Gastrointestinal Digestive Disorders

The Gastrointestinal System: Digestive Disorders

Air-Fluid Levels seen in bowel obstructionJ. Carley MSN, MA, RN, CNEPart II1PHARMACOLOGY ASSESSMENT

Physical Assessment Inspection Palpation Percussion AuscultationKEY ASSESSMENTSLab Monitoring

Care Planning

Plan for client adls, Monitoring, med admin.,Patient education, morebasedOn Nursing Process: A_D_O_P_I_E***Preparing for Diagnostic TestsNursing Interventions & Evaluation

Execute the care plan, evaluate for Efficacy, revise as necessaryPathophysiologyUpper GILower GIInflammatoryInflammatoryNon-InflammatoryG.E.R.D.UlcersGastritisG.E.R.D.Hiatus HerniasAcute AppendicitisPeritonitisUlcerative colitisCrohns DiseaseDiverticulitisNon-InflammatoryConstipation & DiarrheaIrritable Bowel SyndromeDumping SyndromeIntestinal ObstructionHemorrhoids & PolypsMalabsorptionA 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

2A Rough Outline (for the Left Hemispheric Dominant)GastritisDumping SyndromeSmall & Large IntestinesAppendicitisPeritonitisDiverticulitisUlcerative ColitisCrohns DiseaseBowel ObstructionIrritable Bowel Syndrome (IBS)HemorrhoidsPolypsBowel Cancer3Dumping Syndrome S&SEarlyLate30 min after eatingRapid emptyingVertigoSyncopePallorDiaphoresisTachycardiapalpitations90 min-3 hr after eatingExcessive insulin releaseAbdominal distentionCrampingNauseaDizzinessDiaphoresisconfusion6Dumping SyndromeRapid gastric emptying into the small intestines usually occurs after a gastric surgeryTypes: Early and Late

5Medication TreatmentPectin Oral: slows absorption of carbsOctreotide SQ: blocks gastric and pancreatic hormones8Pharmacology:Anti-Acids (Antacids)Prototype: aluminum hydroxide gel ( Amphojel ) Pharmacological Action

Neutralize gastric acid and inactivate pepsin.

Mucosal protection may occur by the antacids 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

78Pharmacology: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)SedationDiarrhea

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 Ringers solution.

Evaluation of Medication Effectiveness

Control of nausea and vomitingBack to Concept Map

79Pharmacology: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 EffectivenessDepending 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

82Pharmacology: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 clients 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 EffectivenessDepending 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 PPIs:omeprazole; lansoprazole; rabeprozole; pantoprazole; esomeprazole;Back to Concept Map

83Pharmacology: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

84AppendicitisAcute inflammation of veriform appendix

14Signs and SymptomsLower right quadrant painLow grade feverNausea and vomitingRebound tenderness @Mc Burneys pointRosving sign positiveIncreased WBC

15Medical ManagementMonitor pain (severe rebound tenderness)Monitor bowel sounds (absent)NPO, IVF, NO laxatives or enemasSurgical management: -Open or laparoscopic appendectomy 16Diagnostic TestsUltrasoundAbdominal x-rayAbdominal CT scan

17Nursing DiagnosisAcute painAlteration in comfortRisk for injuryKnowledge deficitRisk for infection18Nursing InterventionsMonitor vital signsAssess bowel soundsMonitor painMonitor lab valuesPost operative management: -Vitals signs, bowel sounds, diet resumption, antibiotic therapy as ordered

19PeritonitisAcute inflammation of the visceral / parietal peritoneum and endothelial lining of abdominal cavityTypes: primary and secondary

20PeritonitisPrimarySecondaryAcute bacterial infectionContamination of peritoneum via vascular systemTB (tuberculin infection)Alcoholic cirrhosisLeakage

Usually caused by a bacterial invasion in the abdomenGangrenous bowelBlunt or penetrating traumaLeakage

21Sign and SymptomsRigid board like abdomenAbdominal pain/tendernessDistended abdomenNausea and vomitingDiminished to no bowel soundsNo stools or flatusFeverTachycardia

22Diagnostic TestCBC (WBC, H&H)ElectrolytesCR (creatinine) & BUN (Blood urea nitrogen)Abdominal x-rayCT scanPeritoneal lavageSurgery

23Medical interventionsNon-surgical: -IV fluids -Broad spectrum antibiotics -Intake and outputs (I&O) -NG (nasogastric) tube -NPO -Pain management

24Medical InterventionsSurgical: Optimal treatmentExploratory laparotomy: repair or remove inflamed organ

25ComplicationsPeritonitis: EMERGENCY / Life Threatening -Symptoms: rigid abd., distended abd., absent bowel sounds, high fever, decreased urine output, hypotensionFluid shifts from extracellular to peritoneal cavity

26DiverticulitisInflammation of one or more diverticula. Results when diverticulum perforates and a local abscess forms

27SymptomsAbdominal pain, tenderness to palpationElevated temperature >101, may have chillsAbdominal guarding, rebound tenderness

28Diagnostic testsCT scanAbdominal flat plateEGDDO NOT do barium enema with active untreated diverticulitis

29Medical ManagementNon Surgical: -Broad spectrum antibiotics -Anticholinergics -NPO until clear liquids tolerated -Stop fiber therapy until attack is limited -NO enemas or laxatives30Medical ManagementSurgical -completed for ruptured peritonitis, fistula formation, bleeding, bowel obstruction, or unresponsive medical management31Nursing InterventionsHealth teaching: diet, fiber, symptom recognition, activity

Post op management: -Monitor colostomy, if present -monitor VS, urine output, wound condition -Psychosocial adjustment to stoma32Ulcerative ColitisUlcerative colitis: Chronic inflammatory process affecting mucosal lining of colon or rectum

33Symptoms10-20 liquid stools per dayTenesmus (Straining)AnemiaFatigueLLQ pain/crampingWt loss

34Diagnostic TestsCT scansColonoscopy or SiqmoidoscopyBarium Swallow studiesStools for O&P, occult blood, & C&SLabs: electrolyte panel and CBC

35Medication ManagementSalicylate: -inhibit prostglandins to reduce inflammationCorticosteroids: -Suppress immune system and reduce inflammationImmunomodulators: -reduce steroid use and overrides body immune system36Medication ManagementAntibiotics: -acute exacerbations prone to infectionAnti-diarrheals: -Symptomatic relief of severe diarrhea

37Diet TherapyNPO if symptoms are severeTPN if NPO for extended timeElemental formulaLow fiber foodsLactose free productsNo caffeine, spices, alcohol, or smoking

38Surgical ManagementSurgery is curativeTotal colectomy with permanent ileostomyTotal colectomy with continent ileostomy (Kocks pouch)

39Nursing DiagnosisPain acute and chronicFluid volume deficitAlteration in nutrition40Nursing InterventionsNutritional assessmentMonitoring fluid and electrolytesMonitor lab valuesMonitor for complicationsMonitor weightPsychosocial assessmentPost operative care41ComplicationsHemorrhage/perforationCoagulation problemsMalabsorptionIncrease risk for colon cancerToxic megacolon

42Crohns DiseaseInflammatory disease of small intestines, colon, or both (terminal ileum)

43Symptoms5-10 fatty stools per day (steatorrhea)FlatusMalabsorptionWeight lossDiffuse bilateral lower quadrant painFever with perforation or fistulaFluid, electrolyte and vitamin deficits44Diagnostic TestsCBCElectrolyte panelsVitamin & folic acid levelsAlbumin & nutritional labsBarium studiesColonoscopy45Medical ManagementDrug Therapy -Salicylate -Corticosteriods -Immunomodulators -Biologic Therapy -Antibiotics (abscess/perforation)46Diet TherapyTPN for long term useNutritional supplementsElemental supplementsNo caffeine or carbonated beveragesNo ETOHPrebiotics (non-digestive food ingredients)47Surgical ManagementSurgery is NOT a cureRepair of fistulasRelease of intestinal obstructionsPartial resection with primary anastamosisIleostomy48ComplicationsIntestinal obstructionFistulasMalabsorption syndromeLiver and biliary diseasesKidney stonesArthritis49Nursing ConsiderationsAdministering PPN and TPNProvide adequate nutrition: pre-medicate as orderedAssess stools: quality, frequency, amount, and pain issues with stoolingAssess vital signsTeach relaxation techniques50Health TeachingEducation for ileostomy or colostomy for both client and familyReduce or eliminate factors that cause diarrhea and painChronic pain managementProvide small frequent meals with specific dietary preferencesDetailed abdominal assessment51Bowel ObstructionSmall IntestinesLarge IntestinesPain is spasmodicPeristaltic wavesProfuse projectile vomitingFeculent odor to emesisVague diffuse constant painAbdominal distentionInfrequent vomitingPossible diarrhea

Air-Fluid Levels in intestinal obstruction52CauseMechanicalNon-mechanicalAdhesionsTumorsVolvulusIntussusceptionFecal impactionsForeign Bodies / ObjectsDecreased peristalsisElectrolyte imbalanceInflammatory responseNeurogenic disorderVascular disorder

Foreign Body in the Colon53ComplicationsDehydrationPerforationIschemic or strangulated bowelMetabolic acidosis and Alkalosis

54Irritable Bowel Syndrome(IBS)Chronic disorder of diarrhea and constipationNo exact cause knownAffects women 3x more then menPossible causes: diet and behavioral (psychological) illness55Signs and SymptomsManning Criteria: -abdominal pain relieved by defecation -abdominal distention -sensation of incomplete BM (bowel movement) -Presence of mucus56Sign and SymptomsExacerbation (flare up):

-worsening cramps -abdominal pain (LLQ) -diarrhea or constipation -increased pain after eating -nausea with defecation and mealtime57DiagnosisCBCSerum albuminStools for occult bloodSigmoidoscopyColonscopy

58Nursing InterventionStress ManagementDiet Therapy: -Avoid lactose products, caffeine, ETOH, sorbitol or fructose -Increase fiber (30-40 gm) -Fluid intake of 8-10 cups per day -meal planning

59Nursing InterventionMonitor Drug Therapy

-laxatives -diarrheals / antidiarrheals -anticholinergic -tricyclic antidepressants -muscarinic receptor antagonist -antispasmatics -5HT4 (Zelnorm)60HemorrhoidsSwollen or distended veins in rectal regionInternal & externalCause: pregnancy, obesity, constipationSymptoms: bleeding, edema, and prolapsedTreatment: cold packs, sitz bath, diet, Tucks , topical anesthetics, and surgery61

62

The Jackknife PositionRectal Surgery63PolypsSmall growths covered with mucosa and attached to the surface of intestines

Asymptomatic-bleeding, obstruction, & intussusception

Benign vs. malignant

Colorectal cancer

64Colorectal CancerColon and rectum=large intestines

Molecular changes

Metastasize to blood, lymph, surrounding & tissue

65

66Naso-Gastric Tubes (NGT)Purpose for Naso-Gastric Tubes:

1. Decompression2. Feeding3. Administration of Medications***4. LavageGeneral Golden Rule for Feeding Tubes:

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

X-Ray Confirmation67Problems with Nasogastric Tube (NGT) Placement

68

69

70

71Misplaced Feeding TubeAt 1st looks OK but distal tip NOT SEEN

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

72

73

74Tube 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

75NGT insertion documentation to include:Date & timeReason for insertionType of tubeSize of tubeLength of tubeNostril tube insertedNumber of attempts requiredAdditional commentsAny complicationsMethod of placement confirmationSignature: name & designate of Nurse inserting tube76APPENDIX77Call the law offices of..

81***Diagnostic TestsBlood 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 EnemaEndoscopyReturn toConcept Map85

86

87

88Tube Feedings: Enteral Nutritionhttp://www.saddleback.edu/alfa/n170/tubefeeding.aspx89

90

91

92Key Nursing Assesments:Patient on Enteral Feedings

93Tum-E-Vac?

Salem Sump94

Levin Tube(single lumen)

95

96

FDA advisoryFD&C Blue No. 1Maloney JPEN 2002;26:S34-42974 methods to deliver nutrition

IntermittentIntermittent gravityVia Pump:-continuous (or)cyclic98

99Any Questions

100