The Gastrointestinal System:

Digestive Disorders

“Air-Fluid Levels” seen in bowel obstructionJ. Carley MSN, MA, RN, CNE

Part II

PHARMACOLOGY

ASSESSMENT

Physical Assessment Inspection Palpation Percussion AuscultationKEY ASSESSMENTSLab Monitoring

Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, more…basedOn Nursing Process: A_D_O_P_I_E***Preparing for Diagnostic Tests

Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary

Pathophysiology

Upper GI Lower GI

Inflammatory Inflammatory

Non-Inflammatory

G.E.R.D.UlcersGastritis

G.E.R.D.Hiatus Hernias

Acute AppendicitisPeritonitisUlcerative colitisCrohn’s DiseaseDiverticulitis

Non-Inflammatory

Constipation & DiarrheaIrritable Bowel SyndromeDumping SyndromeIntestinal ObstructionHemorrhoids & PolypsMalabsorption

A Concept Map : Selected Topics in Gastro-Intestinal

Nursing

***Diagnostic Testing

Anti-Acids (Antacids)Prototype: aluminum hydroxide gel (Amphojel)

Prokinetic Agents:Prototype: metoclopramide (Reglan)

Histamine 2 Receptor AgonistsPrototype: ranitidine hydrochloride (Zantac)

Proton Pump Inhibitors)Prototype: omeprazole (Prilosec)

Mucosal BarriersPrototype: sucralfate (Carafate)

Disease Specific Medications:

Nursing Skills: NG Tube Insertion Enteral Feedings

A Rough Outline (for the Left Hemispheric Dominant…)

Gastritis Dumping Syndrome Small & Large Intestines Appendicitis Peritonitis Diverticulitis Ulcerative Colitis Crohn’s Disease Bowel Obstruction Irritable Bowel Syndrome (IBS) Hemorrhoids Polyps Bowel Cancer

Gastritis Inflammation of the gastric mucosa Types: erosive vs. non-erosive Acute vs. Chronic S&S: Abdominal tenderness,

bloating, hematesis, melena Diagnostic: EGD with biopsy Management: see GERD

Dumping Syndrome Rapid gastric emptying into the small

intestines usually occurs after a gastric surgery

Types: Early and Late

Dumping Syndrome S&SEARLY LATE

30 min after eating Rapid emptying Vertigo Syncope Pallor Diaphoresis Tachycardia palpitations

90 min-3 hr after eating Excessive insulin release Abdominal distention Cramping Nausea Dizziness Diaphoresis confusion

Nursing Interventions Lying down after a meal Eliminate liquids with meals Avoid milk, sweets, or sugars Eat small frequent meals Consume high protein and fat with

low to moderate carbohydrate

Medication Treatment Pectin Oral: slows absorption of carbs Octreotide SQ: blocks gastric and

pancreatic hormones

Complication Postprandial Hypoglycemia

Time-----------

BLOOD

GLUCOSE

LEVEL

“The Somogyi Effect”, a.k.a., “Rebound Effect”

Increased blood glucose level increases the release of insulin. Insulin causes the blood glucose levels to go down….

Small Intestines = “-entero”

Functions of Small Intestines

Movement Digestion Absorption

Large Intestines, “-colo-”

Function of Large Intestines

Movement Absorption Elimination

Appendicitis Acute inflammation of veriform

appendix

Signs and Symptoms Lower right quadrant pain Low grade fever Nausea and vomiting Rebound tenderness @Mc Burney’s

point Rosving sign positive Increased WBC

Medical Management Monitor pain (severe rebound

tenderness) Monitor bowel sounds (absent) NPO, IVF, NO laxatives or enemas Surgical management: -Open or laparoscopic appendectomy

Diagnostic Tests Ultrasound Abdominal x-ray Abdominal CT scan

Nursing Diagnosis Acute pain Alteration in comfort Risk for injury Knowledge deficit Risk for infection

Nursing Interventions

Monitor vital signs Assess bowel sounds Monitor pain Monitor lab values Post operative management: -Vitals signs, bowel sounds, diet

resumption, antibiotic therapy as ordered

Peritonitis Acute inflammation of the visceral /

parietal peritoneum and endothelial lining of abdominal cavity

Types: primary and secondary

PeritonitisPRIMARY SECONDARY

Acute bacterial infection Contamination of

peritoneum via vascular system

TB (tuberculin infection) Alcoholic cirrhosis Leakage

Usually caused by a bacterial invasion in the abdomen

Gangrenous bowel Blunt or penetrating

trauma Leakage

Sign and Symptoms Rigid board like abdomen Abdominal pain/tenderness Distended abdomen Nausea and vomiting Diminished to no bowel sounds No stools or flatus Fever Tachycardia

Diagnostic Test CBC (WBC, H&H) Electrolytes CR (creatinine) & BUN (Blood urea

nitrogen) Abdominal x-ray CT scan Peritoneal lavage Surgery

Medical interventions Non-surgical: -IV fluids -Broad spectrum antibiotics -Intake and outputs (I&O) -NG (nasogastric) tube -NPO -Pain management

Medical Interventions Surgical: Optimal treatment Exploratory laparotomy: repair or

remove inflamed organ

Complications Peritonitis: EMERGENCY / Life Threatening

-Symptoms: rigid abd., distended abd., absent bowel sounds, high fever, decreased urine output, hypotension

Fluid shifts from extracellular to peritoneal cavity

Diverticulitis Inflammation of one or more

diverticula. Results when diverticulum perforates and a local abscess forms

Symptoms Abdominal pain, tenderness to

palpation Elevated temperature >101, may

have chills Abdominal guarding, rebound

tenderness

Diagnostic tests CT scan Abdominal flat plate EGD DO NOT do barium enema with active

untreated diverticulitis

Medical Management Non Surgical: -Broad spectrum antibiotics -Anticholinergics -NPO until clear liquids tolerated -Stop fiber therapy until attack is limited -NO enemas or laxatives

Medical Management Surgical -completed for ruptured peritonitis,

fistula formation, bleeding, bowel obstruction, or unresponsive medical management

Nursing Interventions Health teaching: diet, fiber, symptom

recognition, activity

Post op management: -Monitor colostomy, if present -monitor VS, urine output, wound

condition -Psychosocial adjustment to stoma

Ulcerative Colitis Ulcerative colitis: Chronic

inflammatory process affecting mucosal lining of colon or rectum

Symptoms 10-20 liquid stools per day Tenesmus (Straining) Anemia Fatigue LLQ pain/cramping Wt loss

Diagnostic Tests CT scans Colonoscopy or Siqmoidoscopy Barium Swallow studies Stools for O&P, occult blood, & C&S Labs: electrolyte panel and CBC

Medication Management Salicylate: -inhibit prostglandins to reduce

inflammation Corticosteroids: -Suppress immune system and

reduce inflammation Immunomodulators: -reduce steroid use and overrides

body immune system

Medication Management Antibiotics: -acute exacerbations prone to

infection Anti-diarrheals: -Symptomatic relief of severe

diarrhea

Diet Therapy NPO if symptoms are severe TPN if NPO for extended time Elemental formula Low fiber foods Lactose free products No caffeine, spices, alcohol, or

smoking

Surgical Management Surgery is curative Total colectomy with permanent

ileostomy Total colectomy with continent

ileostomy (Kock’s pouch)

Nursing Diagnosis Pain acute and chronic Fluid volume deficit Alteration in nutrition

Nursing Interventions Nutritional assessment Monitoring fluid and electrolytes Monitor lab values Monitor for complications Monitor weight Psychosocial assessment Post operative care

Complications Hemorrhage/perforation Coagulation problems Malabsorption Increase risk for colon cancer Toxic megacolon

Crohn’s Disease Inflammatory disease of small

intestines, colon, or both (terminal ileum)

Symptoms 5-10 fatty stools per day

(steatorrhea) Flatus Malabsorption Weight loss Diffuse bilateral lower quadrant pain Fever with perforation or fistula Fluid, electrolyte and vitamin deficits

Diagnostic Tests CBC Electrolyte panels Vitamin & folic acid levels Albumin & nutritional labs Barium studies Colonoscopy

Medical Management Drug Therapy -Salicylate -Corticosteriods -Immunomodulators -Biologic Therapy -Antibiotics (abscess/perforation)

Diet Therapy TPN for long term use Nutritional supplements Elemental supplements No caffeine or carbonated beverages No ETOH Prebiotics (non-digestive food

ingredients)

Surgical Management Surgery is NOT a “cure” Repair of fistulas Release of intestinal obstructions Partial resection with primary

anastamosis Ileostomy

Complications Intestinal obstruction Fistulas Malabsorption syndrome Liver and biliary diseases Kidney stones Arthritis

Nursing Considerations Administering PPN and TPN Provide adequate nutrition: pre-

medicate as ordered Assess stools: quality, frequency,

amount, and pain issues with stooling Assess vital signsTeach relaxation techniques

Health Teaching Education for ileostomy or colostomy

for both client and family Reduce or eliminate factors that

cause diarrhea and pain Chronic pain management Provide small frequent meals with

specific dietary preferences Detailed abdominal assessment

Bowel Obstruction

SMALL INTESTINES LARGE INTESTINES Pain is spasmodic Peristaltic waves Profuse projectile

vomiting Feculent odor to emesis

Vague diffuse constant pain

Abdominal distention Infrequent vomiting Possible diarrhea

“Air-Fluid Levels” in intestinal obstruction

CauseMECHANICAL NON-MECHANICAL

Adhesions Tumors Volvulus Intussusception Fecal impactions Foreign Bodies / Objects

Decreased peristalsis Electrolyte imbalance Inflammatory response Neurogenic disorder Vascular disorder

Foreign Body in the Colon

Complications Dehydration Perforation Ischemic or strangulated bowel Metabolic acidosis and Alkalosis

Irritable Bowel Syndrome(IBS)

Chronic disorder of diarrhea and constipation

No exact cause known Affects women 3x more then men Possible causes: diet and behavioral

(psychological) illness

Signs and Symptoms “Manning Criteria:” -abdominal pain relieved by

defecation -abdominal distention -sensation of incomplete BM (bowel movement) -Presence of mucus

Sign and Symptoms Exacerbation (flare up):

-worsening cramps -abdominal pain (LLQ) -diarrhea or constipation -increased pain after eating -nausea with defecation and

mealtime

Diagnosis

CBC Serum albumin Stools for occult blood Sigmoidoscopy Colonscopy

Nursing Intervention Stress Management Diet Therapy: -Avoid lactose products, caffeine, ETOH, sorbitol or fructose -Increase fiber (30-40 gm) -Fluid intake of 8-10 cups per day -meal planning

Nursing Intervention Monitor Drug Therapy

-laxatives -diarrheals / antidiarrheals -anticholinergic -tricyclic antidepressants -muscarinic receptor antagonist -antispasmatics -5HT4 (Zelnorm)

Hemorrhoids Swollen or distended veins in rectal

region Internal & external Cause: pregnancy, obesity,

constipation Symptoms: bleeding, edema, and

prolapsed Treatment: cold packs, sitz bath, diet,

Tucks ®, topical anesthetics, and surgery

“The Jackknife Position”Rectal Surgery

Polyps Small growths covered with mucosa

and attached to the surface of intestines

Asymptomatic-bleeding, obstruction, &

intussusception

Benign vs. malignant

Colorectal cancer

Colorectal Cancer Colon and rectum=large intestines

Molecular changes

Metastasize to blood, lymph, surrounding & tissue

Naso-Gastric Tubes (NGT) Purpose for Naso-

Gastric Tubes:

1. Decompression 2. Feeding 3. Administration of

Medications ***4. Lavage

General Golden Rule for Feeding Tubes:

Ensure correct placement prior to putting ANYTHING DOWN a TUBE!!!

X-Ray Confirmation

Problems with Nasogastric Tube (NGT) Placement

Misplaced Feeding Tube

At 1st looks OK but distal tip NOT SEEN

This tube ended up exiting the mid abdomen with the feedings entering the peritoneal cavity

Tube feeding formula

remaining in contact with gastric acid can result in the precipitation of casein and the subsequent formation

of a solid mass around the tube

NGT insertion documentation to include:

Date & time Reason for insertion Type of tube Size of tube Length of tube Nostril tube inserted Number of attempts

required

Additional comments Any complications Method of placement

confirmation Signature: name &

designate of Nurse inserting tube

APPENDIX

Pharmacology:

Anti-Acids (Antacids)Prototype: aluminum hydroxide gel ( Amphojel )

Pharmacological Action Neutralize gastric acid and inactivate pepsin.

Mucosal protection may occur by the antacid’s ability to stimulate the production of prostaglandins.

Therapeutic Uses Treat peptic ulcer disease (PUD) by promoting

healing and relieving pain. Symptomatic relief for clients with GERD.

Nursing Interventions and Client Education

Clients taking tablets should be instructed to chew the tablets thoroughly and then drink at least 8 oz of water or milk.

Teach the client to shake liquid formulations to ensure even dispersion of the medication.

Compliance is difficult for clients because of the frequency of administration.

Administered seven times a day: 1 hr before and 3 hr after meals, and again at bedtime.

Teach clients to take all medications at least 1 hr before or after taking an antacid.

Evaluation of Medication Effectiveness

Depending on therapeutic intent, effectiveness may be evidenced by:

Healing of gastric and duodenal ulcers.

Reduced frequency or absence of GERD symptoms.

No signs or symptoms of GI bleeding.

Back to Concept Map

Pharmacology:

Prokinetic AgentsPrototype : metoclopramide ( Reglan )

Pharmacological Action

Block dopamine and serotonin receptors in the chemoreceptor trigger zone (CTZ), and thereby suppress emesis.

Prokinetic agents augment action of acetylcholine which causes an ↑ in upper GI motility.

Therapeutic Uses

Control postoperative and chemotherapy-induced nausea and vomiting.

Prokinetic agents are used to treat GERD.

Prokinetic agents are used to treat diabetic gastroparesis.

Side Effects / Adverse Effects

Extra Pyramidal Symptoms (EPS) Sedation Diarrhea

Contraindications / Precautions

Contraindicated in clients with GI perforation, GI bleeding, bowel obstruction, and hemorrhage

Contraindicated in clients with a seizure disorder due to ↑ risk of seizures

Use cautiously in children and older adults due to the ↑ risk for EPS.

Nursing Interventions and Client Education

Monitor clients for CNS depression and EPS. Can be given orally or intravenously. If dose is <

10 mg, it may be administered undiluted over 2 min. If the dose is > 10 mg, it should be diluted and

infused over 15 min. Dilute medication in at least 50 mL of D5W or lactated Ringer’s solution.

Evaluation of Medication Effectiveness

Control of nausea and vomiting

Back to Concept Map

**Tardive Dyskinesia Overview

Tardive dyskinesia is a disorder that involves involuntary movements, especially of the lower face. Tardive means "delayed" and dyskinesia means "abnormal movement."

Symptoms

Facial grimacing Jaw swinging Repetitive chewing Tongue thrusting

Causes

Tardive dyskinesia is a serious side effect that occurs when you take medications called neuroleptics. It occurs most frequently when the medications are taken for a long time, but in some cases it can also occur after you take them for a short amount of time.

The drugs that most commonly cause this disorder are older antipsychotic drugs, including:

Haloperidol Fluphenazine Trifluoperazine

Other drugs, similar to antipsychotic drugs, that can cause tardive dyskinesia include:

Cinnarizine Flunarizine (Sibelium) Metoclopramide

Prognosis If diagnosed early, the condition may be reversed by stopping the drug

that caused the symptoms.

Even if the antipsychotic drugs are stopped, the involuntary movements may become permanent and in some cases may become significantly worse.

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Pharmacology:

Histamine 2 (H2) Receptor AgonistsPrototype : ranitidine hydrochloride (Zantac)

Pharmacological Action

Suppress the secretion of gastric acid by selectively blocking H2 receptors in parietal cells lining the stomach.

Therapeutic Uses

Gastric and peptic ulcers, gastroesophageal reflux disease (GERD), and hypersecretory conditions, such as Zollinger-Ellison syndrome.

Used in conjunction with antibiotics to treat ulcers caused by H. pylori.

Therapeutic Nursing Interventions and Client Education

Encourage client to avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).

Ranitidine can be taken with or without food.

Treatment of peptic ulcer disease is usually started as an oral dose twice a day until he ulcer is healed, followed by a maintenance dose, which is usually taken once a day at bedtime.

Evaluation of Medication Effectiveness

Depending on therapeutic intent, effectiveness may be evidenced by:

Reduced frequency or absence of GERD symptoms (e.g., heartburn, bloating, belching).

No signs or symptoms of GI bleeding.

Healing of gastric and duodenal ulcers.

Back to Concept Map

Pharmacology:

Proton Pump InhibitorsPrototype : omeprazole (Prilosec)

Pharmacological Action

Reduce gastric acid secretion by irreversibly inhibiting the enzyme that produces gastric acid.

Reduce basal and stimulated acid production.

Therapeutic Uses

Prescribed for gastric and peptic ulcers, GERD, and hypersecretory conditions (e.g., Zollinger-Ellison syndrome).

Precaution:

Increases the risk for pneumonia. Omeprazole ↓ gastric acid pH, which promotes bacterial colonization of the stomach and the respiratory tract.

Use cautiously in clients at high risk for pneumonia (e.g., clients with COPD).

Nursing Interventions and Client Education

Do not crush, chew, or break sustained-release capsules.

The client may sprinkle the contents of the capsule over food to facilitate swallowing.

The client should take omeprazole once a day prior to eating.

Encourage the client to avoid irritating medications (e.g., ibuprofen and alcohol).

Active ulcers should be treated for 4 to 6 weeks.

Pantoprazole (Protonix) can be administered to the client intravenously.

Monitor the client’s IV site for signs of inflammation (e.g., redness, swelling, local pain) and change the IV site if indicated.

Teach clients to notify the primary care provider for any sign of obvious or occult GI bleeding (e.g., coffee ground emesis).

Evaluation of Medication Effectiveness

Depending on therapeutic intent, effectiveness may be evidenced by:

Healing of gastric and duodenal ulcers. Reduced frequency or absence of GERD

symptoms (e.g., heartburn, sour stomach). No signs or symptoms of GI bleeding.

Other PPI’s: omeprazole; lansoprazole; rabeprozole;

pantoprazole; esomeprazole;

Back to Concept Map

Pharmacology:

Mucosal BarriersPrototype: sucralfate ( Carafate )

Pharmacological Action

Changes into a viscous substance that adheres to an ulcer; protects ulcer from further injury by acid and pepsin.

Viscous substance adheres to the ulcer for up to 6 hr.

Sucralfate has no systemic effects.

Therapeutic Uses

Acute duodenal ulcers and maintenance therapy.

Investigational use in gastric ulcers and gastroesophageal reflux disease. (GERD)

Nursing Interventions and Client Education

Assist the client with the medication regimen. Instruct the client that the medication should

be taken on an empty stomach. Instruct the client that sucralfate should be

taken four times a day, 1 hr before meals, and again at bedtime.

The client can break or dissolve the medication in water, but should not crush or chew the tablet.

Encourage the client to complete the course of treatment.

Evaluation of Medication Effectiveness

Depending on therapeutic intent, effectiveness may be evidenced by:

Healing of gastric and duodenal ulcers. No signs or symptoms of GI bleeding.

Back to Concept Map

***Diagnostic Tests

Blood Tests Complete Blood Count (CBC c Diff) Stool Tests: Stool for occult blood; (Guiac) Stool for ova & parasites (O&P); Stool for Clostridium difficile (C-Diff) Stool Culture & Sensitivity (C&S) Upper GI Series (UGI) Upper GI Series with Small Bowel Follow-Through

(UGI-SBFT) Barium Enema Endoscopy

Return toConcept Map

Tube Feedings: Enteral Nutrition

http://www.saddleback.edu/alfa/n170/tubefeeding.aspx

Key Nursing Assesments:Patient on Enteral Feedings

Tum-E-Vac?

Salem Sump

Levin Tube(single lumen)

FDA advisoryFD&C Blue No. 1

Maloney JPEN 2002;26:S34-42

4 methods to deliver nutrition

IntermittentIntermittent gravity

Via Pump:-continuous (or)cyclic

Any Questions