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NURSING PROCESS: THE PATIENT UNDERGOING GASTRIC SURGERY
Before surgery, the nurse assesses the patient’s and family’s knowledge of preoperative and postoperative surgical routines and the rationale for surgery. The nurse also assesses the patient’s nutritional status: Has the patient lost weight? How much? Over how much time? Does the patient have nausea and vomiting? Has the patient had hematemesis? The nurse assesses for the presence of bowel sounds and palpates the abdomen to detect masses or tenderness.
After surgery, the nurse assesses the patient for complications secondary to the surgical intervention, such as hemorrhage, in-fection, abdominal distention, or decreased nutritional status.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
• Anxiety related to surgical intervention
• Acute pain related to surgical incision
• Deficient knowledge about surgical procedures and post-operative course
• Imbalanced nutrition, less than body requirements, related to poor nutrition before surgery and altered GI system after surgery
In addition to the complications to which all postoperative pa-tients are subject, the patient undergoing gastric surgery is at in-creased risk for:
• Dietary deficiencies
• Bile reflux
• Dumping syndrome
The major goals for the patient undergoing gastric surgery may include reduced anxiety, increased knowledge and understanding about the surgical procedure and postoperative course, optimal nutrition and management of the complications that can inter-fere with nutrition, relief of pain, avoidance of hemorrhage and steatorrhea, and enhanced self-care skills at home.
An important part of the preoperative nursing care involves allaying the patient’s fears and anxieties about the impending surgery and its implications. The nurse encourages the patient to express feelings and answers the patient’s and family’s questions. If the patient has an acute obstruction, a perforated bowel, or an active GI hemor-rhage, adequate psychological preparation may not be possible. In this event, the nurse caring for the patient after surgery should an-ticipate the concerns, fears, and questions that are likely to surface and should be available for support and further explanations.
After surgery, analgesics may be administered as prescribed to re-lieve pain and discomfort. It is important to avoid sedating the pa-tient so as not to impair his or her ability to perform pulmonary care activities (deep breathing and coughing) and to ambulate. The nurse assesses the effectiveness of analgesic intervention. Position-ing the patient in a Fowler’s position promotes comfort and allows emptying of the stomach after a partial gastrectomy.
The nurse maintains functioning of the NG tube to prevent dis-tention and resultant pain and damage to the suture line. Normally, the amount of NG drainage after a total gastrectomy is small.
The nurse explains routine preoperative and postoperative activ-ities to the patient, which include preoperative medications, NG intubation, IV fluids, abdominal dressings, and pulmonary care. These explanations need to be reinforced after surgery, especially if the patient had emergency surgery.
The patient’s nutritional status is evaluated before surgery, be-cause many patients with gastric cancer are malnourished and may require preoperative enteral or, more often, parenteral nu-trition. After surgery, parenteral nutrition may be continued to meet caloric needs, to replace fluids lost through drainage and vomitus, and to support the patient metabolically until oral intake is adequate.
After the return of bowel sounds and removal of the NG tube, the nurse may give fluids, followed by food in small portions. The nurse adds foods gradually until the patient is able to eat six small meals a day and drink 120 mL of fluid between meals. The key to increasing the dietary content is to offer food and fluids gradually as tolerated and to recognize that each patient’s tolerance is different.
Dysphagia may occur in patients who have had truncal vagot-omy, a surgical procedure that can result in trauma to the lower esophagus. Gastric retention may be evidenced by abdominal dis-tention, nausea, and vomiting. Regurgitation may also occur if the patient has eaten too much or too quickly. It also may indi-cate that edema along the suture line is preventing fluids and food from moving into the intestinal tract. If gastric retention occurs, it may be necessary to reinstate NG suction; pressure must be low to avoid disrupting the suture line.
Bile reflux gastritis and esophagitis may occur with the removal of the pylorus, which acts as a barrier to the reflux of duodenal con-tents. Burning epigastric pain and vomiting of bilious material manifest this condition. Eating or vomiting does not relieve the situation. Agents that bind with bile acid, such as cholestyramine (Questran), may be helpful. Aluminum hydroxide gel (an antacid) and metoclopramide hydrochloride (Reglan) have been used with some success.
The term dumping syndrome refers to an unpleasant set of vasomotor and GI symptoms that sometimes occur in patients who have had gastric surgery or a form of vagotomy. It may be the mechanical result of surgery in which a small gastric remnant is connected to the jejunum through a large opening. Foods high in carbohydrates and electrolytes must be diluted in the jejunum before absorption can take place, but the passage of food from the stomach remnant into the jejunum is too rapid to allow this to happen. The symptoms that occur are probably a result of rapid distention of the jejunal loop anastomosed to the stomach. The hypertonic intestinal contents draw extracellular fluid from the circulating blood volume into the jejunum to dilute the high con-centration of electrolytes and sugars. The ingestion of fluid at meal-time is another factor that causes the stomach contents to empty rapidly into the jejunum.
Early symptoms include a sensation of fullness, weakness, faint-ness, dizziness, palpitations, diaphoresis, cramping pains, and diar-rhea. Later, there is a rapid elevation of blood glucose, followed by increased insulin secretion. This results in a reactive hypoglycemia, which also is unpleasant for the patient. Vasomotor symptoms that occur 10 to 90 minutes after eating are pallor, perspiration, palpita-tions, headache, and feelings of warmth, dizziness, and even drowsi-ness. Anorexia may also be a result of the dumping syndrome.
Steatorrhea also may occur in the patient with gastric surgery. It is partially the result of rapid gastric emptying, which prevents adequate mixing with pancreatic and biliary secretions. In mild cases, reducing the intake of fat and administering an antimotility medication can control steatorrhea.
Other dietary deficiencies the nurse should be aware of include malabsorption of organic iron, which may require supplementa-tion with oral or parenteral iron, and a low serum level of vitamin B12, which may require supplementation by the intramuscular route. Total gastrectomy results in lack of intrinsic factor, a gas-tric secretion required for the absorption of vitamin B12 from the GI tract. Unless this vitamin is supplied by parenteral injection after gastrectomy, the patient inevitably will suffer vitamin B12 de-ficiency, which eventually leads to a condition identical to perni-cious anemia. All manifestations of pernicious anemia, including macrocytic anemia and combined system disease, may be expected to develop within a period of 5 years or less; they progress in sever-ity thereafter and, in the absence of therapy, are fatal. This com-plication is avoided by the regular monthly intramuscular injection of 100 to 1000 μ g (usual dose is 300 μ g) of vitamin B12.This regimen should be started without delay after gastrectomy. Weight loss is a common long-term problem because the patient experiences early fullness, which suppresses the appetite.
Because the patient may experience any of the described conditions affecting nutrition, nursing intervention includes proper dietary in-struction. The following teaching points are emphasized:
• To delay stomach emptying, the patient should assume a low Fowler’s position during mealtime, and after the meal the patient should lie down for 20 to 30 minutes.
• Antispasmodics, as prescribed, also may aid in delaying the emptying of the stomach.
• Fluid intake with meals is discouraged; instead, fluids may be consumed up to 1 hour before or 1 hour after mealtime.
• Meals should contain more dry items than liquid items.
• The patient can eat fat as tolerated but should keep carbo-hydrate intake low and avoid concentrated sources of car-bohydrates.
• The patient should eat smaller but more frequent meals.
• Dietary supplements of vitamins and medium-chain triglycerides and injections of vitamin B12 and iron may be prescribed.
The nurse also gives instructions regarding enteral or pa-renteral supplementation if it is needed.
Occasionally hemorrhage complicates gastric surgery. The pa-tient has the usual signs of rapid blood loss and shock and may vomit considerable amounts of bright red blood. The nurse assesses NG drainage for type and amount; some bloody drainage for the first 12 hours is expected, but excessive bleeding should be reported. The nurse also assesses the abdom-inal dressing for bleeding. Because this situation is upsetting to the patient and family, the nurse should remain calm. The nurse performs emergency measures, such as NG lavage and adminis-tration of blood and blood products.
Nurse-patient teaching stems from the assessment of the patient’s physical and psychological readiness to participate in self-care. The nurse provides information about nutrition, enteral or parenteral nutrition if required, nutritional supplements, pain management, and the symptoms of dumping syndrome and measures to use to prevent or minimize these symptoms (Chart 37-4). It is important to emphasize the continued need for vitamin B12 injections.
Both the patient and the family can benefit from a team approach to discharge planning. The team members include the home care nurse, physician, dietitian, social worker, patient and family; written instructions about meals, activities, medications, and follow-up care are helpful. The home care nurse supervises the administration of any enteral or parenteral feedings, emphasizing information about detection and prevention of untoward effects or complications related to the feedings. Information about commu-nity support groups is provided to the patient and family.
Expected patient outcomes may include:
1) Reports decreased anxiety; expresses fears and concerns about surgery
2) Demonstrates knowledge regarding postoperative course by discussing the surgical procedure and postoperative course
3) Attains optimal nutrition
a. Maintains a reasonable weight
b. Does not have excessive diarrhea
c. Tolerates 6 small meals a day
d. Does not experience dysphagia, gastric retention, bile reflux, dumping syndrome, or vitamin and mineral deficiencies
4) Attains optimal level of comfort
5) Has no evidence of hemorrhage
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