West Coast University BSN Program NURS 120 . Medical Surgical Nursing Gastrointestinal System - Gastroesophageal Reflux Disease Gastroenteritis Constipation Hemorrhoids Diarrhea. Anatomy of Gastrointestinal system . The GI System.
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Medical Surgical Nursing
- Gastroesophageal Reflux Disease
Blood draining the GI tract empties into the
portal vein, then perfuse to liver.
Small intestine receives from hepatic and
superior mesenteric arteries.
Large intestine receives from superior and inferior
- Ingestion and Propulsion of food (Mouth, Pharynx and Esophagus).
- Digestion and Absorption (Mouth, Stomach, Small Intestine)
- Elimination (Large Intestine)
Saliva is use for food lubrication.
Mechanical breakdown of food.
digestion of protein begins with the
release of pepsinogen turn to pepsin.
-Food stay in the stomach 3-4 hours.
- When food enters stomach and small
intestine,hormones are release into the
- Digestion is complete at the small
intestine. Bile is necessarry for digestion of
- Cholecystokinin – stimulates pancrease to
synthesize and secretes enzymes for digestion of
carbohydrates, fats and protein.
completes digestion process. These
enzymes hydrolyze disaccharides to
monosaccharides and peptides to amino
acids for absorption.
absorption of water and electrolytes.
Large intestine also serve as reservoir for
fecal mass until defecation occurs.
Defecation is a reflex action involving
voluntary and involuntary control.
Defecation can be facilitated by Valsalva
Maneuver. This maneuver involves contracation
of the chest muscles on a close glottis with
simultaneous contraction of the abdominal
pressure. Maybe contraindicated in a client
with head injury, eye surgery, cardiac
problems, hemorrhoids, abdominal
surgery,or liver cirrhosis.
Aminopeptidases, Maltase, Sucrase,
Expected Aging Changes:
Mouth – Gingival Retraction
Decreased taste buds
Decrease volume of saliva
Atrophy of gingival tissue
Esophagus – Decreased esophageal sphincter pressure,
Abdominal Wall – Thinner and less taut.
Decrease in number and sensitivity
of sensory receptors.
digestive enzymes and motility.
Decrease in protein synthesis, ability to
sphincter tone and nerve supply to rectal area
Decrease muscular tone, decreased motility,
Increase in transit time, sensation to defecation
production decrease, pacreatic reserve
Differences in Assessment Findings:
Differences in Assessment Findings: Cont.
The client must have several episodes of reflux for GERD to be present.
- Nurse should ask about health practices related to GI system e.gmaintenace of normal body weight.
- Dietary history should be taken and compared with the food pyramid.
-Client should be asked on the frequency, time of day, and usual consistency of stool should be noted.
- The pt. ambulatory status should be checked.
- The pt. should be asked if GI symptoms affects sleep
- The pt. should be assess with sensory adequacy, change in smell or taste. Pain should also be assessed.
- Assess the pt’s willingness to engage in self-care and
to discuss this situation.
- Assess availability of and satisfaction with support.
- Assess for effect of problems related to GI on pt’s sexuality and reproductive status.
- Determine what is the stressor for the pt. and what
coping mechanisms the pt. uses to function with
Pt’s spiritual and cultural beliefs regarding food preparation should be assessed.
Raw Fruits and Fruit juices esp. prune and
grape juice, raw vegetables, cabbage, sweets,
alcohol and highly spicy foods stimulates
e.g. chocolate, coffee, tea, and other
caffeinated beverages stimulates the anal
sphincters to relax .
bananas, rice, bread, potatoes, cheese, yogurt,
oatmeal, oatbran, boiled milk and pasta.
- Avoid foods that stimulate acid secretions but do not neutralize acids.
- Foods include coffee, tea, meat broth, and alcohol.
- Restricting milk may result in Calcium , riboflavin and Vit. D deficiency.
(dyspepsia) and regurgitation (acid reflux) in relation to eating or activities.
Fluoroscopy is a type of medical imaging that shows a
continuous x-ray image on a monitor, much like an x-
ray movie. It is used to diagnose or treat patients by
displaying the movement of a body part or of an
instrument or dye (contrast agent) through the body.
During a fluoroscopy procedure, an x-ray beam is
passed through the body. The image is transmitted to a
monitor so that the body part and its motion can be
seen in detail.
TIGHT CLOTHING AT THE WAIST
- Fatty and fried foods
- Caffeinated beverages such as coffee
- Spicy foods
- Citrus foods
Hiatal Hernia –LES displacement into the thorax with delayed esophageal clearance.
-Monitor for sign and symptoms – classic
sign: Dyspepsia especially after eating.
chronic cough from irritation, hypersalivation, eructation, flatulence, , atypical chest pain,
NANDA Nursing Diagnosis
A fowler or semi-fowler position is beneficial in reducing the amount of regurgitation as well as in preventing the encroachment of the stomach upward through the opening of the diaphragm.
4. Encourage client to stop eating three hours before bedtime.
5. Teach about commonly prescribed medications ( H2 antagonist, antacids).
avoid large meals
remain upright after eating
avoid eating before going to bed.
Lose weight if applicable.
Elevate the head of the bed with blocks.
Use of pillow is not recommended as this
rounds the back, bringing the stomach
contents up closer to the chest.
administer 1-3 hours after eating and at HS.
Should be separated with other meds at
least 1 hour.
(Ranitidine). Reduce the secretion of acid.
Helicobacter Pylori (H. Pylori).
Risk Factors in the Development of PUD:
NURSING PLANS and INTERVENTIONS
- Antacids (Maalox): Need to take several times a day.
Administer after meals
Assess Hx of renal disease for Mg
products. Electrolyte adjustment can
result in renal insufficiency and
- H2 receptor Antagonist – Cigarette smoking can
interferes with drug action.
leats 1 hour prior to meals.
Antacids interfere with absorption.
Do not crush or chew
IV Pantoprazole to be given over 3 min period.
Inhibit absorption of other drug
Resume oral therapy as soon as feasible.
- Gastric resection
- NSAIDS e.g. Ibuprofen
- Corticosteroid in high dosage
- Reserpine (antihypertensive)
- Cessation of smoking and stress management.
- Dark tarry stools
- coffee ground emesis
- bright red rectal bleeding
- Severe abdominal pain ( report immediately) could denote perforation.
- Viral infection
- Bacterial infection (Salmonella)
- Food-borne illness (such as shellfish) can be the
Virus e.g. Norovirus, Rotavirus
Bacteria e.g Staphylococci, E. Coli, Shigella, Salmonella, Campylobacter. Clostridium Difficile.
Parasite – Giardia (Giardiasis)
Common symptoms may include:
More serious symptoms:
- Frequent use of Laxatives
- Advance age
- Inadequate fluid intake
- Inadequate fiber intake
- Immobilization due to injury
- A sedentary lifestyle
- Viral Gastroenteritis
- Overuse of laxatives/laxative abuse
- Use of certain antibiotics
- Inflammatory bowel disease (Cronh’s disease – subacute, chronic inflammation extending throughout the entire intestinal mucosa (Terminal Ileum).
Certain food like red meat, raw vegetable and medication (aspirin, NSAIDS) can cause false positive. Bleeding can be a sign of CANCER (others include anal fissures, hemorrhoids, inflammatory bowel disease, malignant tumor, peptic ulcer) which can be contributing factor to constipation.
An early sign of COLON cancer is rectal bleeding. Encourage client 50 years of age and older and those with increased risk factor to be screen with FOBT yearly and Routine Colonoscopy at 50.
Dark tarry stools ( Peptic Ulcer due to mixture
of gastric acid and the blood) Macroscopic
Bright –red (constipation, bleeding from
anal fissure or sigmoid area).
Abdominal mass or bruit
Decreased BP, rapid pulse, cool ext. (s/s of
- Abdominal bloating
- Abdominal cramping
- Straining at defecation
- s/s of dehydration
- Frequent loose stools
- Abdominal cramping
- Fecal Impaction
- Development of hemorrhoids and/or rectal fissure
- Bradycardia, hypotension, and syncope associated
with the Valsalva Maneuver (bearing down)
stimulation of Vagus Nerve..
- Monitor constipation carefully and take measures
to treat and prevent constipation
- Removing fecal impaction. Break apart the impact
slowly. Monitor V/S and response. Preceded by application of glycerin or Bisacodyl (Dulcolax supp.)
- Dehydration. Monitor for s/s of fluid and electrolyte imbalance. Monitor for metabolic acidosis cause by excessive loss of bicarbonate.
- Skin breakdown around the anal area. Carefully
follow skin protocol.
- Replace losses as prescribed.
Replacing Fluids and Electrolytes
Vegetables, fruits (especially dried fruits), and some cereals (whole wheat, bran, or oatmeal) are excellent sources of fiber. It is easy to remember that the harder a vegetable is (like celery), the more fiber it has. To reap the benefits of fiber, it is very important to drink an adequate amount of water to help with the passage of stool in the intestines.
Goal/Nursing Management Interventions
Provides body with nutrition such as protein, sugar, vitamins, minerals, and sometimes fat (lipids). TPN is used when unable to eat or cannot get enough nutrition from the foods you eat. TPN always goes into vein (blood vessel) through an intravenous (IV) line. It may be given to you in the hospital, long-term care center, or at home. May need TPN for several days or longer.
-The adhesive-backed opening is designed to cover the
stoma. Should be 1/8 clearance from the stoma.
- A rubber band or clip is use to secure the bottom.
- A simple squirt bottle is used to remove effluence from sides of the bag. Pouch system is changed q 3-7 days.
- Client should maintain extra supply of pouches.
- Empty pouch is 1/3 to ½ full.
- Irrigate same time daily.
- Use warm water (cold or hot can cause cramping)
- Wash around stoma with lukewarm water and a mild
- Commercial skin barriers may be purchased for home use.
Eliminate foods that can cause offensive odors.
maybe eliminated (popcorn, peanuts, unpeeled
Colostomy: Client should resume regular diet
gradually. Problem food preoperatively should be tried
NANDA NURSIN DIAGNOSIS
Tumors or Diverticulitis. Outside the bowel: Hernia and adhesions.
-Sudden onset of abdominal pain.
- Hx of abdominal surgeries
- Increase peristalsis when obstruction first occur then peristalsis becomes absent when paralytic ileus occurs.
- Bowel sound are high-pitched
Proper placement needs to be determined via X-Ray.
Canto, Miller-Abbot, or Harris tubes are passed through the nose into the stomach usually by HCP. Advance tube every 1-2 hours.
Do not secure to nose until reaches specified position.
Reposition q 2 hours to assist with placement of the tube
Connect to suction.
Irrigate with air only
Note amount, color, consistency and any unusual odor of drainage.
Cont/Management of Bowel Obstruction
-Place client on NPO
- NG Tube
- IV fluids
- Surgical preparation of bowels (if obstruction is complete).
- Teaching ( preoperative, nutrition, etc.)
(seeding can occur during surgical resection of tumor).
Family Hxof colorectal cancer.
Inflammatory Bowel Diseases
(Ulcerative colitis, Crohn’s Disease)
High Fat, Low Fiber diet.
Older than 50 year of age.
Hx of ovarian or breast cancer
Most Common Area is the rectosigmoidal region.
- 2 stool samples within 3 consecutive days.
- Instruct the client to avoid ingestion of some food or drugs because result can be false positive. In, general, instruct to avoid meat, NSAID’s, and Vitamin C are avoided for the 48 hour period prior to testing.
Colorectal cancer is the third most frequently diagnosed cancer in men and women and the second highest cause of cancer deaths in the U.S. Yet, when found early, it is highly curable. This type of cancer occurs when abnormal cells grow in the lining of the large intestine (colon) or rectum.
Colorectal cancers often begin as polyps – benign growths on the surface of the colon. The two most common types of intestinal polyps are adenomas and hyperplastic polyps.
Colorectal Cancer ScreeningBecause colorectal cancer is stealthy, screenings are the key to early detection. Beginning at age 50, most people should have a colonoscopy every 10 years. This procedure uses a tiny camera to examine the entire colon and rectum. These tests not only find tumors early, but can actually prevent colorectal cancer by removing polyps (shown here).
Virtual ColonoscopyThere is now an alternative to colonoscopy that uses CT scan images to construct a 3-D model of your colon. Called virtual colonoscopy, the procedure can reveal polyps or other abnormalities without actually inserting a camera inside your body. The main disadvantage is that if polyps are found, a real colonoscopy will still be needed to remove and evaluate them.
X-Rays of the Colon (Lower GI)X-Rays of the colon -- using a chalky liquid known as barium as a contrast agent -- allow your doctor a glimpse at the interior of the colon and rectum, offering another way to detect polyps, tumors, and changes in the intestinal tissue. Shown here is an "apple core" tumor constricting the colon. Like the virtual colonoscopy, any abnormalities that appear on the X-rays will need to be followed up with a conventional colonoscopy.
Staging Colorectal CancerIf cancer is detected, it will be "staged," a process of finding out how far the cancer has spread. Tumor size may not correlate with the stage of cancer. Staging also enables your doctor to determine what type of treatment you will receive.Stage I – Cancer has not spread beyond the inside of the colon or rectumStage II – Cancer has spread into the muscle layer of the colon or rectumStage III - Cancer has spread to one or more lymph nodes in the areaStage IV – Cancer has spread to other parts of the body, such as the liver, lung, or bones. This stage does NOT depend on how deep the tumor has penetrated or if the disease has spread to the lymph nodes near the tumor.
Colorectal Cancer SurgeryIn all but the last stage of colorectal cancer, the usual treatment is surgery to remove the tumor and surrounding tissue. In the case of larger tumors, it may be necessary to take out an entire section of the colon and/or rectum. The good news is that surgery has a very high cure rate in the early stages. If the cancer has spread to the liver, lungs, or other organs, surgery is not likely to offer a cure -- but removing the additional tumors, when possible, may reduce symptoms.
Treating Advanced Colorectal CancerWhen colorectal cancer has spread to one or more lymph nodes (stage III), it can still be cured. Treatment typically involves a combination of surgery, radiation (being administered here), and chemotherapy. If the cancer comes back after initial treatment or spreads to other organs, it becomes much more difficult to cure. But radiation and chemotherapy can still relieve symptoms and help patients live longer
Radiofrequency AblationRadiofrequency ablation (RFA) uses intense heat to burn away tumors. Guided by a CT scan, a doctor inserts a needle-like device that delivers heat directly to a tumor and the surrounding area. This offers an alternative for destroying tumors that cannot be surgically removed. In patients with a limited number of liver metastases that cannot be removed by surgery, chemotherapy is sometimes combined with RFA for tumor destruction.
Preventing Colorectal Cancer: DietThere are steps you can take to dramatically reduce your odds of developing colorectal cancer. Researchers estimate that eating a nutritious diet, getting enough exercise, and controlling body fat could prevent 45% of colorectal cancers. The National Cancer Institute recommends a low-fat diet that includes plenty of fiber and at least five servings of fruits and vegetables per day.
Above are all posiible adjuvant therapies.
- fatigue due to occult blood loss.
- Change in bowel habits ( constipation or diarrhea)
- Visible blood in the stool.
- Mass of digital rectal examination.
- S/s due to metastases – partial bowel obstruction (high pitched tingling bowel sound), complete bowel obstruction ( no BS in 5 minutes).
- assess the color and integrity of the stoma.
(stoma should be reddish pink, moist, and may have small amount of visible blood immediately postoperative):
- report any evidence of stoma ischemia or necrosis e.g dark or cyanosis color.
- monitor for high-pitched BS before site of obstruction with hypoactive BS after, or overall hypoactive bowel sounds.
- decompression and/or surgical intervention.
- Monitor hemoglobin, hematocrit, and stools for evidence of bleeding.
- replace losses ( fluid replacement or blood transfusion).
- Support the client during and following surgical intervention.
- Administer antibiotics as prescribed.
- Prepare the client for incisional/surgical drainage.
- provide antibiotic as prescribed.
- Enlarged veins located in the lower part of the rectum and the anus.
- They become swollen because of increased pressure within them, usually due to straining at stools and during pregnancy because of the pressure of the enlarged uterus.
Bleeding with a bowel movement is never normal and should prompt a visit to a health care practitioner.
NANDA Nursing Diagnosis
- Sitting in a few inches of warm water three times a day for 15-20 minutes may help decrease the inflammation of the hemorrhoids.
- It is important to dry off the anal area completely after each Sitz bath to minimize irritation of the skin surrounding the anus.
- Increased fluid intake and dietary fiber (roughage) will decrease the potential for constipation
- Stool softeners may help but once hemorrhoids are present, liquid stools may cause inflammation and infection of the anus.
-Teach client with hemorrhoids should not sit for long
periods of time.
- May benefit from sitting on an air or rubber donut. Exercise is helpful in relieving constipation and in
decreasing pressure on the hemorrhoidal veins.
Individuals should be encouraged to have a bowel
movement as soon as possible after the urge arises.
In preparing for colonoscopy procedure, which task is most suitable for the nurse to delegate to the UAP?
a. Explain the need for clear liquids 1-3 days prior to
b. Reinforce NPO status 8 hours prior to procedure.
c. Administer laxatives 1-3 days prior to procedure.
d. Administer and enema the night before the
a. Projectile vomiting.
b. Burning sensation 2 hours after eating.
c. Coffee-ground emesis.
d. Board-like abdomen with should pain?
a. MagnisiumTrisilicate (Gaviscon) and Famotidine
b. Ranitidine (Zantac)
c. Pantoprazole (Protonix)
__________, __________, ___________
a. Assess for bowel sounds.
b. Auscultate tube for placement and check pH.
c. Flush the tube with water.
d. Reflush the tube with water.
e. Administer the feeding.
f. Check for residual volume.
a. A client with oral cancer who is scheduled in the
morning for glossectomy.
b. An obese client returned from surgery following
vertical banded gastroplasty.
c. A client with anorexia nervosa with muscle
weakness and decreased urine output.
d. A client with intractable nausea and vomiting
related to chemotherapy.
a. Hang the container at about shoulder height.
b. Allow the solution to flow slowly and steadily for
c. Put 500 to 1000 ml of lukewarm water in the
d. Allow 30 -45 minutes for evacuation.
e. Lubricate the stoma cone and gently insert the
tubing tip into the stoma.
f. Cleanse, rinse, and dry skin, and apply a new drainage
g. Put on a pair of clean gloves.
a. Administer glycerin suppository 15 minutes
before evacuation time.
b. Insert a rectal tube at specified intervals each day.
c. Assist the client to the bedpan or toilet 30
minutes after meals.
d. Use incontinence brief pads or adult-sized
a. Black, tarry stools and decreased urination from
unusually low blood pressure.
b. Shortness of breath and increasing abdominal girth
c. Edematous lower extremities.
d. Sudden relaxation of muscles of the hand and hold
a sustained posture.
a. Teach the client self-care measures for
b. Assist the HCP in incision and drainage of a
c. Evaluate the client’s response to sitz bath for an
d. Describe the basic pathophysiology of an anal
fistula to a client.
a. Abdominal distension and rigidity.
b. NG tube intentionally displaced by client.
c. Absent or hypoactive bowel sounds.
d. Nausea and occasional vomiting.
a. A 35 –year old female with copious, intractable
diarrhea and vomiting.
b. A 43-year old female second day post-op with
c. A 53-year old female with pain related to alcohol-
d. A 62-year old female with colon cancer receiving
chemotherapy and radiation.