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The Gastrointestinal System: Digestive Disorders. Part II. J. Carley MSN, MA, RN, CNE. “Air-Fluid Levels” seen in bowel obstruction. A Concept Map : S elected T opics in G astro- I ntestinal N ursing. Pathophysiology. PHARMACOLOGY. ASSESSMENT Physical Assessment Inspection

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the gastrointestinal system digestive disorders

The Gastrointestinal System: Digestive Disorders

Part II

J. Carley MSN, MA, RN, CNE

“Air-Fluid Levels” seen in bowel obstruction

slide2

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

a rough outline for the left hemispheric dominant
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

gastritis
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

dumping syndrome
Dumping Syndrome

Rapid gastric emptying into the small intestines usually occurs after a gastric surgery

Types: Early and Late

dumping syndrome s s
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
nursing interventions
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

medication treatment
Medication Treatment

Pectin Oral: slows absorption of carbs

Octreotide SQ: blocks gastric and pancreatic hormones

complication
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

functions of small intestines
Functions of Small Intestines

Movement

Digestion

Absorption

function of large intestines
Function of Large Intestines

Movement

Absorption

Elimination

appendicitis
Appendicitis

Acute inflammation of veriform appendix

signs and symptoms
Signs and Symptoms

Lower right quadrant pain

Low grade fever

Nausea and vomiting

Rebound tenderness @Mc Burney’s point

Rosving sign positive

Increased WBC

medical management
Medical Management

Monitor pain (severe rebound tenderness)

Monitor bowel sounds (absent)

NPO, IVF, NO laxatives or enemas

Surgical management:

-Open or laparoscopic appendectomy

diagnostic tests
Diagnostic Tests

Ultrasound

Abdominal x-ray

Abdominal CT scan

nursing diagnosis
Nursing Diagnosis

Acute pain

Alteration in comfort

Risk for injury

Knowledge deficit

Risk for infection

nursing interventions19
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

peritonitis
Peritonitis

Acute inflammation of the visceral / parietal peritoneum and endothelial lining of abdominal cavity

Types: primary and secondary

peritonitis21
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
sign and symptoms
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

diagnostic test
Diagnostic Test

CBC (WBC, H&H)

Electrolytes

CR (creatinine) & BUN (Blood urea nitrogen)

Abdominal x-ray

CT scan

Peritoneal lavage

Surgery

medical interventions
Medical interventions

Non-surgical:

-IV fluids

-Broad spectrum antibiotics

-Intake and outputs (I&O)

-NG (nasogastric) tube

-NPO

-Pain management

medical interventions25
Medical Interventions

Surgical: Optimal treatment

Exploratory laparotomy: repair or remove inflamed organ

complications
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

diverticulitis
Diverticulitis

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

symptoms
Symptoms

Abdominal pain, tenderness to palpation

Elevated temperature >101, may have chills

Abdominal guarding, rebound tenderness

diagnostic tests29
Diagnostic tests

CT scan

Abdominal flat plate

EGD

DO NOT dobarium enema with active untreated diverticulitis

medical management30
Medical Management

Non Surgical:

-Broad spectrum antibiotics

-Anticholinergics

-NPO until clear liquids tolerated

-Stop fiber therapy until attack is limited

-NO enemas or laxatives

medical management31
Medical Management

Surgical

-completed for ruptured peritonitis, fistula formation, bleeding, bowel obstruction, or unresponsive medical management

nursing interventions32
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

ulcerative colitis
Ulcerative Colitis

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

symptoms34
Symptoms

10-20 liquid stools per day

Tenesmus(Straining)

Anemia

Fatigue

LLQ pain/cramping

Wt loss

diagnostic tests35
Diagnostic Tests

CT scans

Colonoscopy or Siqmoidoscopy

Barium Swallow studies

Stools for O&P, occult blood, & C&S

Labs: electrolyte panel and CBC

medication management
Medication Management

Salicylate:

-inhibit prostglandins to reduce inflammation

Corticosteroids:

-Suppress immune system and reduce inflammation

Immunomodulators:

-reduce steroid use and overrides body immune system

medication management37
Medication Management

Antibiotics:

-acute exacerbations prone to infection

Anti-diarrheals:

-Symptomatic relief of severe diarrhea

diet therapy
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

surgical management
Surgical Management

Surgery is curative

Total colectomy with permanent ileostomy

Total colectomy with continent ileostomy (Kock’s pouch)

nursing diagnosis40
Nursing Diagnosis

Pain acute and chronic

Fluid volume deficit

Alteration in nutrition

nursing interventions41
Nursing Interventions

Nutritional assessment

Monitoring fluid and electrolytes

Monitor lab values

Monitor for complications

Monitor weight

Psychosocial assessment

Post operative care

complications42
Complications

Hemorrhage/perforation

Coagulation problems

Malabsorption

Increase risk for colon cancer

Toxic megacolon

crohn s disease
Crohn’s Disease

Inflammatory disease of small intestines, colon, or both (terminal ileum)

symptoms44
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

diagnostic tests45
Diagnostic Tests

CBC

Electrolyte panels

Vitamin & folic acid levels

Albumin & nutritional labs

Barium studies

Colonoscopy

medical management46
Medical Management

Drug Therapy

-Salicylate

-Corticosteriods

-Immunomodulators

-Biologic Therapy

-Antibiotics (abscess/perforation)

diet therapy47
Diet Therapy

TPN for long term use

Nutritional supplements

Elemental supplements

No caffeine or carbonated beverages

No ETOH

Prebiotics (non-digestive food ingredients)

surgical management48
Surgical Management

Surgery is NOT a “cure”

Repair of fistulas

Release of intestinal obstructions

Partial resection with primary anastamosis

Ileostomy

complications49
Complications

Intestinal obstruction

Fistulas

Malabsorption syndrome

Liver and biliary diseases

Kidney stones

Arthritis

nursing considerations
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

health teaching
Health Teaching

Education for ileostomy or colostomy for both client and family

Reduce or eliminate factors that cause diarrhea and pain

Chronic pain management

Provide small frequent meals with specific dietary preferences

Detailed abdominal assessment

bowel obstruction
Bowel Obstruction

Small Intestines

Large Intestines

  • Pain is spasmodic
  • Peristaltic waves
  • Profuse projectile vomiting
  • Feculent odor to emesis
  • Vague diffuse constant pain
  • Abdominal distention
  • Infrequent vomiting
  • Possible diarrhea

“Air-Fluid Levels” in intestinal obstruction

cause
Cause

Mechanical

Non-mechanical

  • Adhesions
  • Tumors
  • Volvulus
  • Intussusception
  • Fecal impactions
  • Foreign Bodies / Objects
  • Decreased peristalsis
  • Electrolyte imbalance
  • Inflammatory response
  • Neurogenic disorder
  • Vascular disorder

Foreign Body in the Colon

complications54
Complications

Dehydration

Perforation

Ischemic or strangulated bowel

Metabolic acidosis and Alkalosis

irritable bowel syndrome ibs
Irritable Bowel Syndrome(IBS)

Chronic disorder of diarrhea and constipation

No exact cause known

Affects women 3x more then men

Possible causes: diet and behavioral (psychological) illness

signs and symptoms56
Signs and Symptoms

“Manning Criteria:”

-abdominal pain relieved by defecation

-abdominal distention

-sensation of incomplete BM (bowel

movement)

-Presence of mucus

sign and symptoms57
Sign and Symptoms

Exacerbation (flare up):

-worsening cramps

-abdominal pain (LLQ)

-diarrhea or constipation

-increased pain after eating

-nausea with defecation and mealtime

diagnosis
Diagnosis

CBC

Serum albumin

Stools for occult blood

Sigmoidoscopy

Colonscopy

nursing intervention
Nursing Intervention

Stress Management

Diet Therapy:

-Avoid lactose products, caffeine, ETOH,

sorbitol or fructose

-Increase fiber (30-40 gm)

-Fluid intake of 8-10 cups per day

-meal planning

nursing intervention60
Nursing Intervention

Monitor Drug Therapy

-laxatives

-diarrheals / antidiarrheals

-anticholinergic

-tricyclic antidepressants

-muscarinic receptor antagonist

-antispasmatics

-5HT4 (Zelnorm)

hemorrhoids
Hemorrhoids

Swollen or distended veins in rectal region

Internal & external

Cause: pregnancy, obesity, constipation

Symptoms: bleeding, edema, and prolapsed

Treatment: cold packs, sitz bath, diet, Tucks ®, topical anesthetics, and surgery

polyps
Polyps

Small growths covered with mucosa and attached to the surface of intestines

Asymptomatic-bleeding, obstruction, &

intussusception

Benign vs. malignant

Colorectal cancer

colorectal cancer
Colorectal Cancer

Colon and rectum=large intestines

Molecular changes

Metastasize to blood, lymph, surrounding & tissue

naso gastric tubes ngt
Naso-Gastric Tubes (NGT)
  • Purpose for Naso-Gastric Tubes:
  • 1. Decompression
  • 2. Feeding
  • 3. Administration of Medications
  • ***4. Lavage
  • General Golden Rule for Feeding Tubes:
  • Ensure correct placement prior to putting ANYTHING DOWN a TUBE!!!
  • X-Ray Confirmation
misplaced feeding tube
Misplaced Feeding Tube
  • At 1st looks OK but distal tip NOT SEEN
  • This tube ended up exiting the mid abdomen with the feedings entering the peritoneal cavity
slide75

Tube feeding formula

remaining in contact with gastric acid can result in the precipitation of casein and the subsequent formation

of a solid mass around the tube

ngt insertion documentation to include
Date & time

Reason for insertion

Type of tube

Size of tube

Length of tube

Nostril tube inserted

Number of attempts required

Additional comments

Any complications

Method of placement confirmation

Signature: name & designate of Nurse inserting tube

NGT insertion documentation to include:
pharmacology anti acids antacids prototype aluminum hydroxide gel amphojel
Pharmacology:Anti-Acids (Antacids)Prototype: aluminum hydroxide gel ( Amphojel )
  • Pharmacological Action
  • Neutralize gastric acid and inactivate pepsin.
  • Mucosal protection may occur by the antacid’s ability to stimulate the production of prostaglandins.
  • Therapeutic Uses
  • Treat peptic ulcer disease (PUD) by promoting healing and relieving pain.
  • Symptomatic relief for clients with GERD.
  • Nursing Interventions and Client Education
  • Clients taking tablets should be instructed to chew the tablets thoroughly and then drink at least 8 oz of water or milk.
  • Teach the client to shake liquid formulations to ensure even dispersion of the medication.
  • Compliance is difficult for clients because of the frequency of administration.
  • Administered seven times a day: 1 hr before and 3 hr after meals, and again at bedtime.
  • Teach clients to take all medications at least 1 hr before or after taking an antacid.
  • Evaluation of Medication Effectiveness
  • Depending on therapeutic intent, effectiveness may be evidenced by:
  • Healing of gastric and duodenal ulcers.
  • Reduced frequency or absence of GERD symptoms.
  • No signs or symptoms of GI bleeding.

Back to Concept Map

pharmacology prokinetic agents prototype metoclopramide reglan
Pharmacology:Prokinetic AgentsPrototype : metoclopramide ( Reglan )
  • Pharmacological Action
  • Block dopamine and serotonin receptors in the chemoreceptor trigger zone (CTZ), and thereby suppress emesis.
  • Prokinetic agents augment action of acetylcholine which causes an ↑ in upper GI motility.
  • Therapeutic Uses
  • Control postoperative and chemotherapy-induced nausea and vomiting.
  • Prokinetic agents are used to treat GERD.
  • Prokinetic agents are used to treat diabetic gastroparesis.
  • Side Effects / Adverse Effects
  • Extra Pyramidal Symptoms (EPS)
  • Sedation
  • Diarrhea
  • Contraindications / Precautions
  • Contraindicated in clients with GI perforation, GI bleeding, bowel obstruction, and hemorrhage
  • Contraindicated in clients with a seizure disorder due to ↑ risk of seizures
  • Use cautiously in children and older adults due to the ↑ risk for EPS.
  • Nursing Interventions and Client Education
  • Monitor clients for CNS depression and EPS.
  • Can be given orally or intravenously. If dose is < 10 mg, it may be administered undiluted over 2 min.
  • If the dose is > 10 mg, it should be diluted and infused over 15 min. Dilute medication in at least 50 mL of D5W or lactated Ringer’s solution.
  • Evaluation of Medication Effectiveness
  • Control of nausea and vomiting

Back to Concept Map

tardive dyskinesia
**TardiveDyskinesia
  • Overview
  • Tardivedyskinesia is a disorder that involves involuntary movements, especially of the lower face. Tardive means "delayed" and dyskinesia means "abnormal movement."
  • Symptoms
  • Facial grimacing
  • Jaw swinging
  • Repetitive chewing
  • Tongue thrusting
  • Causes
  • Tardivedyskinesia is a serious side effect that occurs when you take medications called neuroleptics. It occurs most frequently when the medications are taken for a long time, but in some cases it can also occur after you take them for a short amount of time.
  • The drugs that most commonly cause this disorder are older antipsychotic drugs, including:
  • Haloperidol
  • Fluphenazine
  • Trifluoperazine
  • Other drugs, similar to antipsychotic drugs, that can cause tardivedyskinesia include:
  • Cinnarizine
  • Flunarizine (Sibelium)
  • Metoclopramide
  • Prognosis
  • If diagnosed early, the condition may be reversed by stopping the drug that caused the symptoms.
  • Even if the antipsychotic drugs are stopped, the involuntary movements may become permanent and in some cases may become significantly worse.

Next Page

pharmacology histamine 2 h2 receptor agonists prototype ranitidine hydrochloride zantac
Pharmacology:Histamine 2 (H2) Receptor AgonistsPrototype : ranitidine hydrochloride (Zantac)
  • Pharmacological Action
  • Suppress the secretion of gastric acid by selectively blocking H2 receptors in parietal cells lining the stomach.
  • Therapeutic Uses
  • Gastric and peptic ulcers, gastroesophageal reflux disease (GERD), and hypersecretory conditions, such as Zollinger-Ellison syndrome.
  • Used in conjunction with antibiotics to treat ulcers caused by H. pylori.
  • Therapeutic Nursing Interventions and Client Education
  • Encourage client to avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Ranitidine can be taken with or without food.
  • Treatment of peptic ulcer disease is usually started as an oral dose twice a day until he ulcer is healed, followed by a maintenance dose, which is usually taken once a day at bedtime.
  • Evaluation of Medication Effectiveness
  • Depending on therapeutic intent, effectiveness may be evidenced by:
  • Reduced frequency or absence of GERD symptoms (e.g., heartburn, bloating, belching).
  • No signs or symptoms of GI bleeding.
  • Healing of gastric and duodenal ulcers.

Back to Concept Map

pharmacology proton pump inhibitors prototype omeprazole prilosec
Pharmacology:Proton Pump InhibitorsPrototype : omeprazole (Prilosec)
  • Pharmacological Action
  • Reduce gastric acid secretion by irreversibly inhibiting the enzyme that produces gastric acid.
  • Reduce basal and stimulated acid production.
  • TherapeuticUses
  • Prescribed for gastric and peptic ulcers, GERD, and hypersecretory conditions (e.g., Zollinger-Ellison syndrome).
  • Precaution:
  • Increases the risk for pneumonia. Omeprazole ↓ gastric acid pH, which promotes bacterial colonization of the stomach and the respiratory tract.
  • Use cautiously in clients at high risk for pneumonia (e.g., clients with COPD).
  • Nursing Interventions and Client Education
  • Do not crush, chew, or break sustained-release capsules.
  • The client may sprinkle the contents of the capsule over food to facilitate swallowing.
  • The client should take omeprazole once a day prior to eating.
  • Encourage the client to avoid irritating medications (e.g., ibuprofen and alcohol).
  • Active ulcers should be treated for 4 to 6 weeks.
  • Pantoprazole (Protonix) can be administered to the client intravenously.
  • Monitor the client’s IV site for signs of inflammation (e.g., redness, swelling, local pain) and change the IV site if indicated.
  • Teach clients to notify the primary care provider for any sign of obvious or occult GI bleeding (e.g., coffee ground emesis).
  • Evaluation of Medication Effectiveness
  • Depending on therapeutic intent, effectiveness may be evidenced by:
  • Healing of gastric and duodenal ulcers.
  • Reduced frequency or absence of GERD symptoms (e.g., heartburn, sour stomach).
  • No signs or symptoms of GI bleeding.
  • Other PPI’s:
  • omeprazole; lansoprazole; rabeprozole; pantoprazole; esomeprazole;

Back to Concept Map

pharmacology mucosal barriers prototype sucralfate carafate
Pharmacology:Mucosal BarriersPrototype: sucralfate ( Carafate )
  • Pharmacological Action
  • Changes into a viscous substance that adheres to an ulcer; protects ulcer from further injury by acid and pepsin.
  • Viscous substance adheres to the ulcer for up to 6 hr.
  • Sucralfate has no systemic effects.
  • Therapeutic Uses
  • Acute duodenal ulcers and maintenance therapy.
  • Investigational use in gastric ulcers and gastroesophageal reflux disease. (GERD)
  • Nursing Interventions and Client Education
  • Assist the client with the medication regimen.
  • Instruct the client that the medication should be taken on an empty stomach.
  • Instruct the client that sucralfate should be taken four times a day, 1 hr before meals, and again at bedtime.
  • The client can break or dissolve the medication in water, but should not crush or chew the tablet.
  • Encourage the client to complete the course of treatment.
  • Evaluation of Medication Effectiveness
  • Depending on therapeutic intent, effectiveness may be evidenced by:
  • Healing of gastric and duodenal ulcers.
  • No signs or symptoms of GI bleeding.

Back to Concept Map

diagnostic tests85
***Diagnostic Tests

Return to

Concept Map

Blood Tests

Complete Blood Count (CBC c Diff)

Stool Tests:

Stool for occult blood; (Guiac)

Stool for ova & parasites (O&P);

Stool for Clostridiumdifficile (C-Diff)

Stool Culture & Sensitivity (C&S)

Upper GI Series (UGI)

Upper GI Series with Small Bowel Follow-Through (UGI-SBFT)

Barium Enema

Endoscopy

tube feedings enteral nutrition
Tube Feedings: Enteral Nutrition

http://www.saddleback.edu/alfa/n170/tubefeeding.aspx

slide94

Tum-E-Vac?

Salem Sump

slide95

Levin Tube

(single lumen)

slide97

Maloney JPEN 2002;26:S34-42

FDA advisory

FD&C Blue No. 1

4 methods to deliver nutrition
4 methods to deliver nutrition

Intermittent gravity

Intermittent

Via Pump:

-continuous (or)

cyclic