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Upper GIT by Mind Map: Upper GIT

1. Anthro

1.1. Ht

1.2. Wt

1.2.1. IBW (25xhtxht)

1.2.2. ABW = IBW + ((Actual - IBW) x 25%)

1.2.3. pre-operative wt

1.3. WC

1.4. BMI

1.4.1. Underwt

1.4.2. Healthy wt range (18.5-24.9kg/m2)

1.4.3. Overweight (25.1-29.99kg/m2)

1.4.4. Obese I (30-34.99kg/m2)

1.4.5. Obese II (35-39.99kg/m2)

1.4.6. Obese III (40-44.99kg/m2)

1.4.7. (pre/post surg)

1.5. SGA/ PG-SGA

1.6. Oedema/ ascites

2. Assessment

2.1. Biochem

2.1.1. Cholecystectomy

2.1.1.1. Mg2+ (low)

2.1.1.2. ALP (elevated)

2.1.1.3. Bilirubin (Increased)

2.1.1.4. AST/ALT (increased)

2.1.1.5. Amylase

2.1.1.6. Lipase (increase)

2.1.1.7. Alb/ Transthyretin

2.1.1.8. TG (increased)

2.1.1.9. H&H: Haemoglobin/haematocrit

2.1.1.10. Na+/ K+

2.1.1.11. Ca2++

2.1.1.12. WBC

2.1.2. Wt Loss Surgerys

2.1.2.1. Check for deficiencies

2.1.2.1.1. Protein

2.1.2.1.2. B12

2.1.2.1.3. Fat Soluble (A, D, E, K)

2.1.2.1.4. Cu

2.1.2.1.5. Folate

2.1.2.2. BGL

2.1.2.2.1. Random 3.0-7.7mmol/L

2.1.2.2.2. Fasting

2.1.2.3. CRP

2.1.2.4. Serum Fe

2.1.2.4.1. 10-33umol/L

2.1.2.5. Serum B12

2.1.2.5.1. 100-130ng/L

2.1.2.6. Folate

2.1.2.6.1. Serum (7-45mmol/L)

2.1.2.7. Cholesterol

2.1.2.7.1. <4mmol/L

2.1.2.8. TG

2.1.2.8.1. <2.0 mmol/L

2.1.2.9. IL-6

2.1.2.10. Na+

2.1.2.10.1. 135-145mmol/L

2.1.2.11. K+

2.1.2.11.1. 3.5-5.2mmol/L

2.1.2.12. Ca2+

2.1.2.12.1. 2.25-2.65mmol/L

2.1.2.13. Mg2+

2.1.2.13.1. 0.8-1.0 mmol/L

2.1.2.14. Vitamin D

2.1.2.14.1. (serum) 30-60mmol/L

2.1.2.14.2. Mild Vit deficiency (30-49nmol/L)

2.1.2.15. Haemoglobin (Hb)

2.1.2.15.1. M:130-175 g/L, F: 115-160 g/L

2.1.2.15.2. Anemia = Hb below normal

2.1.2.16. Haematocrit

2.1.2.16.1. M: 40-54%, F: 37-47%

2.2. Client Hx

2.2.1. Social hx

2.2.1.1. Living situation

2.2.1.2. Employment

2.2.1.3. PA

2.2.1.4. Food Accessibility

2.2.1.5. Cultural/ Religious

2.2.1.6. Cooking preparations/ abilities

2.2.1.7. Allergies/ Intolerances

2.2.1.8. Previous education/ interventions/ knowledge

2.2.2. Med Hx

2.2.2.1. Medical conditions

2.2.2.2. Med deficiency

2.2.3. Medication

2.2.3.1. PERT (Pancreatic Endocrine Replacement Therapy) --> Creamon

2.2.3.2. Anti-emetics

2.2.3.2.1. e.g. maxalon, promethathine

2.2.3.2.2. Ondansteron (Zofran) IV/Oral

2.2.3.3. Anti-reflux/ antacids

2.2.3.3.1. neutralise stomach

2.2.3.4. H2 Receptor antagonists

2.2.3.4.1. reduce gastric acid

2.2.3.4.2. reduce basal acid secretion / pepsin section (therefore less production)

2.2.3.5. PPIs

2.2.3.5.1. Inhibit gastric acid secretion by inhibiting h+ / k+ at apical membrane of gastric parietal cells

2.2.4. Age

2.2.5. Risk Factors

2.2.5.1. Barrett's oesophgagus (Grade IV)

2.2.5.2. Obesity

2.2.5.3. Cholelithiasis

2.2.5.3.1. Older age

2.2.5.3.2. Female/Pregnancy

2.2.5.3.3. Obesity

2.2.5.3.4. Rapid wt loss

2.2.6. Co-morbidities

2.3. Diet hx

2.3.1. Food Diary

2.3.1.1. inc. cooking methods/ details

2.3.2. 24-Hr recall

2.3.3. FFQ

2.3.4. EPI

2.3.5. EEI

2.3.6. Fibre intake

2.3.7. Alcohol

2.3.8. Smoking

2.3.9. Hydration/ Fluid intake

2.4. NFPF

2.4.1. Temperature

2.4.2. Jaundice

2.4.3. Fatigue

2.4.4. Anorexia

2.4.5. Reflux

2.4.6. SGA/ PG-SGA

2.4.7. NIS

2.4.7.1. Heartburn

2.4.7.2. Reguritation

2.4.7.3. Taste Changes (Dysguesia)

2.4.7.4. Pain/ reflux

2.4.7.5. Nausea

2.4.7.6. Vomiting

2.4.7.7. Steatorrhea (loose, yellow, smelly, floating)

2.4.7.7.1. May require PERT

2.4.7.8. Intolerance to fatty foods

2.4.7.9. Early Satiety

2.4.7.10. Pain/diarrhoea after high fat meals

2.4.7.11. (Note severity/ duration)

3. Diagnosis

3.1. PES

3.2. Problem

3.2.1. Intake Delivery

3.2.1.1. Malnutrition

3.2.1.2. Inadequate protein/ inadequate energy intake

3.2.1.3. Impaired nutrient utilisation

3.2.1.4. Altered GI function

3.2.1.5. Inadequate enteral feed infusion

3.2.1.5.1. ... as related too ... slow titration of JEJ feeds post oesophagectomy

3.2.1.6. Less than optimal parenteral nutrition

3.2.1.7. Inadequate fibre intake

3.2.1.8. Inappropriate intake of types of carbohydrates (E.g. Lactose)

3.2.2. Clinical Domain

3.2.2.1. Impaired Nutrient Utilisation

3.2.2.2. Unintended wt loss

3.2.3. Behaviural-Environmental Domain

3.2.3.1. Food and nutrition-related knowledge deficit

3.2.3.2. Limited adherance to nutrition-related recommendations

3.2.3.3. Undesirable food choices

3.3. Eitology

3.3.1. Anorexia

3.3.2. Early Satiety

3.3.3. Nausea

3.3.4. Abdominal discomfort

3.3.5. Pancreatic insufficiency... newly dx pancreatic cancer...

3.3.6. Agressive epigastric pain

3.3.7. Vomiting

3.3.8. Newly dx oesophageal cancer...

3.4. Signs/Symptoms

3.4.1. Steatorrhea

3.4.2. PG-SGA

3.4.3. Inadequate dietary intake/ dietary fibre intake %%

3.4.4. % wt loss

3.4.5. Loose bowels

3.5. NCP

4. Monitoring and Evaluation

4.1. Anthro

4.1.1. Wt

4.1.2. BMI

4.2. Biochem

4.2.1. Dumping Syndome

4.2.1.1. BGL

4.2.1.1.1. HbA1C

4.2.1.1.2. fasting glucose

4.2.1.1.3. Random

4.2.2. RFS

4.2.2.1. electrolytes

4.2.2.1.1. K

4.2.2.1.2. PO4

4.2.2.1.3. Mg

4.2.2.2. oedema / acute circulatory overload

4.2.2.3. organ function disturbance

4.2.3. Vitamins

4.2.3.1. Vit D

4.2.3.2. B9, B12

4.2.4. Minerals

4.2.4.1. Fe

4.2.4.2. Ca

4.2.4.3. Na

4.2.4.4. Mg

4.2.4.5. K

4.2.5. Cholesterol

4.2.5.1. Total

4.2.5.2. HDL / LDL

4.2.6. Heam

4.2.6.1. Hb

4.2.6.2. hemocrit

4.2.7. Proteins

4.2.7.1. albumin

4.2.7.2. Prealbumin

4.3. Food and Nutrition

4.3.1. PERT adherence

4.3.2. Tolerance of oral intake?

4.3.3. Adherence to dietary advice

4.3.3.1. HEHP

4.3.3.2. ONS

4.3.3.3. fluid

4.3.3.4. soft

4.3.3.5. puree

4.3.3.6. high fibre

4.3.3.7. low-fat

4.4. NFPF

4.4.1. Dumping Syndrome

4.4.1.1. Prevention strategies

4.4.1.1.1. Small frequent meals (6-8x per day), avoid large meals

4.4.1.1.2. Avoid drinking fluids with meals, drink fluids 30min pre/post

4.4.1.1.3. Chew food well and eat slowly

4.4.1.1.4. Lying down after meals may help to lessen the effect of gravity

4.4.1.2. Side effect of UGI surgeries

4.4.1.2.1. Oesophagectomy

4.4.1.2.2. Gastrectomy

4.4.1.2.3. Whipples

4.4.1.2.4. Without a pyloric sphincter it is difficult to regular food

4.4.2. jaundice

4.4.2.1. blockage of bile flow

4.4.3. SGA

4.4.3.1. muscle / fat wasting

4.4.3.1.1. malnutrition

4.4.4. NIS

4.4.4.1. appetite

4.4.4.2. nausea

4.4.4.3. vomiting

4.4.4.4. constipation

4.4.4.5. diarrhoea

4.4.4.6. abdominal discomfort

4.4.4.7. early satiety

4.4.4.8. flatulence

4.4.4.9. reflux

4.4.4.10. Odynophagia

4.4.5. steatorrhea

5. Intervention

5.1. SMART goals

5.1.1. Assess Malnutrition

5.1.2. Vitamin and Mineral Deficiencies

5.1.3. Maintaining muscle mass

5.1.4. Baratric surgury

5.1.4.1. Wt loss/ maintenance

5.1.4.2. Infection

5.1.5. Maintain/ reduce wt and subcutaneous fat loss

5.1.6. dehydration

5.2. Nutrition and Food Delivery

5.2.1. Acute Cholecytitis

5.2.1.1. Low-fat diet may be needed

5.2.1.2. Progress diet with fewer condiments and gas-forming vegetables

5.2.1.2.1. Causes distention, increased peristalsis, irritation

5.2.2. Chronic cholecystitis

5.2.2.1. Fat/calorie controlled diet to promote drainage to gallbladder

5.2.3. Cholelithiasis

5.2.3.1. Encourage diet high in fibre, low in calories (if needed)

5.2.4. Oesophagectomy

5.2.4.1. Initial Postoperative Feeding - Jejunostomy feeding within 24hrs of surgery, upgraded to goal rate.

5.2.4.2. Oral diet as per surgeon.

5.2.5. Gastrectomy

5.2.5.1. Initial Postoperative Feeding - Oral diet upgrades as per surgeon +/- jejunal feeding within 24hrs.

5.2.6. Whipple’s

5.2.6.1. Initial Postoperative Feeding - Oral diet upgrades as per surgeon.

5.2.6.2. May require jejunal feeding if prolonged gastroparesis.

5.2.6.3. Have drinks 30 minutes before or after meals, instead of with meals, Avoid foods and drinks containing lots of sugar e.g. cordial, soft drink, sports drinks, energy drinks, lollies.

5.2.7. Laparoscopic fundoplication

5.2.7.1. Initial Postoperative Feeding - encourage to eat and drink slowly

5.2.7.2. Diet = fluid, pureed or soft – two weeks with R/V

5.2.7.3. Food Groups

5.2.7.3.1. Foods to avoid = plain bread, donuts, crackers, course/dry cereals, cereals with fruit and nuts

5.2.7.3.2. Breads/cereals

5.2.7.3.3. Vegetables & Legumes

5.2.7.3.4. Foods to avoid = raw veg, hard fibrous or stringy veg

5.2.7.3.5. Avoid fizzy drinks, chewing gum or drinking straws to reduce bloating/gas. Sit upright when eating and remain upright for 60 minutes after meals.

5.2.8. TF

5.2.8.1. PN

5.2.8.2. EN

5.2.8.3. Barium swallow

5.2.9. Queensland Health (2017). Gastroenterology and Liver Disease – Framework for Effective and Efficient Dietetic Service (FEEDS). Retrieved on 25th August 2019. https://www.health.qld.gov.au/__data/assets/pdf_file/0022/668020/feeds-gastroenterology.pdf

5.3. Nutrition education

5.3.1. for all surgery

5.3.1.1. High protein high energy diet

5.3.1.2. Small regular meals (6x per day)

5.3.1.3. Chew food well, eat slowly

5.3.1.4. Monitor weight and bowels regularly

5.3.2. GORD

5.3.2.1. Lifestyle Modifications

5.3.2.2. Avoid gut irritants – Alcohol, fatty and spicy foods, caffeine, citrus juice

5.3.2.3. Small regular meals, avoid large meals

5.3.2.4. Avoid laying down for >3hrs after a meal

5.3.3. ONS

5.3.4. Nutrition Resources

5.3.4.1. NEMO. (2018). Sore mouth or throat. https://www.health.qld.gov.au/__data/assets/pdf_file/0024/145455/oncol_mouth.pdf NEMO. (2018). Loss of Appetite. https://www.health.qld.gov.au/__data/assets/pdf_file/0025/147067/oncol_loa.pdf NEMO. (2018). Nausea and Vomiting. https://www.health.qld.gov.au/__data/assets/pdf_file/0025/149236/oncol_nausea.pdf NEMO. (2018). Taste Changes. https://www.health.qld.gov.au/__data/assets/pdf_file/0027/364446/oncol_taste.pdf

5.3.4.2. ESPEN guidelines on nutrition in cancer pt

5.3.4.2.1. Arends, J., Bachmann, P., Baracos, V., Barthelemy, N., Bertz, H., Bozzetti. F., . . . Fakulteten för hälsa, n.-o. t. (2016). ESPEN guidelines on nutrition in cancer patients. Clinical Nutrition, 36(1), 11-48. doi:10.1016/j.clnu.2016.07.015

5.3.4.3. NEMO. (2019). Nutrition after Fundoplication. Retrieved from https://www.health.qld.gov.au/__data/assets/pdf_file/0033/149685/gastro_fundo.pdf NEMO. (2018). Nutrition after Whipples. Retrieved from https://www.health.qld.gov.au/__data/assets/pdf_file/0024/151557/gastro-whipples.pdf

5.3.4.4. Common problems and management -

5.3.4.4.1. Feeling Full longer:

5.3.4.4.2. Reflux and difficulty swallowing

5.3.4.4.3. Weight loss

5.3.4.5. Oesophagectomy

5.3.4.5.1. Include high fibre foods if you have late dumping symptoms or trial a fibre supplement e.g. Metamucil or Benefiber. High fibre foods include lentils, baked beans, oat bran, wholegrain breads and cereals, and skins on fruit and vegetables.

5.3.4.5.2. NEMO. (2018). Nutrition after Oesophagectomy. Retrieved from https://www.health.qld.gov.au/__data/assets/pdf_file/0047/698888/gastro_oesoph.pdf

5.3.4.6. PERT

5.3.4.6.1. NEMO. (2017). Pancreatic enzyme replacement therapy. Retrieved from https://www.health.qld.gov.au/__data/assets/pdf_file/0015/154203/gastro_pancr_enzyme.pdf

5.3.4.7. NEMO. (2018) Gastroparesis. Retrieved from https://www.health.qld.gov.au/__data/assets/pdf_file/0048/698889/gastro_gparesis.pdf

5.3.5. Oesophagectomy

5.4. Nutrition Counselling

5.4.1. MI

5.4.2. Goal setting

5.4.3. stages of change

5.4.3.1. Not ready for diet changes

5.5. Co-ordination of Care

5.5.1. Care of the jejunostomy tube – nursing support

5.5.2. Primary Care provider

5.5.3. Support groups

5.5.4. GP

5.5.5. Clinical Referral

5.5.6. Feed Assistant (in hospital)

5.5.7. Psychologist

5.5.8. Social Worker

6. Treatment

6.1. Gastroesophageal Reflex (GORD)

6.1.1. Medication

6.1.1.1. Antacids (neutralise stomach)

6.1.1.2. H2 receptor antagonists

6.1.1.2.1. reduce gastric acid, reduce basal acid secretion/ pepsin production

6.1.1.3. PPI

6.1.1.3.1. inhibit gastric acid secretion by inhibiting H+/ K+ at apical membrane of gastric parietal calls (inhibiting H+ into stomach)

6.1.2. Symptoms

6.1.3. lifestyle modifications

6.1.4. surgical mx

6.1.4.1. Laparoscopic Fundoplication

6.2. Oesophageal Cancer/ High grade dysplasia/ Barrett's Oesophagus Feeding

6.2.1. Oesophagectomy

6.2.1.1. Stomach is translocated, re-anastomosed, section is removed

6.2.1.2. Result in surgical jejenoscopy

6.2.1.2.1. Skin to jejunum

6.3. Gastric Cancer, wt loss (bariatric), ulcers

6.3.1. Gastrectomy

6.3.1.1. Total gastrectomy

6.3.1.1.1. Long term; more likely to place a feeding tube tha a lesser

6.3.1.2. Slow diet upgrade req.

6.3.1.3. Partial Gastrectomy

6.3.1.3.1. Distal stomach removed

6.4. Bariatric Surgeries

6.4.1. Gastric Band

6.4.2. Sleeve Gastrectomy

6.4.3. Roux-en Y gastric bypass

6.4.3.1. Malabsorption pt - high risk

6.5. Whipple's Procedure

6.5.1. Surgical mx for tumours

6.5.1.1. Head pancrease

6.5.1.2. Bile ducls

6.5.1.3. Cholangiocarcinoma

6.5.2. Removal of distal stomach (traditional vs pylorus

6.5.3. Wt loss

6.5.3.1. Increased nutr req

6.5.3.2. Surgical trauma

6.5.3.3. Extended fasting time

6.5.3.4. Delayed gastric emptying

6.5.3.5. Early satiety / poor appetite

6.5.3.6. Fat malabs

6.6. Cholelithiasis (Gallstones)

6.7. Cholecystecomy

6.7.1. Symptomatic choleslithiasis

6.7.2. Low fat diet helpful

7. GIT Anatomical System Function

7.1. Mouth

7.1.1. Breaks up food

7.2. Salivary glands

7.2.1. Saliva moistens food. Amylase digests polysaccharides

7.3. Oesophagus

7.3.1. Peristalsis of food

7.3.2. Lower oesophageal sphincter contains acid (reflux)

7.4. Stomach

7.4.1. Stores/ churns food; forms Chyme

7.4.2. Pepsin digests protein

7.4.3. HCI activates enzymes, breaks food up/ kills germs

7.4.4. Mucus protects stomach/limits abs

7.4.5. IF to bind to B12

7.4.6. Fe3+ to Fe2+

7.4.7. Monitor pH

7.4.8. Abs ETOH, Cu

7.5. Pancreas (release enzymes duodenum)

7.5.1. Hormones regulate BGL (insulin from beta cells, Glucagon from alpha)

7.5.2. Bicarbonate neutralises stomach acid

7.5.3. Pancreatic Lipase

7.5.3.1. Digests TG (fat) into FA+monoglycerides

7.5.4. Trypsin and chymotrpysin digest protein

7.5.5. Phospholipase

7.5.5.1. Phospholipids

7.5.6. Cholesterol esterase

7.5.6.1. Cholesterol into S.I.

7.5.7. Amylase

7.5.7.1. breaks CHO to disaccharides

7.5.8. Proteases (peptidase)

7.5.8.1. catalyses proteolysis (into smaller AA)

7.6. Gall bladder

7.6.1. Stores and concentrates bile

7.7. Liver

7.7.1. Stores vitamins, minerals, iron and glycogen

7.7.2. Metabolises/detoxifies drugs

7.7.3. Produces/Secretes bile to gallbladder to aid in digestion

7.7.4. Excretion of bile, bilirubin, cholesterol, drugs, hormones.

7.7.5. Synthesis of blood clotting factors, plasma proteins and albumin

7.8. Duodenum

7.8.1. Muscus protects gut wall

7.8.2. Amylase digests polysachharides

7.8.3. Disaccharides into monosaccharides for abs

7.8.4. Surcases digest sugar

7.8.5. Peptidase digests proteins

7.8.6. FA into FFA abs

7.8.7. Absorption

7.8.7.1. Iron abs (Fe2+)

7.8.7.2. Ca2+, Mg, P, Cu, Se

7.8.7.3. Folate Abs

7.8.7.4. B12

7.8.7.5. Fat soluble vitamins (A, D, E, K abs)

7.9. Rectum

7.9.1. Stores/ expels faeces

7.10. Anus

7.10.1. Anorectal sphincter

7.10.2. Elimination of faeces