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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 - PowerPoint PPT Presentation
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Gastrointestinal Digestive Disorders
The Gastrointestinal System: Digestive Disorders
Air-Fluid Levels seen in bowel obstructionJ. Carley MSN, MA, RN, CNEPart II1PHARMACOLOGY ASSESSMENT
Physical Assessment Inspection Palpation Percussion AuscultationKEY ASSESSMENTSLab Monitoring
Care Planning
Plan for client adls, Monitoring, med admin.,Patient education, morebasedOn Nursing Process: A_D_O_P_I_E***Preparing for Diagnostic TestsNursing Interventions & Evaluation
Execute the care plan, evaluate for Efficacy, revise as necessaryPathophysiologyUpper GILower GIInflammatoryInflammatoryNon-InflammatoryG.E.R.D.UlcersGastritisG.E.R.D.Hiatus HerniasAcute AppendicitisPeritonitisUlcerative colitisCrohns DiseaseDiverticulitisNon-InflammatoryConstipation & DiarrheaIrritable Bowel SyndromeDumping SyndromeIntestinal ObstructionHemorrhoids & PolypsMalabsorptionA Concept Map : Selected Topics in Gastro-Intestinal Nursing***Diagnostic Testing
Anti-Acids (Antacids)Prototype: aluminum hydroxide gel (Amphojel)Prokinetic Agents:Prototype: metoclopramide (Reglan)Histamine 2 Receptor AgonistsPrototype: ranitidine hydrochloride (Zantac)Proton Pump Inhibitors)Prototype: omeprazole (Prilosec)Mucosal BarriersPrototype: sucralfate (Carafate)Disease Specific Medications: Nursing Skills: NG Tube Insertion Enteral Feedings
2A Rough Outline (for the Left Hemispheric Dominant)GastritisDumping SyndromeSmall & Large IntestinesAppendicitisPeritonitisDiverticulitisUlcerative ColitisCrohns DiseaseBowel ObstructionIrritable Bowel Syndrome (IBS)HemorrhoidsPolypsBowel Cancer3Dumping Syndrome S&SEarlyLate30 min after eatingRapid emptyingVertigoSyncopePallorDiaphoresisTachycardiapalpitations90 min-3 hr after eatingExcessive insulin releaseAbdominal distentionCrampingNauseaDizzinessDiaphoresisconfusion6Dumping SyndromeRapid gastric emptying into the small intestines usually occurs after a gastric surgeryTypes: Early and Late
5Medication TreatmentPectin Oral: slows absorption of carbsOctreotide SQ: blocks gastric and pancreatic hormones8Pharmacology:Anti-Acids (Antacids)Prototype: aluminum hydroxide gel ( Amphojel ) Pharmacological Action
Neutralize gastric acid and inactivate pepsin.
Mucosal protection may occur by the antacids 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
78Pharmacology: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)SedationDiarrhea
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 Ringers solution.
Evaluation of Medication Effectiveness
Control of nausea and vomitingBack to Concept Map
79Pharmacology: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 EffectivenessDepending 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
82Pharmacology: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.
Therapeutic Uses
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 clients 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 EffectivenessDepending 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 PPIs:omeprazole; lansoprazole; rabeprozole; pantoprazole; esomeprazole;Back to Concept Map
83Pharmacology: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
84AppendicitisAcute inflammation of veriform appendix
14Signs and SymptomsLower right quadrant painLow grade feverNausea and vomitingRebound tenderness @Mc Burneys pointRosving sign positiveIncreased WBC
15Medical ManagementMonitor pain (severe rebound tenderness)Monitor bowel sounds (absent)NPO, IVF, NO laxatives or enemasSurgical management: -Open or laparoscopic appendectomy 16Diagnostic TestsUltrasoundAbdominal x-rayAbdominal CT scan
17Nursing DiagnosisAcute painAlteration in comfortRisk for injuryKnowledge deficitRisk for infection18Nursing InterventionsMonitor vital signsAssess bowel soundsMonitor painMonitor lab valuesPost operative management: -Vitals signs, bowel sounds, diet resumption, antibiotic therapy as ordered
19PeritonitisAcute inflammation of the visceral / parietal peritoneum and endothelial lining of abdominal cavityTypes: primary and secondary
20PeritonitisPrimarySecondaryAcute bacterial infectionContamination of peritoneum via vascular systemTB (tuberculin infection)Alcoholic cirrhosisLeakage
Usually caused by a bacterial invasion in the abdomenGangrenous bowelBlunt or penetrating traumaLeakage
21Sign and SymptomsRigid board like abdomenAbdominal pain/tendernessDistended abdomenNausea and vomitingDiminished to no bowel soundsNo stools or flatusFeverTachycardia
22Diagnostic TestCBC (WBC, H&H)ElectrolytesCR (creatinine) & BUN (Blood urea nitrogen)Abdominal x-rayCT scanPeritoneal lavageSurgery
23Medical interventionsNon-surgical: -IV fluids -Broad spectrum antibiotics -Intake and outputs (I&O) -NG (nasogastric) tube -NPO -Pain management
24Medical InterventionsSurgical: Optimal treatmentExploratory laparotomy: repair or remove inflamed organ
25ComplicationsPeritonitis: EMERGENCY / Life Threatening -Symptoms: rigid abd., distended abd., absent bowel sounds, high fever, decreased urine output, hypotensionFluid shifts from extracellular to peritoneal cavity
26DiverticulitisInflammation of one or more diverticula. Results when diverticulum perforates and a local abscess forms
27SymptomsAbdominal pain, tenderness to palpationElevated temperature >101, may have chillsAbdominal guarding, rebound tenderness
28Diagnostic testsCT scanAbdominal flat plateEGDDO NOT do barium enema with active untreated diverticulitis
29Medical ManagementNon Surgical: -Broad spectrum antibiotics -Anticholinergics -NPO until clear liquids tolerated -Stop fiber therapy until attack is limited -NO enemas or laxatives30Medical ManagementSurgical -completed for ruptured peritonitis, fistula formation, bleeding, bowel obstruction, or unresponsive medical management31Nursing InterventionsHealth teaching: diet, fiber, symptom recognition, activity
Post op management: -Monitor colostomy, if present -monitor VS, urine output, wound condition -Psychosocial adjustment to stoma32Ulcerative ColitisUlcerative colitis: Chronic inflammatory process affecting mucosal lining of colon or rectum
33Symptoms10-20 liquid stools per dayTenesmus (Straining)AnemiaFatigueLLQ pain/crampingWt loss
34Diagnostic TestsCT scansColonoscopy or SiqmoidoscopyBarium Swallow studiesStools for O&P, occult blood, & C&SLabs: electrolyte panel and CBC
35Medication ManagementSalicylate: -inhibit prostglandins to reduce inflammationCorticosteroids: -Suppress immune system and reduce inflammationImmunomodulators: -reduce steroid use and overrides body immune system36Medication ManagementAntibiotics: -acute exacerbations prone to infectionAnti-diarrheals: -Symptomatic relief of severe diarrhea
37Diet TherapyNPO if symptoms are severeTPN if NPO for extended timeElemental formulaLow fiber foodsLactose free productsNo caffeine, spices, alcohol, or smoking
38Surgical ManagementSurgery is curativeTotal colectomy with permanent ileostomyTotal colectomy with continent ileostomy (Kocks pouch)
39Nursing DiagnosisPain acute and chronicFluid volume deficitAlteration in nutrition40Nursing InterventionsNutritional assessmentMonitoring fluid and electrolytesMonitor lab valuesMonitor for complicationsMonitor weightPsychosocial assessmentPost operative care41ComplicationsHemorrhage/perforationCoagulation problemsMalabsorptionIncrease risk for colon cancerToxic megacolon
42Crohns DiseaseInflammatory disease of small intestines, colon, or both (terminal ileum)
43Symptoms5-10 fatty stools per day (steatorrhea)FlatusMalabsorptionWeight lossDiffuse bilateral lower quadrant painFever with perforation or fistulaFluid, electrolyte and vitamin deficits44Diagnostic TestsCBCElectrolyte panelsVitamin & folic acid levelsAlbumin & nutritional labsBarium studiesColonoscopy45Medical ManagementDrug Therapy -Salicylate -Corticosteriods -Immunomodulators -Biologic Therapy -Antibiotics (abscess/perforation)46Diet TherapyTPN for long term useNutritional supplementsElemental supplementsNo caffeine or carbonated beveragesNo ETOHPrebiotics (non-digestive food ingredients)47Surgical ManagementSurgery is NOT a cureRepair of fistulasRelease of intestinal obstructionsPartial resection with primary anastamosisIleostomy48ComplicationsIntestinal obstructionFistulasMalabsorption syndromeLiver and biliary diseasesKidney stonesArthritis49Nursing ConsiderationsAdministering PPN and TPNProvide adequate nutrition: pre-medicate as orderedAssess stools: quality, frequency, amount, and pain issues with stoolingAssess vital signsTeach relaxation techniques50Health TeachingEducation for ileostomy or colostomy for both client and familyReduce or eliminate factors that cause diarrhea and painChronic pain managementProvide small frequent meals with specific dietary preferencesDetailed abdominal assessment51Bowel ObstructionSmall IntestinesLarge IntestinesPain is spasmodicPeristaltic wavesProfuse projectile vomitingFeculent odor to emesisVague diffuse constant painAbdominal distentionInfrequent vomitingPossible diarrhea
Air-Fluid Levels in intestinal obstruction52CauseMechanicalNon-mechanicalAdhesionsTumorsVolvulusIntussusceptionFecal impactionsForeign Bodies / ObjectsDecreased peristalsisElectrolyte imbalanceInflammatory responseNeurogenic disorderVascular disorder
Foreign Body in the Colon53ComplicationsDehydrationPerforationIschemic or strangulated bowelMetabolic acidosis and Alkalosis
54Irritable Bowel Syndrome(IBS)Chronic disorder of diarrhea and constipationNo exact cause knownAffects women 3x more then menPossible causes: diet and behavioral (psychological) illness55Signs and SymptomsManning Criteria: -abdominal pain relieved by defecation -abdominal distention -sensation of incomplete BM (bowel movement) -Presence of mucus56Sign and SymptomsExacerbation (flare up):
-worsening cramps -abdominal pain (LLQ) -diarrhea or constipation -increased pain after eating -nausea with defecation and mealtime57DiagnosisCBCSerum albuminStools for occult bloodSigmoidoscopyColonscopy
58Nursing InterventionStress ManagementDiet Therapy: -Avoid lactose products, caffeine, ETOH, sorbitol or fructose -Increase fiber (30-40 gm) -Fluid intake of 8-10 cups per day -meal planning
59Nursing InterventionMonitor Drug Therapy
-laxatives -diarrheals / antidiarrheals -anticholinergic -tricyclic antidepressants -muscarinic receptor antagonist -antispasmatics -5HT4 (Zelnorm)60HemorrhoidsSwollen or distended veins in rectal regionInternal & externalCause: pregnancy, obesity, constipationSymptoms: bleeding, edema, and prolapsedTreatment: cold packs, sitz bath, diet, Tucks , topical anesthetics, and surgery61
62
The Jackknife PositionRectal Surgery63PolypsSmall growths covered with mucosa and attached to the surface of intestines
Asymptomatic-bleeding, obstruction, & intussusception
Benign vs. malignant
Colorectal cancer
64Colorectal CancerColon and rectum=large intestines
Molecular changes
Metastasize to blood, lymph, surrounding & tissue
65
66Naso-Gastric Tubes (NGT)Purpose for Naso-Gastric Tubes:
1. Decompression2. Feeding3. Administration of Medications***4. LavageGeneral Golden Rule for Feeding Tubes:
Ensure correct placement prior to putting ANYTHING DOWN a TUBE!!!
X-Ray Confirmation67Problems with Nasogastric Tube (NGT) Placement
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71Misplaced Feeding TubeAt 1st looks OK but distal tip NOT SEEN
This tube ended up exiting the mid abdomen with the feedings entering the peritoneal cavity
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74Tube 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
75NGT insertion documentation to include:Date & timeReason for insertionType of tubeSize of tubeLength of tubeNostril tube insertedNumber of attempts requiredAdditional commentsAny complicationsMethod of placement confirmationSignature: name & designate of Nurse inserting tube76APPENDIX77Call the law offices of..
81***Diagnostic TestsBlood Tests Complete Blood Count (CBC c Diff)Stool Tests: Stool for occult blood; (Guiac) Stool for ova & parasites (O&P); Stool for Clostridium difficile (C-Diff) Stool Culture & Sensitivity (C&S)Upper GI Series (UGI)Upper GI Series with Small Bowel Follow-Through (UGI-SBFT)Barium EnemaEndoscopyReturn toConcept Map85
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88Tube Feedings: Enteral Nutritionhttp://www.saddleback.edu/alfa/n170/tubefeeding.aspx89
90
91
92Key Nursing Assesments:Patient on Enteral Feedings
93Tum-E-Vac?
Salem Sump94
Levin Tube(single lumen)
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FDA advisoryFD&C Blue No. 1Maloney JPEN 2002;26:S34-42974 methods to deliver nutrition
IntermittentIntermittent gravityVia Pump:-continuous (or)cyclic98
99Any Questions
100