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NUR240. Stressors of the Gastrointestinal System. Overview of the Gastrointestinal Tract. Structure Function Nerve supply Blood supply Oral cavity. Stomach Pancreas Liver and gallbladder Intestines Esophagus. Assessment Techniques. History Demographic data

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Nur240

NUR240

Stressors of the Gastrointestinal System


Overview of the gastrointestinal tract
Overview of the Gastrointestinal Tract

  • Structure

  • Function

  • Nerve supply

  • Blood supply

  • Oral cavity

  • Stomach

  • Pancreas

  • Liver and gallbladder

  • Intestines

  • Esophagus


Assessment techniques
Assessment Techniques

  • History

  • Demographic data

  • Family history and genetic risk

  • Personal history

  • Diet history

    • Anorexia

    • Dyspepsia


Current health problems
Current Health Problems

  • Pattern of bowel movements

  • Color and consistency of the feces

  • Occurrence of diarrhea or constipation

  • Effective action taken to relieve diarrhea or constipation

  • Presence of frank blood or tarry stools

  • Presence of abdominal distention or gas


Skin changes related to gastrointestinal disorders
Skin Changes Related to Gastrointestinal Disorders

  • Skin discolorations or rashes

  • Itching

  • Jaundice

  • Increased susceptibility to bruising

  • Increased tendency to bleed


Physical assessment
Physical Assessment

  • Mouth and pharynx

  • Abdomen and extremities

    • Inspection (Cullen’s sign)

    • Auscultation, look for borborygmus

    • Percussion

    • Palpation


Laboratory tests
Laboratory Tests

  • Complete blood count

  • Clotting factors

  • Electrolytes

  • Assays of liver enzymes—aspartate and alanine aminotransferase

  • Serum amylase and lipase

  • Bilirubin: the primary pigment in bile

    (Continued)


Laboratory tests continued
Laboratory Tests (Continued)

  • Evaluation of oncofetal antigens CA 19-9 and CEA

  • Urine tests—amylase, urine urobilinogen

  • Stool tests—fecal occult blood test, ova parasites, Clostridium difficile infection

  • Radiographic examinations


Upper gastrointestinal series and small bowel series
Upper Gastrointestinal Series and Small Bowel Series

  • Before test:

    • Maintain NPO for 8 hr.

    • Withhold analgesics and anticholinergics for 24 hr.

  • Client drinks 16 ounces of barium.

  • Rotate examination table.

  • After the test:

    • Give plenty of fluids.

    • Administer mild laxative or stool softener; stools may be chalky white for 24 to 72 hr.


Barium enema
Barium Enema

  • Barium enema enhances radiographic visualization of the large intestine.

  • Only clear liquids are given 12 to 24 hr before the test; NPO the night before; bowel cleansing is done.

  • After the test, expel the barium: drink plenty of fluids; stool is chalky white for 24 to 72 hr.


Percutaneous transhepatic cholangiography
Percutaneous Transhepatic Cholangiography

  • X-ray study of the biliary duct system

  • Laxative before the procedure

  • NPO for 12 hr before test

  • Coagulation tests, intravenous infusion

  • Bedrest for several hours after procedure

  • Assessment of vital signs

  • Client positioned on right side with a firm pillow or sandbag placed against the lower ribs and abdomen

    (Continued)


Other tests
Other Tests

  • Computed tomography

  • Endoscopy: direct visualization of the gastrointestinal tract by means of a flexible fiberoptic endoscope

  • Ultrasonography

  • Endoscopic ultrasonography

  • Liver-spleen scan


Esophagogastroduodenoscopy
Esophagogastroduodenoscopy

  • Visual examination of the esophagus, stomach, and duodenum

  • NPO for 6 to 8 hr before the procedure

  • Conscious sedation

  • After the test, assessment of vital signs every 30 min

  • NPO until gag reflex returns

  • Throat discomfort possible for several days


Endoscopic retrograde cholangiopancreatography ercp
Endoscopic Retrograde Cholangiopancreatography (ERCP)

  • Visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas

  • NPO for 6 to 8 hr before test

  • Access for intravenous sedation

  • Return of gag reflex checked

  • Assessment for pain, colicky abd pain


Small bowel capsule enteroscopy
Small Bowel Capsule Enteroscopy

  • Visualization of the small intestine (camera pill)

  • Only water for 8 to 10 hr before test

  • NPO for first 2 hr of the testing

  • Application of belt with sensors


Colonoscopy
Colonoscopy

  • Endoscopic examination of the entire large bowel

  • Liquid diet for 12 to 24 hr before procedure, NPO for 6 to 8 hr before procedure

  • Bowel cleansing routine

  • Assessment of vital signs every 15 min

  • If polypectomy or tissue biopsy, blood possible in stool


Gastric analysis
Gastric Analysis

  • Measurement of the hydrochloric acid and pepsin content for evaluation of aggressive gastric and duodenal disorders (Zollinger-Ellison syndrome)

  • Basal gastric secretion and gastric acid stimulation test

  • NPO for 12 hr before test

  • Nasogastric tube insertion


Gastroesophageal reflux disease aka gerd
Gastroesophageal Reflux Disease AKA GERD

  • Occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus

  • Reflux esophagitis characterized by acute symptoms of inflammation

  • Esophageal reflux occurs when gastric volume or intra-abdominal pressure is elevated, the sphincter tone of the lower esophageal sphincter (LES) is decreased, or it is inappropriately relaxed.


Gastroesophageal reflux disease
Gastroesophageal Reflux Disease

  • Etiology: smoking, caffeine, alcohol

  • Increased abdominal pressure from obesity, ascites, pregnancy, tight clothing

  • Contributing factors: fatty foods, Ca channel blockers, nitrate, theophylline, peppermint, chocolate, anticholinergics


Clinical manifestations
Clinical Manifestations

  • Dyspepsia

  • Regurgitation

  • Hypersalivation

  • Dysphagia

  • Others manifestations: chronic cough, asthma, atypical chest pain, eructation (belching), flatulence, bloating, after eating, nausea and vomiting


Diagnostic assessment
Diagnostic Assessment

  • 24-hr ambulatory pH monitoring

  • Endoscopy

  • Esophageal manometry


Nonsurgical management
Nonsurgical Management

  • Diet therapy- 4-6 small meals/day. Limit caffeine, tea, cola and chocolate

  • Remain upright 1-2 hrs after meals

  • Client education

  • Lifestyle changes: elevate head of bed 6 in. for sleep, sleep in left lateral decubitus position; stop smoking and alcohol consumption; reduce weight; wear nonbinding clothing; refrain from lifting heavy objects, straining, or working in a bent-over posture


Drug therapy
Drug Therapy

  • Antacids neutralize excess acids, give 1-3hr pc and at hs

  • Histamine receptor antagonists decrease acid production. Ex. Zantac, Pepcid, Axid, Tagamet

  • Proton pump inhibitors provide effective, long-acting inhibition of gastric acid secretion. Ex. Protonix, Prilosec, Nexium, Prevacid

  • Prokinetic drugs increase gastric emptying and improve LES pressure and esophageal peristalsis. Ex. Reglan


Other treatments
Other Treatments

  • Endoscopic therapies

  • Surgical therapies

    For more info , check out these websites:

    www.ddnc.org

    www.gastro.org

    www.heartburnalliance.org


Hiatal hernia
Hiatal Hernia

  • Protrusion of the stomach through the esophageal hiatus of the diaphragm into the thorax


Assessment
Assessment

  • Heartburn

  • Regurgitation

  • Pain

  • Dysphagia

  • Belching

  • Worsening symptoms after eating or when in recumbent position


Nonsurgical management1
Nonsurgical Management

  • Drug therapy: antacids, histamine receptor antagonists

  • Diet therapy: avoid eating in the late evening and avoid foods associated with reflux

  • Weight reduction

  • Elevate head of bed 6 in. for sleep, remain upright for several hours after eating, avoid straining and vigorous exercise, avoid nonbinding clothing.


Nursing considerations
Nursing Considerations

  • Imbalanced nutrition

  • Risk for aspiration

  • Acute pain


Surgical management hiatal hernia repair
Surgical ManagementHiatal Hernia Repair

  • Preoperative care

  • Operative procedures

  • Postoperative care

    • Respiratory care

    • Nasogastric tube management

    • Nutritional care for complications of surgery including gas bloat syndrome and aerophagia (air swallowing)


Diverticula
Diverticula

  • A pouchlike herniation through the muscular wall of a tubular organ.

  • May occur in the stomach, SI, or most commonly, the colon.

  • Zenker’s diverticulum most common

  • Diet therapy : size and frequency of meals

  • Surgical management

  • Both sexes are equally affected

  • Incidence increases with age

  • Diet high in refined sugars


Diverticulosis
Diverticulosis

  • Indicates the presence of diverticula

  • Symptoms: cramping, narrow stools, constipation, weakness and fatigue

  • Complications: hemorrhage, diverticulitis


Diverticulitis
Diverticulitis

  • Inflammation around the divericular sac

  • Undigested food and bacteria collect in the sacs

  • Primarily in individuals older than 50

  • S&S: localized pain (LLQ), fever, elevated WBCs

  • Dx: colonscopy, BE, CT Scan

  • Complications: perforation, hemorrhage, obstruction, abscess


Treatment
Treatment

  • Broad spectrum antibiotics

  • Pain relief

  • Diet- hi fiber

  • Avoid seeds, popcorn, figs, berries, seeds, etc.

  • Sx: if peritonitis or abscess, segment is resected with temp colostomy

  • Anti-anxiety measures


Inflammatory bowel disease
Inflammatory Bowel Disease

  • Etiology: uncertain, may be a genetic predisposition, may be autoimmune

  • Umbrella term for ulcerative colitis and Crohn’s disease

  • Manifestations:

    diarrhea- up to 20/day with exacerbations

    crampy abdominal pain

    exacerbations/ remissions

    Definitive dx by colonoscopy


Ulcerative colitis
Ulcerative Colitis

  • Edematous, inflamed mucosa with multiple abscesses beginning in the rectum and moving up through the LI

  • Inflammation, microscopic hemorrhages and abscesses develop- becomes ulcerated

  • Primarily affects large bowel distal to proximal, mucosal to submucosal involvement

  • Affects younger people (age 15-25)

  • More common in females


Crohn s disease
Crohn’s Disease

  • Any part of the intestine, most commonly in terminal ileum and ascending colon

  • Patchy lesions (shallow ulcers), inflammation, edema and formation of fistulastransmural (entire bowel wall)

  • Etiology:

  • Dx:

  • Manifestations:

  • Complications:


Acute tx for all disorders
Acute tx for all disorders

  • Fluids and bowel rest

  • Medications

  • Potential surgery: Colectomy

    Colostomy

    Long Term- low-fiber, low, residue diet


Assessments
Assessments

  • WBC, Hgb, Electrolytes, ESR

  • Ulcerative Colitis: Bloody diarrhea with mucus and cramping, abd pain

  • Crohn’s Disease: Non-bloody diarrhea, crampy abd pain, insidious weight loss, fatigue, LGT

  • Bowel sounds

  • F&E balance

  • S&S infection


Acute exacerbation
Acute exacerbation

  • Keep pt NPO with an IV and promote bowel rest

  • Correct malnutrition

  • Pain control

  • Administer prescribed meds

  • Provide high calorie, high protein, low fat, low fiber diet with instructions

  • Provide nutritional supplements


Complications and nursing implications
Complications and Nursing Implications

  • Fluid and electrolyte imbalance, malnutrition

  • Bowel obstruction or perforation

    Ulcerative Colitis

  • Toxic megacolon

  • Increased risk for colon Ca

    Crohn’s Disease

  • Fistulas

  • Massive or repeated bowel resections

  • Risk for cholelithiasis and pancreatitis


Medications
Medications

  • 5-aminosalicylic acid drugs- anti-inflammatory effects

    sulfasalazine (Azulfidine)

    mesalamine (Asacol)

  • Corticosteroids

  • Immunosuppressive agents

    azathioprine (Imuran)

  • Antibiotics and antidiarrheal drugs if applicable


Irritable bowel syndrome ibs
Irritable Bowel Syndrome (IBS)

  • AKA spastic bowel or functional colitis

  • Motility disorder of GI tract

  • Intermittent constipation/diarrhea patterns

  • No inflammation


Ibs manifestations
IBS Manifestations

  • Abdominal pain, may be relieved by defecation

  • Intermittent colicky abdominal pain

  • Altered bowel elimination

  • Abdominal bloating, flatulence

  • Possible nausea and vomiting


Ibs dx
IBS Dx

  • Stool- occult blood, O& P

  • CBC and ESR

  • Sigmoidoscopy or colonoscopy

  • Upper GI or small bowel series


Ibs tx
IBS Tx

  • Bulk forming laxatives

  • Anticholinergics- Antispas, Bentyl

  • Immodium, lomotil for diarrhea

  • Antidepressants and SSRIs may relieve abd pain

  • High fiber diet

  • Avoid gas forming foods-if excess gas is problem

  • Avoid caffeine

  • Stress and anxiety reduction


Peptic ulcer disease pud
Peptic Ulcer Disease (PUD)

  • Mucosal lesion of the gastric mucosa or duodenum

  • Gastric ulcers, duodenal ulcers, stress ulcers

  • Mucosal defenses are impaired, edema, degenerative changes of superficial epithelium

  • Causes: Helicobacter pylori infection – up to 90%, infection is cause

    NSAID use

    Severe stress

    Hypersecretory states


Pud s s
PUD S&S

  • Dyspepsia

  • Pain

  • Orthostatic changes


Pud dx procedures
PUD: Dx Procedures

  • Helicobacter pylori testing

  • Gastric sampling

  • Urea breath test, IgG testing

  • EGD-Esophagogastroduodenoscopy-definitive test for PUD

  • Stool samples for occult blood


Treatment1
Treatment

  • Triple Therapy:

    Bismuth or Proton Pump Inhibitors

    2 Antibiotics- Flagyl + tetracycline, clarithromycin, amoxicillin

    Antacids

    Sucralfate (Carafate)

  • Avoid substances that increase gastric secretion

  • Avoid foods that cause discomfort

  • Smaller meals


Complications and nsg implications
Complications and Nsg Implications

  • Assess for perforation/peritonitis

  • Assess for GI Bleeding

    What to look for??

    What to do?


Intestinal obstruction
Intestinal Obstruction

  • May be from mechanical (90% of all) or nonmechanical causes (paralytic ileus)

  • Symptoms vary according to location

  • Bowel sounds hyperactive above obstruction and hypoactive below

  • Tx focuses on F&E balance, decompressing the bowel and relief/removal of obstruction


Dx procedures
Dx Procedures

  • CBC

  • Acid-base balance assessment

  • Electrolytes- hypokalemia

  • Xray- F&U abd xrays look for free air and gas

  • Endoscopy and BE

  • Cat Scan


Nursing interventions
Nursing Interventions

NPO with bowel rest

NGT

IVF and electerolytes

Pain management

Ambulation

Possible preop the patient


Complications and nsg implications1
Complications and Nsg Implications

Dehydration

Electrolyte Imbalance

Perforation

Ischemic or Strangulated Bowel

Peritonitis

Shock

Metabolic Alkalosis- UGI Obstruction

Metabolic Acidosis- LGI Obstruction


Gastric and colorectal cancer
Gastric and Colorectal Cancer

  • Early gastric (malignant neoplasms in stomach) Ca- manifestations:

  • Indigestion, loss appetite, bloating

  • Weight loss, fatigue, abdominal discomfort

  • Many clients have no clinical manifestations.

  • Advanced Ca- Vomiting, occult blood in stool, Iron deficiency anemia, palpable mass, enlarged lymph nodes, pallor


Gastric ca
Gastric Ca

  • Gastric Ca- Interventions :

  • Relieve pain- analgesics, position for comfort, NG tube initially.

  • Monitor for complications- hemorrhage.

  • To maintain nutrition- may need TPN

  • Patient and family education regarding diet, supplements, medication.


Gastric ca tx
Gastric Ca- Tx

  • Drug – 5FU Fluorouracil, FAM protocol Adriamycin and mitomycin C combined.

  • Surgical management- In early Ca- surgery is usually curative, palliative resection for Advanced Ca.

  • Standard post op care

  • .


Colorectal ca
Colorectal Ca

  • Diagnostic tests- CBC, fecal occult blood, CEA, colonoscopy, CT, C-Xray, biopsy.

  • ACS Recommendation for Early Colorectal Ca Detection:

  • FOBT every year

  • Flexible sigmoidoscopy every 5 years

  • FOBT every year plus flexible sigmoidoscopy every 5 years

  • Double contrast BE every 5 years

  • Colonoscopy every 10 years

  • Staging of CA, 0-4. 0= CA in situ, 4=distant mets.

  • Ostomy surgery

  • Radiation

  • Chemo


Colorectal ca1
Colorectal Ca

  • Ileostomy- stoma formed from ileum

  • Colostomy- stoma formed from colon

  • Reasons-colorectal CA, colitis, Crohn’s, diverticulitits

  • Temporary or permanent colostomy.


Colorectal ca2
Colorectal Ca

  • Most tumors in rectum or sigmoid colon

  • Manifestations- Bleeding, change in bowel habits, pain, anorexia and weight loss with advanced disease.

  • Complications- Obstruction, perforation and extension (metastasis) of disease.


Colorectal surgery
Colorectal Surgery

  • NPO- until peristalsis returns, clears to advance, low residue, high calorie diet.

    Cough and deep breathe

  • PCA for pain

  • Inspect stoma- color- pink, red.

  • Patient teaching- stoma will shrink over 3 months, appliance fitted

  • IV, I and O, Foley

  • Monitor electrolytes


Colorectal surgery1
Colorectal Surgery

Life style- sexuality, self esteem, body image, enterostomal therapy nurse, support groups.

  • Assess educational needs of client, learning disabilities, hand dexterity, vision.

  • Educate patient and family- regarding care.

  • Teach assessment of stoma, clean skin and stoma gently, assess for irritation.

  • Skin barriers to protect skin. http://www.colorectal-cancer.net/

  • http://www.ostomy.50megs.com/ostomies.html


The nurse should explain that a diet for a peptic ulcer will most likely consist of which of the following?

  • 1. Bland foods

  • 2. High protein foods

  • 3. Any foods that are tolerated.

  • 4. Large amounts of milk.


Interventions for clients with morbid obesity

Interventions for Clients with Morbid Obesity most likely consist of which of the following?


Nutritional standards to promote health
Nutritional Standards to Promote Health most likely consist of which of the following?

  • Dietary recommendations, food guide pyramids for adequate nutrition

  • Nutritional assessment includes:

    • Diet history

    • Anthropometric measurements

    • Measurement of height and weight

    • Assessment of body fat (body mass index)


Laboratory assessment
Laboratory Assessment most likely consist of which of the following?

  • Hematology

  • Protein studies

  • Serum cholesterol

  • Other laboratory tests


Obesity
Obesity most likely consist of which of the following?

  • Overweight: increase in body weight for height compared to standard

  • Obesity: at least 20% above upper limit of normal range for ideal body weight

  • Morbid obesity: severe negative effect on health


Obesity complications
Obesity Complications most likely consist of which of the following?

  • Diabetes mellitus

  • Hypertension

  • Hyperlipidemia

  • CAD

  • Obstructive sleep apnea

  • Obesity hypoventilation syndrome

  • Depression and other mental health/behavioral health problems

    (


Obesity complications1
Obesity Complications most likely consist of which of the following?

  • Urinary incontinence

  • Cholelithiasis

  • Chronic back pain

  • Early osteoarthritis

  • Decreased wound healing

  • Increased susceptibility to infection


Obesity and health promotion
Obesity and Health Promotion most likely consist of which of the following?

  • Health promotion/illness prevention

    • Teach the potential consequences and complications.

    • Teach the importance of eating a healthy diet.

    • Teach that foods eaten away from home tend to be higher in fat, cholesterol, and salt, and lower in calcium.


Obesity and health promotion1
Obesity and Health Promotion most likely consist of which of the following?

  • Reinforce need for regular moderate activity for at least 30 min per day.

  • Educate regarding diet and activity for children and adolescents, and continuing throughout adulthood.


Nonsurgical management2
Nonsurgical Management most likely consist of which of the following?

  • Very low-calorie diets of 200 to 800 calories per day

  • Balanced and unbalanced low-energy diets

  • Novelty diets

  • Diet therapy

  • Exercise program

  • Drug therapy

  • Complementary and alternative therapies and treatments


Surgical management
Surgical Management most likely consist of which of the following?

Indications-Morbid obesity with co-morbidities and weight control measures that have failed.

  • Liposuction

  • Panniculectomy

  • Bariatric surgery

  • Preoperative care


Operative procedures
Operative Procedures most likely consist of which of the following?

  • Vertical banded gastroplasty

  • Circumgastric banding

  • Gastric bypass

  • Roux-en-Y gastric bypass

    Gastric bypass- create a small stomach which empties directly into jejunum.

    Gastric banding- laparoscopic- adjustable band around upper part of stomach.

    Vertical banded Gastroplasty- “stomach stapling”.


Postoperative care
Postoperative Care most likely consist of which of the following?

  • Analgesia

  • Skin care

  • Nasogastric tube placement

  • Diet

  • Prevention of postoperative complications – Upper GI with gastrograffin

  • Observe dumping syndrome signs such as tachycardia, nausea, diarrhea, and abdominal cramping


Summary of bariatric sx
Summary of Bariatric Sx most likely consist of which of the following?

  • Multidisciplinary team should evaluate and educate potential surgical candidates

  • Life altering way of eating, surgery will limit amt of food one is able to eat

  • Teach how to prevent dumping syndrome

  • Prevent postop complications, infections, monitor wound healing, nutrition, body image


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