagotomy: Removal of the vagal innervation to the fundus, decreasing acid produced by the parietal cells of the stomach (Figure 5-8); usually done with a Billroth I or II procedure or with a pyloroplasty.

• Pyloroplasty: Surgical enlargement of the pyloric sphincter to facilitate passage of contents from the stomach; commonly done after vagotomy or to enlarge an opening that has been constricted from scar tissue. A vagotomy decreases gastric motility and subsequently gastric emptying. A pyloroplasty accompanying vagotomy increases gastric emptying (Johns Hopkins, n.d.c).

The choice of which procedure to use is difficult and depends on the surgeon's preference and results of diagnostic testing. Regardless of the procedure selected, postoperative complications are possible. Bleeding may occur up to 7 days after gastric surgery. Abdominal rigidity, abdominal pain, restlessness, elevated temperature, increased pulse, decreased blood pressure, and leukocytosis are all possible indications of postoperative bleeding. Note the amount and type of drainage from the incision. Surgical intervention may be necessary to correct the bleeding.

Dumping syndrome is a rapid gastric emptying of undigested food from the stomach to the small intestine, causing distention of the duodenum or jejunum. Increased intestinal motility and peristalsis and changes in blood glucose levels occur. Patients may report diaphoresis, nausea, vomiting, epigastric pain, explosive diarrhea, borborygmi (rumbling noises made by gas passing through the liquid of the small intestine), and dyspepsia. Dumping syndrome is the direct result of surgical removal of a large portion of the stomach and the pyloric sphincter. Approximately one third to one half of patients experience dumping syndrome after peptic ulcer surgery. Treatment includes eating six small meals daily that are high in protein and fat and low in carbohydrates, eating slowly, and avoiding fluids during meals. Treatment also includes (1) anticholinergic agents to decrease stomach motility, and (2) reclining for approximately 1 hour after meals. To increase long-term compliance, reassure patients that following the recommended treatment will decrease symptoms within a few months. The symptoms are self-limiting and often disappear within several months to a year after surgery.

Several other complications after gastric surgery present serious health threats. Diarrhea is common and usually responds to conservative treatment of controlled diet and antidiarrheal agents. Diphenoxylate with atropine (Lomotil), loperamide (Imodium), paregoric, or codeine is often used. Reflux esophagitis and nutritional deficits—leading to weight loss, malabsorption, anemia, and vitamin deficiency—can also be life-threatening.

Pernicious anemia is a serious potential complication for any patient who has had a total gastrectomy or extensive resections. This is caused by a deficiency of intrinsic factor, produced exclusively by the stomach, which aids intestinal absorption of vitamin B₁₂. Recommend that all patients with a partial gastrectomy have a blood serum vitamin B₁₂ level measured every 1 to 2 years so that replacement therapy of vitamin B₁₂ via a monthly injection, or weekly via the nasal route, can be instituted before anemia appears.

Wound healing may be disrupted by dehiscence (a partial or complete separation of the wound edges) or by evisceration (protrusion of viscera through the disrupted wound). Dehiscence and evisceration may be caused by problems in suturing the wound or by poor tissue integrity. Excessive coughing, straining, malnutrition, obesity, and infection may also increase the chances of dehiscence. Nursing interventions for dehiscence include instructing the patient to remain quiet, to cover the wound with a dry sterile dressing, and to avoid coughing or straining. Keep the patient in a dorsal recumbent position (on the back with the knees flexed) to remove stress on the wound and notify the surgeon. If evisceration occurs, keep the patient on bed rest and loosely cover the protruding viscera with a warm sterile saline dressing. Notify the surgeon immediately because treatment consists of reapproximating (i.e., drawing together) the wound edges.

Chemotherapy yields greater response and longer survival rates than radiation. Because the radiosensitivity of stomach cancer is low, radiation therapy is of little value. Radiation therapy may be used as a palliative measure to decrease tumor mass and temporarily relieve obstruction. The combination of chemotherapy and radiation therapy is sometimes used for patients who are at high risk for disease recurrence after surgery. These treatment modalities are often used in conjunction with surgery (Mayo Clinic, 2013).

Nursing Interventions and Patient Teaching

The nurse must provide further clarification about the disease and the surgical intervention to the patient and family. Preoperative preparation includes improving the patient's nutritional status by monitoring total parenteral nutrition (TPN; complete nutrition provided intravenously) and providing supplemental feedings. Postoperative teaching is necessary to relieve anxiety and promote understanding of drainage tubes, feeding tubes, dressing changes, weakness, medications, and other routine care. Close monitoring of intake and output, maintenance of TPN, and being alert to weight loss are important in the postoperative period for surgeries involving the stomach.

Nursing diagnoses and interventions for the patient with cancer of the stomach include but are not limited to the following:

Because care encompasses so many areas, instruction should be (1) planned according to the patient's needs and level of understanding, (2) given when the patient is free of pain, and (3) communicated both verbally and in print. The nurse should address areas such as surgery, chemotherapy, radiation therapy, continued nutritional needs, pain relief, and support groups for psychosocial needs.

Weight loss indicates the need for additional caloric intake and can be measured by monitoring weight and comparing it with the patient's normal weight before illness. If a gastrostomy tube (G-tube) is necessary, prevention of skin excoriation around the G-tube site should be ensured. Hypermotility or diarrhea that follows radiation therapy can be treated with dietary therapy and/or medication. The debilitated patient and family may require referral for hospice care.

Prognosis

The prognosis for patients with gastric cancer depends on the stage at which the cancer was detected. The overall average 5-year survival rate is about 30%. Five-year survival rates range from 71% if the gastric cancer is at stage 1A (i.e., cancer cells are limited to the gastric mucosa) to a 4% survival rate for stage IV (i.e., cancer has extended into nearby organs or has metastasized to more distant areas in the body) (NCI, n.d.b; Mayo Clinic, 2013).