Gastrointestinal, Hepatic and Pancreatic DisordersAssessment A. History of Problem B. General Appearance1. Thin, emaciated 2. Obese 3. Skin turgor,poor

C. GI system1. Nausea and vomiting , what precipitates it , what relieves it, appearance and characterisitcs

2. Pain: location,precipitating factors, what relieves it, how long ,characteristics and quality 3. Elimination pattern : patterns and consistency of stools , laxative use 4. Nutrition: intake and output, difficulties in swallowing ,likes and dislikes(consider cultural diversity) , normal intake per day

D. Examination of Abdomen1. Inspection 2. Auscultation 3. Percussion 4. Palpation

E. Associated symptoms: flatus, eructation,

A. Upper GI

Diagnostic Procedures

1. Method: barium swallow 2. Purpose: assessment of esophagus and stomach 3. NPO 6-8 hours before procedure 4. Laxative after use 5. Follow up x-ray after procedure

B. Lower GI1. Method: barium enema 2. Purpose: assessment of large colon 3. Liquid before procedure 4. Laxative before and after procedure 5. Initially, feces will be white .Should be

During the procedure, you will drink a barium preparation- a chalky drink with a consistency of a milk shake, the barium can be seen on an x-ray as it passess through the digestive tract

instillation of barium contrast through the rectum into the the abdomen, after which an x-ray of the colon is taken.

C. Endoscopy(Gastroscopy, Esophagogastric Duodenoscopy)1. method: visualization of the inside of the body by means of a lighted tube 2. Purpose: assessment of esophagus and stomach 3. Gag reflex inactivated 4. NPO 6-8 hours before procedure 5. Resume diet only if gag reflex returns 6. Complications: perforation, bleeding, bloating

D. Sigmoidoscopy/ Colonoscopy1. Method: endoscope inserted through anus 2. Purpose: assessment of sigmoid colon

E. Analysis of Gastrointestinal Secretions1. Stool Analysis:a. Method: culture, fat analysis, guiac- no aspirin (ASA), NSAID, redmeat, Vit C for 3 days before b. Purpose: assessment for bacteria,virus, ova, parasites,malabsorption, blood c. do not refrigerate stool samples, organisms present could be killed.

F. Evaluation of Gallbladder and Liver1. Cholecystogram(Gallbladder series)a. Method:dye conjugated in the liver and excreted into the bile that outlines the gall bladder b. Purpose; assessment of gallstones, proper gall bladder function c. check for allergy to iodine and seafood d. Telepaque tablets 12 hours before test

Contrast tablets are swallowed to help visualize the gall blasser on x-ray

Intravenous cholangiogram: Abbreviated IVC. A radiologic procedure used primarily to look at the larger bile ducts in the liver and the bile ducts outside the liver. IVC can be used to locate gallstones within the bile ducts and identify other causes of obstruction to the flow of bile. For an IVC, an iodine-containing dye is injected intravenously. The dye is removed from blood by the liver which excretes it into the bile. The dye outlines the bile ducts and any gallstones that

d. NPO after midnight e. Less commonly performed than ultrasound

2. Cholangiograma.Method: bile ducts visualized b. Check for allergy to iodine and seafood

3. Ultrasound of Gallbladder and Livera. Strict NPO after midnight prior to procedure b. Able to visualize if stones are present

G. Flat Plate of the Abdomen1. No preparation 2. Gives an overall impression of the abdominal cavity

Flat plate

Liver biopsy

H. Liver Biopsy1. Method: removal of liver tissue to rule out lliver disease 2. Obtain consent and results of hemostasis tests before biopsy 3. Usually performed under fluoroscopic guidance 4. Two weeks prior , client must discontinue aspririn, NSAIDS and anticoagulants 5. NPO after midnight 6. Position on the left side before biopsy 7. Position on the right side after biopsy for 2 hrs. 8. Prescribed for prescribed time after biopsy

I. Paracentesis1. Removal of fluid accumulated in the peritoneum 2. Indicated when ventilation is impaired,abdominal discomforta. Therapeutic: to relieve shortness of breath when ventilation is impaired b. Diagnostic: to examine contents of peritoneal fluid

3. Void immediately after the procedure 4. During the procedure: sitting up with feet resting on stool 5. Fluid should be removed slowly over 30-90 minutes , generally < 1500 cc 6. Bed rest after the procedure 7. Observe for complications:

Paracentesis

J. Liver Function Tests1. Alkaline phosphatasea. Elevated in cardiac disorder, bone disease, biliary obstruction b. enzyme found in the liver tissue c. Released during liver damage

2. Prothrombin timea. Value is prolonged during liver damage b. Assess extrinsic clotting process

3. Blood Ammonia : assess liver's ability to deaminate protein products 4. Serum transaminase studiesa. Elevated in liver disease b. SGOT, SGPT, LDH, AST, ALT

5. Cholesterol

6. Bilirubina. Direct: indicative of pre-hepatic cause b. Indirect: Indicative of post hepatic cause

Gastrointesinal IntubationA. Types:1. Nasogastric tube: decompression of stomach 2. Salem pump- for continuous or itermittent suction prevents trauma 3. Miller-Abbot/ Anderson : intestinal suction 4. Ewald- removal of secretions through the mouth 5. Sengstaken Blakemore: for treatment of esophageal varices

NGT

Miller abbot

Salem sump

Ewald

Sengstaken

Sengstaken blakemore

B. Nasogastric Tube Feeding/ Suction1. Feeding Tubes Nursing Interventionsa. assess placement before each feeding in continuous feeding b.semi-fowler's position c. check for residual; always refeed unless amount increases d. nose and mouth care e. hold for aspirates of >100cc, recheck in one hour f. replace aspirated contents to prevent metabolic alkalosis

2. Suction Tube Nursing Interventiona. should drain stomach contents b. over time should see a decrease in volume of drainage c. always irrigate with normal saline

C. Gastrostomy Tube1. Anterior wall of the stomach is sutured to the abdominal wall 2. Primarily placed for long term feeding

D. Percutaneous Endoscopic gastrostomy (PEG)1. No need to check for placement 2. Primarily placed for long term feeding needs 3. Preffered over gastrostomy tube because of ease of insertion and care 4. Make sure tube is anchored continuously with ring at same number point on tube .This assure that the stomach is clearly anchored to the abdominal wall and decrease the chance of complications.

the difference between the g tube and Peg tube is the way it is inserted, in Peg tube,the procedure starts of with EGD( esophagogastroduodenoscopy) ,where they look at the stomach from the inside, then shine a light through, if the light is visualized,then a small stab wound is inserted, and the catheter can be placed that way. In the regular G-tube, is normally placed in the OR and requires a surgical procedure

E. Total Parenteral Nutrition(TPN)1. Definition:intravenous administration of a hypertonic solution of glucose ,nitrogen and other nutrients to achieve tissue synthesis and anabolism; lipids may be given as supplement,provides 3,000-4,000 caloriesper day. Note: any concentration of glucose greater than 10 percent must be given through a central intravenous line. 2. Indications for use a. inability of the gastrointestinal tract to absorb nutrients adequately( eg. Gastrointestinal obstuction, paralytic ileus, bowel resection,ulcerative colitis etc)

b. Inability to take food by mouth(eg. Neurosurgical problem:coma,anorexia nervosa) c. Excessive nutritional needs that cannot be met by the usual method(eg. Burns, multiple fracture, carcinoma being treated with chemotherapy or radiation therapy,severe infection)

3. Nursing Interventionsa. Chest X-ray immediately after subclavian line insertion for proper placement b. Assess weight, baseline electrolytes, blood glucose, zinc and copper level before treatment begins. c. Maintain aseptic (sterile)technique during

d. Maintain infusion rate , do not increase or decrease rate without order, may cause hypo or hyperglycemia e. Assess weight daily ,should maintain or increase weight while receiving TPN f. monitor for complications1. Infection-filters and tubing changed with every bottle 2. Hypogycemia or hyperglycemia 3. Air embolism: Never open central line to air.Chance of air embolism is decreased with multiple lumen set-ups.When central line is set up or opened,have client perform valsalva maneuver and place it in trendelenberg position. 4. Pneumothorax especially during insertion 5. Zinc deficiency

6. fluid overload 7. Hyperglycemic,hyperosmolar nonketotic coma

g. Gradual increase in rate of solution when discontinuing therby avoiding hypoglycemia h. Continually evaluate effectiveness of therapy. Seek consultation if it is not effective.

Hiatal HerniaA. Definition:portion of the stomach herniated through the esophageal hernia of the diaphragm

B. Manifestations1. Heartburn

C. Nursing Interventions1. Small frequent meals 2. Upright position during and after meals 3. Head of bed elevated 4. Antacids 5. Avoid anticholinergic drugs 6. Reduce intrabdominal pressure by avoiding lifting and tight clothes around the waist 7. Avoid coughing 8. Reduce spicy food intake- irritants

Duodenal and Gastric UlcersA. Types of Ulcers1. Chronic gastric and duodenal ulcers 2. Stress ulcersa. Maybe caused by physical as well as psychological stress b. Burns cause Curling's ulcer , a complication from sever burns when reduced plasma volume leads to sloughing of the gastric mucosa. c. Steroid therapy 1. usually occurs atleast 1-2 weeks after sterss 2. no pain 3. may be diagnosed due to gastric bleeding and resulting low hemoglobin and hematocrit

Comparisson of Chronic Gastric and Duodenal ulcerCHRONIC GASTRIC Age: Sex: Incidence : General nourishment: Etiology factors: Usually 50 years or more M:F 2:1 20 % Malnourished Excessive ingestion of salicylates, smoking Normal to hypo secretion Lesser curvature 1/2- 1 hour after meal,rarely at night. -Relieved by vomiting.Ingestion of food does not help ,sometimes causes pain CHRONIC DUODENAL Usually 25-50 years M:F 3:1 80% Well nourished Most result from Helicobacter pylori infection,smoking,O blood type hypersecretion Within 3 cm of pylorus 2-3 hours after meal;night, early morning. -Ingestion of food relieves pain -Pain is gnawing sensation sharply localized in midepigastrium or in back

Acid production in the stomach: Location Pain

CHRONIC GASTRIC Vomiting

CHRONIC DUODENAL

Common : caused by Uncommon pyloric obstruction either by muscular spasm of pylorus or mechanical obstruction from scarring Hematemesis more common than melena Usually less than 10 % Hemorrhage and perforation Melena more common than hematemesis None Hemmorhage , perforation and obstruction

Hemorrhage Malignancy possibility Complications

Ulcerogenic drugs

Salicylates, butazolodin,,steroids

same

B. Nursing Interventions1. Major goal is to prevent complications and allow ulcer to heala. Rest: physical and mental; lower stress b. Eliminate stimulants: caffeine, alcohol, spicy foods, cigarette smoking c. Diet has no therapeutic effect: milk may be used but is not recommended d. Antacid: aluminum hydroxide(Amphojel) magnesium carbonate (Maalox) e. Cimetidine (Tagamet): decrease acid production f. Ranitidine (Zantac) : decreases acid production g. Sucralfate (Carafate): protects lining of stomach h. Omeprazole(Prilosec): heals ulcer

C. Gastric resection 1. Typesa. Billroth 1 (gastruduodenostomy) b. Billroth 11 (gastrojejunostomy c. total gastrectomy: will cause pernicious anemia

Gastrectomy

2. Nursing Interventionsa. NG tube in place: do not move as it may stimulate bleeding at the surgical site b. Evaluate need for KCL in IV to prevent metabolic alkalosis c. NPO until suture is totally healed d. Assess drainage: will initially be sanguineous but should change in 2-3 days

3. Complicationsa. Hemorrhage b. Pulmonary c. Dumping syndrome: due to rapid entry of food into the jejunum without proper mixing and normal digestive process of duodenum1. Early: 5-30 minutes after eating,verrtigo, sweating, diarrhea, nausea due to fluid shift 2. Late: 2-3 hours after eating ,hypoglycemia occurs due to excess insulin secretion 3.Intervention: avoid salty , high carbohydrate meals, eat small frequent meals,avoid liquid with meals,lie down after meals (30-60 min),avoid antispasmodics, eat high protein, high fat,low carbohydrate meals . No fluids for one hour before, with or 2 hours after meals

d. Major complication : Peritonitis

COMPARISON OF CHRON'S DISEASE AND ULCERATIVE COLITISCHRON'S DISEASE Small Bowell Pathology : Transmural : primarily involving ileum and right colon 20-30, 40-50 Unknown , genetic, Jewish Usually not Common Common 20 % Less severe ULCERATIVE COLITIS Large Bowel Mucosal ulceration of the lower colon and rectum 20-40 Unknown familial, Jewish Common , sever Rare ,mild Rare 100% Severe Yes yes

Age : Etiologic factors: Bleeding : Perianal involvement Fistulas Rectal involvement Diarrhea

Abdominal pain after eating Yes Weight loss Yes

CHRONS'S DISEASE Treatment: Steroids : sulfazaline(Azulfidine) hyperlimentation:partial or complete colostomy & ileostomy and anastomosis Deteriorating, progressive

ULCERATIVE COLITIS Steroids : sulfazaline (Azulfidine) -partial or complete colostomy and proctolectomy % ileostomy Exacerbations, remissions

History:

Complications :

Scarring, obstruction

Perforation, susceptible to cancer, toxic megacolon, fistulas obsruction, abscess

Chron's disease

Ulcerative colitis

Diverticulosis and DiverticulitisA. Definition:1. Outpouching of the colon is deverticulosis 2. When the outpouching is infected, it is called diverticulitis. 3. Problem: the pouch gets filled with feces, becomes inflamed, can obstruct and perforate leading to peritonitis

B. Nursing Interventions1. Prevent by increasing fiber in diet 2. Avoiding all seeds 3. Preventing constipation by using bulk agents and increased water

Bowel ObstructionA. Definition: anything that obstructs the bowel; iflammation, tumor B. Manifestations:1. Increased bowel sounds proximal to the obstruction 2. No stool 3. Pain 4. Distention 5. Vomiting (projectile from reverse peristalsis) 6. Hypovolemia and shock

C.Nursing Interventions1. Intestinal tube: refer care to the preceding section 2. Ambulation 3. Treat cause and relieve 4. Surgical intervention: colon resection

Comparisson of colostomy and ileostomyCOLOSTOMY Defined: Portion of the colon brought to the abdominal wall ILEOSTOMY Portion of the ileum brought to the abdominal wall creating a permanent opening for exit of waste products Involves small bowel Chron 's disease Ulcerative colitis

Areas : Indications :

Involved large bowel Inflammatory or obstructive process of the lower intestinal tract;trauma to the intestinal tract;cancer of the rectum or sigmoid colon where anastomosis is not possible Semiformed to formed

Stool :

Liquid

Control

Maybe controlled by diet and/or irrigation depending on the location in the colon,maybe able to control evacuation

No control, must wear appliance at all times

Nursing Interventions 1. Preoperative carea. emotional support(anticipatory grieving) b. client teaching concerning impending surgery(ileostomy/colostomy)

2. Postoperative carea. general postop care b. psychological support c. NG tube d. observe stoma, surrounding tissues and type of secretion( should be pink, above skin level; may have bloody discharge at first)

e. teach self care to client1. type of equipment to use and how 2. skin care 3. diet: decrease fat and odor forming foods

Comparisson of Hepatitis A;Hepatitis B;Hepatitis nonHEPATITIS A HEPATITIS B HEPATITIS A;non-B;Hepatitis HEPATITIS C C (Infectious (Serum hepatitis) NONA;NOhepatitis) Cause - virus transmitted by fecal-oral contact;often seen during floods,earthwakes NB -virus transmitted -thought through similar to percutaneous or type B oral exposure to the blood of person with Hepa B -transmitted via blood, by personal contact & possible fecal oral route -hepatitis C causes 4% of hepatitis cases; causes 90% of posttransfusion hepatitis -risk factors are the same with hep B -same as type B,may lead to need of liver tranplantation(30%)

Manifest ations

-flu-like, upper -similar to type A respiratory without respiratory infection,headache, symptoms malaise,jaundice,d ark urine,liver tenderness -enteric precautions,bed rest,low fa

-same as type B

Nursing

-same as type A -same as except blood type B precatoninstead of

Same as type B

HEPATITIS A (Infectious hepatitis) Prevention Good sanitation;if in contact with infected client,administer serum immune globulin within 27 days; Hep A vaccine is available Note: vaccine protects at least 10 yrs

HEPATITIS B (Serum hepatitis)

HEPATITIS NONA;NON B

HEPATITIS C

Mandatory Same as screening of type B blood donors-use of disposable needles and syringes;administ er Hepatitis B immune globulin 2- 7 days after exposure.Hepatit s B vaccine: series of 3 injections after 6 months

No sharing of needles by drug users;care to avoid accidental needle sticks(health care workers);safe sexual practices

Liver CirrhosisA. Definition: liver cells destroyed and replaced by scar tissue;cause not clear , frequently seen in alcoholics but also occurs in non-alcoholics; associated with nutritional deficiency with decreased protein intake B. Functions of the Liver1. synthesis of clotting factors(fibrinogen, prothrombin, factor VII,IX,X) 2. metabolism of hormones(aldosterone,antidiuretic hormone, estrogen, testosterone) 3. synthesis of albumin

5. protein metabolism 6.fat metabolism through bile production 7. filter action, especially drugs 8. blood storage

C. Manifestations: these would be the same for a client with liver failure from other causes also, except for the enlargement of the liver and the alcohol related psychosis 1. Early stagea. enlarged liver with fatty infiltration b. jaundice c. GI disturbances

2. Late stagea. liver becomes smaller and nodular b. spleen enlarges: anemia c. ascites, distended abdominal veins, back-up of pressure in the portal system d. bleeding tendencies, decreased Vit K and prothrombin e. Wernicke- Korsakoff psychosis: alcohol relatedr/t thiamine/niacine deficiency and increase NH3 level

f. esophageal varices(painless condition),internal hemorrhoids, back up of pressure in the portal area g. dyspnea from ascites and anemia

3. End stagea. Hepatic encephalopathy stages1. Prodromal: slurred speech, vacant stare, restless, involves neuro deterioration 2. Impending: asterixis, apraxia, lethargy, confusion 3. stuporous: noisy, abusive, somnolence 4. coma: positve babinski, fetor hepaticas, decorticate/decerebrate posturing

b. Convulsions c. death

d. Nursing Interventions:goal is treating the manifestation and maximizing liver functions1. encourage client to rest 2. avoid hepatotoxic drugs and alcohol 3. high calorie, low protein(20-40g/day),low fat, low sodium(maintain protein restrictions during stage 1 and II of encephalopathy, no protein allowed durig stages III and IV 4. fat soluble vitamin supplements, folic acid may need to be given IV 5. restrict fluids 6. albumin IV 7. weigh client daily

9. skin care: cool temperature, aveeno baths, lulbricate 10. monitor I and O 11. assess for bleeding, hemorrhoids 12. diuretics: spironolactone(Aldactone), furosemide( Lasix) 13. Neomycin: reduces intestinal bacteria, thereby decreases breakdown of protein reducing ammonia levels 14. Lactulose(Heptalac): decrease ammonia levels 15. thiamine daily

Esophageal varicesA. Definition: esophageal varices are dilated veins found in the lower esophagus that occur secondary to portal hypertension;bleeding may result because of coughing,trauma or vomiting, bleeding esophageal varices is a medical emergency

B. Nursing Interventions1. maintain client airway before inserting sengstaken-blakemore tube 2. care of client with sengstaken blakemore tubea.maintain traction and manometer pressure of 40 mmHg b. keep scissors by bed side( to cut the tube in emergency) c. oral suctioning,mouth care; cannot swallow saliva or will aspirate d. deflate gastric balloon every 24-36 hours ;usually deflate esophageal balloon every 12 hours as ordered

3. semi folwer's position

5. monitor intake and output 6. Vit K 7. vasopressin(Pitressin) : vasoconstrictor 8. endoscopic sclerotherapya. sclerosing agent introduced via endoscope b. thromboses and obliterates the distended veins

Gall bladder diseaseA. Definition:1. inflammation of the gall bladder 2. cholelithiasis: stones in the gall bladder 3. at risk: 4 F: fair, fat, forty, fertile( oral contraceptive users)

B. Manifestations:1. right upper quadrant or epigastric pain, shoulder pain 2. nausea and vomiting 3. fat intolerance

4.. Murphy's sign: have client take deep breath and palpate the the right subcostal area. If the client has extreme pain and stops breathing on ispiration , this is a + murphy's sign and indicative of acute cholecystitis 5. jaundice indicates obstruction

C. Nursing Intervention1. Relieve pain-meperidine(Demerol). Do not use mophine, will case spasm and more pain 2. Maintain fluid and electrolytes balance 3. Administer antiemtic prn 4. Maintain low fat diet

D. Cholecystectomy: postoperative1. Nursing care same as abdominal surgery 2. Penrose drain in gall bladder area 3. T-tube to gravity after cholecystectomy and chole-dochostomy 4. Resume regular diet as tolerated

Penrose drain(rubber)

T-tube

PancreatitisA. Definition: inflammation brought about by the digestion of this organ by the very enzymes it produces.Clients at greater risk are those suffering from alcohol abuse,clients with other liver and gall bladder diseases. B. Manifestations:1. extreme upper abdominal pain radiating into the back 2. persistent vomiting 3. abdominal distention 4. weight loss 5. steatorrhea: fatty stool, bulky pale, foul

6. elevated serum amylase and lipase 7. pleural effusion

C. Nursing Interventions: rest the organ1. administer anticholinergics,antacids, pancreatic extracts: pancrelipase(Viokase) 2. NPO with NGT in place: no ice chips osr hard candies as these will stimulate the pancreas 3. IV fluids: may require TPN in moderate or severe cases 4. Provide meperidine (Demerol) for pain relief 5. Administer fat soluble vit 5. Home care management/teachingno alcohol or caffeine, infusion of IV fluids, signs and symptoms to report( fever, nausea, vomiting)