Alterations of GI System

Nur 302 Unit I

Carcinoma of Oral Cavity

Predisposing factors: tobacco & alcoholS/S: leukoplakia, erythroplakia, ulcer, sore or rough spotDiagnosis: biopsyCollaborative Care: surgery, radiation, chemo or combinationHealth PromotionExpected Outcomes

Mandibular Fracture

Rx: immobilization by wiring- 4-6 weeks

Pre-op teaching

Post-op Care: Airway, oral hygiene, communication, nutrition

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 emptyingIV and NG tube, begin diet with clear liquids.

GERDPredisposing Factors

Hiatal herniaIncompetent lower esophageal sphincterDecreased esophageal clearanceDecreased gastric emptying.Esophagitis- trypsin & bile salts.

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 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

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

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 Cancers

Pre-op care: high calorie, high P, liquid diet or TPN oral care teaching

Post-op care :NG bloody 8-12 hourssemi-Fowler’s position prevent resp. complication

Gastritis

Types: Acute or Chronic, Type A (Fundal) & Type B (Antral).Etiology: breakdown in normal mucosa barrierCorticosteroids, NSAIDS, ASA,spicy foods, alcoholPresence of Helicobacter pylori

Gastritis Signs & Symptoms

Anorexia

N/V

Epigastric tenderness

Feeling of fullness

Hemorrhage

Diagnostic Studies

Endoscopic exam

CBC

Stool for occult blood

Cytologic exam

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

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

May have no painGastric 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 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

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

Post-op Care

Observe NG tube drainageRed, decreasing in color 1st 24 hoursObserve for clogged NG tubeDo not irrigate without MD order, surgeon

replaces NG if pt pulls out tube

Observe for decreased peristalsis

I&O, VS

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 consentTake initial set VSPick up blood from labAssess IV siteStart transfusionVerify pt ID, & blood compatability

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 transfusionSave transfusion unitInform MD/RNSave next voided specimenStart 0.9NS Take VS

Post-op complications

Dumping Syndrome

Postprandial hypoglycemia

Bile reflux gastritis

Dumping Syndrome

Large amount hyperosmolar chyme in intestine->fluid is drawn in->decrease of plasma volumeBowel also becomes distended->increased motility15-30 minutes after eating->s/s last 1 hrWeakness, sweating, dizzy, cramps, urge to have BM

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

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 PostgastrectomyDumping Syndrome

Six small mealsDo not have fluids with mealsFluids 45 minutes before or after meals

Dry foods low CHO, moderate protein & fatsAvoid concentrated sweets (jams, candy, etc)Lie down after meals, short rest period

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

S/S: n/v, diarrhea, colicky abdominal pain

Types: acute bacterial gastroenteritis- staph, clostridial, salmonella, botulism, escherichia coli, see table 42-27

Food PoisoningHealth Promotion

Correct food preparation

Cleanliness

Cooking

Refrigeration

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

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

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”

Etiology: see table 43-12S/S: PAIN, abd tenderness, vomiting, diarrhea, abd tenderness, constipation, flatulence, fatigue, fever, increased abd girthDX: H&P, preg test, rectal & pelvic exam, CBC, U/A, abd x-raysEmergency management: table 43-13

“Acute Abdomen”

Assess: VS, inspect, palpate & auscultate abdomen, pain, n/v, change in bowel habits, vaginal dischargePre-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

Irritable bowel syndrome, peptic ulcer , diverticulitis, chronic pancreatitis, hepatitis, cholecystitis, pelvic inflam. disease, vascular insuffic., psychogenic

Diagnosis & treatment: “critical thinking skills”

Abdominal Trauma

Etiology: blunt trauma or penetrating injuriesLacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears, diaphragmatic rupture, urinary bladder rupture, great vessel tears, renal injury, stomach or intestinal ruptureS/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 Trauma

Dx: CBC, u/a, abd cat, x-rays, periton. lavageAssessment: 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 tendernessInterventions: airway, control bleeding, cover protruding organs, IV, labs, foley, VS, LOC, see table 43-14

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

Etiology: rupture of an organ, trauma, pancreatitis, peritoneal dialysisS/S: tenderness over area, rebound tenderness, muscle rigidity & spasms, abd distention, n/v, tachycardia, tachypnea, alt bowel habitsComplications: hypovolemic shock, septicemia, abscess, paralytic ileus, organ failureDX: CBC, C&S perit. Fld, CT, x-ray

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

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

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

Intestinal: hemorrhage, strictures, perforation, toxic megacolon, colonic dilatation, risk for colon cancerExtraintestinal: due to malabsorbtion or problem with immune system – joints, skin, mouth & eyesDx: CBC, lytes, albumin, stool analysis, sigmoidascope & colonoscopy, barium enema

Nursing & Collaborative Care

Rest bowel

Control inflammation

Prevent / treat infection

Correct malnutrition

Meds to relieve s/s

Alleviate stress

See NCP 40-3

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

Total proctocolectomy with perm. ileostomyTotal protocolectomy with continent ileostomy called a Knock pouch Total colectomy & ileal reservoirSurgery “cures” diseasePost-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

Inflammation of segments GI tract esp ileum,jejunum, colon & involves all layers of bowel wallClassic “cobblestone” appearance, normal bowel between diseased, longitudinal, deep ulcerated partsThickening bowel wall & stricturesAbscesses & fistulas with bladder, vagina, bowel

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, uveitisDx: same as ulcerative colitis

Collaborative Care

Sulfasalazine – large intestine involvementCorticosteroids – taper off when s/s subsideImmunosuppressive meds if steroids ineffectiveFlagyl – perianal areaFish 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

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 Care

Patient & family teaching regarding nature of disease & limitations of txTeach: diet, importance of rest, meds, when to seek medical care, reduce stress, perianal carePost-op: ulcerative colitis NCP 43-3Skin care, referral to wound care nurse for abscess / fistulas

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 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 Care

Assessment: pain, s/s, BS, dehydration, labs

Insertion & care NG tube

Intestinal tubes: Harris tube, Miller-Abbott tube, Cantor tube

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 Cancer

Dx: H&P, rectal exam, sigmoidoscopy, air contrast barium enema, CT scan colonoscopy, CBC, clotting studies, liver enzymes, CEAStaging: primary tumor, regional lymph node involvement, distant metastasisSurgery: R or L hemicolectomy, abdominal perineal resectionChemo & radiation: post-op or palliative

Health Promotion

Assess risk factorsAmerican 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 riskBarriers: lack of info & fear of dxResearch: use of anti-inflammatory drugs or long term use of ASADiet

Nursing Care Abd-Perineal Resection

Teach extent of surgery for abdom-perineal resection, positioning for comfort & sitz bath, ostomy questionsAbd wound, perineal wound, stomaProfuse 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

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

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

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

Protrusion of viscous thru wall of cavity.Reducible, irreducible or incarcerated, strangulatedTypes: inguinal, femoral, ventral or incisionalS/S: bulge, discomfort, pain->strangulatedTx: herniorrhaphy, hernioplasty, trussPost-op: check voiding, scrotal support, ice pack, no coughing, splint incision with mouth open if sneeze, no lifting 6-8 weeks

Malabsorption Syndrome

Causes: biochemical or enzyme deficiency, bacterial profileration, disruption sm intestine mucosa, disturbed lymph or vascular circulation,surface area lossLactose intolerance, inflam bowel disease, celiac, tropical sprue, cystic fibrosisS/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

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

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 Problems

Anal fissure –crack or skin ulcer in anal wall, associated with constipationAnorectal abscess- perirectal infection E. coli, staph or strep, foul smell, sepsisSurgically drained, packed q day with petroleum jelly gauze, keep clean, heal by granulation, sitz bath, lo residue dietPilonidal cyst- tract @ sacrcoccyx, congenital, lined with epithelium & hair, abscess formsTx- I&D