inflammation concept: gerd, hiatal hernia, appendicitis
DESCRIPTION
Inflammation Concept: GERD, Hiatal Hernia, Appendicitis. Brunner ch. 35 & 38. Gastroesophageal Reflux Disease (GERD) (1014). Backflow of gastric contents into esophagus. Incidence increases with age Affects infants as well but is referred to as GER. Etiology. Motility problems - PowerPoint PPT PresentationTRANSCRIPT
INFLAMMATION CONCEPT: GERD, HIATAL HERNIA, APPENDICITISBrunner ch. 35 & 38
Gastroesophageal Reflux Disease (GERD) (1014)
Backflow of gastric contents into esophagus.
Incidence increases with age Affects infants as well but is referred to
as GER
Etiology Motility problems Incompetent esophageal sphincter Pyloric stenosis (more common in
infants)
Assessment Pyrosis Dyspepsia Odynophagia Dysphagia Acid regurgitation Eructation Hypersalivation
(brash) Globus sensation
Nocturnal cough Wheezing Hoarseness Lying down or
straining exacerbates symptoms
Diagnosed by barium swallow or endoscopy
Complications Mucosal inflammation and breakdown Sphincter incompetence Chronic esophagitis, ulceration, and
changes in the mucosa (Barrett’s epithelium).
Barrett’s is associated stricture and a 30% risk of cancer. Endoscopy shows red mucosa. Bx reveals dysplasia of the epithelium (looks more like intestinal than esophageal tissue)
Dietary Management Small frequent meals Fluids between meals Low fat diet Lose weight if indicated Avoid spicy or acid foods, caffeine,
carbonated drinks , chocolate, beer, mint, very hot or cold drinks
Other Suggestions Sit up 1-2h after meals Don’t eat 2h before bed Reverse Trendelenberg with 6-8” blocks Upper body elevated on pillows Don’t strain or bend or wear tight
clothing Stop smoking
Pharmacologic Management Antacids H2 blockers (Pepcid, Zantac) Proton pump inhibitors (Prilosec,
Nexium). Increases incidence of stomach infection.
GI stimulants (Urecholine, Reglan). Watch for extrapyramidal side effects.
Hiatal Hernia (1012) Herniation of stomach thru an enlarged
esophageal opening in the diaphragm (1013).
Type 1 (sliding): upper stomach slides thru the opening into the chest cavity (90% ).
Type 2 (paraesophageal or rolling): upper stomach pushes up against diaphragm.
Contributing Factors Age Obesity Congenital weakness Trauma Surgery Pregnancy Ascites Heavy lifting
Assessment
50% have dysphagia, dyspepsia, reflux
50% asymptomatic Dx by x-ray,
barium swallow, fluoroscopy
Most complain of fullness or chest pain after eating
May be asymptomatic
Dx by x-ray, barium swallow, fluoroscopy
Type 1 Type 2
Complications Hemorrhage Obstruction Strangulation
Management Similar to GERD Small frequent meals and may need
dietary restrictions if reflux is present No reclining for at least 1 hr after eating
to prevent upward movement of the stomach
HOB up on 4-8” blocks H2 blockers or proton pump inhibitors If needed, Nissen fundoplication
Surgical ManagementIf all else fails, Nissen fundoplication can be done by laparoscopic or open method.
Repair of the hernia is done first then part of fundus is wrapped around distal esophagus and sutured.
Postop Care for Nissen Fundoplication
Physical assessment HOB up 30 degrees TCDB, IS Analgesics IVF I&O NPO with possible NGT (suction) unless laparoscopic May have po after peristalsis returns (HCP decides) No gassy foods, carbonated drinks, gum, straws Ambulate!!
Appendicitis (1075) Inflammation and infection of appendix Appendix is attached to the cecum
immediately past the ileocecal valve.
Etiology Easily obstructed due to small lumen
and inefficient emptying. Caused by kinking, fecalith, tumor, or
foreign body.
Assessment Periumbilical pain moving to McBurney’s
point (halfway between iliac crest and umbilicus)
+Rovsing’s sign (pressing on LLQ causes RLQ pain)
+Blumberg’s sign (rebound) +Obturator muscle test (internal rotation
of hip causes RLQ pain) +Ileopsoas muscle test (hip flexion or
hip abduction causes RLQ pain)
Assessment con’t Guarding Pain with digital rectal examination (DRE) Low grade fever Anorexia NVD or constipation (NO LAXATIVES for
anyone with RLQ pain) Elevated WBC (usually 11-16,000) +Abd x-ray or CT (shows RLQ density or
bowel distention)
Complications Ruptured appendix—pain becomes
diffuse and generalized; WBC elevates from 16-40,000
Peritonitis (inflammation of peritoneum) Sepsis Paralytic ileus
Plan of Care: Expected Outcomes
Patient will receive proper management of appendicitis
Patient’s pain will be controlled Infectious and inflammatory processes
will subside Patient will experience full recovery
without complications (wound infection, DVT, respiratory infection, etc.)
Patient will receive and understand all instructions
Surgical Management Appendectomy:
-Open or laparoscopic-Usually 24h stay -If perforated, several days with NG, IV, drains, possible open wound, IV meds-Pre and postop antibiotics
Nursing Management Depends on whether OP or inpatient Preoperatively, pt is assessed, IV with antibiotics,
site is marked, laxatives & enemas are contraindicated
Postop VS per protocol Pain control—IV to po IVF and meds Wound assessment and changes (if inpatient) Advance DAT and activity Pt education re: wound care, S&S infection, pain
mgmt, activity restrictions, RTC time, when to call MD.
Plan of Care: Evaluation Appendicitis has been resolved:
Appendectomy performed successfully Infection and inflammation has subsided as
evidenced by VS and WBC returned to normal levels
Patient’s pain is controlled Patient had no complications Patient received and understood all
instructions