NURSING PROCESS: THE PATIENT WITH GASTRITIS
When obtaining the history, the nurse asks about the patient’s presenting signs and symptoms. Does the patient have heartburn, indigestion, nausea, or vomiting? Do the symptoms occur at any specific time of the day, before or after meals, after ingesting spicy or irritating foods, or after the ingestion of cer-tain drugs or alcohol? Has there been recent weight gain or loss? Are the symptoms related to anxiety, stress, allergies, eat-ing or drinking too much, or eating too quickly? How are the symptoms relieved? Is there a history of previous gastric disease or surgery? A diet history plus a 72-hour dietary recall (a list of everything the patient ate and drank in the last 72 hours) may be helpful.
A thorough history is important because it helps the nurse to identify whether known dietary excesses or other indiscretions are associated with the current symptoms, whether others in the pa-tient’s environment have similar symptoms, whether the patient is vomiting blood, and whether any known caustic element has been ingested. The nurse also identifies the duration of the cur-rent symptoms, any methods used by the patient to treat these symptoms, and whether the methods are effective. Signs to note during the physical examination include abdominal tenderness, dehydration, and evidence of any systemic disorder that might be responsible for the symptoms of gastritis.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
• Anxiety related to treatment
• Imbalanced nutrition, less than body requirements, related to inadequate intake of nutrients
• Risk for imbalanced fluid volume related to insufficient fluid intake and excessive fluid loss subsequent to vomiting
• Deficient knowledge about dietary management and disease process
• Acute pain related to irritated stomach mucosa
The major goals for the patient may include reduced anxiety, avoidance of irritating foods, adequate intake of nutrients, mainte-nance of fluid balance, increased awareness of dietary management, and relief of pain.
If the patient has ingested acids or alkalis, emergency measures may be needed. The nurse offers supportive therapy to the patient and family during treatment and after the ingested acid or alkali has been neutralized or diluted. In some cases, the nurse may need to prepare the patient for additional diagnostic studies (endoscopy) or surgery. The patient usually feels anxious about the pain and the treatment modalities. The nurse uses a calm approach to assess the patient and to answer all questions as completely as possible. It is important to explain all procedures and treatments according to the patient’s level of understanding.
For acute gastritis, the nurse provides physical and emotional sup-port and helps the patient manage the symptoms, which may include nausea, vomiting, heartburn, and fatigue. The patient should take no foods or fluids by mouth—possibly for days—until the acute symptoms subside, thus allowing the gastric mucosa to heal. If IV therapy is necessary, the nurse monitors it regularly, along with serum electrolyte values. After the symptoms sub-side, the nurse can offer the patient ice chips followed by clear liquids. Introducing solid food as soon as possible will provide oral nutrition, decrease the need for IV therapy, and minimize irri-tation to the gastric mucosa. As food is introduced, the nurse evaluates and reports any symptoms that suggest a repeat episode of gastritis.
The nurse discourages the intake of caffeinated beverages, be-cause caffeine is a central nervous system stimulant that increases gastric activity and pepsin secretion. It also is important to dis-courage alcohol use. Discouraging cigarette smoking is important because nicotine reduces the secretion of pancreatic bicarbonate and thus inhibits the neutralization of gastric acid in the duodenum (Eastwood, 1997). When appropriate, the nurse refers the patient for alcohol counseling and smoking cessation programs.
Daily fluid intake and output are monitored to detect early signs of dehydration (minimal urine output of 30 mL/hour, minimal intake of 1.5 L/day). If food and fluids are withheld, IV fluids (3 L/day) usually are prescribed and a record of fluid intake plus caloric value (1 L of 5% dextrose in water = 170 calories of carbohydrate) needs to be maintained. Electrolyte values (sodium, potassium, chloride) are assessed every 24 hours to detect imbalance.
The nurse must always be alert for any indicators of hemor-rhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. If these occur, the physician is noti-fied and the patient’s vital signs are monitored as the patient’s con-dition warrants. Guidelines for managing upper GI tract bleeding are discussed later.
Measures to help relieve pain include instructing the patient to avoid foods and beverages that may be irritating to the gastric mucosa (described earlier) and instructing the patient about using medications to relieve chronic gastritis. To follow up, the nurse assesses the patient’s level of pain and the extent of comfort at-tained from the use of medications and avoidance of irritating substances.
The nurse evaluates the patient’s knowledge about gastritis and de-velops an individualized teaching plan that includes information about stress management, diet, and medications (Chart 37-1). Dietary instructions take into account the patient’s daily caloric needs, food preferences, and pattern of eating. The nurse and pa-tient review foods and other substances to be avoided (eg, spicy, irritating, or highly seasoned foods; caffeine; nicotine; alcohol). Consultation with a dietitian may be recommended.
Providing information about prescribed antibiotics, bismuth salts, medications to decrease gastric secretion, and medications to protect mucosal cells from gastric secretions can help the pa-tient recover and prevent recurrence. Patients with pernicious anemia need information about long-term vitamin B12 injections; the nurse may instruct a family member about administering these injections or make arrangements for the patient to receive the in-jections from a health care provider. Finally, the nurse empha-sizes the importance of keeping follow-up appointments with health care providers.
Expected patient outcomes may include the following:
1) Exhibits less anxiety
2) Avoids eating irritating foods or drinking caffeinated bev-erages or alcohol
3) Maintains fluid balance
a. Has intake of at least 1.5 L daily
b. Drinks six to eight glasses of water daily
c. Has a urinary output of about 1 L daily
d. Displays adequate skin turgor
4. Adheres to medical regimen
a. Selects nonirritating foods and beverages
b. Takes medications as prescribed
5. Maintains appropriate weight
6. Reports less pain