The Gastrointestinal System: Digestive Disorders

1. The Gastrointestinal System: Digestive Disorders Part II J. Carley MSN, MA, RN, CNE “Air-Fluid Levels” seen in bowel obstruction

2. A Concept Map : Selected Topics in Gastro-Intestinal Nursing Pathophysiology PHARMACOLOGY ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation KEY ASSESSMENTS Lab Monitoring Upper GI Lower GI Anti-Acids (Antacids) Prototype: aluminum hydroxide gel (Amphojel) Inflammatory Inflammatory G.E.R.D. Ulcers Gastritis Prokinetic Agents: Prototype: metoclopramide (Reglan) Acute Appendicitis Peritonitis Ulcerative colitis Crohn’s Disease Diverticulitis Histamine 2 Receptor Agonists Prototype: ranitidine hydrochloride (Zantac) ***Diagnostic Testing Proton Pump Inhibitors) Prototype: omeprazole (Prilosec) Non-Inflammatory Non-Inflammatory G.E.R.D. Hiatus Hernias Constipation & Diarrhea Irritable Bowel Syndrome Dumping Syndrome Intestinal Obstruction Hemorrhoids & Polyps Malabsorption Mucosal Barriers Prototype: sucralfate (Carafate) Disease Specific Medications: Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more…based On Nursing Process: A_D_O_P_I_E ***Preparing for Diagnostic Tests Nursing Skills: NG Tube Insertion Enteral Feedings Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary

3. A Rough Outline (for the Left Hemispheric Dominant…) Gastritis Dumping Syndrome Small & Large Intestines Appendicitis Peritonitis Diverticulitis Ulcerative Colitis Crohn’s Disease Bowel Obstruction Irritable Bowel Syndrome (IBS) Hemorrhoids Polyps Bowel Cancer

4. Gastritis Inflammation of the gastric mucosa Types: erosive vs. non-erosive Acute vs. Chronic S&S: Abdominal tenderness, bloating, hematesis, melena Diagnostic: EGD with biopsy Management: see GERD

5. Dumping Syndrome Rapid gastric emptying into the small intestines usually occurs after a gastric surgery Types: Early and Late

6. Dumping Syndrome S&S Early Late • 30 min after eating • Rapid emptying • Vertigo • Syncope • Pallor • Diaphoresis • Tachycardia • palpitations • 90 min-3 hr after eating • Excessive insulin release • Abdominal distention • Cramping • Nausea • Dizziness • Diaphoresis • confusion

7. Nursing Interventions Lying down after a meal Eliminate liquids with meals Avoid milk, sweets, or sugars Eat small frequent meals Consume high protein and fat with low to moderate carbohydrate

8. Medication Treatment Pectin Oral: slows absorption of carbs Octreotide SQ: blocks gastric and pancreatic hormones

9. Complication Increased blood glucose level increases the release of insulin. Insulin causes the blood glucose levels to go down…. B L O O D G L U C O S E L E V E L Time----------- “The Somogyi Effect”, a.k.a., “Rebound Effect” Postprandial Hypoglycemia

10. Small Intestines = “-entero”

11. Functions of Small Intestines Movement Digestion Absorption

12. Large Intestines, “-colo-”

13. Function of Large Intestines Movement Absorption Elimination

14. Appendicitis Acute inflammation of veriform appendix

15. Signs and Symptoms Lower right quadrant pain Low grade fever Nausea and vomiting Rebound tenderness @Mc Burney’s point Rosving sign positive Increased WBC

16. Medical Management Monitor pain (severe rebound tenderness) Monitor bowel sounds (absent) NPO, IVF, NO laxatives or enemas Surgical management: -Open or laparoscopic appendectomy

17. Diagnostic Tests Ultrasound Abdominal x-ray Abdominal CT scan

18. Nursing Diagnosis Acute pain Alteration in comfort Risk for injury Knowledge deficit Risk for infection

19. Nursing Interventions Monitor vital signs Assess bowel sounds Monitor pain Monitor lab values Post operative management: -Vitals signs, bowel sounds, diet resumption, antibiotic therapy as ordered

20. Peritonitis Acute inflammation of the visceral / parietal peritoneum and endothelial lining of abdominal cavity Types: primary and secondary

21. Peritonitis Primary Secondary • Acute bacterial infection • Contamination of peritoneum via vascular system • TB (tuberculin infection) • Alcoholic cirrhosis • Leakage • Usually caused by a bacterial invasion in the abdomen • Gangrenous bowel • Blunt or penetrating trauma • Leakage

22. Sign and Symptoms Rigid board like abdomen Abdominal pain/tenderness Distended abdomen Nausea and vomiting Diminished to no bowel sounds No stools or flatus Fever Tachycardia

23. Diagnostic Test CBC (WBC, H&H) Electrolytes CR (creatinine) & BUN (Blood urea nitrogen) Abdominal x-ray CT scan Peritoneal lavage Surgery

24. Medical interventions Non-surgical: -IV fluids -Broad spectrum antibiotics -Intake and outputs (I&O) -NG (nasogastric) tube -NPO -Pain management

25. Medical Interventions Surgical: Optimal treatment Exploratory laparotomy: repair or remove inflamed organ

26. Complications Peritonitis: EMERGENCY / Life Threatening -Symptoms: rigid abd., distended abd., absent bowel sounds, high fever, decreased urine output, hypotension Fluid shifts from extracellular to peritoneal cavity

27. Diverticulitis Inflammation of one or more diverticula. Results when diverticulum perforates and a local abscess forms

28. Symptoms Abdominal pain, tenderness to palpation Elevated temperature >101, may have chills Abdominal guarding, rebound tenderness

29. Diagnostic tests CT scan Abdominal flat plate EGD DO NOT dobarium enema with active untreated diverticulitis

30. Medical Management Non Surgical: -Broad spectrum antibiotics -Anticholinergics -NPO until clear liquids tolerated -Stop fiber therapy until attack is limited -NO enemas or laxatives

31. Medical Management Surgical -completed for ruptured peritonitis, fistula formation, bleeding, bowel obstruction, or unresponsive medical management

32. Nursing Interventions Health teaching: diet, fiber, symptom recognition, activity Post op management: -Monitor colostomy, if present -monitor VS, urine output, wound condition -Psychosocial adjustment to stoma

33. Ulcerative Colitis Ulcerative colitis: Chronic inflammatory process affecting mucosal lining of colon or rectum

34. Symptoms 10-20 liquid stools per day Tenesmus(Straining) Anemia Fatigue LLQ pain/cramping Wt loss

35. Diagnostic Tests CT scans Colonoscopy or Siqmoidoscopy Barium Swallow studies Stools for O&P, occult blood, & C&S Labs: electrolyte panel and CBC

36. Medication Management Salicylate: -inhibit prostglandins to reduce inflammation Corticosteroids: -Suppress immune system and reduce inflammation Immunomodulators: -reduce steroid use and overrides body immune system

37. Medication Management Antibiotics: -acute exacerbations prone to infection Anti-diarrheals: -Symptomatic relief of severe diarrhea

38. Diet Therapy NPO if symptoms are severe TPN if NPO for extended time Elemental formula Low fiber foods Lactose free products No caffeine, spices, alcohol, or smoking

39. Surgical Management Surgery is curative Total colectomy with permanent ileostomy Total colectomy with continent ileostomy (Kock’s pouch)

40. Nursing Diagnosis Pain acute and chronic Fluid volume deficit Alteration in nutrition

41. Nursing Interventions Nutritional assessment Monitoring fluid and electrolytes Monitor lab values Monitor for complications Monitor weight Psychosocial assessment Post operative care

42. Complications Hemorrhage/perforation Coagulation problems Malabsorption Increase risk for colon cancer Toxic megacolon

43. Crohn’s Disease Inflammatory disease of small intestines, colon, or both (terminal ileum)

44. Symptoms 5-10 fatty stools per day (steatorrhea) Flatus Malabsorption Weight loss Diffuse bilateral lower quadrant pain Fever with perforation or fistula Fluid, electrolyte and vitamin deficits

45. Diagnostic Tests CBC Electrolyte panels Vitamin & folic acid levels Albumin & nutritional labs Barium studies Colonoscopy

46. Medical Management Drug Therapy -Salicylate -Corticosteriods -Immunomodulators -Biologic Therapy -Antibiotics (abscess/perforation)

47. Diet Therapy TPN for long term use Nutritional supplements Elemental supplements No caffeine or carbonated beverages No ETOH Prebiotics (non-digestive food ingredients)

48. Surgical Management Surgery is NOT a “cure” Repair of fistulas Release of intestinal obstructions Partial resection with primary anastamosis Ileostomy

49. Complications Intestinal obstruction Fistulas Malabsorption syndrome Liver and biliary diseases Kidney stones Arthritis

50. Nursing Considerations Administering PPN and TPN Provide adequate nutrition: pre-medicate as ordered Assess stools: quality, frequency, amount, and pain issues with stooling Assess vital signs Teach relaxation techniques