10. Gastric surgery: peformed when ulcer medical regimen is unsuccessful, ulcer is determined to be precancerous, or complications are present.
    1. Types:
       1. Subtotal gastrectomy: removal of a portion of the stomach.
       2. Total gastrectomy: removal of the entire stomach.
       3. Antrectomy: removal of entire antrum (lower) portion of the stomach.
       4. Pyloroplasty: repair of the pyloric opening of the stomach.
       5. Vagotomy: interruption of the impulses carried by the vagus nerve, which results in reduction of gastric secretions and decreased physical activity of the stomach (being done less often).
       6. Combination of vagotomy and gastrectomy.
    2. Analysis/nursing diagnosis:
       1. Pain related to surgical incision.
       2. Ineffective breathing pattern related to high surgical incision.
       3. Risk for trauma related to possible complications postgastrectomy.
       4. Knowledge deficit regarding medication regimen and factors that aggravate condition.
       5. Fear related to possible precancerous lesion.
       6. Ineffective individual coping related to adjustments in lifestyle needed to lessen symptoms.
    3. Nursing care plan/implementation:
       1. Goal: promote comfort in the postoperative period.
          1. Analgesics: to relieve pain and allow patient to cough, deep breathe to prevent pulmonary complications.
          2. Position: semi-Fowler’s to aid in breathing.
       2. Goal: promote wound healing.
          1. Keep dressings dry.
          2. NG tube to low intermittent suction (Levin) or low continuous suction (Salem-sump).
             1. Check drainage from NG tube; normally bloody first 2-3 hours postsurgery, then brown to dark green.
             2. Excessive bright-red blood drainage: take vital signs; report vital signs, color and volume of drainage to MD immediately.
             3. Irrigate gently with saline in amount ordered; do not irrigate against resistance; may not be done in early postoperative period.
             4. Tape securely to face, but prevent obstructed vision.
             5. Frequent mouth and nostril care.
       3. Goal: promote adequate nutrition and hydration.
          1. Administer parenteral fluids as ordered.
          2. Accurate I&O.
          3. Check bowel sounds, at least q4h; NPO 1-3 days; bowel sounds normally return 21-36 hours; oral fluids as ordered when bowel sounds present-usually 30 mL, then small feedings, then bland liquids to soft diet.
          4. Observe for nausea and vomiting due to suture line edema, food intake (too much, too fast).
       4. Goal: prevent complications.
          1. Check dressing q4h for bleeding.
          2. Vitamin B₁₂ and iron replacement as indicated to avoid pernicious anemia and iron deficiency anemia.
          3. Avoid dumping syndrome.
    4. Evaluation/outcome criteria:
       1. Hemorrhage, dumping syndrome avoided.
       2. Healing begins.
       3. Adjust lifestyle to prevent recurrence/marginal ulcer.