Episode 9, Class 9: Tube Feedings

Next we want to talk about tube feeding, also known as enteral nutrition, and that means it is feeding something through a tube, a catheter, a stoma, anything leading to a functioning GI tract. It can be going through the nose, through the esophagus, through the side of the abdomen into either the stomach or the j-junum. There are lots of different options, they are all going to operate kind of the same way though as far as how we do the feedings, but let's talk about the tubes first. So the reasons why we might give somebody a feeding tube would be anorexia, some kind of oral facial cancer or surgery, or a gastrectomy, like we just talked about. Somebody who is in a persistent vegetative state that needs to be nourished, to be kept alive. Anybody with severe burns who can't eat chemo or radiation patients sometimes may not be able to eat because of the nausea, so they would put a J-tube in them. So it goes to the j-junum, which bypasses the stomach, which means there's not going to be the nausea or risk for aspiration. Or sometimes people with psych issues who just refuse to eat. So there's a picture of a few different kinds of tubes, and we will have a chance to play with them in class and tell you more about them then. If they go through the nose, it would be an NG or an NJ, nasogastric or nasal J-junum tube, the NJ would go to the small intestine again. These both have very small lumens, so they're easily clogged. So if you're going to be administering medications through here, well, it'd be best if you could get them in liquid form, but if you have to crush pills, make sure they're crushed very well and flush very well. These tubes are going to be about 22 to 26 inches on average. We always need to confirm placement before putting anything in them. If they're being dropped for suction to decompress a stomach, like if somebody has a bowel obstruction or something, you'll know when you get into the right place because the stuff starts coming out, and it'd be a really good idea to have that already connected to suction before you put it in because it's going to start coming out. If it is for feeding, we need to confirm placement with X-ray. So make sure they get an X-ray before you start any food. They should be taped at the nose, and there's usually a marker, there's inch or centimeter markers so you can tell where it is. We always want to assess that and make sure that it's still in the right place. If it comes on taped and it falls out a little bit, even up to 6 to 8 inches, you could still push it back in because it's still going to be in the stomach or the g-junum. But if they take it out all the way, then they're going to have to have anyone put in assuming they still need it. And there are some securing devices to hold them in place that we'll talk about as well. Next thing is a peg tube percutaneous endoscopic gastric tube, and so gastric means it goes into the stomach. We'll watch a couple of videos about how these are put in. They're going to be done in endoscopy under fluoroscopy in the OR. So we don't need to worry about how those go in exactly. And then there's a peg tube PEJ percutaneous endoscopic g-junal tube. So same idea, just goes to the g-junum. And again, with the g-junum, it's better that there's no risk for nausea. Some tubes, and I'll show you an example of one in class they have two lemons, and one ends in the stomach and one ends in the intestine. And we'll talk about why they do that, wouldn't you, maybe think about that before then. So when can we start feeding? It depends on why the patient's getting it. But we want to make sure they have bowel sounds for one thing, and we want to make sure that there's been x-ray to confirm placement. When we do feedings, the head of bed should be greater than 30 degrees. Again, we're going to use gravity to keep the stuff where we want it, and we don't want it to come up. So if they were lying down, it would easily come up, because remember who this person is, they may not have a stomach, or a part of a stomach, their spincers may not be there. So they lie down, things could just come straight up. So they have to stay at least 30 degrees, and some policies will say 45 even. The head of bed needs to remain elevated for 30 to 60 minutes after the feeding. And there's different ways we're going to give the feedings. So administration of feedings, one is a bulless, and this resembles your normal feeding pattern. You eat three or four or five times a day. So this is where they're giving small amounts, 300 to 400 mls, over 30 to 60 minutes. So they might just open up a can of insurer or something, and pour that in every few hours, giving every three to six hours. It could be continuous, which would be for a 24-hour period, and that means the patient has to remain in a soundfowler's position, they have to remain upright. And sometimes it might be 20 or 22 hours, maybe not, it might not be completely around the clock, but it's most of the day. And then sicklick, those are going to be given over an 8 to 16-hour period, and they usually start those at night, maybe at 8 o'clock at night, so that they can get the majority of it in while they're sleeping, and it doesn't impact their day so much, so they can be disconnected during the day when the feeding is completed. So the two positioning, we want to check placement before we do anything. So before you start a new feeding, before you give any medications, before you do a flush, you always want to check placement. And residual. So we want to see what's left in there. Continuous feedings have a pump that's similar to an IV pump, it works very much the same way, but it is simpler, it's a little less sophisticated, but it has an occlusion alarm. So just like the IV, when they bend the arm, it'll start beeping. If that line gets occluded in some way, and it's not going in, or it gets clogged by the feeding, or it gets bent, or whatever, that alarm's going to go off, and it'll make you come in and assess that. Some machines, some setups have a water bag that infuses every hour or right along with the food, so it's kind of a Y tubing, almost like a blood setup if you want to think of it that way. It's a Y tubing. One bag carries water, and one bag carries the feeding, and they both go in at the same time. They may have it where you can set it up where it runs 60 ml of food, and then 20 ml of water. Or it runs maybe on time, food for 55 minutes, and then water for five minutes, so sometimes they're automatically like that, and that's really nice because it helps keep the line flushed out, because that feeding can kind of clog up. It's kind of thick, it's kind of like milky, you might say, but it's got a lot of sugar and things in it, and so it can tend to clog up the line, and those lines are sometimes quite small. So it's nice if you have that kind of setup. If you don't, that means you have to irrigate it yourself with water before and after each feeding, and each medication administration, and just make sure that that line gets completely flushed out, so it stays open for when you are doing the feeding. So before the feeding, we want to aspirate the gastric contents and measure the amount of residual. And there's going to be policies about this, or orders specifically, patient by patient. An example of one might be, if it's greater than 100, wait half an hour and check it again. Okay. And when you pull that out, that 100 ml, you got a syringe there, you're holding with all this stuff that's been in the stomach. What do you do with that? We throw it out or give it back. We need to give it back to them, because if we don't, that's going to throw them into an acid base or electric electrolyte in balance. There's a lot of stuff in there in the stomach that we need to keep in. So always give that back. There may be an order where it says, if the residual is greater than say 200, discard what is greater than 200, but return the 200. So just know your policy and know your orders. Some general nursing considerations for people with tube feeds. If anyone is immunocompromised, the water flush should be sterile water, otherwise you can just use sink water or regular bottled water. We want to do daily weights and labs and look at them. We're going to need to assess them and see how their levels are. Now, when somebody's first getting on a tube feeding after a recent GI surgery, they're going to be the surgeon and the registered dietitian. They're going to be working together to make sure that that patient has all the nutrients that they need. So they're going to trial and error again. They're going to make up a formula, give it to them, and then check their labs the next day and see how that worked. If their labs are out of whack, then they're going to adjust it. So every day, that's going to be changing. So that's important for you as a nurse to make sure that you have the right bag. Just compare the information on the bag to the order, sometimes two nurses will do that, they'll look back and forth and call it off and make sure they have the right bag because the pharmacy could have sent up yesterday's bag, you know, by mistake. So that's why daily weights and labs are born. We don't want these people losing weight, so we want them to be maintaining or gaining. And if they have, they may also check their urine and if they have glucose in their urine, that means they're going to need more insulin in the feeding. So a lot of them are out there. to consider. So speaking of it, so they will be doing glucose checks initially when it's started and then every four to six hours depending on policy or orders because there's a lot of glucose in this stuff so we need to stay on top of that and then give the patients insulin. We're always going to listen for bowel sounds before feedings. Accuritized nose, as always, label the bottle and the tubing when you start at date and time. Feetings have a life of eight to 24 hours, generally 24. The tubing needs to be changed every 24 hours, no more than that. So typically, if a feeding is up for 22 or 24 hours, you just discard the whole thing when it's done or when the 24 hour mark is hit and then you get all new setup. If you have the bolus dosing or you're doing it several times a day, you know, you're going to just give the bag or the can of insurer or whatever every few hours, but you need to always look at the tubing and make sure it's still good. The formula that you're feeding them should be room temp or body temp. Sometimes they're stored in a refrigerator so they should be taken out and left out for a while before instilling them because it could give the patients a chill. There are some complications listed here next, vomiting, diarrhea, constipation, dehydration. I'm going to let you think on those for a little bit and then we will talk about those in class. You guys can figure out what's going to cause those different things to happen. Aspiration is something that can happen. If that does, that's probably because their head of bed was down. So, or maybe we didn't check the residual, there already was a lot in the stomach and then we instilled more. So there's more than the stomach and handle, so it came up. The clogged tube, that happens sometimes if it's not been flushed adequately, that's a problem. So, use liquid medications whenever possible. Like I said before, if you can't get them liquid, make sure they're crushed into a really fine powder and then flushed with plenty of water. And I would look at protocols, but a good policy is to use 30 to 50 ml of water between medications and then flush pretty good at the end as well. And maybe a hundred or something. Unless someone's on a fluid restriction, you want to be careful about that. But if it does get clogged, you can put in warm water or hot water and kind of try to push it through. Just a little bit and kind of try to use a piston action with the big syringe and try to force through it. Something that you would not see in a policy unless it is too forbidden, it would be to use soda, like some Coke or Sprite. That's kind of an old nurse trick. Wouldn't do that as a student, but when you're working some of the older nurses might do that. You put in a little bit of soda in there and the bubbles kind of just break up the clog. A couple other problems for tubes, skin irritation where it's either going into the skin, if it's going into the abdomen or if it's taped around the nose, if it's going in the nose, that could be a problem. Pulling out the tube, of course, that's going to be a problem. The peg and pitch tubes, they have a bubble, like an inflatable bubble that's on the inside, but somebody can still pull that out. Somebody that's confused, just yank, really good on that thing, and I've seen it a couple times. So that can happen. And then the feeding is just going in the bed, you come in and there's food dripping on the floor. Toronto Logic considerations, well, they're the ones that are likely to pull it out probably because they're, you know, somebody that's confused. They are going to be more vulnerable to all the complications, so fluid and electrolyte imbalances can happen more quickly, glucose intolerance, and inability to handle large volumes. So they may, we want to run, we may want to run their feeding a little more slowly, and they're going to have an increased risk of aspiration. So make really certain that they're sitting up well. Okay, we're going to start out the GI unit now. So we're going to talk about nursing care of the patient with GI diseases, including hyalurna, esophageal cancer, diverticulitis, strictures and barisies, accolacia, and ending today with GERD, gastroesophageal reflex. So first with hyalurna, what it is, it's a herniation of part of the stomach, it goes through the hiatus, which is the hole in the diaphragm through which the esophagus runs, and part of the stomach goes up through that. So that's why it's also known as a diaphragmatic hernia, or esophageal urnia, because part of the stomach is coming up where the esophagus should be. So part of the stomach goes into the esophagus through the opening of the diaphragm. There's two types, sliding and parisophageal. Slighting is very much more common. The stomach slides into the thoracic cavity when they lie down, and then it slides back down when they sit up. And 50% of patients that have this are asymptomatic, they don't even know that they have it. So they lie down, the stomach comes up into the thoracic cavity when they sit up and goes back down. Parisophageal all are part of the stomach pushes through the diaphragm beside the esophagus. So some causes is commonly structural changes, so weakening of the muscles of the diaphragm or intra-addominal pressure. So anything that increases abdominal pressure, like obesity or pregnancy, heavy lifting, tumors, ascites, anything that's pushing up on the stomach, it needs a space to go, and so it ends up going through the hiatus. So hydrohernias can lead to gird, esophageitis, esophageal stenosis, hemorrhage from erosion, strangulation of the hernia, and regurgitation with tracheum aspiration. So it's definitely not a good thing, it needs to be addressed. Most commonly they will have the patient eliminate alcohol and stop smoking. And these two things are going to be indicated for all of the GI disorders that we talk about from here on out. So everything alcohol and cigarettes are implicated, so they need to stop or reduce both of those. We also want to elevate the head of the bed because again when they lie down, it tends to get worse, and then avoid straining or lifting and weight reduction if that's an issue, if they have an obese, if they have a large diaphragm, they will need to lose that. And then teaching, we're going to talk about this again in gurren a little bit, but with a lot of the GI stuff, the teaching is going to be small frequent meals. And this is six. So several small frequent meals. So the three meal a day plan that we have here is not really ideal. We want to eat smaller portions more often, and also limit liquids with meals because the more your stomach is filled up, the more it's going to need another place to go. So they should sit up an hour after meals again because that makes the stomach come up in the thoracic cavity, and then avoid anti-colonurgics. Why is that important? Let's think about what anti-colonurgics do. Do they increase or decrease stomach emptying? Well, they inhibit the parasympathetic nervous system, which increases digestion. So if they're inhibiting it, that means it's going to delay emptying, it's going to decrease digestion. So there is a surgical intervention that can do if the lifestyle modifications don't work, and it's called an SNF duplication. And this is for GERD and hyalurnea. And the surgeon wraps around part of the stomach, the top of the stomach, around the esophagus. And then that helps hold it in place. And the post-op care is going to be the same for any abdominal surgery, and we're going to talk a lot about all of those, but basically small frequent meals, get them up walking, as soon as possible, bowel sounds are going to be your focused assessment. Next, let's talk about esophageal cancer. This occurs mostly in the middle and inferior portions, and it can be an ulcerated lesion, often advanced before it's seen or the patient experiences symptoms. There does tend to be an occupational exposure risk, so anyone that works with cement or lie, and is also related to GERD, alcohol, and smoking. So there's over 17,000 new cases a year, and only 3,800 of them are in women, so much more common men, and 15,816,000 deaths annually, and that's from 2018. The cancer for only 1% of the cancers in the US, but the five-year survival rate is less than 20%, so it is not good. It says the causes are unknown, but it is related to GERD and smoking and alcohol as well, frequently, and the incidence increases with age, and it's also increased in African-Americans and Alaska natives. So risk factors, smoking, central obesity, that means you have just a large abdomen, baritisophagus, and that is when the acids are coming up because of GERD into the esophagus and it burns the lining, changes the lining into different kinds of cells, and then it with continual erosion, that puts you at risk for cancer. Accessive alcohol intake and diets low in fruits and vegetables, so high meat diets are often to blame for a lot of the cancers. There's a BBC study that said that life choices are behind more than four in 10 cancers, and you can see that on campus, I believe. So let's look at smoking, all the good things that are in cigarettes, so there's a slide here that has all of the compounds are in cigarettes including lighter fluid, cadmium, which is in batteries, nicotine isn't insecticide, ammonia is a toilet cleaner, methanol is rocket fuel, so that's fun, and candle wax. But vaping is cool though, right bro? No, it's not. And I think in the recent, or in this, not too far future we're going to, people are really going to find out the problems with that. There's a couple of links here you can look at to read up on it. One jewel pod contains roughly the same amount of nicotine found in 20 cigarettes, and they're probably not dosing it out over 20 puffs. So aside from nicotine, e-cigarettes also have a lot of other harmful ingredients, just like regular cigarettes. But something that's different is the ultra fine particles, you know, the mist that comes out of them, really trying out to breathe that in second hand because it's so fine, it can get very deep into the lungs, it can get into all the cells. So that's not going to be good. Some of the flavorings contain diacetyl, which is linked to lung disease, volatile organic chemicals or compounds, benzene, which is found in car exhaust, heavy metals like nickel, chromium, cadmium, tin, aluminum and lead, have all our all potential carcinogens. So no, vaping is not cool bro. Next is this esophageal diverticula. And anything that says diverticula is going to be an outpouching in something. We'll mostly talk about that with the large intestine diarticulitis. But this is esophageal diverticula, same idea. So there's little outpouchings along the esophagus. If we look down on esophagus through an EGD or even an X-ray, it should be just a nice straight tube. And what happens with diverticulitis, it's got these little bulges, these little outpouchings. And when you swallow, things fall into them and get caught in them. And so the patient's going to report a foul breath odor because of the rotted food that's hanging out in the pouches, which that can cause malnutrition because they're not digesting, everything, ingesting, everything that they take in. It can also lead to perforation because as that food hangs out in there, it rots, gases build up and it could pop the diverticula, it could also lead to aspiration. And how they're going to diagnose it is probably going to be a barium swallow or endoscopy. Barium swallow would be least invasive and that's where they'll have them drink a chalky liquid, kind of like a smoothies kind of thick. And then they'll take some X-rays of it. And like I said, they would normally see a nice straight tube. But if there's diverticula, they'll be bulges out along the side of it. It's thisophageal strictures. Anytime we see strictures, that means a narrowing. And these tend to develop over a long period of time. They can be related to ingesting strong acids or alkalides, so if somebody drinks some bleach or something like that. Also trauma or previous surgery because that's going to lead to scar formation and we know scars or hypertrophic. And so as they continue to get hypertrophic, the lumen can narrow and also gird because that leads to scarring. So the patient is going to experience progressive dysphagia. So at first they'll have a little bit of trouble swallowing tough stuff like meat. And then it will progress to softer things or give them trouble. And then finally, water is going to be hard to swallow. And they're going to feel like there's a lump in their throat. So it results in dysphagia or agurgitation and weight loss again because they're not digesting everything that they take in. Acolesia is a very rare disorder only about one in a hundred thousand people or about three thousand people a year. And what this is, there is an increased pressure in the lower esophageal sphincter or LES. So it increased PSI in the LES and the failure of the LES to relax. And then there's also an absence of useful peristalsis in the LES. So the lower part of the esophagus is just not working right. Okay. And what happens is that the food can't get from the esophagus into the stomach because it's constricted down there and there's no peristalsis. It's not moving it and the sphincter's not working. So the esophagus fills up when people eat. They get, they feel full quickly. They're going to have sub-sternal chest pain after meal because all the stuff is just hanging out in their esophagus. They're also going to have halotosis because again, the food's going to rot in there. They'll not be able to belch. They may feel a gird sensation and they may regurgitate which is not the same as vomiting. That means that if they bend over like to tie their shoes, the food's going to come up because it hasn't been swallowed into the stomach. It's still hanging out in the esophagus and then that, of course, will lead to weight loss. So how they treat acolytias, they can do a pneumatic dilation. So they stick a tube down there as if they were doing an EGD. They'll take a small tube and then thread it down through the esophagus just into the bit of the stomach and then they inflate it. And that opens up that narrow passage way and they also can give muscle relaxants or Botox and that is going to have to be done semi-regularly like probably every three to six months because they don't last that long. So these treatments are not permanent, unfortunately. Next thing is the esophageal varices. Everybody know what a hemorrhoid is? Okay, so esophageal varices are basically hemorrhoids in your esophagus but that doesn't sound very nice. You don't want to call somebody up and tell them that you got hemorrhoids in your throat. So they changed it to esophageal varices. So what it is, same as hemorrhoids, is dilated tortures, veins and they're bulging out and these happen to be in the lower esophagus. And they're related to portal hypertension which is related to what, cirrhosis which is related to what alcoholism. So it's very dangerous because there's high pressure because that hort portal hypertension it exerts pressure back behind it up, backwards up into the esophagus. So there's a lot of pressure behind it. So these varices can burst and cause life threatening bleeding. And they have about a 50% fatality. It varies with the extent. So if they only have a couple of varices it's not that serious if they have more, obviously it's more serious. The counts for 10 to 30% of all GI bleeds and 30% of cirrhosis patients have esophageal varices when they're diagnosed and 90% if they live 10 years they will get it. So 90% of cirrhosis patients if they live 10 years will end up with varices. So they don't know they have them until sometimes they'll have a coughing fit and they'll start coughing up blood and that usually gets people to call their doctor or they might be vomiting because it's dripping. They may have burst it you know by doing heavy lifting or coughing or something like that. And then it's dripping down into their stomach and the stomach isn't going to like that so it may end up rejecting it may they may vomit or they may see old blood in their stool. So any of that happens hopefully that'll lead somebody to come in for treatment. And what they'll do for treatment and those scopic variceal ligation or banding and that's where they're going to go in with an endoscope and they just put a little band it can be either like a kind of a rubber band a little plastic thing on there and they just put that around the bulging varice and it causes it to it cuts off circulation it causes it to die and it just kind of falls off it slips off and then just passes through the digestive tract. They also can do sclerotherapy which is where they inject a strong and irritating solution into the veins. The blood clots the vein wall thickens and it stops bleeding and again they'll just kind of shrivel up and die after a while. They may need multiple treatments but this does reduce the fatality and the risk of recurrence. That's the same thing that people get in their legs when they have varicose veins that have sclerotherapy and it just causes the veins to shrivel up and go away. So in an emergency we need to stop the blood loss and how do we stop blood loss? We apply pressure right? How do we apply pressure to the esophagus? It has to be from within so it's going to require a balloon. So we have a Blakemore tube and it's put in through the nose it's like an NG tube and they put it in down the esophagus into the stomach and then they blow it up and then that pressure from the blown up balloon exerts pressure on the interior walls of the esophagus and stops the bleeding. It also has a larger balloon that stays in the stomach and that anchors it in because think about who's getting this. Probably in alcoholic they may be actively drunk or detoxing, confused, hallucinating, combative, angry, they may need to be in restraints because are they going to like having a tube up their nose? No, but that's why there's the big balloon in the stomach to help stop them from pulling it out. So that is an emergency situation you may never see it but just be aware of what that is. So we've got to stop the blood loss, maintain the plasma values, they may need a transfusion and then there's going to be coagulation problems because of the cirrhosis. Whenever the liver is messed up there's going to be clotting issues so we're going to need to correct that and then often they'll be given antibiotics in case of infection happening from the bleeding. It's going to move into GERD which is gastroesophageal reflex disease and it's not really disease per se, it's more like a set of symptoms that occurred together. It's mostly related to an incompetent LES. So that's the primary factor in GERG. There is just the [BLANK_AUDIO] the acid is supposed to close up when you swallow. After you swallow, it closes tight and it doesn't do that in the situation. And that allows the gastric contents to come back up. So we've got the gastric juices, the acids and food particles that come up into the esophagus. So over time, that's going to cause damage. It's not going to be good. So certain foods, some people have different triggers, but caffeine and chocolate are often to blame and anticholinergics because they delay the gastric emptying. There also could be a problem if there's a problem with the pyloric sphincter, which prevents the food from leaving the stomach. Pressure can build up and then it has nowhere to go but up. So that can also lead to good. So it gets worse when somebody is supine if they lie down. So one of the teachings we're going to do is not have them lie flat. So watch how should we do the head of bed? At least 30 degrees. And at the hospital, that's easy. Just push a button. At home, they can put their bed up on some of blocks or milk crates or something like that. Or at the very least, have two or three pillows or wedge pillow. So they need to keep their head of bed elevated. What about meal size and number? Small, frequent meals, not the three big ones. And then as they are lying in bed, too, if we want them to tilt one side or the other, which side would be better to have them lie on. The right side, because that's where the pyloric sphincter is. So that's going to have the food move out of the stomach and prevent it from coming up. So those are some patient teachings there. So the biggest manifestation is going to be heartburn. So they feel this burning around their heart. That's why it's called that, but it's actually in the suffocates. So a burning tight sensation felt beneath the lower sternum. It can spread upward to the throat or the jaw. And it's felt intermittently, most frequently after meals. It can be relieved by alkaline substances or sometimes water. More commonly, we're going to treat it with medications, though. We'll talk about that in a minute. So Baratosophagus is one of the complications that can happen. And I mentioned that a bit ago. And what happens there is the normal squamous epithelium of the esophagus is replaced by columnar epithelium. And columnar epithelium is what the stomach cells are. So it's actually changing the cells of the esophagus into the cells of the stomach. So they're more acid resistant. But it does become a precancerous lesion. And only about 5 to 15% of people with gourd get this. So that's good. Science and symptoms it can be none or there could be some bleeding or even perforation. It can go all the way through. And so when someone has been diagnosed with Baratosophagus, they need to have endoscopy monitoring every six to 12 months. And do you think people do that? No. So there's some pictures that show you how that manifests. Take a look at those. Other gourd complications, esophageal ulcers and then esophageal cancer again because of the chronic irritations. So anytime anything in the body that's chronically irritated by acid or just something poking at it or whatever that's causing an injury, that predisposes you to cancer in that area. So the acid continually eroding at those cells can lead to cancer. Respiratory problems because the upper airway can be damaged by secretions. They can also inhale that into lungs. Dental erosion especially in the back teeth and vocal changes which is my situation. The gourd has made my vocal cords all red and irritated and that's why the more I talk the worse I sound. There is a chart that shows the progression of gourd. So take a look at those pictures and you can see exactly what's happening in there. And then we've got some foods to avoid. So there's a chart with just some common foods. Gas forming foods, anything with carbonation like sodas are going to be bad. Peppermint, chocolate and coffee. So peppermint mocas are out. That's not good. So what are we going to do to treat it? We're going to be able to give them medications. And there's two approaches to step up and a step down. And with a step up we're going to start with a weaker medication and hope that that works. And if it doesn't then we'll step up to the harder drugs. And with a step down opposite they're in a pretty serious outbreak or situation with gourd. And so we're going to start with the big guns and then drop it down hopefully as things get better. So the step up is when their symptoms are more minor and step down is when their symptoms are major. So the first one is the histamine receptor blockers. And those are the tedines. Fumotidine, renididine, cementedine, nasadidine. And H2 receptor blockers. They antagonize the parietal cell receptors. The H2 receptor blockers. And so that decreases the gastric secretion, the amount of acid that's available there. It reduces symptoms and allows for autosophageal healing in about half of the patients. So this medication does not heal and it doesn't fix the problem. But it decreases the acid which allows the tissue to kind of rest and repair itself. Not a lot of side effects. And it's best taken at night to decrease the histamine release that occurs in the stomach. There's a caution with cementedine. It increases the bioavailability of many drugs like beta blockers and morphine and morphine. So if they are taken together, it will increase their potency. It also passes the blood brain barrier and can cause CNS effects. And it reacts with antacids. So if we give antacids, they need to be separated from the tedines. Then we have the PPI, the proton pump inhibitors. And they inhibit the proton pump. Protons are acid molecules. And so as the proton pump squirts out protons, that means there's more acid. And these block that they decrease it. So these are the prosol. A meprosol as a meprosol, pectodeprosol, lansoprosol. They suppress acid secretion and they promote healing in 80 to 90 percent of patients. So these are the harder stronger medications. And they have some side effects, headache, diarrhea, abdominal pain, nausea. Long-term use has some issues as well. We'll get to that in a minute. And then antacids are the basic, easy meds. Those are all we had until about 20 years ago or so. And they are quick acting, but short lasting. So you take a tongues or a role aides and you feel better pretty quickly, but then an hour or two later you might have symptoms again. So they are basic and they neutralize the acid. They should be taken one to three hours after meals or a bedtime as needed. And we want to allow one hour between administering antacids and other medications because medications need the acid to break them down, the acid in the stomach. So we don't want to give antacids when we give other regular medications. There are aluminum containing preparations that may locks or how you cap. These are slower acting and they have a lot of sodium. So you want to take care with people that have kidney or heart disease or hypertension. And they may also cause constipation. Then we have calcium carbonate. That's your myelanta and tongues. Those are fast acting. They also may cause constipation. Side effects, belching and flatulence because of the carbon dioxide that's being released in the stomach. And then we have magnesium hydroxide or milk of magnesium. And this is fact acting. It has magnesium in it. So we want to take care in patients that have kidney disorders because the kidneys get rid of the magnesium. And so if they can't, then we could lead to, that could lead to magnesium toxicity. And because they cause diarrhea, they're more commonly used as an oxidative in the hospital. And then we have colonurgics. So they're going to increase the pressure in the LES and that improves the sapodio emptying. That increases gastric emptying. The negative side effect, it does stimulate hydrochloric acid secretion. So that's no good. And then gastrointestinal stimulants. There's a prokinetic drug that we talked about with nausea that stimulates GI motility. What was that? It's a clopermine or reglin. So PPI's are stronger than H2s. And there's been evidence, evidence has shown that CDIF is a higher risk if someone's on PPI's. So think about what's happening. They are taking these pills every day that decreases the acid in their stomach. We need the acid to break down our food and it also kills bugs and pathogens that we take in. And so without that acid, CDIF can flourish. And then they get a CDIF infection. Blocking acid production also decreases intrinsic factor. And what is intrinsic factor for? We need that to escort B12 to be absorbed in the small intestine. B12 cannot be absorbed without intrinsic factors. So they bond together and then they go to the small intestine and get absorbed. And if you're not getting B12, the type of anemia you're going to have is pernicious anemia. And B12 is important for the health of your peripheral and central nervous system. So brain health, nerve health, also red blood cell production, and happiness. So every have a B12 deficiency, it can be because of an adequate intake of B12, but also if we have lack of absorption because of the lack of acid and the lack of intrinsic factor. So treatment, sometimes with diet, citrus fruits, dry beans, green leafy vegetables, liver nuts, and organ meats, gross, oral supplementation, or cyanocobalamin injections. So if somebody has had their stomach removed, or part of their stomach removed, or they've got chronic dirt and they're on PPI's all the time, they may need injections. So if somebody doesn't have a stomach, they're definitely going to need them, and they're going to get them weekly at first and then monthly all through their life. So decrease B12 levels lead to irritability. And so that's why we want to help treat that as well as the nerve and brain health. So again, our nursing interventions, just to recap, nursing interventions for GERD medications, the H2s, PPI's prokinetics, and antacids be familiar with those, patient education, small frequent meals, avoid caffeine, smoking, chocolate, peppermint, spicy foods, alcohol, carbonated drinks, all the good stuff. Elevate the headbed even at home, and avoid tight or restricted clothing that's going to force the digestive contents up into the esophagus. And as far as we're going to go here, we'll continue on with other stomach disorders in the next episode.