Chapter 34 Lee Resurreccion Assessment of Digestive and Gastrointestinal Function

1. Chapter 34Lee ResurreccionAssessment of Digestive and Gastrointestinal Function

2. Organs of the Digestive System

3. Examination of the Abdomenp.1128, fig. 34-4Rovsing's sign

4. Gastroscopyp. 1134, fig. 34-6

5. Colonoscopy p. 1135, fig. 34-7

6. Sigmoidoscopyp. 1137, fig. 34-8

7. Chapter 35Management of Patients Esophageal Disorders

8. Upper GI Complications • GERD • Hiatal hernia • CA

9. Gastroesophageal Reflux Disease(GERD) Causes: • Impaired motility of the esophagus • Delayed gastric emptying • Defective defenses of the esophagus • Dysfunction of the lower esophageal sphincter (LES)

10. Hiatal (Hiatus) Hernia : Pathophysiology • Structural changes • Weakening muscles of diaphragm • Increased intraabdominal pressure • Obesity/pregnancy/ascites/tumors/physical exertion • Age • Poor nutrition (atrophy) • Prolonged illness (confined to bed)

11. Sliding Esophageal and Paraesophageal Hernia

12. Chapter 36Gastrointestinal Intubation and Special Nutritional Modalities

13. Types of Tubes • Gastric tubes • Levin • Sump • Enteric tubes

14. TPN / T-Lumen

15. Chapter 37: Management of Patients With Gastric and Duodenal Disorders

16. Gastritis • A common GI problem that causes inflammation of the stomach • Acute: rapid onset of symptoms usually caused by dietary indiscretion. Other causes include medications, alcohol, bile reflux, and radiation therapy. Ingestion of strong acid or alkali may cause serious complications. • Chronic: prolonged inflammation due to benign or malignant ulcers of the stomach or Helicobacterpylori. May also be associated with some autoimmune diseases, dietary factors, medications, alcohol, smoking, and chronic reflux of pancreatic secretions or bile.

17. Gastritis

18. Erosive Gastritis

19. Manifestations of Gastritis • Acute: abdominal discomfort, headache, lassitude, nausea, vomiting, and hiccupping • Chronic: epigastric discomfort, anorexia, heartburn after eating, belching, sour taste in the mouth, nausea, vomiting, and intolerance of some foods; may cause vitamin deficiency due to malabsorption of B12 • May be associated with achlorhydria, hypochlorhydria, and hyperchlorhydria • Diagnosis is usually by UGI x-ray or endoscopy and biopsy

20. Medical Management of Gastritis • Acute • Refrain from alcohol and food until symptoms subside • If due to strong acid or alkali treatment to neutralize the agent, avoid emetics and lavage due to danger of perforation and damage to the esophagus • Supportive therapy • Chronic • Modify diet, promote rest, reduce stress, and avoid alcohol and NSAIDs • Pharmacologic therapy: see Table 37-1

21. Gastritis Signs and Symptoms: • Anorexia • Nausea and vomiting • Epigastric tenderness • Feeling of fullness

22. Gastritis Therapy Acute phase: NPO IV fluids Possible NG tube Antiemetics Antacids H2 antagonists or proton pump inhibitor Antibiotics for H. pylori (for chronic) Blood transfusions for hemorrhage Bed rest

23. Nursing ManagementGastritis • Assessments • Dry mucous membrane, • poor skin turgor, • bowel sound • Coffee ground emesis • electrolytes • Interventions • Diet • IV • Positioning • Environment • Emotional support • Antiemetics

24. Nursing Process—Assessment of the Patient With Gastritis • History including presenting signs and symptoms • Dietary history and dietary associations with symptoms • Monitor dietary intake and keep 72-hour diet diary • Abdominal assessment

25. Nursing Process—Diagnosis of the Patient With Gastritis • Anxiety • Imbalanced nutrition • Risk for fluid volume imbalance • Deficient knowledge • Acute pain

26. Nursing Process—Planning the Care of the Patient With Gastritis Major goals include: • reduced anxiety • avoidance of irritating foods • adequate intake of nutrients • maintenance of fluid balance • increased awareness of dietary management • and relief of pain

27. Interventions • Reduce anxiety; use calm approach and explain all procedures and treatments • Promote optimal nutrition. For acute gastritis, the patient should take no food or fluids by mouth; introduce clear liquids and solid foods as prescribed. Evaluate and report symptoms. Discourage caffeinated beverages, alcohol, and cigarette smoking. Refer patient for alcohol counseling and smoking cessation. • Promote fluid balance; monitor I&O for signs of dehydration, electrolyte imbalance, and hemorrhage • Measures to relieve pain: diet and medications • See Chart 37-1

28. Peptic Ulcer • Erosion of a mucous membrane forms an excavation in the stomach, pylorus, duodenum, or esophagus • Associated with infection of H. pylori • Risk factors include excessive secretion of stomach acid, dietary factors, chronic use of NSAIDs, alcohol, smoking, and familial tendency • Manifestations include a dull gnawing pain or burning in the midepigastrium; heartburn and vomiting may occur • Treatment includes medications, lifestyle changes, and occasionally surgery: see Tables 37-1 and 37-3

29. Erosion

30. attach to the epithelial cells Helicobacter pylori spiral shape with flagella to move through the mucus of the stomach

31. Antisecretory H2 antagonists Cimetidine Ranitidine Famotidine Nizatidine Proton pump inhibitors Omeprazole Lansoprazole Pantoprazole Anticholinergics Antisecretory and cytoprotective Misoprostol (Cytotec) Cytoprotective Sucralfate Pepto-bismol Antacids Antibiotics for H. pylori Amoxicillin Metronidazole Tetracycline UlcerDrug Therapy

32. Deep Peptic UlcerErosion

33. Surgical Procedures for Peptic Ulcers Vagotomy Pyloroplasty Billroth I-Gastroduodenostomy Billroth II-Gastrojejunostomy

34. Nursing Process—Assessment of the Patient With Peptic Ulcer • Assess pain and methods used to relieve pain • Lifestyle and habits such as cigarette and alcohol use • Provide medications, including use of NSAIDs • Monitor for signs and symptoms of anemia or bleeding • Provide abdominal assessment

35. Nursing Process—Diagnosis of the Patient With Peptic Ulcer • Acute pain • Anxiety • Imbalanced nutrition • Deficient knowledge

36. Collaborative Problems/Potential Complications • Hemorrhage: Excessive discharge of blood from the blood vessels • Perforation: A hole or series of holes punched or bored through something • Penetration: act or process of piercing or penetrating something • Pyloric obstruction (gastric outlet obstruction)

37. Nursing Process—Planning the Care of the Patient With Peptic Ulcer Major goals for the patient may include: • relief of pain • anxiety reduction • maintenance of nutritional requirements • knowledge about the management and prevention of ulcer recurrence • and absence of complications

38. Anxiety • Assess anxiety • Maintain calm manner • Explain all procedures and treatments • Help identify stressors • Explain various coping and relaxation methods such as biofeedback, hypnosis, and behavior modification

39. Patient Teaching • Medication usage • Dietary restrictions • Lifestyle changes • See Chart 37-2

40. Management of Potential Complications • Management of hemorrhage • Assess for evidence of bleeding, hematemesis (vomiting blood), or melena (black, tarry stool), and symptoms of shock/impending shock and anemia • Treatment includes IV fluids, NG, and saline or water lavage; oxygen; treatment of potential shock including monitoring of VS and UO; may require endoscopic coagulation or surgical intervention

41. Gastric Cancer • Incidence is deceasing, but accounts for 12,000 U.S. deaths annually • Increased incidence: in men Native Americans Hispanic Americans African Americans typically between the ages of 40 to 70

42. Risk factors • diet • H. pylori infection • pernicious anemia • smoking, • chronic inflammation of the stomach • Achlorhydria • gastric ulcers • previous subtotal gastrectomy • And genetics

43. Gastric Cancer (cont.)Manifestations include • pain relieved by antacids • , dyspepsia • early satiety • weight loss • abdominal pain • loss or decrease in appetite • , bloating after meals • nausea • and vomiting • diagnosis of the disease is often late

44. Treatment • surgical removal of the tumor if possible • palliative care if the tumor is not resectable or has metastasized

45. Nursing Process—Assessment of the Patient With Gastric Cancer • Dietary history and nutritional status • Risk factors and smoking and alcohol history • Social support, individual and family coping • Resources • Physical assessment including assessment of the abdomen

46. Nursing Process—Diagnosis of the Patient With Gastric Cancer • Anxiety • Imbalanced nutrition • Pain • Anticipatory grieving • Deficient knowledge

47. Nursing Process—Planning the Care of the Patient With Gastric Cancer Major goals include reduced anxiety, optimal nutrition, relief of pain, adjustment to the diagnosis, and anticipated lifestyle changes

48. Anxiety • Provide a relaxed, nonthreatening atmosphere • Allow patient to express fears and concerns • Provide support and encourage family support • Promote positive coping measures • Explain treatments and procedures • Provide referral to support persons such as social workers or clergy

49. Promote Optimal Nutrition • Encourage small, frequent meals of non-irritating foods • Provide foods high in calories and vitamins A and C and iron • Provide diet and teaching for potential dumping syndrome after gastric resection • Provide 6 small feedings low in carbohydrates and sugar, with fluids between, not with, meals • Assess I&O, daily weights, signs of dehydration, and nutritional status

50. Other Interventions • Pain • Administer analgesics as prescribed • Provide nonpharmacologic pain relief measures • Psychosocial support • Allow patient to express fears, concern, and grief • Allow patient to participate in decisions • Include family members and significant others • Provide referral/involvement of other support persons as needed • Patient teaching: see Chart 37-5