46
Upper Gastrointestinal Problems
Kara Ann Ventura
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Fluid and Electrolytes Sleep
Nutrition Stress
Pain Tissue Integrity
LEARNING OUTCOMES
1. Describe the etiology, complications, and interprofessional 6. Compare acute and chronic gastritis, including the
and nursing management of nausea and vomiting. etiology, pathophysiology, and interprofessional and
2. Discuss the etiology, clinical manifestations, and nursing management.
interprofessional and nursing management of common 7. Distinguish gastric and duodenal ulcers, including
oral inflammations and infections. the etiology, pathophysiology, clinical manifestations,
3. Describe the etiology, clinical manifestations, complications, and interprofessional and nursing
complications, and interprofessional and nursing management.
management of oral cancer. 8. Outline the clinical manifestations and interprofessional
4. Explain the types, pathophysiology, clinical and nursing management of stomach cancer.
manifestations, complications, and interprofessional and 9. Explain the common etiologies, clinical manifestations,
nursing management of gastroesophageal reflux disease and interprofessional and nursing management of upper
and hiatal hernia. gastrointestinal bleeding.
5. Relate the pathophysiology, clinical manifestations, 10. Identify common types of foodborne illnesses and nursing
complications, and interprofessional management of responsibilities related to food poisoning.
esophageal cancer, diverticula, achalasia, and esophageal
strictures.
KEY TERMS
achalasia hiatal hernia
Barrett esophagus nausea
dysphagia peptic ulcer disease (PUD)
esophageal cancer stomach (gastric) cancer
esophagitis stress-related mucosal disease (SRMD)
gastritis vomiting
gastroesophageal reflux disease (GERD)
This chapter reviews several upper gastrointestinal (GI) prob- eating, drinking, or talking may cause pain and impair the abil-
lems and the care of the patient undergoing upper GI surgery. ity to communicate. Pain can disrupt sleep and cause fatigue.
These include nausea and vomiting, oral and gastric cancers, Problems swallowing increase the risk for aspiration.
gastroesophageal reflux, ulcerative disease, inflammatory and
infectious bowel disorders, GI bleeding, and structural prob-
lems. Conceptually, patients with impaired GI function may
NAUSEA AND VOMITING
have malnutrition from decreased intake. Many are at risk for Nausea and vomiting are the most common manifesta-
altered fluid, electrolyte, and acid-base balance. Problems with tions of GI disease. Although nausea and vomiting can occur
1050
, CHAPTER 46 Upper Gastrointestinal Problems 1051
independently, they are closely related and usually treated as labyrinthine stimulation (e.g., motion sickness). Once stim-
one problem. Nausea is a feeling of discomfort in the epigas- ulated, the CTZ transmits impulses directly to the vomiting
trium with a conscious desire to vomit. Vomiting is the forceful center. This activates the autonomic nervous system, result-
ejection of partially digested food and secretions (emesis) from ing in both parasympathetic and sympathetic stimulation.
the upper GI tract. Sympathetic activation causes tachycardia, tachypnea, and dia-
phoresis. Parasympathetic stimulation causes relaxation of the
Etiology and Pathophysiology LES, an increase in gastric motility, and increased saliva.
Nausea and vomiting occur in a wide variety of GI problems and
in many conditions unrelated to GI disease. These include preg- Clinical Manifestations
nancy, infection, central nervous system (CNS) problems (e.g., Nausea is subjective. Anorexia (lack of appetite) usually accom-
meningitis, tumor), and cardiovascular disease (CVD) (e.g., panies nausea. When nausea and vomiting occur over a long
myocardial infarction, heart failure). They can occur with psy- period, dehydration can develop rapidly. Water and essential
chologic states (e.g., stress, fear) or when the GI tract becomes electrolytes (e.g., potassium, sodium, chloride) are lost. As
overly irritated, excited, or distended. Patients may have nausea vomiting persists, the patient may have severe electrolyte imbal-
and vomiting after surgery with general anesthesia or as a drug ances, fluid volume loss, and, eventually, circulatory failure.
side effect (e.g., chemotherapy, opioids). Women are more likely Metabolic alkalosis can result from loss of gastric hydro-
to have nausea and vomiting associated with anesthesia and chloric (HCl) acid. Metabolic acidosis can occur with vomiting
motion sickness.1 of small intestine contents. However, metabolic acidosis is less
A vomiting center in the medulla coordinates the multiple common than metabolic alkalosis. Weight loss resulting from
components involved in vomiting. This center receives input fluid loss can occur in a short time with severe vomiting.
from various stimuli. Neural impulses reach the vomiting cen-
ter via afferent pathways through branches of the autonomic Interprofessional Care
nervous system. Receptors for these afferent fibers are found in In managing nausea and vomiting, the goals of care are to deter-
the GI tract, kidneys, heart, and uterus. When stimulated, these mine and treat the underlying cause, recognize and correct any
receptors relay information to the vomiting center, which then complications, and provide symptomatic relief.
initiates the vomiting reflex (Fig. 46.1).
Vomiting is a complex act. It requires the coordinated activ- Drug Therapy
ity of several structures: closure of the glottis, deep inspiration The use of drugs to treat nausea and vomiting depends on the
with contraction of the diaphragm in the inspiratory position, cause (Table 46.1). Many antiemetic drugs act in the CNS via the
closure of the pylorus, relaxation of the stomach and lower CTZ to block the neurochemicals that trigger nausea and vom-
esophageal sphincter (LES), and contraction of the abdominal iting. When the cause has not been determined, use drugs with
muscles with increasing intraabdominal pressure. These simul- caution. Using antiemetics before knowing the cause can mask
taneous activities force the stomach contents up through the the underlying problem and delay diagnosis and treatment.
esophagus, into the pharynx, and out the mouth.
The chemoreceptor trigger zone (CTZ), found in the brain-
DRUG ALERT
stem, responds to chemical stimuli from drugs, toxins, and
Promethazine
Smell center
• A void parenteral routes because of the risk for severe tissue injury.
Sight center
• Use oral or rectal formulations.
Eye
5-HT3 (Serotonin) receptor antagonists are effective in reduc-
ing chemotherapy-induced vomiting (CINV), postoperative
Nose
nausea and vomiting (PONV), and nausea and vomiting related
to migraine headache and anxiety. Dexamethasone is given
with other antiemetics to manage acute and delayed CINV.2
Neurokinin-1 receptor antagonists (NK1RAs) (e.g., aprepitant
Emetic center
[Emend], rolapitant [Varubi]) can treat CINV and PONV.
DRUG ALERT
CTZ Metoclopramide (Reglan)
Skeletal
muscle • C hronic use or high doses carry the risk for tardive dyskinesia.
Vestibular
GI tract stimulation • Tardive dyskinesia is a neurologic condition characterized by involuntary
and repetitive movements of the body (e.g., extremity movements, lip
smacking).
Fig. 46.1 Stimuli involved in the act of vomiting. CTZ, Chemoreceptor • It may persist after stopping the drug.
trigger zone.
,1052 SECTION 9 Problems of Ingestion, Digestion, Absorption, and Elimination
TABLE 46.1 Drug Therapy
Nausea and Vomiting
Drug Mechanism of Action Side Effects
Anticholinergics
scopolamine transdermal Block cholinergic pathways to vomiting center Dry mouth, somnolence
Antihistamines
dimenhydrinate (Dramamine) Block histamine receptors that trigger nausea and Dry mouth, hypotension, sedation, rashes, constipation
diphenhydramine vomiting
hydroxyzine
meclizine (Antivert)
Cannabinoids
dronabinol (Marinol) Inhibit vomiting control mechanism in the medulla Dry mouth, amnesia, ataxia, confusion, coordination prob-
nabilone (Cesamet) oblongata lems, dizziness, somnolence
Corticosteroids
dexamethasone Not well understood how it prevents nausea and vomiting Hyperglycemia, insomnia, euphoria
Dopamine D2/D3 Receptor Antagonist
amisulpride (Barhemsys) Block dopaminergic receptors in the CTZ Chills, hypokalemia, hypotension, abdominal distention
5-HT3 (Serotonin) Antagonists
granisetron Block action of serotonin Constipation, diarrhea, headache, fatigue, malaise, ↑ liver
ondansetron (Zofran) function tests
palonosetron (Aloxi)
Phenothiazines
chlorpromazine Act in the CNS level of the CTZ. Block dopamine receptors Dry mouth, hypotension, sedation, rashes, constipation
prochlorperazine that trigger nausea and vomiting
promethazine
Prokinetic
metoclopramide (Reglan) Inhibit action of dopamine. CNS side effects ranging from anxiety to hallucinations, extra-
↑ Gastric motility and emptying pyramidal side effects, including tremor and dyskinesias
Substance P/Neurokinin-1 Receptor Antagonists
aprepitant (Emend) Block interaction of substance P at NK-1 receptor Headache, hiccups, fatigue, constipation, diarrhea, anorexia
netupitant and palonosetron (Akynzeo)
rolapitant (Varubi)
An oral cannabinoid (e.g., dronabinol) may be part of the food several hours after a meal indicates gastric outlet obstruc-
plan to manage CINV. Because of the potential for abuse and tion or delayed gastric emptying. The presence of fecal odor
sedation, this is an option only when other therapies are not and bile after prolonged vomiting suggests intestinal obstruc-
effective. tion below the level of the pylorus. Bile in the emesis suggests
obstruction below the ampulla of Vater.
NURSING MANAGEMENT: NAUSEA AND The color of the emesis helps determine the presence and
VOMITING source of any bleeding. Bright red blood occurs with active
bleeding. This could be due to a Mallory-Weiss tear (disruption
Assessment of the mucosal lining near the esophagogastric junction), esoph-
Each patient with prolonged or persistent nausea or vomiting ageal varices, gastric or duodenal ulcer, or cancer. Vomitus with
needs a thorough assessment. You need to be able to identify the a “coffee-grounds” appearance is related to gastric bleeding. The
patient who is at high risk. Assess the patient for precipitating blood changes to dark brown because of its interaction with
factors and describe the contents of the emesis. Table 46.2 pres- HCl acid.
ents subjective and objective data to obtain from a patient with Discern among vomiting, regurgitation, and projectile vom-
nausea and vomiting. iting. Regurgitation is an effortless process in which partially
When food is the precipitating cause of nausea and vomiting, digested food slowly comes up from the stomach. Retching or
help the patient identify the specific food. Determine when it vomiting rarely occurs before it. Projectile vomiting is a forceful
was eaten, prior history with the food, and whether anyone else expulsion of stomach contents without nausea. It often occurs
who ate the food is sick. Emesis containing partially digested with brain and spinal cord tumors.
, CHAPTER 46 Upper Gastrointestinal Problems 1053
Implementation
TABLE 46.2 NURSING ASSESSMENT
Acute Care
Nausea and Vomiting
Most people with nausea and vomiting are at home. When symp-
Subjective Data toms persist, the patient may need hospitalized to diagnose the
Important Health Information underlying problem. Until we confirm a diagnosis, the patient is
Health history: GI problems, chronic indigestion, food allergies, pregnancy, NPO and given IV fluids. The patient with persistent vomiting, a
infection, CNS problems, recent travel, eating disorders, metabolic prob- possible bowel obstruction, or paralytic ileus may need a nasoga-
lems, cancer, CVD, renal disease stric (NG) tube connected to suction to decompress the stomach.
Medications: Antiemetics, digitalis, opioids, ferrous sulfate, aspirin, amino-
Secure the NG tube to prevent its movement in the nose and back
phylline, alcohol, antibiotics, chemotherapy. General anesthesia
of the throat. This can stimulate nausea and vomiting.
Surgery or other treatments: Recent surgery
With prolonged vomiting, there is a chance of dehydration and
Functional Health Patterns acid-base and electrolyte imbalances. Record intake and output.
Nutritional-metabolic: Amount, frequency, character, and color of vomitus. Dry Monitor vital signs and assess for signs of dehydration. Maintain
heaves. Anorexia, weight loss a quiet, odor-free environment. Provide oral care. Observe for
Activity-exercise: Weakness, fatigue changes in mentation. Pulmonary aspiration is a concern when
Cognitive-perceptual: Abdominal tenderness or pain vomiting occurs in older or unconscious patients or in those with
Coping–stress tolerance: Stress, fear an impaired gag reflex. To prevent aspiration, put the patient who
Objective Data
cannot manage self-care in a semi-Fowler’s or side-lying position.
General
Lethargy, sunken eyeballs
Nutrition Therapy
The patient with severe vomiting needs IV fluid therapy with
GI electrolyte and glucose replacement until able to tolerate oral
Amount, frequency, character (e.g., projectile), content (undigested food, intake. Start oral nutrition beginning with clear liquids once
blood, bile, feces), and color of vomitus (red, coffee-grounds, green-yellow) symptoms have subsided. A patient may be reluctant to resume
Skin
intake because of fear of symptoms recurring. Water is the initial
Pallor, dry mucous membranes, poor skin turgor fluid of choice for oral rehydration. Have the patient sip small
amounts of room temperature fluids (5 to 15 mL) every 15 to 20
Urinary minutes. Other options include carbonated beverages with the
Decreased output, concentrated urine carbonation removed at room temperature and warm tea. Very
hot or cold liquids are often hard to tolerate. Broth and sports
Possible Diagnostic Findings
drinks (e.g., Gatorade) are high in sodium, so give them with
Altered serum electrolytes (especially hypokalemia), metabolic alkalosis,
abnormal upper GI findings on endoscopy or abdominal x-rays
caution. Dry toast, crackers, and plain gelatin may be helpful.
As the patient’s condition improves, provide a diet high
in carbohydrates and low in fat. Bland foods, such as a baked
The timing of nausea and vomiting can help determine potato, rice, cooked chicken, and cereal, are ideal. Many patients
its cause. Early morning vomiting is common in pregnancy. do not tolerate coffee, spicy foods, highly acidic foods, and those
Emotional stressors may elicit vomiting during or right after with strong odors. Tell the patient to eat food slowly and in small
eating. Those with cyclic vomiting syndrome have recurring amounts to prevent stomach distension. Liquids taken between
episodes of nausea, vomiting, and fatigue that last from a few meals rather than with meals reduce distention. Consult a dieti-
hours up to 10 days. tian about nutritious foods that the patient can tolerate.
Clinical Problems CHECK YOUR PRACTICE
Clinical problems for the patient with nausea and vomiting may
include: You are caring for a newly admitted 76-year-old man who reports vomiting
for the past 3 days. He says, “I cannot keep anything down, not even water.”
• Fluid imbalance
• What assessment do you need to perform?
• Electrolyte imbalance • What findings would show he is dehydrated?
• Nutritionally compromised • What are your priority nursing interventions?
• Impaired GI function
More information on clinical problems and interventions
are in eNursing Care Plan 41.1 (available on the website for this Ambulatory Care
chapter). Teach the patient and caregiver (1) how to manage nausea, (2)
ways to prevent nausea and vomiting, and (3) how to maintain
Planning fluid and nutrition intake. Tell them to keep the immediate envi-
The overall goals are that the patient with nausea and vomit- ronment quiet, free of noxious odors, and well ventilated. Avoiding
ing will (1) have minimal or no nausea and vomiting, (2) have sudden changes of position and unnecessary activity are helpful.
normal electrolyte levels and hydration status, and (3) return to Encourage the use of relaxation techniques, frequent rest periods,
their normal fluid and nutrient intake. and diversion. Provide effective pain management. Cleansing the
Upper Gastrointestinal Problems
Kara Ann Ventura
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Fluid and Electrolytes Sleep
Nutrition Stress
Pain Tissue Integrity
LEARNING OUTCOMES
1. Describe the etiology, complications, and interprofessional 6. Compare acute and chronic gastritis, including the
and nursing management of nausea and vomiting. etiology, pathophysiology, and interprofessional and
2. Discuss the etiology, clinical manifestations, and nursing management.
interprofessional and nursing management of common 7. Distinguish gastric and duodenal ulcers, including
oral inflammations and infections. the etiology, pathophysiology, clinical manifestations,
3. Describe the etiology, clinical manifestations, complications, and interprofessional and nursing
complications, and interprofessional and nursing management.
management of oral cancer. 8. Outline the clinical manifestations and interprofessional
4. Explain the types, pathophysiology, clinical and nursing management of stomach cancer.
manifestations, complications, and interprofessional and 9. Explain the common etiologies, clinical manifestations,
nursing management of gastroesophageal reflux disease and interprofessional and nursing management of upper
and hiatal hernia. gastrointestinal bleeding.
5. Relate the pathophysiology, clinical manifestations, 10. Identify common types of foodborne illnesses and nursing
complications, and interprofessional management of responsibilities related to food poisoning.
esophageal cancer, diverticula, achalasia, and esophageal
strictures.
KEY TERMS
achalasia hiatal hernia
Barrett esophagus nausea
dysphagia peptic ulcer disease (PUD)
esophageal cancer stomach (gastric) cancer
esophagitis stress-related mucosal disease (SRMD)
gastritis vomiting
gastroesophageal reflux disease (GERD)
This chapter reviews several upper gastrointestinal (GI) prob- eating, drinking, or talking may cause pain and impair the abil-
lems and the care of the patient undergoing upper GI surgery. ity to communicate. Pain can disrupt sleep and cause fatigue.
These include nausea and vomiting, oral and gastric cancers, Problems swallowing increase the risk for aspiration.
gastroesophageal reflux, ulcerative disease, inflammatory and
infectious bowel disorders, GI bleeding, and structural prob-
lems. Conceptually, patients with impaired GI function may
NAUSEA AND VOMITING
have malnutrition from decreased intake. Many are at risk for Nausea and vomiting are the most common manifesta-
altered fluid, electrolyte, and acid-base balance. Problems with tions of GI disease. Although nausea and vomiting can occur
1050
, CHAPTER 46 Upper Gastrointestinal Problems 1051
independently, they are closely related and usually treated as labyrinthine stimulation (e.g., motion sickness). Once stim-
one problem. Nausea is a feeling of discomfort in the epigas- ulated, the CTZ transmits impulses directly to the vomiting
trium with a conscious desire to vomit. Vomiting is the forceful center. This activates the autonomic nervous system, result-
ejection of partially digested food and secretions (emesis) from ing in both parasympathetic and sympathetic stimulation.
the upper GI tract. Sympathetic activation causes tachycardia, tachypnea, and dia-
phoresis. Parasympathetic stimulation causes relaxation of the
Etiology and Pathophysiology LES, an increase in gastric motility, and increased saliva.
Nausea and vomiting occur in a wide variety of GI problems and
in many conditions unrelated to GI disease. These include preg- Clinical Manifestations
nancy, infection, central nervous system (CNS) problems (e.g., Nausea is subjective. Anorexia (lack of appetite) usually accom-
meningitis, tumor), and cardiovascular disease (CVD) (e.g., panies nausea. When nausea and vomiting occur over a long
myocardial infarction, heart failure). They can occur with psy- period, dehydration can develop rapidly. Water and essential
chologic states (e.g., stress, fear) or when the GI tract becomes electrolytes (e.g., potassium, sodium, chloride) are lost. As
overly irritated, excited, or distended. Patients may have nausea vomiting persists, the patient may have severe electrolyte imbal-
and vomiting after surgery with general anesthesia or as a drug ances, fluid volume loss, and, eventually, circulatory failure.
side effect (e.g., chemotherapy, opioids). Women are more likely Metabolic alkalosis can result from loss of gastric hydro-
to have nausea and vomiting associated with anesthesia and chloric (HCl) acid. Metabolic acidosis can occur with vomiting
motion sickness.1 of small intestine contents. However, metabolic acidosis is less
A vomiting center in the medulla coordinates the multiple common than metabolic alkalosis. Weight loss resulting from
components involved in vomiting. This center receives input fluid loss can occur in a short time with severe vomiting.
from various stimuli. Neural impulses reach the vomiting cen-
ter via afferent pathways through branches of the autonomic Interprofessional Care
nervous system. Receptors for these afferent fibers are found in In managing nausea and vomiting, the goals of care are to deter-
the GI tract, kidneys, heart, and uterus. When stimulated, these mine and treat the underlying cause, recognize and correct any
receptors relay information to the vomiting center, which then complications, and provide symptomatic relief.
initiates the vomiting reflex (Fig. 46.1).
Vomiting is a complex act. It requires the coordinated activ- Drug Therapy
ity of several structures: closure of the glottis, deep inspiration The use of drugs to treat nausea and vomiting depends on the
with contraction of the diaphragm in the inspiratory position, cause (Table 46.1). Many antiemetic drugs act in the CNS via the
closure of the pylorus, relaxation of the stomach and lower CTZ to block the neurochemicals that trigger nausea and vom-
esophageal sphincter (LES), and contraction of the abdominal iting. When the cause has not been determined, use drugs with
muscles with increasing intraabdominal pressure. These simul- caution. Using antiemetics before knowing the cause can mask
taneous activities force the stomach contents up through the the underlying problem and delay diagnosis and treatment.
esophagus, into the pharynx, and out the mouth.
The chemoreceptor trigger zone (CTZ), found in the brain-
DRUG ALERT
stem, responds to chemical stimuli from drugs, toxins, and
Promethazine
Smell center
• A void parenteral routes because of the risk for severe tissue injury.
Sight center
• Use oral or rectal formulations.
Eye
5-HT3 (Serotonin) receptor antagonists are effective in reduc-
ing chemotherapy-induced vomiting (CINV), postoperative
Nose
nausea and vomiting (PONV), and nausea and vomiting related
to migraine headache and anxiety. Dexamethasone is given
with other antiemetics to manage acute and delayed CINV.2
Neurokinin-1 receptor antagonists (NK1RAs) (e.g., aprepitant
Emetic center
[Emend], rolapitant [Varubi]) can treat CINV and PONV.
DRUG ALERT
CTZ Metoclopramide (Reglan)
Skeletal
muscle • C hronic use or high doses carry the risk for tardive dyskinesia.
Vestibular
GI tract stimulation • Tardive dyskinesia is a neurologic condition characterized by involuntary
and repetitive movements of the body (e.g., extremity movements, lip
smacking).
Fig. 46.1 Stimuli involved in the act of vomiting. CTZ, Chemoreceptor • It may persist after stopping the drug.
trigger zone.
,1052 SECTION 9 Problems of Ingestion, Digestion, Absorption, and Elimination
TABLE 46.1 Drug Therapy
Nausea and Vomiting
Drug Mechanism of Action Side Effects
Anticholinergics
scopolamine transdermal Block cholinergic pathways to vomiting center Dry mouth, somnolence
Antihistamines
dimenhydrinate (Dramamine) Block histamine receptors that trigger nausea and Dry mouth, hypotension, sedation, rashes, constipation
diphenhydramine vomiting
hydroxyzine
meclizine (Antivert)
Cannabinoids
dronabinol (Marinol) Inhibit vomiting control mechanism in the medulla Dry mouth, amnesia, ataxia, confusion, coordination prob-
nabilone (Cesamet) oblongata lems, dizziness, somnolence
Corticosteroids
dexamethasone Not well understood how it prevents nausea and vomiting Hyperglycemia, insomnia, euphoria
Dopamine D2/D3 Receptor Antagonist
amisulpride (Barhemsys) Block dopaminergic receptors in the CTZ Chills, hypokalemia, hypotension, abdominal distention
5-HT3 (Serotonin) Antagonists
granisetron Block action of serotonin Constipation, diarrhea, headache, fatigue, malaise, ↑ liver
ondansetron (Zofran) function tests
palonosetron (Aloxi)
Phenothiazines
chlorpromazine Act in the CNS level of the CTZ. Block dopamine receptors Dry mouth, hypotension, sedation, rashes, constipation
prochlorperazine that trigger nausea and vomiting
promethazine
Prokinetic
metoclopramide (Reglan) Inhibit action of dopamine. CNS side effects ranging from anxiety to hallucinations, extra-
↑ Gastric motility and emptying pyramidal side effects, including tremor and dyskinesias
Substance P/Neurokinin-1 Receptor Antagonists
aprepitant (Emend) Block interaction of substance P at NK-1 receptor Headache, hiccups, fatigue, constipation, diarrhea, anorexia
netupitant and palonosetron (Akynzeo)
rolapitant (Varubi)
An oral cannabinoid (e.g., dronabinol) may be part of the food several hours after a meal indicates gastric outlet obstruc-
plan to manage CINV. Because of the potential for abuse and tion or delayed gastric emptying. The presence of fecal odor
sedation, this is an option only when other therapies are not and bile after prolonged vomiting suggests intestinal obstruc-
effective. tion below the level of the pylorus. Bile in the emesis suggests
obstruction below the ampulla of Vater.
NURSING MANAGEMENT: NAUSEA AND The color of the emesis helps determine the presence and
VOMITING source of any bleeding. Bright red blood occurs with active
bleeding. This could be due to a Mallory-Weiss tear (disruption
Assessment of the mucosal lining near the esophagogastric junction), esoph-
Each patient with prolonged or persistent nausea or vomiting ageal varices, gastric or duodenal ulcer, or cancer. Vomitus with
needs a thorough assessment. You need to be able to identify the a “coffee-grounds” appearance is related to gastric bleeding. The
patient who is at high risk. Assess the patient for precipitating blood changes to dark brown because of its interaction with
factors and describe the contents of the emesis. Table 46.2 pres- HCl acid.
ents subjective and objective data to obtain from a patient with Discern among vomiting, regurgitation, and projectile vom-
nausea and vomiting. iting. Regurgitation is an effortless process in which partially
When food is the precipitating cause of nausea and vomiting, digested food slowly comes up from the stomach. Retching or
help the patient identify the specific food. Determine when it vomiting rarely occurs before it. Projectile vomiting is a forceful
was eaten, prior history with the food, and whether anyone else expulsion of stomach contents without nausea. It often occurs
who ate the food is sick. Emesis containing partially digested with brain and spinal cord tumors.
, CHAPTER 46 Upper Gastrointestinal Problems 1053
Implementation
TABLE 46.2 NURSING ASSESSMENT
Acute Care
Nausea and Vomiting
Most people with nausea and vomiting are at home. When symp-
Subjective Data toms persist, the patient may need hospitalized to diagnose the
Important Health Information underlying problem. Until we confirm a diagnosis, the patient is
Health history: GI problems, chronic indigestion, food allergies, pregnancy, NPO and given IV fluids. The patient with persistent vomiting, a
infection, CNS problems, recent travel, eating disorders, metabolic prob- possible bowel obstruction, or paralytic ileus may need a nasoga-
lems, cancer, CVD, renal disease stric (NG) tube connected to suction to decompress the stomach.
Medications: Antiemetics, digitalis, opioids, ferrous sulfate, aspirin, amino-
Secure the NG tube to prevent its movement in the nose and back
phylline, alcohol, antibiotics, chemotherapy. General anesthesia
of the throat. This can stimulate nausea and vomiting.
Surgery or other treatments: Recent surgery
With prolonged vomiting, there is a chance of dehydration and
Functional Health Patterns acid-base and electrolyte imbalances. Record intake and output.
Nutritional-metabolic: Amount, frequency, character, and color of vomitus. Dry Monitor vital signs and assess for signs of dehydration. Maintain
heaves. Anorexia, weight loss a quiet, odor-free environment. Provide oral care. Observe for
Activity-exercise: Weakness, fatigue changes in mentation. Pulmonary aspiration is a concern when
Cognitive-perceptual: Abdominal tenderness or pain vomiting occurs in older or unconscious patients or in those with
Coping–stress tolerance: Stress, fear an impaired gag reflex. To prevent aspiration, put the patient who
Objective Data
cannot manage self-care in a semi-Fowler’s or side-lying position.
General
Lethargy, sunken eyeballs
Nutrition Therapy
The patient with severe vomiting needs IV fluid therapy with
GI electrolyte and glucose replacement until able to tolerate oral
Amount, frequency, character (e.g., projectile), content (undigested food, intake. Start oral nutrition beginning with clear liquids once
blood, bile, feces), and color of vomitus (red, coffee-grounds, green-yellow) symptoms have subsided. A patient may be reluctant to resume
Skin
intake because of fear of symptoms recurring. Water is the initial
Pallor, dry mucous membranes, poor skin turgor fluid of choice for oral rehydration. Have the patient sip small
amounts of room temperature fluids (5 to 15 mL) every 15 to 20
Urinary minutes. Other options include carbonated beverages with the
Decreased output, concentrated urine carbonation removed at room temperature and warm tea. Very
hot or cold liquids are often hard to tolerate. Broth and sports
Possible Diagnostic Findings
drinks (e.g., Gatorade) are high in sodium, so give them with
Altered serum electrolytes (especially hypokalemia), metabolic alkalosis,
abnormal upper GI findings on endoscopy or abdominal x-rays
caution. Dry toast, crackers, and plain gelatin may be helpful.
As the patient’s condition improves, provide a diet high
in carbohydrates and low in fat. Bland foods, such as a baked
The timing of nausea and vomiting can help determine potato, rice, cooked chicken, and cereal, are ideal. Many patients
its cause. Early morning vomiting is common in pregnancy. do not tolerate coffee, spicy foods, highly acidic foods, and those
Emotional stressors may elicit vomiting during or right after with strong odors. Tell the patient to eat food slowly and in small
eating. Those with cyclic vomiting syndrome have recurring amounts to prevent stomach distension. Liquids taken between
episodes of nausea, vomiting, and fatigue that last from a few meals rather than with meals reduce distention. Consult a dieti-
hours up to 10 days. tian about nutritious foods that the patient can tolerate.
Clinical Problems CHECK YOUR PRACTICE
Clinical problems for the patient with nausea and vomiting may
include: You are caring for a newly admitted 76-year-old man who reports vomiting
for the past 3 days. He says, “I cannot keep anything down, not even water.”
• Fluid imbalance
• What assessment do you need to perform?
• Electrolyte imbalance • What findings would show he is dehydrated?
• Nutritionally compromised • What are your priority nursing interventions?
• Impaired GI function
More information on clinical problems and interventions
are in eNursing Care Plan 41.1 (available on the website for this Ambulatory Care
chapter). Teach the patient and caregiver (1) how to manage nausea, (2)
ways to prevent nausea and vomiting, and (3) how to maintain
Planning fluid and nutrition intake. Tell them to keep the immediate envi-
The overall goals are that the patient with nausea and vomit- ronment quiet, free of noxious odors, and well ventilated. Avoiding
ing will (1) have minimal or no nausea and vomiting, (2) have sudden changes of position and unnecessary activity are helpful.
normal electrolyte levels and hydration status, and (3) return to Encourage the use of relaxation techniques, frequent rest periods,
their normal fluid and nutrient intake. and diversion. Provide effective pain management. Cleansing the
