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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 Mg2+ (low) ALP (elevated) Bilirubin (Increased) AST/ALT (increased) Amylase Lipase (increase) Alb/ Transthyretin TG (increased) H&H: Haemoglobin/haematocrit Na+/ K+ Ca2++ WBC

2.1.2. Wt Loss Surgerys Check for deficiencies Protein B12 Fat Soluble (A, D, E, K) Cu Folate BGL Random 3.0-7.7mmol/L Fasting CRP Serum Fe 10-33umol/L Serum B12 100-130ng/L Folate Serum (7-45mmol/L) Cholesterol <4mmol/L TG <2.0 mmol/L IL-6 Na+ 135-145mmol/L K+ 3.5-5.2mmol/L Ca2+ 2.25-2.65mmol/L Mg2+ 0.8-1.0 mmol/L Vitamin D (serum) 30-60mmol/L Mild Vit deficiency (30-49nmol/L) Haemoglobin (Hb) M:130-175 g/L, F: 115-160 g/L Anemia = Hb below normal Haematocrit M: 40-54%, F: 37-47%

2.2. Client Hx

2.2.1. Social hx Living situation Employment PA Food Accessibility Cultural/ Religious Cooking preparations/ abilities Allergies/ Intolerances Previous education/ interventions/ knowledge

2.2.2. Med Hx Medical conditions Med deficiency

2.2.3. Medication PERT (Pancreatic Endocrine Replacement Therapy) --> Creamon Anti-emetics e.g. maxalon, promethathine Ondansteron (Zofran) IV/Oral Anti-reflux/ antacids neutralise stomach H2 Receptor antagonists reduce gastric acid reduce basal acid secretion / pepsin section (therefore less production) PPIs Inhibit gastric acid secretion by inhibiting h+ / k+ at apical membrane of gastric parietal cells

2.2.4. Age

2.2.5. Risk Factors Barrett's oesophgagus (Grade IV) Obesity Cholelithiasis Older age Female/Pregnancy Obesity Rapid wt loss

2.2.6. Co-morbidities

2.3. Diet hx

2.3.1. Food Diary 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 Heartburn Reguritation Taste Changes (Dysguesia) Pain/ reflux Nausea Vomiting Steatorrhea (loose, yellow, smelly, floating) May require PERT Intolerance to fatty foods Early Satiety Pain/diarrhoea after high fat meals (Note severity/ duration)

3. Diagnosis

3.1. PES

3.2. Problem

3.2.1. Intake Delivery Malnutrition Inadequate protein/ inadequate energy intake Impaired nutrient utilisation Altered GI function Inadequate enteral feed infusion ... as related too ... slow titration of JEJ feeds post oesophagectomy Less than optimal parenteral nutrition Inadequate fibre intake Inappropriate intake of types of carbohydrates (E.g. Lactose)

3.2.2. Clinical Domain Impaired Nutrient Utilisation Unintended wt loss

3.2.3. Behaviural-Environmental Domain Food and nutrition-related knowledge deficit Limited adherance to nutrition-related recommendations 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 BGL HbA1C fasting glucose Random

4.2.2. RFS electrolytes K PO4 Mg oedema / acute circulatory overload organ function disturbance

4.2.3. Vitamins Vit D B9, B12

4.2.4. Minerals Fe Ca Na Mg K

4.2.5. Cholesterol Total HDL / LDL

4.2.6. Heam Hb hemocrit

4.2.7. Proteins albumin 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 HEHP ONS fluid soft puree high fibre low-fat

4.4. NFPF

4.4.1. Dumping Syndrome Prevention strategies Small frequent meals (6-8x per day), avoid large meals Avoid drinking fluids with meals, drink fluids 30min pre/post Chew food well and eat slowly Lying down after meals may help to lessen the effect of gravity Side effect of UGI surgeries Oesophagectomy Gastrectomy Whipples Without a pyloric sphincter it is difficult to regular food

4.4.2. jaundice blockage of bile flow

4.4.3. SGA muscle / fat wasting malnutrition

4.4.4. NIS appetite nausea vomiting constipation diarrhoea abdominal discomfort early satiety flatulence reflux 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 Wt loss/ maintenance 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 Low-fat diet may be needed Progress diet with fewer condiments and gas-forming vegetables Causes distention, increased peristalsis, irritation

5.2.2. Chronic cholecystitis Fat/calorie controlled diet to promote drainage to gallbladder

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

5.2.4. Oesophagectomy Initial Postoperative Feeding - Jejunostomy feeding within 24hrs of surgery, upgraded to goal rate. Oral diet as per surgeon.

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

5.2.6. Whipple’s Initial Postoperative Feeding - Oral diet upgrades as per surgeon. May require jejunal feeding if prolonged gastroparesis. 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 Initial Postoperative Feeding - encourage to eat and drink slowly Diet = fluid, pureed or soft – two weeks with R/V Food Groups Foods to avoid = plain bread, donuts, crackers, course/dry cereals, cereals with fruit and nuts Breads/cereals Vegetables & Legumes Foods to avoid = raw veg, hard fibrous or stringy veg 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 PN EN 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.

5.3. Nutrition education

5.3.1. for all surgery High protein high energy diet Small regular meals (6x per day) Chew food well, eat slowly Monitor weight and bowels regularly

5.3.2. GORD Lifestyle Modifications Avoid gut irritants – Alcohol, fatty and spicy foods, caffeine, citrus juice Small regular meals, avoid large meals Avoid laying down for >3hrs after a meal

5.3.3. ONS

5.3.4. Nutrition Resources NEMO. (2018). Sore mouth or throat. NEMO. (2018). Loss of Appetite. NEMO. (2018). Nausea and Vomiting. NEMO. (2018). Taste Changes. ESPEN guidelines on nutrition in cancer pt 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 NEMO. (2019). Nutrition after Fundoplication. Retrieved from NEMO. (2018). Nutrition after Whipples. Retrieved from Common problems and management - Feeling Full longer: Reflux and difficulty swallowing Weight loss Oesophagectomy 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. NEMO. (2018). Nutrition after Oesophagectomy. Retrieved from PERT NEMO. (2017). Pancreatic enzyme replacement therapy. Retrieved from NEMO. (2018) Gastroparesis. Retrieved from

5.3.5. Oesophagectomy

5.4. Nutrition Counselling

5.4.1. MI

5.4.2. Goal setting

5.4.3. stages of change 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 Antacids (neutralise stomach) H2 receptor antagonists reduce gastric acid, reduce basal acid secretion/ pepsin production PPI 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 Laparoscopic Fundoplication

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

6.2.1. Oesophagectomy Stomach is translocated, re-anastomosed, section is removed Result in surgical jejenoscopy Skin to jejunum

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

6.3.1. Gastrectomy Total gastrectomy Long term; more likely to place a feeding tube tha a lesser Slow diet upgrade req. Partial Gastrectomy 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 Malabsorption pt - high risk

6.5. Whipple's Procedure

6.5.1. Surgical mx for tumours Head pancrease Bile ducls Cholangiocarcinoma

6.5.2. Removal of distal stomach (traditional vs pylorus

6.5.3. Wt loss Increased nutr req Surgical trauma Extended fasting time Delayed gastric emptying Early satiety / poor appetite 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 Digests TG (fat) into FA+monoglycerides

7.5.4. Trypsin and chymotrpysin digest protein

7.5.5. Phospholipase Phospholipids

7.5.6. Cholesterol esterase Cholesterol into S.I.

7.5.7. Amylase breaks CHO to disaccharides

7.5.8. Proteases (peptidase) 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 Iron abs (Fe2+) Ca2+, Mg, P, Cu, Se Folate Abs B12 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