Nursing Care Plans and Management
Nursing Problem Priorities
Priorities for the patient after gastric resection:
- Manage post-resection pain and discomfort.
- Promote wound healing and prevent surgical site infection.
- Catch complications early, especially anastomotic leaks and bleeding.
- Provide nutritional support and diet guidance.
- Watch for and manage dumping syndrome and other GI symptoms.
- Address digestion and nutrient absorption concerns.
- Teach postoperative care and lifestyle adjustments.
- Set up regular followup for monitoring and treatment adjustment.
Nursing Assessment
Assess for subjective and objective data. See the assessment cues under each intervention below.
Nursing Diagnosis
After assessment, formulate a nursing diagnosis that fits the patient's specific situation and your clinical judgment. Diagnostic labels are a framework, not the point. Prioritize the patient's actual health concerns.
Nursing Goals
Goals and expected outcomes may include:
- The client will verbalize understanding of the procedure and disease process or prognosis.
- The client will verbalize understanding of functional changes.
- The client will identify interventions and behaviors needed to maintain an appropriate weight.
- The client will correctly perform necessary procedures and explain the reasons for them.
Nursing Interventions and Actions
1. Promoting Adequate Nutrition Balance
Auscultate for return of bowel sounds and note passage of flatus. Peristalsis usually returns around day 3 postop, signaling readiness to resume oral intake.
Monitor tolerance to fluid and food intake, noting abdominal distension and reports of increased pain, cramping, nausea, and vomiting. Paralytic ileus, obstruction, delayed gastric emptying, and gastric dilation can occur and may require reinserting the NG tube.
Note the character and amount of gastric drainage. Drainage runs bloody for the first 12 hr, then clears and turns greenish. Continued or recurrent bleeding suggests complications. A decline in output may reflect returning GI function.
Note admission weight and compare with later readings. Shows whether dietary intake is adequate and helps determine nutritional needs.
Monitor laboratory studies (Hb and Hct, electrolytes, total protein, prealbumin). These track fluid and nutritional needs, gauge therapy, and flag developing complications.
Maintain NG tube patency. Notify the physician if the tube dislodges. The tube rests the GI tract through the acute postop phase until normal function returns. The physician or surgeon may need to reposition it endoscopically to avoid injuring the operative area.
Limit the patient's intake of ice chips. Too much ice causes nausea and washes out electrolytes through the NG tube.
Provide frequent oral hygiene, including petroleum jelly for the lips. Prevents the dry mouth and cracked lips that come with fluid restriction and the NG tube.
Avoid milk and high-carbohydrate foods. Both can trigger dumping syndrome.
Administer IV fluids, TPN, and lipids as indicated. Meets fluid and nutritional needs until oral intake resumes.
Progress diet as tolerated, from clear liquids to a bland diet with several small feedings. The NG tube is usually clamped for set periods once peristalsis returns to test tolerance. After it comes out, advance intake gradually to prevent gastric irritation and distension.
Administer medications as indicated:
- Anticholinergics: atropine, propantheline bromide (Pro-Banthine). Control dumping syndrome and improve digestion and absorption.
- Fat-soluble vitamin supplements, including vitamin B12 and calcium. Removing the stomach cuts vitamin B12 absorption (loss of intrinsic factor), which can lead to pernicious anemia. Rapid gastric emptying also reduces calcium absorption.
- Iron preparations. Correct and prevent iron deficiency anemia.
- Protein supplements. Support tissue repair and healing.
- Pancreatic enzymes, bile salts. Aid digestion.
- Medium-chain triglycerides (MCT). Promote absorption of fats and fat-soluble vitamins to prevent malabsorption.
2. Patient Education and Health Teaching
Identify foods that irritate the stomach and increase gastric acid (chocolate, spicy foods, whole grains, raw vegetables). Limiting these lowers the risk of gastric bleeding and ulceration. Balance fresh fruit (which can reduce dumping syndrome) against its irritant effect.
Teach the signs of dumping syndrome: weakness, profuse sweating, epigastric fullness, nausea and vomiting, abdominal cramping, faintness, flushing, explosive diarrhea, and palpitations within 15 minutes to 1 hour after eating. It can cause severe discomfort or shock and reduces nutrient absorption. Usually self-limiting (1 to 3 weeks after surgery) but it can become chronic.
Teach the warning signs that need medical evaluation: persistent nausea, vomiting, or abdominal fullness; weight loss; diarrhea; foul-smelling fatty or tarry stools; bloody or coffee-ground vomitus or bile; fever. Report any change in pain. Early recognition can prevent pancreatitis, peritonitis, and afferent loop syndrome.
Identify stressful situations and how to avoid them, including job-related stress. Stress alters gastric motility and interferes with digestion. The patient may need vocational counseling if a job change is indicated.
Review the surgery and long-term expectations. Recovery after gastric surgery is often slower than patients expect. Improved strength and a partly normalized diet may take at least 3 months, and full return to usual intake (three normal meals a day) can take up to 12 months. Prepare the patient and family for this so the long convalescence is not a surprise.
Review the diet (low-carbohydrate, low-fat, high-protein) and the importance of vitamin supplementation. Prevents deficiencies, supports healing, and improves adherence. A low-fat diet may also reduce the risk of alkaline reflux gastritis.
Teach small, frequent, slow meals in a relaxed setting; resting after meals; avoiding very hot or cold food; restricting high-fiber foods, caffeine, milk products, alcohol, excess sugar, and salt; and taking fluids between meals rather than with food. These steps reduce gastric distension, irritation, stress on the repair, dumping syndrome, and reactive hypoglycemia. Ice-cold fluids and foods can cause gastric spasms.
Teach the patient to avoid certain fibrous foods and to chew well. The remaining stomach digests foods like citrus skin and seeds poorly, and they can collect into a mass (phytobezoar) that does not pass.
Recommend pectin-containing foods (citrus fruits, bananas, apples, yellow vegetables, beans). May reduce dumping syndrome.
Teach the signs of hypoglycemia and how to correct it (cheese and crackers, orange or grape juice). Lets the patient act before symptoms progress.
Have the patient weigh regularly. Diet changes, early satiety, and efforts to avoid dumping syndrome can limit intake and cause weight loss.
Review medication purpose, dose, schedule, and side effects. Anticholinergics or pectin powder may be given for dumping syndrome; antacids and histamine antagonists reduce gastric irritation.
Tell the patient to read labels and avoid products containing ASA and ibuprofen. Both cause gastric irritation and bleeding.
Discuss why smoking cessation matters. Smoking stimulates gastric acid and causes vasoconstriction, compromising mucous membranes and raising the risk of gastric irritation and ulceration.
Stress regular checkups with a healthcare provider. Needed to catch anemia, nutrition problems, and recurrence of disease.
Frequently Asked Questions
What are the nursing priorities after a subtotal gastrectomy? Protect the anastomosis, keep the NG tube patent, catch anastomotic leaks and bleeding early, control pain, and rebuild the nutrition lost along with stomach capacity. Gastric drainage runs bloody for the first 12 hours, then clears and turns greenish; continued or recurrent bleeding suggests a complication.
What is dumping syndrome and when does it happen? Dumping syndrome is a cluster of symptoms (weakness, sweating, epigastric fullness, nausea, cramping, faintness, flushing, explosive diarrhea, and palpitations) caused by rapid gastric emptying. Early symptoms typically begin within 15 minutes to 1 hour after eating, and according to NIDDK it affects a sizable share of people after gastric surgery. It is usually self-limiting over 1 to 3 weeks but can become chronic.
How do patients reduce dumping syndrome through diet? Eat small, frequent, slow meals in a relaxed setting; rest after meals; take fluids between meals rather than with food; and limit high-carbohydrate foods, milk, excess sugar, caffeine, and alcohol. Pectin-containing foods such as citrus fruits, bananas, apples, yellow vegetables, and beans may help.
Why do gastrectomy patients need vitamin B12? Removing part of the stomach cuts production of intrinsic factor and gastric acid, both needed to absorb vitamin B12 in the terminal ileum. Without supplementation this leads to deficiency and pernicious anemia, so patients take oral B12 or intramuscular or subcutaneous injections, along with iron and calcium.
Which warning signs need medical evaluation after discharge? Persistent nausea, vomiting, or abdominal fullness; weight loss; diarrhea; foul-smelling fatty or tarry stools; bloody or coffee-ground vomitus; and fever. Early recognition can prevent pancreatitis, peritonitis, and afferent loop syndrome.
How long does recovery take? Recovery is often slower than patients expect. Improved strength and a partly normalized diet may take at least 3 months, and full return to three normal meals a day can take up to 12 months. Patients should also avoid aspirin (ASA) and ibuprofen, which cause gastric irritation and bleeding.