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Alterations of GI System. Nur 302 Unit I. Carcinoma of Oral Cavity. Predisposing factors: tobacco & alcohol S/S: leukoplakia, erythroplakia, ulcer, sore or rough spot Diagnosis: biopsy Collaborative Care: surgery, radiation, chemo or combination Health Promotion Expected Outcomes .

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carcinoma of oral cavity
Carcinoma of Oral Cavity
  • Predisposing factors: tobacco & alcohol
  • S/S: leukoplakia, erythroplakia, ulcer, sore or rough spot
  • Diagnosis: biopsy
  • Collaborative Care: surgery, radiation, chemo or combination
  • Health Promotion
  • Expected Outcomes
mandibular fracture
Mandibular Fracture
  • Rx: immobilization by wiring- 4-6 weeks
  • Pre-op teaching
  • Post-op Care: Airway, oral hygiene, communication, nutrition
nausea vomiting
Nausea & Vomiting
  • Problems- Dehydration, loss of electrolytes, decreased plasma volume, metabolic alkalosis,aspiration.
  • History, regurgitation, projectile, fecal odor, partially digested food, color, time of day, emotional stressors.
  • Antiemetics, med’s that stimulate gastric emptying
  • IV and NG tube, begin diet with clear liquids.
gerd predisposing factors
GERDPredisposing Factors
  • Hiatal hernia
  • Incompetent lower esophageal sphincter
  • Decreased esophageal clearance
  • Decreased gastric emptying.
  • Esophagitis- trypsin & bile salts.
hiatal hernia etiology
Hiatal Hernia Etiology
  • Weakening of diaphragm muscles, increased intraabdominal pressure, age, trauma, poor nutrition, recumbent position.
  • Types: Sliding & Paraesophageal or rolling. Complications: hemorrhage from erosion, stenosis, stomach ulceration, strangulation hernia, esophagitis.
  • Treatment : See GERD, elevate HOB on 4-6” blocks, lose weight.
gerd hiatal hernia signs symptoms
GERD & Hiatal HerniaSigns & Symptoms
  • Heartburn
  • Wheezing, coughing, dyspnea
  • Hoarseness, sore throat
  • Post eating bloating
  • N/V, regurgitation
  • Hiatal hernia s/s mimic GB disease, angina, peptic ulcer
diagnostic studies
Barium swallow

Esophagoscopy

Biopsy

Esophageal motility studies

Check ph

Diagnostic Studies
gerd hiatal hernia treatment
GERD & Hiatal Hernia Treatment
  • Med’s: Antacids, H2-Blockers, Prokinetic drugs, Antisecretory drugs.
  • Nutritional Therapy: diet high in P & low in Fat, avoid milk, chocolate, peppermint, coffee and tea, small frequent meals, avoid spicy foods and late meals.
  • Teaching: avoid smoking, decreased stress, do not lie down three hours after eating.
hiatal hernia treatment
Hiatal Hernia Treatment
  • Surgery: valvuloplasties or antireflux procedures.
  • Post-op care:
    • Prevent respiratory complications maintain fluid & electrolyte balance prevent infection.
    • Chest tube
    • NG tube.
esophageal cancer
Barrett’s esophagus/syndrome.

Etiology: smoking, alcohol, chronic trauma, poor oral hygiene, asbestos.

S/S: progressive dysphagia, late s/s pain.

Complication: hemorrhage, mets to liver and lung.

Treatment: surgery, radiation, & chemo.

Esophageal Cancer
esophageal cancers
Esophageal Cancers
  • Pre-op care:
    • high calorie, high P, liquid diet or TPN
    • oral care
    • teaching
  • Post-op care :
    • NG bloody 8-12 hours
    • semi-Fowler’s position
    • prevent resp. complication
gastritis
Gastritis
  • Types: Acute or Chronic, Type A (Fundal) & Type B (Antral).
  • Etiology: breakdown in normal mucosa barrier
  • Corticosteroids, NSAIDS, ASA,spicy foods, alcohol
  • Presence of Helicobacter pylori
gastritis signs symptoms
Gastritis Signs & Symptoms
  • Anorexia
  • N/V
  • Epigastric tenderness
  • Feeling of fullness
  • Hemorrhage
diagnostic studies15
Diagnostic Studies
  • Endoscopic exam
  • CBC
  • Stool for occult blood
  • Cytologic exam
gastritis16
Gastritis
  • Treatment: eval. & eliminate the specific cause, double & triple antibiotic combinations for H. pylori, no smoking, bland diet.
  • Assessment: dehydration, vomiting, hemorrhage.
  • Teaching: stress close medical follow-up, diet, meds.
peptic ulcers
Peptic Ulcers
  • Types: acute or chronic, gastric or duodenal (80%).
  • Person with a gastric ulcer has normal to less than normal gastric acidity compared with a person with a duodenal ulcer.
  • Etiology: H.pylori disrupted mucosal barrier, increased vagal nerve stimulation (eg. emotions), genetic, medications
peptic ulcer signs symptoms
Peptic Ulcer Signs & Symptoms
  • May have no pain
  • Gastric ulcer pain
    • epigastric, burning, “gassy”
    • 1- 2 hrs after meals, stomach empty or when eat food
  • Duodenal ulcer pain
    • back or mid-epigastric, burning, cramp-like
    • 2-4 hrs after meals, antacids relieve pain
peptic ulcers19
Peptic Ulcers
  • Complications: hemorrhage, perforation, gastric outlet obstruction.
  • Diagnostics: fiberoptic endoscopy, H.pylori tests, barium contrast studies, gastric analysis, CBC, urine analysis, liver enzymes studies, serum amylase, stool for occult blood.
  • Conservative therapy: (see gastritis).
nursing care
Nursing Care
  • Acute care: NPO, NG, IV fluid,v/s qh till stable
  • Hemorrhage: assess color of hematemesis, s/s shock.
  • Perforation: assess for sudden severe pain to abd. & shoulder, rigid abdomen, decreased or absent B.S.
surgical therapy
Partial gastrectomy

Billroth I – Gastroduodenostomy, removes distal 2/3 stomach & attaches to duodenum

Billroth II – Gastrojejunostomy, removes distal 2/3 stomach & attaches to jejunum

Vagotomy-eliminates stimulus for acid secretion

Pyloroplasty –enlarges pyloric sphincter, increases gastric emptying

Surgical Therapy
post op care
Post-op Care
  • Observe NG tube drainage
    • Red, decreasing in color 1st 24 hours
    • Observe for clogged NG tube
    • Do not irrigate without MD order, surgeon replaces NG if pt pulls out tube
  • Observe for decreased peristalsis
  • I&O, VS
post op care23
Post-op Care
  • Observe for bleeding/ hemorrhage, NG & dressing
  • Pain management
  • What are the general post-op complications & nursing care?
  • If you do not have HCl, what disease are you at risk for?
case scenario prioritization
BK is post-op Bilroth I and is to receive 2 units of blood. As you get out of report, lab calls and says the first unit of blood is ready. Prioritize:

Verify order to transfuse blood and consent

Take initial set VS

Pick up blood from lab

Assess IV site

Start transfusion

Verify pt ID, & blood compatability

Case Scenario & Prioritization
prioritization
Prioritization
  • Pre-transfusion T98.6, P80, R18, BP136/78. Transfusion started, slow …..15 minutes later- T98.2, P90, R22, BP 130/70, no itching, rate increased 100/h……20 minutes later- skin flushed, p 120, R32, BP100/60, c/o chest pain & chills.
  • Priority problem??? What do you do first? Prioritize:
  • Stop transfusion
  • Save transfusion unit
  • Inform MD/RN
  • Save next voided specimen
  • Start 0.9NS
  • Take VS
post op complications
Post-op complications
  • Dumping Syndrome
  • Postprandial hypoglycemia
  • Bile reflux gastritis
dumping syndrome
Dumping Syndrome
  • Large amount hyperosmolar chyme in intestine->fluid is drawn in->decrease of plasma volume
  • Bowel also becomes distended->increased motility
  • 15-30 minutes after eating->s/s last 1 hr
  • Weakness, sweating, dizzy, cramps, urge to have BM
postprandial hypoglycemia
Postprandial Hypoglycemia

Like dumping syndrome

2 hours after eating

Bolus of high CHO fluid into small intestine->bolus of insulin secretion->hypoglycemia

What are the s/s of hypoglycemia?

bile reflux gastritis
Bile Reflux Gastritis
  • Alkaline gastritis from bile salts
  • Continuous epigastric s/s which increase after meals & relieved by vomiting (temporarily)
  • Treatment – Questran ac or pc, Aluminum hydroxide antacids
nutrition postgastrectomy dumping syndrome
Nutrition PostgastrectomyDumping Syndrome
  • Six small meals
  • Do not have fluids with meals
    • Fluids 45 minutes before or after meals
  • Dry foods low CHO, moderate protein & fats
  • Avoid concentrated sweets (jams, candy, etc)
  • Lie down after meals, short rest period
ca of the stomach
Ca of the stomach
  • Etiology: smoked, spicy, highly salted foods may be carcinogenic, genetics, Type A blood, p.anemia, polyps.
  • S/S of anemia, peptic ulcer disease, or indigestion.
  • Diagnostics: CEA test, stool and gastric analysis, CBC, liver enzymes, amylase, barium studies, endoscopic exams.
  • Surgery: (see peptic ulcer disease).
  • Radiation & chemo
food poisoning
Food Poisoning
  • S/S: n/v, diarrhea, colicky abdominal pain
  • Types: acute bacterial gastroenteritis- staph, clostridial, salmonella, botulism, escherichia coli, see table 42-27
food poisoning health promotion
Food PoisoningHealth Promotion
  • Correct food preparation
  • Cleanliness
  • Cooking
  • Refrigeration
diarrhea
Diarrhea
  • “Symptom”, acute or chronic
  • Etiology: decreased fluid absorption, increased fluid secretion, motility disturbance.
  • Dx studies: H&P, labs, endoscopy
  • Care: replace fluid & lytes, decrease # stools, treat cause, meds
acute infectious diarrhea
Acute Infectious Diarrhea
  • Assessment: freq & duration, char & consistency, laxatives, antibiotics, diet travel, stress, family history, food prep
  • VS, ht & wt, skin turgor, skin breakdown BS, distention, abdominal tenderness
  • Nsg Care: hand washing, contact isolation, teach pt & family
constipation
Constipation
  • Etiology: insufficient dietary fiber, inadeq fluid intake, meds, little exercise
  • Complications: hemorrhoids, Valsalva’s maneuver, diverticulosis
  • Teaching: 20 – 30 g of fiber/day, drink 3 qts/day, exercise 3X/week, avoid laxatives/enemas, record elimination pattern, do not delay defecation & establish a pattern
acute abdomen
“Acute Abdomen”
  • Etiology: see table 43-12
  • S/S: PAIN, abd tenderness, vomiting, diarrhea, abd tenderness, constipation, flatulence, fatigue, fever, increased abd girth
  • DX: H&P, preg test, rectal & pelvic exam, CBC, U/A, abd x-rays
  • Emergency management: table 43-13
acute abdomen38
“Acute Abdomen”
  • Assess: VS, inspect, palpate & auscultate abdomen, pain, n/v, change in bowel habits, vaginal discharge
  • Pre-op Care: CBC, type & cross match, clotting studies, cath, skin prep, NG
  • Post-op care of NG tube, mouth & nare care, control of n/v, abd distention & gas pains
chronic abdominal pain
Chronic Abdominal Pain
  • Irritable bowel syndrome, peptic ulcer , diverticulitis, chronic pancreatitis, hepatitis, cholecystitis, pelvic inflam. disease, vascular insuffic., psychogenic
  • Diagnosis & treatment: “critical thinking skills”
abdominal trauma
Abdominal Trauma
  • Etiology: blunt trauma or penetrating injuries
  • Lacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears, diaphragmatic rupture, urinary bladder rupture, great vessel tears, renal injury, stomach or intestinal rupture
  • S/S: abd guarding & splinting, distended, hard abd, decr or absent BS, contusions, abrasions, bruising on abd, pain, shock, hematemesis or hematuria, Cullen’s sign
abdominal trauma41
Abdominal Trauma
  • Dx: CBC, u/a, abd cat, x-rays, periton. lavage
  • Assessment: shock – decreased LOC & BP, increased resp & P; check abd, flank for abrasions, open wounds, impaled objects, old scars; n/v, hematuria, abd pain, distention, rigidity,pain radiating to shoulder & back, rebound tenderness
  • Interventions: airway, control bleeding, cover protruding organs, IV, labs, foley, VS, LOC, see table 43-14
appendicitis
Appendicitis
  • S/S: periumbilical pain, then shifting to RLQ & localizing @ McBurrey’s point, tenderness, rebound tenderness, muscle guarding, Rovsing’s sign, anorexia, n/v, low grade fever
  • Complic: perforation, peritonitis, abscess
  • Dx: H&P, WBC, u/a
  • Nsg Care: NPO, no laxatives or heat to area, post-op: OOB next day & advance diet
peritonitis
Peritonitis
  • Etiology: rupture of an organ, trauma, pancreatitis, peritoneal dialysis
  • S/S: tenderness over area, rebound tenderness, muscle rigidity & spasms, abd distention, n/v, tachycardia, tachypnea, alt bowel habits
  • Complications: hypovolemic shock, septicemia, abscess, paralytic ileus, organ failure
  • DX: CBC, C&S perit. Fld, CT, x-ray
nursing care44
Nursing Care
  • Assess pain, BS, distention, guarding, temp, labs, s/s shock
  • VS, I&O, lytes, NPO, antiemetics, NG
  • Surgical site drains (penrose, Jackson Pratt, “open belly”) check color & amt drainage, I & O if irrigation of wound
  • Antibiotics, analgesics, maybe TPN
gastroenteritis
Gastroenteritis
  • S/S: n/v, diarrhea, fever abd cramps
  • Rx: NPO til stop vomiting, then flds with glucose & electrolytes (Pedialyte)
  • Complication: dehydration, loss of lytes
  • Strict handwashing & medical asepsis, rest & increased fld intake
ulcerative colitis
Ulcerative Colitis
  • Inflammation, abscesses in mucosa break into submucosa & ulcerate, decreased area for absorption, granulation tissue forms & mucosa becomes thick & short.
  • S/S: bloody diarrhea & abd pain - acute or chronic, mild or severe exacerbations. Fever, malaise, anorexia, wt loss, dehydration, anemia, tachycardia
complications
Complications
  • Intestinal: hemorrhage, strictures, perforation, toxic megacolon, colonic dilatation, risk for colon cancer
  • Extraintestinal: due to malabsorbtion or problem with immune system – joints, skin, mouth & eyes
  • Dx: CBC, lytes, albumin, stool analysis, sigmoidascope & colonoscopy, barium enema
nursing collaborative care
Nursing & Collaborative Care
  • Rest bowel
  • Control inflammation
  • Prevent / treat infection
  • Correct malnutrition
  • Meds to relieve s/s
  • Alleviate stress
  • See NCP 40-3
slide49
Meds
  • Sulfasalazine – maintenance & remission, for 1 year
  • 5-ASA – active disease, 4-ASA given as retention enemas
  • Corticosteroids :IV, enema, Prednisone
  • Cyclosporin
  • Sedatives, antibiotics, vitamins
surgery
Surgery
  • Total proctocolectomy with perm. ileostomy
  • Total protocolectomy with continent ileostomy called a Knock pouch
  • Total colectomy & ileal reservoir
  • Surgery “cures” disease
  • Post-op: stoma care, skin integrity, I&O, observe for hemorrhage, abscess, small bowel obstruction, electrolyte imbalance & dehydration, diet teaching & care of ileostomy
crohn s disease
Crohn’s Disease
  • Inflammation of segments GI tract esp ileum,jejunum, colon & involves all layers of bowel wall
  • Classic “cobblestone” appearance, normal bowel between diseased, longitudinal, deep ulcerated parts
  • Thickening bowel wall & strictures
  • Abscesses & fistulas with bladder, vagina, bowel
crohn s disease52
Crohn’s Disease
  • Chronic disease, intermittent remissions & recurrences
  • S/S: diarrhea & abd pain, arthritis may precede s/s, progressive disease – wt loss, dehydration, anemia, pain RLQ & umbilicus
  • Complications: fistulas, malabsorption of A,D,E,K, gluten intolerance, arthritis, liver disease, cholelithiasis, nephrolithiasis, uveitis
  • Dx: same as ulcerative colitis
collaborative care
Collaborative Care
  • Sulfasalazine – large intestine involvement
  • Corticosteroids – taper off when s/s subside
  • Immunosuppressive meds if steroids ineffective
  • Flagyl – perianal area
  • Fish oil, B-12 IM,
  • Balloon dilation of strictures
  • Element diet- hi calorie, hi Nitrogen no fat; OR lo residue & roughage, hi calorie & P, possibly lactate free diet
surgery54
Surgery
  • Indications: fistulas, abscess, intestinal obstruction, perforation, ? Carcinoma, hemorrhage, no response to therapy
  • Surgery is not a cure, high recurrence
  • Procedure – intestinal resection with anastomosis
nursing care55
Nursing Care
  • Patient & family teaching regarding nature of disease & limitations of tx
  • Teach: diet, importance of rest, meds, when to seek medical care, reduce stress, perianal care
  • Post-op: ulcerative colitis NCP 43-3
  • Skin care, referral to wound care nurse for abscess / fistulas
intestinal obstruction
Intestinal Obstruction
  • Mechanical: adhesions, neoplasms, hernias
  • Nonmechanical: paralytic ileus, pseudoobstructions, vascular
  • Pathophysiology: feces, fld & gas collect proximal to obstruction, distention, collapse distal bowel, decr absorption of fld, incr pressure, flds & lytes into peritoneal cavity. Edema, necrosis, congestion from decr bld supply, possible bowel rupture & shock
intestinal obstruction57
Intestinal Obstruction
  • Obstructions: simple, closed loop, strangulated, incarcerated
  • S/S: n/v, pain, distention, inability to pass gas, hi pitched BS above area of obstruction
  • Dx: H&P, abd x-rays, barium enema, sigmoidoscopy, colonoscopy, CBC, lytes, BUN, amylase, WBC, guiac stool
  • Tx: decompress intestine, surgery
nursing care58
Nursing Care
  • Assessment: pain, s/s, BS, dehydration, labs
  • Insertion & care NG tube
  • Intestinal tubes: Harris tube, Miller-Abbott tube, Cantor tube
colon rectal cancer
Colon & Rectal Cancer
  • Risk factors
  • Adenomatous polyps->adenocarcinoma Spread thru walls of intestine -> lymph system, metastasis to liver-> portal vein
  • S/S: L lesions- rectal blding, alt constipation & diarrhea, ribbon like stools, sensation of incomplete evacuation, s/s obstruction. R lesions- vague abd pain, weakness & fatigue from anemia
colon rectal cancer60
Colon & Rectal Cancer
  • Dx: H&P, rectal exam, sigmoidoscopy, air contrast barium enema, CT scan colonoscopy, CBC, clotting studies, liver enzymes, CEA
  • Staging: primary tumor, regional lymph node involvement, distant metastasis
  • Surgery: R or L hemicolectomy, abdominal perineal resection
  • Chemo & radiation: post-op or palliative
health promotion
Health Promotion
  • Assess risk factors
  • American Ca Society recommends screening @ age 40- rectal exam q yr. Age 50 sigmoidoscopy q 5 yrs & stool occult bld q yr: if + findings->colonoscopy, BE. Hi risk pts- colonoscopy q? depends on risk
  • Barriers: lack of info & fear of dx
  • Research: use of anti-inflammatory drugs or long term use of ASA
  • Diet
nursing care abd perineal resection
Nursing Care Abd-Perineal Resection
  • Teach extent of surgery for abdom-perineal resection, positioning for comfort & sitz bath, ostomy questions
  • Abd wound, perineal wound, stoma
  • Profuse drainage from perineal wound immed post op – reinforce dsg. Keep clean & dry.
  • Packing left 2-3 days then irrigate wound with NS; drains left in 3-5 days; closed wound- sitz bath. Check s/s infection. C/O pain, itching.
home care
Home Care
  • Psychological support
  • Pain/discomfort management
  • Nutrition
  • Care of perineal wound
  • Home health nurse – assessment & teaching of pt & family
  • Community Services
ostomy surgery
Temporary or permanent

Stoma

Ileostomy, knock pouch, ileoanal reservoir

Cecostomy

Colostomy, loop & double barrel

Ostomy Care: assess stoma, skin care, select pouch/bag, psychol support & adaptation to stoma, sexual dysfunction

Ostomy Surgery
diverticular disease
Diverticular Disease
  • Lack of fiber, retention of stool & bacteria, fecalith-> inflammation, small perforations, edema, abscess, peritonitis
  • S/S diverticulosis: none or LLQ crampy abd pain, alt constipation & diarrhea. Diverticulitis: localized pain, tender LLQ mass, fever, chills, n/v, anorexia, leukocytosis, elderly-afebrile, little tenderness
diverticulitis
Diverticulitis
  • Complications: perforation & peritonitis, abscess & fistula, bowel obstruction, bleeding – hematochezia (maroon stools)
  • Tx uncomplicated disease: hi fiber diet, bulk laxatives (Metamucil), anticholinergic meds (Donnatal), incr flds, obese->loose wt, avoid staining @ stool
  • Diverticulitis: rest bowel- NPO, IV, BR,NG, antibiotics, complications->surgery
hernias
Hernias
  • Protrusion of viscous thru wall of cavity.
  • Reducible, irreducible or incarcerated, strangulated
  • Types: inguinal, femoral, ventral or incisional
  • S/S: bulge, discomfort, pain->strangulated
  • Tx: herniorrhaphy, hernioplasty, truss
  • Post-op: check voiding, scrotal support, ice pack, no coughing, splint incision with mouth open if sneeze, no lifting 6-8 weeks
malabsorption syndrome
Malabsorption Syndrome
  • Causes: biochemical or enzyme deficiency, bacterial profileration, disruption sm intestine mucosa, disturbed lymph or vascular circulation,surface area loss
  • Lactose intolerance, inflam bowel disease, celiac, tropical sprue, cystic fibrosis
  • S/S: steatorrhea (except lactose intol)
  • Dx: stool for fat, screening for CHO absorption, pancreatic secretion test, BE, sm bowel biopsy, CBC, lytes, PT, Ca, Chol, vit A
short bowel syndrome
Short Bowel Syndrome
  • Excessive resection of small intestine.
  • Rapid intestinal transit, impaired digestion & absorption, fld & lyte loss
  • S/S: diarrhea & steatorrhea, malnutrition &vit & mineral deficiencies, wt loss, lactase def, bacterial overgrowth, kidney stones
  • Tx: antidiarrheal meds, TPN-> hi CHO, low F diet, 6 meals/day
anorectal problems
Anorectal Problems
  • Hemorrhoids- internal or external dilated veins
  • Tx: hi fiber diet, increase fld, prevent constipation, nupercaine oint, astringents, suppositories, ice pack, sclerosing agent or ligate, hemorrhoidectomy
  • Post-op: pain, sitz baths, packing removed 1-2 days, stool softener, teaching- diet, avoid constipation, complication- bleeding
anorectal problems71
Anorectal Problems
  • Anal fissure –crack or skin ulcer in anal wall, associated with constipation
  • Anorectal abscess- perirectal infection E. coli, staph or strep, foul smell, sepsis
  • Surgically drained, packed q day with petroleum jelly gauze, keep clean, heal by granulation, sitz bath, lo residue diet
  • Pilonidal cyst- tract @ sacrcoccyx, congenital, lined with epithelium & hair, abscess forms
  • Tx- I&D