|
Subtotal gastrectomy or gastric resection is the removal of a portion of the stomach indicated for gastric hemorrhage/intractable ulcers, dysfunctional lower esophageal sphincter, pyloric obstruction, perforation, cancer. During subtotal gastrectomy, the surgeon removes only the portion of the stomach affected by cancer.
Nursing Care Plans
1. Risk for Imbalanced Nutrition
Nursing Diagnosis
- Risk for Imbalanced Nutrition: Less Than Body Requirements
Risk factors may include
- Restriction of fluids and food
- Change in digestive process/absorption of nutrients
Possibly evidenced by
- Not applicable. Existence of signs and symptoms establishes an actual nursing diagnosis.
Desired Outcomes
- Maintain stable weight/demonstrate progressive weight gain toward goal with normalization of laboratory values.
- Be free of signs of malnutrition.
| Nursing Interventions |
Rationale |
| Maintain patency of NG tube. Notify physician if tube becomes dislodged. |
Provides rest for GI tract during acute postoperative phase until return of normal function. Note: The physician or surgeon may need to reposition the tube endoscopically to prevent injury to the operative area. |
| Note character and amount of gastric drainage. |
Will be bloody for first 12 hr, and then should clear and turn greenish. Continued or recurrent bleeding suggests complications. Decline in output may reflect return of GI function. |
| Caution patient to limit the intake of ice chips. |
Excessive intake of ice produces nausea and can wash out electrolytes via the NG tube. |
| Provide oral hygiene on a regular, frequent basis, including petroleum jelly for lips. |
Prevents discomfort of dry mouth and cracked lips caused by fluid restriction and the NG tube. |
| Auscultate for resumption of bowel sounds and note passage of flatus. |
Peristalsis can be expected to return about the third postoperative day, signaling readiness to resume oral intake. |
| Monitor tolerance to fluid and food intake, noting abdominal distension, reports of increased pain, cramping, nausea and vomiting. |
Complications of paralytic ileus, obstruction, delayed gastric emptying, and gastric dilation may occur, possibly requiring reinsertion of NG tube. |
| Avoid milk and high-carbohydrate foods in the diet. |
May trigger dumping syndrome. |
| Note admission weight and compare with subsequent readings. |
Provides information about adequacy of dietary intake and determination of nutritional needs. |
| Administer IV fluids, TPN, and lipids as indicated. |
Meets fluid and nutritional needs until oral intake can be resumed. |
| Monitor laboratory studies (Hb and Hct, electrolytes, and total protein, prealbumin). |
Indicators of fluid and nutritional needs and effectiveness of therapy, and detects developing complications. |
| Progress diet as tolerated, advancing from clear liquid to bland diet with several small feedings. |
Usually NG tube is clamped for specified periods of time when peristalsis returns to determine tolerance. After NG tube is removed, intake is advanced gradually to prevent gastric irritation and distension. |
| Administer medications as indicated: |
| Anticholinergics: atropine, propantheline bromide (Pro-Banth ı-ne); |
Controls dumping syndrome, enhancing digestion and absorption of nutrients. |
| Fat-soluble vitamin supplements, including vitamin B12, calcium; |
Removal of the stomach prevents absorption of vitamin B12 (owing to loss of intrinsic factor) and can lead to pernicious anemia. In addition, rapid emptying of the stomach reduces absorption of calcium. |
| Iron preparations; |
Corrects and prevents iron deficiency anemia. |
| Protein supplements; |
Additional protein may be helpful for tissue repair and healing. |
| Pancreatic enzymes, bile salts; |
Enhances digestive process. |
| Medium-chain triglycerides (MCT). |
Promotes absorption of fats and fat soluble vitamins to prevent malabsorption problems. |
2. Knowledge Deficit
Nursing Diagnosis
May be related to
- Lack of exposure/recall
- Information misinterpretation
- Unfamiliarity with information resources
Possibly evidenced by
- Questions, statement of misconception
- Inaccurate follow-through of instruction
- Development of preventable complications
Desired Outcomes
- Verbalize understanding of procedure, disease process/prognosis.
- Verbalize understanding of functional changes.
- Identify necessary interventions/behaviors to maintain appropriate weight.
- Correctly perform necessary procedures, explaining reasons for actions.
| Nursing Interventions |
Rationale |
| Review surgical procedure and long-term expectations. |
Provides knowledge base from which informed choices can be made. Recovery following gastric surgery is often slower than may be anticipated with similar types of surgery. Improved strength and partial normalization of dietary pattern may not be evident for at least 3 mo, and full return to usual intake (three “normal” meals per day) may take up to 12 mo. This prolonged convalescence may be difficult for the patient and SO to deal with, especially if he or she has not been prepared. |
| Discuss and identify stress situations and how to avoid them. Investigate job-related issues. |
Can alter gastric motility, interfering with optimal digestion. Note: Patient may require vocational counseling if change in employment is indicated. |
| Review dietary needs and regimen (low-carbohydrate, low-fat, high-protein) and importance of maintaining vitamin supplementation. |
May prevent deficiencies, enhance healing, and promote cooperation with therapy. Note: Low-fat diet may be required to reduce risk of alkaline reflux gastritis. |
| Discuss the importance of eating small, frequent meals slowly and in a relaxed atmosphere; resting after meals; avoiding extremely hot or cold food; restricting high-fiber foods, caffeine, milk products and alcohol, excess sugars and salt; and taking fluids between meals, rather than with food. |
These measures can be helpful in avoiding gastric distension, irritation or stress on surgical repair, dumping syndrome, and reactive hypoglycemia. Note: Ice-cold fluids and foods can cause gastric spasms. |
| Instruct in avoiding certain fibrous foods, and discuss the necessity of chewing food well. |
Remaining gastric tissue may have reduced ability to digest such foods as citrus skin or seeds, which can collect, forming a mass (phytobezoar formation) that is not excreted. |
| Recommend foods containing pectin (citrus fruits, bananas, apples, yellow vegetables, and beans). |
Increased intake of these foods may reduce incidence of dumping syndrome. |
| Identify foods that can cause gastric irritation and increase gastric acid (chocolate, spicy foods, whole grains, raw vegetables). |
Limiting or avoiding these foods reduces risk of gastric bleeding and ulceration in some individuals. Note: Ingesting fresh fruits to reduce risk of dumping syndrome should be tempered with adverse effect of gastric irritation. |
| Identify symptoms that may indicate dumping syndrome, (weakness, profuse perspiration, epigastric fullness, nausea and vomiting, abdominal cramping, faintness, flushing, explosive diarrhea, and palpitations occurring within 15 min to 1 hr after eating). |
Can cause severe discomfort or even shock, and reduces absorption of nutrients. Usually self-limiting (1–3 wk after surgery) but can become chronic. |
| Discuss signs of hypoglycemia and corrective interventions, (ingesting cheese and crackers, orange or grape juice). |
Awareness helps patients take actions to prevent progression of symptoms. |
| Suggest patient weight self on a regular basis. |
Change in dietary pattern, early satiety, and efforts to avoid dumping syndrome may limit intake, causing weight loss. |
| Review medication purpose, dosage, and schedule and possible side effects. |
Understanding rationale and therapeutic needs can reduce risk of complications ( anticholinergics or pectin powder may be given to reduce incidence of dumping syndrome; antacids and histamine antagonists reduce gastric irritation). |
| Caution patient to read labels and avoid products containing ASA, ibuprofen. |
Can cause gastric irritation and bleeding. |
| Discuss reasons and importance of cessation of smoking. |
Smoking stimulates gastric acid production and may cause vaso constriction, compromising mucous membranes and increasing risk of gastric irritation and ulceration. |
| Identify signs and symptoms requiring medical evaluation such as persistent nausea and vomiting or abdominal fullness; weight loss; diarrhea; foul-smelling fatty or tarry stools; bloody or coffee-ground vomitus or presence of bile, fever. Instruct patient to report changes in pain characteristics. |
Prompt recognition and intervention may prevent serious consequences or potential complications such as pancreatitis, peritonitis, and afferent loop syndrome. |
| Stress importance of regular checkup with healthcare provider. |
Necessary to detect developing complications (anemia, problems with nutrition, and recurrence of disease). |
Other Possible Nursing Care Plans
- Nutrition: imbalanced, risk for less than body requirements—change in digestive process/absorption of nutrients, early satiety, gastric irritation.
- Fatigue—decreased energy production, states of discomfort, increased energy requirements to perform activities of daily living (ADLs).
|