NURSING CARE OF PATIENT WITH DISTURBANCES IN METABOLISM
MAJOR FUNCTIONS OF THE GI SYSTEM Secretion Digestion Motility Absorption Elimination
ASSESSMENTNUTRITIONAL PROBLEMSASSESS CHARACTERISTICS
Typical 24-hour diet recall Usual weight Weight loss or gain Appetite
ASSESS ASSOCIATED FACTORS Food preferences Family or individual routines associated with eating Cultural and religious values Psychological factors Physical factors Access/transportation to grocery stores Eating habits, self-imposed dietary restrictions Body image Nutritional knowledge Finances
ASSESS ASSOCIATED FACTORS Other symptoms: fever, nausea, vomiting, diarrhea, constipation,
anorexia, weight loss, dyspepsiaASSESS HISTORY
Family history of GI cancer, ulcer disease, inflammatory bowel diseases
Previous history of tumors, malignancy, or ulcers
INDIGESTION (DYSPEPSIA)ASSESS CHARACTERISTICS
Associated Symptoms: feeling of fullness, heartburn, excessive belching, flatus, nausea, bad taste, mild or severe pain
Appetite Pain or tenderness and location Pain radiation Precipitating factors of pain Alleviating or aggravating factors Symptoms association with food intake If associated with food, describe the amount and type of food
ASSESS ASSOCIATED FACTORS Presence of nausea, vomiting, blood in bowel movements or
diarrhea History of alcohol, non-steroidal anti-inflammatory drugs (NSAIDs) or
aspirin useASSESS HISTORY
Cancer, inflammatory bowel disease Bowel obstruction Previous abdominal surgeries
NAUSEA AND VOMITINGASSESS CHARACTERISTICS
Stimuli such as specific foods, odors, activity or a certain time of the day
Occurence: before or after food intake How many times per day? Specific foods/fluids tolerated when vomiting occurs Amount, color and consistency of vomitus
ASSESS ASSOCIATED FACTORS Fever, headache, dizziness, weakness or diarrhea Missed menstrual period Weight loss
ASSESS HISTORY Gallbladder disease Ulcer disease GI cancer Unprotected intercourse
NATURE OF VOMITUS
CHARACTER POSSIBLE SOURCE
Yellowish or GreenishMay contain bileMedication e.g. Senna
Bright red (arterial) Hemorrhage or peptic ulcer
Dark red (venous)HemorrhageEsophageal or gastric varices
Coffee groundsDigested blood from slowlybleeding gastric or duodenal ulcer
Undigested foodGastric tumourUlcer, obstruction
Bitter Taste Bile
Sour or Acid Gastric contents
Fecal components Intestinal obstruction
DIARRHEAASSESS CHARACTERISTICS
Duration Frequency, consistency, color, quantity, and odor of stools Presence of blood, mucus, food particles in the stools Change in bowel habits Nocturnal diarrhea Aggravating or alleviating factors Weight loss
ASSESS ASSOCIATED FACTORS Fever, nausea, vomiting, abdominal pain, abdominal distention,
flatus, cramping, urgency with straining Use of antibiotics Recent travel to foreign countries with highest risk of traveler’s
diarrhea (Mexico, South America, Africa, and Asia) Emotional stress or anxiety
ASSESS HISTORY Colon cancer, ulcerative colitis, Crohn’s disease or malabasorption
syndrome Use of ginger as antiemetic (known to cause heartburn)
Use of licorice root for upset stomach and ulcers (known to cause sodium and water retention and loss of potassium)
POSSIBLE CAUSES OF DIARRHEA Infectious agents Food poisoning Medications Fecal impaction Bowel diseases Malabsorption syndromes Short bowel syndrome Malignant syndromes e.g. Zollinger-Ellison syndrome
CONSTIPATIONASSESS CHARACTERISTICS
Frequency, consistency, color of the stools Change in bowel habits Gradual or sudden Size of the stools Dietary changes Presence of blood or mucus Use of laxatives
ASSESS ASSOCIATED FACTORS Periods of diarrhea Abdominal pain or distention Stress Changes in activity level Regular time for defecation Use of antacids containing calcium or anticholinergics
ASSESS HISTORY Family history of colorectal cancer Depression or metabolic disorders such as hypothyroidism or
hypercalcemiaPOSSIBLE CAUSES OF CONSTIPATION
Inadequate fluid intake Psychological factors Electrolyte imbalances Hormonal abnormalities Mechanical bowel obstruction Medications Loss of innervation e.g. Hirschprung’s disease Neurological disorders
Anorectal disordersDYSPHAGIAASSESS CHARACTERISTICS
Onset: acute or gradual Problem with swallowing: intermittent or continuous Association with solid foods, liquids or both
ASSESS ASSOCIATED FACTORS Presence of regurgitation, heartburn, chest or back pain, weight loss Any hoarseness, voice change, or sore throat
ASSESS HISTORY Family history of esophageal cancer Stroke, palsy or any other neurologic conditions Alcohol or tobacco intake
Physical ExaminationASSESSMENTTECHNIQUES FOR PHYSICAL ASSESSMENTI – Inspection A – Auscultation P – Percussion P – Palpation
SIGNIFICANT FINDINGSFINDINGS SIGNIFICANCE/IMPLICATIONTenting of the skin DehydrationAbnormal body weight Obesity, anorexia nervosa or malignancyPalpable mass Enlarged organ, inflammation,
malignancy or herniaRebound tenderness, guarding
Appendicitis, cholecystitis, peritonitis, pancreatitis, duodenal ulcer
Protuberant or bulging abdomen
Ascites (may be confirmed by test for SHIFTING DULLNESS and FLUID WAVE)
Distention and absence of bowel sounds
Intestinal obstruction
Shifting Dullness Test1. The patient is examined in the supine position.2. Direct percussion is done over the abdomen, from the umbilicus to the flanks.3. The location of the transition from tympany to dullness is noted.4. Positive test: Percussion note is tympanitic over the umbilicus and dull over the lateral abdomen and flank areas.
Fluid Wave Test
STOOL CHARACTERISTICS AND IMPLICATIONSCHARACTERISTIC IMPLICATION/SIGNIFICANCE
Tarry black (MELENA) Upper GI bleeding
Bright red Lower GI bleeding
Blood streaked Lower rectal or anal bleeding
fatty, bulky, foamy, grayish stool (STEATORRHEA)
Liver problem or hepatitis
Clay-colored (NO BILE) Biliary obstruction
With mucus or pus Ulcerative colitis or shigellosis
Small, dry, rocky-hard Constipation, obstruction
Currant jelly Intussusception
Ribbon-like Hirschprung’s disease
Marble-sized stool pellets Spastic colon syndrome
Laboratory Tests:HEMOCCULT OR GUAIAC TEST (FECAL OCCULT BLOOD)
test to CHECK PRESENCE OF BLOOD in stoolINDICATION
detects presence of GASTROINTESTINAL BLEEDING and COLORECTAL CANCER
PATIENT INSTRUCTIONS BEFORE THE PROCEDURE (should be observed by the patient 3 DAYS BEFORE THE TEST)
Consume a HIGH-FIBER diet Avoid RED MEAT in the diet Avoid foods with HIGH PEROXIDASE content such as TURNIPS,
CAULIFLOWER, BROCCOLI, HORSERADISH AND MELON Avoid IRON PREPARATIONS, IODIDES, BROMIDES, ASPIRIN,
NSAIDS, VITAMIN C supplements greater than 250 mg/day Avoid ENEMA OR LAXATIVE before stool collection
INSTRUCTIONS ON COLLECTION OF SPECIMEN Stool must not be contaminated with TOILET PAPER OR TISSUE Specimen should be submitted for laboratory exam WITHIN 6 DAYS
FECALYSIS examination of stool AMOUNT, CONSISTENCY AND COLOUR
INDICATION detects presence of PARASITES, PUS, BLOOD CELLS and other
abnormal findings suggestive of pathologyPATIENT INSTRUCTIONS
avoid drugs such as CASTOR OIL AND LAXATIVES avoid drugs that interfere with results such as MINERAL OIL,
NEOMYCIN AND POTASSIUM CHLORIDE Eat HIGH-FAT DIET and refrain from ALCOHOL FOR 3 DAYS before
the test and during the collection (if the patient is for STOOL EXAM FOR LIPIDS)
Submit stool within 30 MINUTES TO 1 HOUR after collection
HYDROGEN BREATH TEST
Test used to EVALUATE CARBOHYDRATE ABSORPTION A radioactive substance is ingested, and, after a certain period of
time, exhaled gases are measuredINDICATION
Detects presence SHORT BOWEL SYNDROME LACTOSE INTOLERANCE Bacterial overgrowth of the intestine like in CROHN’S DISEASE
NURSING AND PATIENT CARE CONSIDERATIONS NPO 12 HOURS before the procedure AVOID SMOKING after midnight before the test AVOID ANTIBIOTICS AND LAXATIVES OR ENEMAS 1 WEEK before
the test
HELICOBACTER PYLORI TESTING1. SERUM IMMUNOGLOBULIN G ANTIBODY TEST
POSITIVE ANTIBODY TEST may not differentiate between active and inactive disease
A NEGATIVE TEST mean no antibodies or antibodies are presentINDICATION
Detects GASTRITIS and PEPTIC ULCER DISEASE caused by helicobacter pylori
NURSING AND PATIENT CARE CONSIDERATIONS Stop treatment 2 weeks before the test to prevent false-negative test Negative tests may require second test for confirmation
2. PY test H. PYLORI BREATH TEST Client take a 14C urea capsules Waits approximately 10 minutes & blows up a balloon. Air balloon is the transferred to a special vial for analysis Presence of gastric urease - the client most likely has H.pylori
infection 90% accurate
Nursing considerations Avoid antibiotic or bismuth for 1 month Avoid proton pump inhibitors for 2 weeks NPO for 6 hours before the test Advice client to swallow the capsule intact
GASTRIC ANALYSIS Analysis of gastric fluids Assists in determining problems with secretory activity of the gastric
mucosa
NURSING AND PATIENT CARE CONSIDERATIONS NPO for 8-12 hours before the test Content are aspirated every 15 minutes for at least 1 hour Analyze for Acidity ( pH ),volume and cytology
Radiology And Imaging Studies BARIUM SWALLOW (UPPER GI SERIES)
Fluoroscopic X-ray examinations of the ESOPHAGUS, STOMACH AND SMALL INTESTINE after ingestion of BARIUM SULFATE
INDICATION detects presence of strictures, ulcers, tumors, polyps, hiatal hernias
and motility problemsPATIENT PREPARATION BEFORE THE TEST
Maintain on LOW-RESIDUE DIET for 2-3 days No smoking, chewing gum, and mints Place on NPO after midnight before the test Instruct to avoid SMOKING Withhold OPIOIDS and ANTICHOLINERGICS 24 hours before the test
CARE OF THE PATIENT AFTER THE PROCEDURE Administer LAXATIVE to help expel the barium and prevent fecal
impaction Assess abdomen for distention and bowel sounds Observe stool for presence of barium Check the color of stool (initially whitish but should be brown within
72 hours) Check for barium impaction (manifested by constipation with
distended abdomen)
BARIUM ENEMA (LOWER GI SERIES) Flouroscopic X-ray examination of the large intestine after enema
with barium sulfate Air may be introduced after barium to provide a double contrast
study Procedure usually takes about 15 to 30 minutes INDICATION Detects structural changes such as tumors, polyps, diverticula,
fistula, obstructions, and ulcerative colitisCLIENT PREPARATION
maintain on low-residue, low-fat or clear liquid diet for 2 days prior to the test
Administer laxative a day before the test Place on NPO after midnight Perform enema on the morning before the examination Instruct client that barium sulfate will be given per rectum
PATIENT CARE AFTER THE PROCEDURE Administer laxative or perform enema after the test to prevent barium
impaction Instruct client to increase fluid intake to prevent fecal impaction Check color of stool (stools are white for 24-72 hours after the test) Instruct the client to report pain, bloating, absence of stool, or
bleeding (may indicate BARIUM IMPACTION)
ULTRASONOGRAPHY (ULTRASOUND) Non-invasive test using high-frequency sound waves to obtain image
of the abdominal organsINDICATION
Detects small abdominal masses, fluid-filled cysts, gallstones, dilated bile ducts, ascites and vascular abnormalities
CLIENT PREPARATION Maintain patient on a special diet, laxative, or other medication to
cleanse the bowel and decrease gas Place patient on NPO 8-12 hours before the test
COMPUTED TOMOGRAPHY SCAN (CT SCAN) An X-ray technique that provides excellent anatomic definition May be used with ultrasound to perform guided needle aspiration of
fluid or cells from lesions anywhere in the abdomenINDICATION
Detects tumors, cysts and abscesses Detects dilated bile ducts, pancreatic inflammation, gallstones Detects changes in intestinal wall thickness
CLIENT PREPARATION Place patient on NPO after midnight ENEMA or administer LAXATIVES to cleanse the bowel Check for allergy to IODINE and SEAFOODS if a contrast will be used Inform the client that the procedure is PAINLESS Instruct the client to REMAIN STILL during the procedure Withhold the procedure if patient is PREGNANT
REPORT ITCHING OR SHORTNESS OF BREATH after administration of contrast medium (may INDICATE ALLERGIC REACTION)
PARACENTESIS Procedure in which a needle or catheter is inserted into the
peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes
ENDOSCOPIC PROCEDURESENDOSCOPY
Use of flexible (fiberoptic endoscope) tube to visualize the GI tract and perform certain diagnostic and therapeutic procedures
Images are produces through a video screen or telescopic eyepiece It may be inserted through the rectum or mouth
TYPES 1) Capsule endoscopy 2) Esophagogastroduodenoscopy 3) Proctosigmoidoscopy and Colonoscopy
CAPSULE ENDOSCOPY Involves swallowing a capsule (camera device) which passes
through the GI tract After 8 hours, the capsule is excreted and connected to computer to
the download the imagesINDICATION
Detects abnormalities of the small bowel such as ACTIVE BLEEDING, POLYPS, ULCERATIONS, TUMORS, CAUSES OF DIARRHEA and NUTRITIONAL MALABSORPTION
CONTRAINDICATIONS Small bowel obstruction Dysphagia Fistula Severe delayed gastric emptying Gastrectomy with gastrojejunostomy GI stricture Pacemakers or implanted defibrillators
CLIENT PREPARATION Discontinue IRON PREPARATIONS AND CARAFATE 5 days before to
prevent mucosal staining
Discontinue ANTISPASMODICS, PEPTO-BISMOL AND ANTI-DIARRHEALS 24 HOURS before procedure
Instruct to STOP SMOKING 24 HOURS before the test to prevent mucosal staining
Maintain on CLEAR LIQUID DIET A DAY BEFORE the procedure NPO AFTER MIDNIGHT or 10 hours before SHAVE AREA ABOVE AND BELOW UMBILICUS before attaching
sensor array leads Instruct patient to AVOID STRENUOUS ACTIVITY, HEAVY LIFTING,
BENDING OR STOOPING, OR IMMERSION IN WATER while wearing leads and recorder
After ingesting the capsule, instruct the patient NOT TO EAT OR DRINK FOR AT LEAST 2 HOURS, then can advance to CLEAR LIQUID DIET
Instruct patient to avoid RADIO EQUIPMENT which may interfere with capsule’s signal
Tell patient that capsule is excreted after1-3 DAYS Watch out for signs of CAPSULE OBSTRUCTION such as
ABDOMINAL PAIN, CHEST PAIN, NAUSEA AND VOMITING, STRIKING SENSATION OR FEVER
ESOPHAGOGASTRODUODENOSCOPY (UPPER GI ENDOSCOPY)
Visualization of the ESOPHAGUS, STOMACH AND DUODENUM May also be used to perform biopsy, remove polyps, foreign bodies,
control bleeding, or open strictures INDICATION
Detects acute or chronic upper GI bleeding, esophageal or gastric varices, polyps, malignancy, ulcers, gastritis, esophagitis, gastroesophageal reflux
CLIENT PREPARATION NPO 8 HOURS before the test Remove DENTURES and BRIDGES to prevent airway obstruction Administer medications as prescribed ANTICHOLINERGICS (ATROPINE SULFATE) SEDATIVES, NARCOTICS OR TRANQUILIZERS (DIAZEPAM,
MEPERIDINE HCL) * LOCAL SPRAY ANESTHETIC to the posterior pharynx.
PATIENT CARE AFTER THE PROCEDURE Maintain patient in LATERAL POSITION to prevent aspiration Maintain NPO until gag reflex returns (2-4 hours) Offer LOZENGES or NORMAL SALINE GARGLES for throat irritation
or hoarseness Assess for SIGNS OF PERFORATION (abdominal or chest pain,
dyspnea, tachycardia, lightheadedness, distended abdomen, bleeding, fever, and dysphagia)
Instruct to AVOID DRIVING FOR 12 HOURS if sedative was used
PROCTOSIGMOIDOSCOPY AND COLONOSCOPY(LOWER GI ENDOSCOPY)
PROCTOSIGMOIDOSCOPY – visualization of the ANAL CANAL, RECTUM, AND SIGMOID COLON through a fiber optic sigmoidoscope
COLONOSCOPY – visualization of the ENTIRE LARGE INTESTINE, SIGMOID COLON, RECTUM AND ANAL CANAL
INDICATION detects malignancy, polyps, inflammation, or strictures
COLONOSCOPY is used for surveillance in patients with history of chronic ulcerative colitis, previous colon cancer or colon polypsCLIENT PREPARATION
Withhold ASPIRIN or ASPIRIN-CONTAINING products or IRON SUPPLEMENTS 7 days before the test
Maintain on CLEAR LIQUID DIET 24 HOURS before the test Administer CASTOR OIL or LAXATIVE to clear bowel Perform CLEANSING ENEMA Place patient in KNEE-CHEST, LATERAL OR SIM’S POSITION
CLEAR LIQUID DIET
FOOD GROUP FOODS INCLUDED
Fruit juices All clear or strained fruit juices
Soup Clear broth
DessertsClear flavored gelatin, ice pops,fruit-flavored ices, hard candy
BeveragesCoffee, tea, carbonated beverages, beverages, such as Kool-aid, Gatorade
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY Visualization of the common bile duct, the pancreatic , hepatic ducts
through the ampula of vater in the duodenum Uses the endoscope in combination with xray techniques. Uses contrast material (dye)
CLIENT PREPARATION Place on NPO 8 HOURS before the test Remove DENTURES and BRIDGES to prevent airway obstruction Administer medications as prescribed ANTICHOLINERGICS (ATROPINE SULFATE) SEDATIVES, NARCOTICS OR TRANQUILIZERS (DIAZEPAM,
MEPERIDINE HCL) * LOCAL SPRAY ANESTHETIC to the posterior pharynx Assess for allergy to dye
Disorders of the MouthSTOMATITIS
Inflammation of the oral cavityTYPES OF STOMATITIS1) Primary
APHTHOUS STOMATITIS or canker sores – MOST COMMON TYPE herpes simplex virus I and II
2) Secondary candidiasis or oral thrush may be due to overgrowth of normal flora
ETIOLOGY Infection Allergy to coffee, potatoes, cheese, nuts, citrus fruits, and gluten Vitamin deficiency Systemic disease Irritants Chemotherapy Radiation
Clinical Manifestations CANKER SORES – whitish gray center and erythematous ring Whitish plaque-like lesion, appears red and sore when wiped away –
COMMON IF WITH CANDIDIASIS Dysphagia Dry or hot sensation on area of lesions Elevation of temperature – RARE
Nursing diagnosis Pain r/t inflammation of oral mucous membrane. Imbalanced nutrition, less than body requirements r/t difficulty
swallowingLABORATORY ASSESSMENT
COMPLETE BLOOD COUNT – may reveal INFECTION CYTOLOGIC CULTURE and GRAM STAIN TESTING – to identify the
CAUSATIVE MICROORGANISM
NURSING CARE Provide ORAL CARE EVERY 2 HOURS and twice at night Use SOFT-BRISTLED TOOTHBRUSH OR FOAM SWABS Use SODIUM BICARBONATE solution (baking soda), WARM SALINE
or HYDROGEN PEROXIDE in rinsing the mouth Avoid COMMERCIAL MOUTHWASHES Provide SOFT, BLAND and NONACIDIC foods Apply TOPICAL ANALGESICS or ANESTHETICS as prescribed
DRUG THERAPYTYPE OF STOMATITIS
DRUG CONSIDERATIONS
General Tetracycline Syrup
USUAL DOSE:
250 mg/10 ml for 10 days
INSTRUCTION: rinse for 2 minutes then swallow
Herpes Simplex Acyclovir (Zovirax)
USUAL DOSE:
5 mg/kg for 1 hour IV
INSTRUCTION: make sure client has no renal problem
Fungal
Nystatin
(Mycostatin)
USUAL DOSE: 600,000 units QID oral suspension
ANTI-INFLAMMATORY AGENTS AND IMMUNE MODULATORS Triamcinolone in Benzocaine Dexamethasone Levamisole Amlexanox
ThalidomideSYMPTOMATIC TOPICAL AGENTS FOR PAIN
Benzocaine Camphor phenol 15 ml 2% viscous Lidocaine gargle of mouthwash every 3 hours
(maximum of 8 doses per day)
Disorders of the EsophagusGASTROESOPHAGEAL REFLUX DISEASE (GERD)
BACKWARD FLOW (reflux) of gastrointestinal contents into the esophagus
MOST COMMON upper GI disorder Common in PEOPLE OVER AGE 45
CAUSE Inappropriate relaxation of lower esophageal sphincter
PREDISPOSING FACTORS Ingestion of LARGE MEALS Conditions associated with DECREASED GASTRIC EMPTYING Recumbent or SUPINE positioning Insertion of nasogastric tube (NGT) INCREASED INTRAABDOMINAL and INTRAGASTRIC PRESSURE
FACTORS THAT RELAX LOWER ESOPHAGEAL SPHINCTER TONE Fatty foods Caffeinated beverages Chocolate Citrus fruits, tomatoes and tomato products Nicotine in cigarette smoke Medications e.g. calcium channel blockers, anticholinergic drugs Peppermint, spearmint Alcohol High levels of estrogen and progesterone
ASSESSMENT HEARTBURN or PYROSIS – suggests reflux DYSPHAGIA – suggests narrowing of lumen Dyspepsia – MOST COMMON SYMPTOM; occurs 30-60 minutes after
meals and with reclining position Regurgitation – with sour or bitter taste Hypersalivation (water brash) Odynophagia Chronic cough Eructation (belching)
DIAGNOSTIC TESTS 24-hour ambulatory pH monitoring – most accurate method
Endoscopy Esophageal manometry
Nursing diagnosis Imbalanced nutrition less than body requirements, r/t difficulty
swallowing Risk for for aspiration r/t difficulty swallowing Acute pain r/t difficulty swallowing Deficient knowledge
MANAGEMENTDIET THERAPY Avoid CAFFEINATED AND CARBONATED foods Avoid SPICY and ACIDIC FOODS SMALL FREQUENT FEEDINGS (4-6 small meals) Avoid foods 3 hours before going to bedLIFESTYLE CHANGES ELEVATE HEAD OF THE BED 6-8 inches for sleep DO NOT LIE DOWN 3-4 hours after eating Avoid NICOTINE and ALCOHOL LOSE WEIGHT – if the patient is obese Avoid CONSTRICTIVE CLOTHING, STRAINING or BENDING OVER
DRUG THERAPY ANTACIDS
Aluminum or Magnesium Hydroxide Maalox, Mylanta INDICATION: management of heartburn ACTION: elevates gastric pH and deactivates pepsin SIDE EFFECTS: constipation and diarrhea CLIENT INSTRUCTIONS: take the antacid 1 hour before and 2-3
hours after mealsHISTAMINE RECEPTOR ANTAGONISTS
famotidine (Pepcid) ranitidine (Zantac) cimetidine (Tagamet) nizatidine (Axid) INDICATION: management of heartburn ACTION: lowers the acidity of the gastric mucosa DRUG INTERACTION: CIMETIDINE may have significant interactions
with WARFARIN, THEOPHYLLINE, PHENYTOIN, NIFEDIPINE and PROPANOLOL
PROTON PUMP INHIBITORS Omeprazole (Priolosec)
Lansoprazole (Prevacid) Rabeprazole (Aciphex) Pantoprazole (Protonix) Esomeprazole (Nexium) INDICATION: management of heartburn ACTION: inhibits production of gastric acid secretion CLIENT INSTRUCTIONS: should be taken 30-60 minutes before
meals OTHER DRUGS
ANTI-EMETIC Metoclopramide (Plasil) ACTION – increase rate of gastric emptying ADVERSE EFFECTS – fatigue, anxiety, ataxia and hallucinations
SURGICAL MANAGEMENT LAPAROSCOPIC NISSEN FUNDOPLICATION (LNF) GOLD STANDARD for surgical management of GERD WRAPPING and ANCHORING a portion of the stomach fundus
around the lower esophageal sphincterNURSING CARE AFTER SURGERY
Elevate head of the bed at least 30 degrees to lower the diaphragm and facilitate lung expansion
Facilitate insertion of NGT to prevent excessive tightening of the fundoplication
Monitor drainage of NGT (should be normal yellowish green after within first 8 hours after surgery)
Check placement every 4-8 hours Avoid alcohol, caffeinated and carbonated foods Monitor for dysphagia (sign that fundoplication is too tight) Monitor for gas bloat syndrome Administer Simethicone 80 mg QID for excessive gas
ENDOSCOPIC THERAPIESSTRETTA PROCEDURE to INHIBIT THE ACTIVITY of the vagus nerve
use of radiofrequency energy through needles to induce THERMAL BURN in the gastroesophageal junction
ENTERYX PROCEDURE to TIGHTEN the lower esophageal sphincter
INJECTION OF SOFT, SPONGY PERMANENT IMPLANT made of liquid polymeric material into the LES muscle
PATIENT CARE AFTER ENDOSCOPIC THERAPIES Maintain on CLEAR LIQUIDS for 24 hours
After the DAY 1 – shift to SOFT DIET such as custard, pureed vegetables, mashed potatoes
Avoid NSAIDs and ASPIRIN for 10 days Give LIQUID MEDICATIONS as much as possible Avoid NGT INSERTION for at least 1 month Watch out for CHEST or ABDOMINAL PAIN, BLEEDING, DYPHAGIA,
SHORTNESS OF BREATH, NAUSEA or VOMITING
HIATAL HERNIA The opening of the diaphragm through which the esophagus passes
becomes enlarged. Part of the stomach tends to move into the lower portion of the
thorax TYPES
Sliding Hiatal Hernia Upper stomach and the gastroesophageal junction are
displaced upward and slide in and out of the thorax Paraesophageal Hiatal Hernia
All part of the stomach pushes through the diaphragm beside the esophagus
Clinical Manifestation Heartburn Regurgitation Dysphagia Sense of fulness after eating or chest pain
Diagnostic Procedure Xray Barium swallow Fluoroscopy
Management Same pharmacological management w/ GERD Small frequent feeding Advised not to recline 1 hour after eating Elevate HOB Surgery is indicated in about 15% of patients
Surgical Management Nissen Fundoplication
NISSEN FUNDOPLICATION(to treat GERD and hiatal hernia)
Disorders of the Stomach and Small IntestineGASTRITIS
Inflammation of the stomach mucosaCLASSIFICATION
A. Acute Gastritis – includes erosive gastritis and stress ulcersB. Chronic Gastritis – includes non-erosive gastritis
TYPES OF CHRONIC GASTRITIS1. Type A – inflammation of the glands in the
fundus and body2. Type B – inflammation of the glands from fundus to antrum3. Atrophic – diffuse inflammation and destruction of deeply located
glandsETIOLOGY
Acute Gastritis Local irritants (drug, alcohol, corrosive subs.) Bacterial invasion by salmonella, E. Coli and H. Pylori)Chronic Gastritis Atrophy of the gastric glands and achlorydria May occur due to bile acid reflux (complication of gastrojejunal
surgery or peptic ulcer disease) Chronic use of irritants
PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONACUTE GASTRITIS
rapid onset of epigastric pain Pain not relieved by food Dyspepsia hematemesis gastric haemorrhage
CHRONIC GASTRITIS vague epigastric pain pain relieved by food
intolerance of fatty or spicy foods pernicious anemia
SIMILARITIES ANOREXIA Nausea and Vomiting
DIAGNOSTIC TEST Esophagogastroduodenoscopy with biopsy
DRUG THERAPY H2 Receptor Antagonists Antacids Proton Pump Inhibitors Vitamin B12 (if there is pernicious anemia)
Triple Therapy (if there is H. Pylori in biopsy)1) 1 Bismuth subsalicylates or proton pump inhibitor (omeprazole)2) 1 Antibiotic (metronidazole)3) 1 Antibiotic (tetracycline, clarithromycin, amoxicillin) DRUGS TO AVOID – aspirin, ibuprofen
DIET THERAPY Instruct client to limit intake of foods and spices that cause distress Instruct client to avoid alcohol and tobacco Give soft, bland diet and smaller, more frequent meals
STRESS REDUCTION Progressive muscle relaxation Cutaneous stimulation Guided imagery Distraction
SURGICAL MANAGEMENT Partial gastrectomy Pyloroplasty Vagotomy Total gastrectomy
PEPTIC ULCER DISEASE ulceration of the gastric mucosa, duodenum and rarely the lower
esophagus and jejunumTYPES1. Gastric Ulcers
2. Duodenal Ulcers3. Stress Ulcers (Curling Ulcer)
Parameter Gastric Ulcer Duodenal Ulcer
Age Usually 50 years or olderUsually 50 years or older
Gender Male:Female 1:1 Male: Female 1:1
Blood group No differentiation Most often type O
General Nourishment May be malnourished Usually well nourished
Stomach acid production
Normal secretion or hyposecretion
Hypersecretion
OccurrenceMucosa exposed to acid-pepsin secretion
Mucosa exposed to acid-pepsin secretion
Clinical course Healing and recurrenceHealing and recurrence
PainOccurs 30-60 minutes after meal; at night rarely
Occurs 1-3 hours after a meal;at night 1-2 am
Pain QualityAccentuated by ingestion of food
Relieved byingestion of food
Response to treatmentHealing with appropriate therapy
Healing with appropriate therapy
Hemorrhage Hematemesis more common than melena
Melena more common that hematemesis
Malignant change Perhaps in less than 10% Rare
RecurrenceTends to heal and recurs often in the same location
60% recurrence in the same year
Surrounding mucosa Atrophic gastritis No gastritis
PREDISPOSING FACTORS Stress Irregular hurried meals Smoking and alcoholism Caffeinated, fatty, spicy, acidic foods Ulcerogenic medications – Aspirin, NSAIDs, Steroids GI disorders – Gastritis, Zolliger-Ellison Syndrome Type A personality Type O blood
COMPLICATIONS Hemorrhage Perforation Pyloric Obstruction Intractable Disease
ASSESSMENT
HISTORY Alcohol and tobacco use Use of corticosteroids, aspirin and NSAIDs
CLINICAL MANIFESTATIONS Epigastric tenderness Rigid, boardlike abdomen with rebound tenderness Diminishing hyperactive bowel sounds Dyspepsia Vomiting
DIAGNOSTIC TESTS Low hemoglobin and hematocrit Positive fecal occult blood test Barium examination Esophagogastroduodenoscopy (most accurate) Elevated Immunoglobulin G antibodies (suggest H. Pylori infection) Fecalysis
DRUG THERAPYTRIPLE THERAPY (most successful regimen)
1. Bismuth compound or proton-pump inhibitor (omeprazole) 2. Metronidazole 3. Tetracyline or Clarithromycin and Amoxicillin
HYPOSECRETORY DRUGS1) Histamine Receptor Antagonists2) Proton Pump Inhibitors3) Prostaglandin Analogues
MISOPROSTOL (CYTOTEC) ↓gastric secretion and ↑resistance of mucosa to injury CONTRAINDICATION: pregnancy MUCOSAL BARRIER FORTIFIERS SUCRALFATE (CARAFATE) ACTION: binds bile and pepsin to reduce mucosal injury INSTRUCTION: take 1 hour before meals and at bedtime SIDE EFFECT: constipation
DIET THERAPY Bland diet Small frequent feedings (6 small meals/day) Avoid caffeine-containing foods Avoid tobacco and alcohol
MANAGEMENT FOR HYPOVOLEMIA
Monitor VS, I/O Monitor serum electrolytes to determine need for replacement Administer ISOTONIC SOLUTIONS (NSS or lactated Ringer’s) Perform BLOOD TRANSFUSION as prescribed to expand blood
volume If there is active bleeding, administer FRESH FROZEN PLASMA
MANAGEMENT FOR BLEEDING Monitor for the following: signs of SHOCK (hypotension, chills, palpitations, diaphoresis, weak
thready pulse) Occult blood hematocrit, hemoglobin and coagulation studies Perform GASTRIC DECOMPRESSION OR LAVAGE AVOID NSAIDS to minimize GI bleeding
ENDOSCOPIC THERAPYGOAL: promote blood clot formation METHODS OF ENDOSCOPIC THERAPY
(1) THERMAL CONTACT – heater probe or multi electrocoagulation
(2) Inject bleeding site with diluted EPINEPHRINE(3) Laser therapy(4) Mechanical clip
CLIENT PREPARATION Administer SEDATIVES e.g. midazolam and meperidine Place on NPO 6 hours prior the procedure
CARE AFTER THE PROCEDURE Resume diet once gag reflex is present
MANAGEMENT FOR PERFORATION Replace lost fluids, blood and electrolytes* Administer of antibiotics Place on NPO Gastric lavage or decompression Monitor for signs of septic shock (fever, pain, tachycardia, lethargy
or anxietySURGICAL MANAGEMENT FOR OBSTRUCTION
Gastroduodenostomy (Billroth I) Gastrojejunostomy (Billroth II) Partial Gastrectomy Pyloroplasty
CLIENT PREPARATION Insert NGT connected to suction to remove secretions and empty the
stomachPOST-OPERATIVE CARE
Monitor placement, patency and drainage of NGT Monitor for DUMPING SYNDROME
Gastric Dumping Syndrome Rapid gastric emptying is a condition where ingested foods bypass the stomach too
rapidly and enter the small intestine largely undigested.EARLY SIGNS OF DUMPING SYNDROME (within 30 minutes after feeding)
Vertigo Tachycardia Syncope Sweating Pallor Desire to lie down
LATE SIGNS OF DUMPING SYNDROME(90 minutes-3 hours after feeding)
Dizziness Light-headedness Palpitations Diaphoresis Confusion
MANAGEMENT FOR DUMPING SYNDROME Small frequent feeding Do not take fluids with meals Advise high-protein, high-fat, low-to-moderate carbohydrate
diet Administer pectin to prevent the syndrome
GASTROENTERITIS Inflammation of the mucous membranes of the stomach and the
intestinal tractCLASSIC MANIFESTATION
increase in the frequency and water content of the stools or vomitingTYPES
o VIRAL – caused by norwalk virus or rotavirus
o BACTERIAL – caused by E. Coli, campylobacter enteritis or shigellosis
PATHOPHYSIOLOGY
ASSESSMENT Nausea and vomiting (first 2 days of illness) Diarrhea Myalgia Headache Malaise Abdominal tenderness
SIGNS OF DEHYDRATION Poor skin turgor
Dry mucous membranes Hypotension Oliguria
ViralCampylobacter
E. Coli Shigella
Duration of Diarrhea
24-48 hours20-30 defecation for 7 days
10 days 5 days
Stool WateryWateryFoul-smellingSome blood
Watery Some bloodSome mucus
WaterySome bloodSome mucus
WBCs None None None Yes
RBCs None Yes None None
MANAGEMENT FLUID REPLACEMENT
Monitor vital signs, I and O and weight (1 kg weight loss is equivalent to 1 L loss)
Administer HYPOTONIC IV FLUIDS (0.45% NaCl) Oral Rehydration Salts (Oresol) If with HYPOKALEMIA – Incorporate potassium supplements Observe standard precautions
DIET THERAPY IF NOT ACTIVELY VOMITING – clear liquids with electrolytes IF VOMITING – NPO IF TREATED – saltine crackers, toast and jelly IF IMPROVING – bland diet AVOID caffeine
DRUG THERAPY LOPERAMIDE (IMODIUM) – to inhibit peristalsis BISMUTH SUBSALICYLATES (PEPTO-BISMUL) – to reduce watery
volume of stool ANTIBIOTICS NORFLOXACIN OR CIPROFLOXACIN – If caused by bacteria TRIMETHOPRIM OR SULFAMETHOXAZOLE (BACTRIM) – if caused
by If shigellosis is the cause.SKIN CARE
Avoid toilet paper and harsh soap
Use warm water and absorbent cotton Apply cream, oil or gel to excoriated skin Provide witch hazel compress and sitz bath
Disorders of the Lower GI TractINFLAMMATORY BOWEL DISEASESULCERATIVE COLITIS
chronic inflammatory process affecting the mucosa and submucosa of the COLON and RECTUM
CROHN’S DISEASE (REGIONAL ENTERITIS) chronic inflammatory bowel disease affecting segmental areas along
the ENTIRE WALL OF THE GI TRACT; most commonly noted at within the TERMINAL ILEUM
PARAMETER ULCERATIVE COLITIS CROHN’S DISEASEOther Name None Regional Enteritis
Location Rectum/lower colonIleum/ascendingcolon
Cause
Unknown Familial JewishEmotional stress
Unknown Jewish raceEnvironmental
Age 15-40 y.o20-30 y.o40-60 y.o
Bleeding Severe Stool with pus, mucus and blood
moderateStool with pus and mucus
Perianal Involvement Mild SevereRectal Involvement 100% 20%Diarrhea 20-30 watery stool/day 5-6 soft stool/dayAbdominal pain Yes yesWeight loss Yes Yes
Intervention
TPNSteroidsAzulfidine Ileostomy or Proctosigmoidoscopy
TPNAzulfidineIleostomy or Colectomy
PATHOPHYSIOLOGY OF ULCERATIVE COLITIS AND CROHN’S DISEASECLINICAL MANIFESTATIONS
PARAMETERULCERATIVE COLITIS
CROHN’S DISEASE
FEVER Low-grade Low-grade
FOOD INTOLERANCE
Intolerance to dairy, spicy and greasy foods
none
WEIGHT LOSS Yes Yes FREQUENCY OF BM
10-20/day 5-6/day
STOOL Bloody Loose ABDOMINAL PAIN Cramping Periumbilical
OTHER SIGNSTenesmus AnorexiaFatigue
Perianal ulceration
Tenesmus - the feeling of constantly needing to pass stools, even though bowels are already empty.
DIAGNOSTIC ASSESSMENTPARAMETER ULCERATIVE COLITIS CROHN’S DISEASEHEMOGLOBIN Low LowHEMATOCRIT Low LowWBC High NormalALBUMIN Low Low ESR High HighSODIUM Low Normal POTASSIUM Low Low CHLORIDE Low Normal MAGNESIUM Normal Low FOLIC ACID Normal LowCOBALAMIN Normal Low PYURIA None YesOCCULT BLOOD Yes NoneOTHER TESTS Barium Enema ProctosigmoidoscopyDRUG THERAPYSALICYLATE COMPOUNDS
Sulfasalazine (Azulfidine) Indication – Management of ulcerative colitis Action – inhibit prostaglandin synthesis to reduce inflammation Adverse effects – leukopenia and anemia take the drug with a full glass of water take the drug after meal to prevent GI discomfort
ORAL OR INTRAVENOUS CORTICOSTEROIDS Prednisone Indication – to reduce inflammation Adverse Effects – hyperglycemia, osteoporosis, peptic ulcer disease,
increased risk for infectionIMMUNOSUPPRESIVE DRUGS
Should be given in combination with steroids to be effective
Drug Name – cyclosporine, mercaptopurine Indication – to reduce inflammation Adverse Effects – thrombocytopenia, leukopenia, anemia, renal
failure, infection, headache, stomatitis, hepatotoxicityANTI-DIARRHEAL DRUGS
diphenoxylate HCl, atropine sulfate (lomotil), loperamide (imodium)
INFLIXIMAB (REMICADE) for refractory disease or for toxic megacolon an immunoglobulin G that neutralizes activity of tumour necrosis
factorDIET THERAPYIf client has severe symptoms:
NPO Total Parenteral Nutrition (TPN) If client has slightly less severe symptoms: Elemental formula e.g. Vivonex If client has less severe symptoms: Low-fiber (low-residue) diet
Foods to avoid: Whole-wheat grains Nuts fresh fruits and vegetables lactose containing foods caffeinated beverages Pepper Alcohol Smoking
COMPLEMENTARY AND ALTERNATIVE THERAPIES Vitamin C Biofeedback Hypnosis Yoga Acupuncture
SURGICAL MANAGEMENTINDICATIONS FOR SURGERY
Bowel perforation Toxic megacolon Hemorrhage
Colon cancer Failure of conventional treatment
TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY Terminal ileum is pulled through the abdominal wall and forms a
stoma or ostomy PRE-OPERATIVE CARE
Administer oral or parenteral antibiotic such as neomycin sulfate (Mycifradin) as a bowel antiseptic
Administer laxative or enemaPOST-OPERATIVE CARE
Monitor color, odor, consistency of ileostomy output (effluent) Instruct client to report any foul or unpleasant odor (it may indicate
intestinal blockage or infection) Instruct the client to wear pouch system at all times Apply skin barrier (gelatin, pectin) to prevent irritation and injury to
the skinTOTAL COLECTOMY WITH CONTINENT ILEOSTOMY
Alternative to traditional ileostomy with external pouch Creation of an internal reservoir called a Kock’s ileostomy or ileal
reservoir to be drained periodicallyPost-Operative Care
Monitor character and quality of effluent Teach the client to drain stoma when sensation of fullness is felt Apply a small dressing to keep stoma moist
TOTAL COLECTOMY WITH ILEOANAL ANASTOMOSIS Removal of the colon and rectum with anastomosis of the ileum and
the anal canalDISCHARGE INSTRUCTIONS FOR CLIENTS WITH ILEOSTOM
o SKIN CARE Use pectin-based skin barrier to protect skin from irritation Use skin sealants and ostomy skin creams Monitor skin for irritation
o POUCH CARE Empty pouch when it is 1/3 full Change pouch at intervals such as before meals, before
bedtime, before walking at morning, 2-4 hours after meals
Change pouch system every 3-7 daysDIET
Chew food thoroughly
Be cautious in taking high-fiber and high-cellulose foods such as popcorn, peanuts, coconut, string beans, shrimp and lobster, rice, skinned vegetables (tomatoes, corn and peas)
MEDICATIONS Avoid taking enteric-coated and capsule medications Do not take laxative or enema Contact physician if no stool has passed in 6-12 hours
DANGER SIGNS Drastic increase or decrease in effluent Stomal swelling, abdominal cramping, distention, and absence of
drainageINTERVENTIONS FOR DANGER SIGNS
Remove pouch Lie down and assume knee-chest position Begin abdominal massage Apply moist towels to the abdomen Drink hot tea Contact health care provider
IRRITABLE BOWEL SYNDROME Also known as SPASTIC BOWEL OR MUCUS COLITIS Different from ulcerative colitis because there is no inflammation or
ulceration presentRISK FACTORS
Emotional stress or anxiety Diverticulitis Intolerance to gastric stimulants such as caffeine or spicy foods or
lactoseINCIDENCE
Common among women, Caucasians and Jewish population
PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS
NURSING INTERVENTIONS Administer antidiarreals, antispasmodics, bulk-forming laxatives as
ordered Encourage high-fiber diet and avoid fatty and gas forming foods
(carbonated beverages, cauliflower or beans) Instruct client to avoid alcohol and tobacco Encourage to increase oral fluids intake Instruct on lifestyle changes (regular exercise, adequate rest
periods, stress management)
TWO FORMS OF DIVERTICULAR DISEASE
1. DIVERTICULOSIS – asymptomatic multiple out-pouching of the intestinal mucosa WITHOUT INFLAMMATION
2. DIVERTICULITIS – symptomatic multiple out-pouching of the intestinal mucosa WITH INFLAMMATION; causes retention of hardened stool
INCIDENCE More common in older adults More prevalent in men
PREDISPOSING FACTORS Diet low in fiber Diet high in refined carbohydrates
COMPLICATIONS Bowel perforation and peritonitis
Bowel obstruction Hemorrhage
ASSESSMENT Crampy abdominal pain in the left lower quadrant Abdominal distention Low-grade fever Chronic constipation Occult bleeding Nausea and vomiting Leucocytosis
DIAGNOSTIC TESTS Barium enema and colonoscopy (contraindicated if there is
diverticulitis) Complete blood count Urinalysis
NURSING INTERVENTIONS Instruct client to eat high-fiber foods Encourage to increase fluids Administer bulk laxatives and anticholinergics as prescribed Encourage client to lose weight and avoid activities that increase
intra-abdominal pressure SURGICAL MANAGEMENT
Colon resection with temporary colostomy
APPENDICITIS Inflammation of the vermiform appendix More common in males 10-30 years of age
ETIOLOGY Obstruction by fecal impaction, kinking of the appendix, parasites or
infections Low fiber diet High intake of refined carbohydrates
PATHOPHYSIOLOGY
ASSESSMENT Acute abdominal pain at RLQ or McBurney’s point (halfway between
the umbilicus and the anterior iliac crest) Anorexia, nausea and vomiting Rigid and guarded abdomen Blumberg sign (rebound tenderness)
Fever (temperature of 38-38.5 °C) Psoas Sign (lateral position with right hip flexion) Decreased or absent bowel sounds
DIAGNOSTIC TESTS WBC Count Leukocytosis: WBC above10,000/mm3 Perforation: suggested if WBC is above 20,000/mm3 Ultrasound may reveal enlarged appendix Barium Enema or CT Scan Ordered if symptoms are recurrent or prolonged May reveal presence of fecalith
MANAGEMENT Maintain patient on NPO for possible admission Administer IV fluids as prescribed to prevent fluids and electrolyets
imbalance Maintain patient in semi-Fowler’s position to prevent upward spread
of infection DO NOT GIVE LAXATIVE NOR ENEMA to prevent perforation of the
appendix DO NOT APPLY LOCAL HEAT to prevent inflammation and
perforation; instead apply COLD HEATSURGICAL MANAGEMENT
LAPAROSCOPY A small incision in the umbilicus is made and a small
endoscope is used to visualize the appendix If diagnosis is not definitive
LAPAROTOMY An open approach in which large abdominal incision is made
APPENDECTOMY Removal of the inflamed appendix Guided with laparoscopy Done with spinal anesthesia
NURSING CARE AFTER APPENDECTOMY Maintain client flat on bed for 6-8 hours Monitor for return of sensation in the lower extremities Maintain on NPO until peristalsis returns Instruct client to ambulate after 24 hours Tell the client that he can resume normal activities within 2-4
week
PERITONITIS
Inflammation of the peritoneumTYPES OF PERITONITIS
1. PRIMARY PERITONITIS acute bacterial infection resulting from contamination of the
peritoneum through the vascular system May occur from tuberculosis, cirrhosis and ascites
2. SECONDARY PERITONITIS bacterial invasion resulting from acute bacterial abdominal
disorder May occur from gangrenous bowel, visceral perforation, bile
leakage, blunt or penetrating trauma
PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONS RIGID, BOARDLIKE ABDOMEN (CLASSIC SIGN) Abdominal pain (localized, may refer to shoulder or thorax) Distended abdomen Nausea, anorexia and vomiting Diminishing bowel sounds Inability to pass flatus or feces Rebound tenderness in the abdomen
High fever Dehydration Oliguria Hiccups
DIAGNOSTIC ASSESSMENT ELEVATED WBC: 20,000/MM3 Abdominal x-ray may show dilation, edema, inflammation of the
small and large intestine Peritoneal Lavage may reveal the following WBC: 500/ml RBC: 50,000/ml Gram stain: (+) bacteria
MANAGEMENT Administration of the following as prescribed IV fluids to replace lost fluids Broad spectrum antibiotics Oxygen if there is dyspnea due to ascites Monitor daily weight, I/O to monitor fluid status NGT insertion to decompress the stomach and intestine Maintain client on NPO
SURGICAL MANAGEMENT 1. Abdominal surgery guided by exploratory laparotomy2. Appendectomy if there is appendicitis3. Colon resection with or without colostomy if there is bowel
perforationNURSING CARE AFTER SURGERY
Maintain patient in SEMI-FOWLER’S POSITION to promote drainage of peritoneal contents and allow adequate lung expansion
Perform PERITONEAL IRRIGATION as prescribed Check for presence of abdominal distention or pain (suggetive of
irrigant retention) Instruct client to AVOID LIFTING for at least 6 weeks
HEMORRHOIDS dilated and painful veins in the rectum
CLASSIFICATIONS Internal – hemorrhoids ABOVE the anal sphincter External – hemorrhoids BELOW the anal sphincter
RISK FACTORS Familial tendency Straining at stool
Prolonged sitting or standing Pregnancy Obesity Portal hypertension Anal intercourse Colon malignancy
ASSESSMENT Bleeding with defecation and pain (suggestive of internal
hemorrhage)DIAGNOSTIC TESTS
Digital rectal examination Sigmoidoscopy
NURSING INTERVENTIONS Instruct client on the importance of HIGH-FIBER DIET and
INCREASED FLUID INTAKE Instruct client to take STOOL SOFTENERS and use ointments such
as dibucaine, anti-inflammatories, or astringents Apply ICE PACKS for several hours followed by warm packs
SURGICAL MANAGEMENTHEMMORHOIDECTOMY
Laser surgery Atomising Cryosurgery Sclerotherapy (5% phenol in oil) Rubber band ligation
PREOPERATIVE CARE Advise low residue diet Administer stool softeners
NURSING CARE AFTER HEMORRHOIDECTOMY Watch out for bleeding Place the client in PRONE OR SIDE-LYING POSITION Administer analgesics as prescribed Administer stool softeners Offer warm Sitz baths 3-4 times a day
Disorders Involving the Accessory OrgansCHOLELITHIASIS
STONE FORMATION in the in the gallbladder and accessory ductsCHOLECYSTITIS
INFLAMMATION of the gallbladder
RISK FACTORS: 5F’s1. Female gender2. Fat (Obesity)3. Fair (Caucasian)4. Forty (age)5. Fertile (multigravida; use of contraceptive pills)
PATHOPHYSIOLOGY
CAUSE EFFECTS/MANIFESTATIONS
↓ fat emulsificationFat intoleranceAnorexia
Nausea and vomitingWeight lossGaseous eructationFlatulenceSteatorrhea
InflammationPain (Right Upper Quadrant)FeverLeukocytosis
↓ bile flow to colonAcholic stool↓ vitamin K absorption
↑ serum bilirubinJaundicePruritusTea-colored urine
DIAGNOSTIC TESTS Ultrasonography Oral cholecystogram IV cholangiogram Liver function tests Complete blood count
ORAL CHOLECYSTOGRAPHY – radiographic examination of the gallbladderPURPOSES OF ORAL CHOLECYSTOGRAPHY
To detect gallstones Assess the ability of the gallbladder to fill, concentrate its contents, contract and empty
NURSING CONSIDERATIONS ASSESS FOR ALLERGIES to iodine, seafood, or contrast media Administer contrast medium 10-12 hours before x-ray study Instruct patient to remain NPO AFTER TAKING THE CONTRAST
medium to prevent contraction and emptying of the gallbladder DEFER THE PROCEDURE IF PATIENT IS JAUNDICED!!!
TYPES OF CHOLECYSTOGRAPHY1) ORAL – done 10 HOURS after administration of contrast medium2) INTRAVENOUS – done 10 MINUTES after administration of contrast
mediumPREPARING A PATIENT FOR CHOLECYSTOGRAPHY
Instruct to have FAT FREE DINNER Place patient on NPO 2 HOURS BEFORE the test
PREPARING A PATIENT FOR CHOLANGIOGRAPHY ASSESS FOR ALLERGY TO IODINE!!! Instruct to drink ample amount of fluids after administration of dye
NURSING CARE AFTER CHOLANGIOGRAPHY Check for HYPERSENSITIVITY REACTION Instruct client that excretion of dye would cause BURNING
SENSATION during urinationNURSING INTERVENTIONS
Administer MEPERIDINE HCL (drug of choice) as prescribed for pain relief
AVOID ADMINISTERING MORPHINE!!! – it may cause spasm of the sphincter of Oddi
Use BAKING SODA or CALAMINE-CONTAINING LOTIONS for pruritus
Encourage LOW-FAT DIET Administer BILE SALTS such as Chenodeoxycholic acid or
Ursodioxycholic acid (UDCA)SURGICAL MANAGEMENT
CholecystectomyPREOPERATIVE NURSING CARE
Administer IV fluids to replace electrolytes Administer vitamin K injection, especially if prothrombin time is
prolongedPOSTOPERATIVE NURSING CARE
Place patient in SEMI-FOWLER’S POSITION to promote lung expansion
NGT DECOMPRESSION to prevent gastric distention LOW-FAT DIET for 2-3 months Encourage ambulation after 24 hours Encourage to resume normal activities within 2-3 days Monitor T-Tube if common bile duct exploration was done
T-TUBE INSERTION to DRAIN BILE
Drainage Characteristics It should be BROWNISH RED for the first 24 hours It should be 300-500 ML for the first 24 hours
Nursing Responsibilities Place drainage bottle AT THE LEVEL OF THE INCISION
PANCREATITIS Inflammation of the pancreas
TYPES
1. Acute Pancreatitis2. Chronic Pancreatitis
RISK FACTORS Alcohol abuse MEDICATIONS: Antihypertensives, diuretics, antimicrobials,
immunosuppresives, oral contraceptives GI DISORDERS: Biliary obstruction and intestinal diseases
PATHOPHYSIOLOGY
ASSESSMENTACUTE PANCREATITIS
SEVERE, CONTINUOUS left upper quadrant pain radiating to the back
Pain aggravated by eating Pain not relieved by vomiting Flexion of the spine Low-grade fever and leukocytosis
CHRONIC PANCREATITIS
HEAVY, GNAWING, OCCASIONAL BURNING OR CRAMPY L.U.Q abdominal pain
malabsorption and weight loss mild jaundice with dark urine and steatorrhea diabetes mellitus
DIAGNOSTIC TESTS Elevated serum and urinary amylase serum lipase serum bilirubin alkaline phosphatase sedimentation rate White blood cell count Fecal fat determinations Blood and urine glucose
NURSING INTERVENTIONS Administer MEPERIDINE HCL (DEMEROL) as ordered MORPHINE SULFATE PAIN MEDICATION OF CHOICE Place client on NPO DURING ACUTE PHASE bland, LOW-FAT DIET; avoid alcohol NGT DECOMPRESSION insertion to remove gastrin and prevent
further stimulation of the pancreas Administer CALCIUM SUPPLEMENTS (WITH VITAMIN D) if there is
hypocalcemia Administer INSULIN as ordered if there is hyperglycemia
LIVER CIRRHOSIS Irreversible chronic inflammatory disease characterized by massive
degeneration and destruction of hepatocytes resulting in a disorganized lobular pattern of regeneration
TYPES/CAUSES1. LAENNEC’S - caused by ALCOHOLISM or hepatotoxic drugs2. POST-NECROTIC- caused by viral HEPATITIS or industrial
hepatotoxins3. BILIARY - caused by BILIARY PROBLEMS4. CARDIAC - caused by CHF
PATHOPHYSIOLOGY
ASSESSMENT
↓ vitamin K absorption → bleeding tendencies ↓ glycogen stores → hypoglycemia ↓ serum albumin → ↓ hydrostatic pressure → edema and ascites ↓ bilirubin metabolism → hyperbilirubinemia → jaundice Portal hypertension → esophageal varices, hepatomegaly ↑ ADH → hyponatremia ↑ serum ammonia → hepatic encephalopathy
Portal hypertension - an increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver). The increase in pressure is caused by a blockage in the blood flow through the liver. Increased pressure in the portal vein causes large veins (varices) to develop across the esophagus and
stomach to bypass the blockage. The varices become fragile and can bleed easily.
DIAGNOSTIC TESTS LIVER BIOPSY (definitive test) Abdominal x-ray Ct scan Endoscopy Elevated Aspartate Aminotrasferase (AST), Alanine Aminotrasferase
(ALT), bilirubin Prolonged prothrombin time (PT) Decreased serum albumin CBC reveals anemia
PREPARING A PATIENT FOR ULTRASOUND OF THE LIVER NPO 8-12 hours before the procedure Administer laxative a night before the test Maintain adequate hydration
PREPARING A PATIENT FOR LIVER BIOPSY Place patient on NPO 2-4 hours prior ADMINISTER VITAMIN K Monitor prothrombin time Position patient in LEFT LATERAL POSITION with pillow under right
shoulder Instruct to HOLD BREATH 5-10 seconds during needle insertion
NURSING CARE AFTER LIVER BIOPSY Turn the patient to sides q4 hours Place on bed rest for 24 hours Monitor for signs of bleeding
NURSING INTERVENTIONS Place client on BED REST with bathroom privileges Offer LOW-PROTEIN, HIGH CARBOHYDRATES and vitamins (ADEK,
B-complex), LOW SODIUM RESTRICT AMOUNT OF ORAL FLUIDS and eliminate alcohol intake Provide meticulous skin care Monitor weight, I/O and ABDOMINAL GIRTH Assist in paracentesis if necessary Monitor for bleeding of esophageal varices Perform tap water or NSS enema Avoid giving aspirin (causes bleeding) and sedatives (hepatotoxic)
MEDICATIONS FOR A PATIENT WITH CIRRHOSIS ANTACID – to prevent GI bleeding SPIRONOLACTONE (Potassium-sparing diuretic) – diuretic of choice
to manage ascites; does not cause hypokalemia
FUROSEMIDE – diuretic given if patient has hyperkalemia after prolonged use of spironolactone
VITAMIN K – prevents bleeding tendencies INTRAVENOUS ALBUMIN – to manage ascites and edema DUPHALAC (Lactulose) – reduces levels of ammonia NEOMYCIN SULFATE – reduce colonic bacteria responsible for
ammonia formationPREVENTION OF BLEEDING OF ESOPHAGEAL VARICES
Avoid Valsalva maneuver Avoid bending or stooping Avoid hot spicy foods Avoid lifting heavy objects
INTERVENTIONS FOR BLEEDING ESOPHAGEAL VARICES Place patient in SEMI-FOWLER’S POSITION to prevent aspiration Suction the mouth Perform gastric lavage with tap water Insert SENGSTAKEN-BLAKEMORE TUBE Administer IV fluids, blood transfusion as ordered Administer VASOPRESSIN to constrict splanchnic arteries
PREPARING A PATIENT FOR PARACENTESIS Ask to empty bladder to prevent puncture Check serum protein studies Place patient in sitting or upright position
NURSING CARE AFTER PARACENTESIS Check urine output Watch out for board-like abdomen (sign of PERITONITIS) Monitor for signs of hypovolemic shock
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