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GI Test 4/25/2011 2:11:00 PM
GI
Terminologies
y Visceral pain; dull poorly localized painy Somatic pain; sharp pain, well localizedy Referred pain; pain experience at a distance from disease processy Fetor hepaticus; sweet fecal odor caused by hepatic failurey Feculent breath; foul fecal odor caused by severe bowel obstructiony Severe halitosis; foul breath odor can be caused by poor dental
hygience or neoplasms or esophagus and stomach
y Jaundice; yellowish discoloration of skin caused by high bilirubinlevel associated with liver disease, biliary obstruction, excessive
hemolysis
y Grey turners sign; ecchymosis to flanks indicative ofretroperitoneal bleeding
y Ascitis; intraperitoneal fluid infrequently associated withy Anasarca; entire body edema seen in end stage renal diseasey Diastasis recti abdominis; abnormal separation of two abdominal
muscles by raising his or her head from bed
y Ballottment; technique of examining a fluid filled part of body todetect floating object.
y Cullens sig; ecchymosis around umbilicus indicative inintraparanteal bleeding
y Mcburney's sign: is a sign of acute appendicitisy Rovsing
Salivary glands
y 1000-1500 ml/dayy Enzymes pityalin (amylase) and lysozymey Initiates carb metabolism, destroy bacterial protects muscus
membrane, and tooth decay
Stomach 2500 ml/day
y Enzyme pesiny Converts proteins into proteoses and peptones
Liver bile 500-100 ml/day
y No enzymesy Emulsifies fat
Pancrease 1000-1500 ml/day
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y Enzymes trypsin , amylase, mylasey Digest major components of chime
Differntation of abd pain
y Gastritis; epigastric or slightly left midline, maybe described asindigestion, nausea vomiting, hematamesis, abd tenderness
y Peptic ulcer, epigastric or RUQ, gnawing or burning, abdtenderness, hematemesis or melena
y Pancreatitis; epigastric or LUQ may radiate to back, flanks or leftshoulder, boring worsen by lying down, nausea or vomiting,
jaundice maybe present if common bile duct is obstructed.
y Cholecystitis; epigastric PRRUQ area, cramping, maybe referred tobelow right scapula, murphys sign; nausea vomiting, abd
tenderness in RUQ
y Appendicitis; epigastric or periumbilical pain, later localizes in RLQ,mcburneys sign, rovsing sing, dull to sharp pain, anorexia, fever,
diarrhea, leukocytosis, rebound tenderness, indicates peritoneal
irriation
y Intestinal obstruction, epigastric or umbilical, spastic to dull, changein bowel habits, melena or hematochezia, hyperactive to hypoactive
bowel sounds
y Stepso Inspection
Inspection; Landmarks General survey Mouth Skin Contour of abd Abd girth Weakness of abd wall Movement of abd
o Auscultation Put pillow under knees to relax abd muscle Bowel sounds Succussion splash Vascular sounds; use bell
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Peritoneal friction rub; presence of peritoneal fluido Percussion
Percussion tones normally heard are Dull liver, full sigmoid colon, full bladder, flute tone,
tympani gastric bulle (drum like sound) When testing for ascitis (fluid like, shifting dullness,
midline dullness)
Organ borders (spleen, liver, stomach, bladder,intestine)
o Palpation Method Light palpation 1-2 cm Deep palpation 4-5 cm only physician Ballottement
Laboratory and Diagnostic exams
y Upper GI studyy series of radiographys of lower esophagus, stomach, duodenum,
using barium sulfate as contrast medium
y Detects any abnormal conditions of GI tracty Tumorsy Other ulcerative lesionsy Prep
o NPO post midnighto No smoking night before studyo Explain importance of expelling barium solutiono Stools will be whitish or light in color until all solution expelled
out (72) hrs
o Eventual absorption of fecal water may cause hardenedbarium impaction
o Advice increase fluid intakeo Administer MOM after exam to promote expulsion of solution
unless contraindicated
y Tube Gastric analysiso Stomach contents aspirated to determine amount of acid
produced by parietal cells in stomach
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o Analysis helps determine completeness of vagotomy, confirmhypersecretions of achlohydria, estimate acid secretory
capacity or test for intrinsic factor.(vitamin B12)
o Nursing interventions No anti cholinergic for 24 hrs prior to test NPO after midnight No smoking Label specimens properly and send to lab asap Remove NG tube as soon as specimens collected.
y EGDo Evaluates esophagus, stomach and duodenum.o Nursing careo NPO PMNo Consento Pre op check listo Pt usually given midazolam IVo Spraying of pharynx with lidocaine hydrochlorideo NPO until further order or until gag reflex returnedo Assess for any S/S of perforation; abd pain, tenderness,
guarding, oral bleeding, melena (black stool), hypovolemic
shock.
y Capsule Endoscopyo Pt swallows capsule with camerao Collect about 57000 imageso Visualizes small intestineo Use to diagnose Chrons diseaseo Celiac diseaseo Malabsorptiono Helps identify possible sources of GI bleedingo Capsule relays images to a data recorder that pt wears on
belt.
o Nursing intervention Diet prep is similar to colonoscopy Pt swallows video capsule and kept 4-6 hrs later Device is removed after 8 hrs Peristalsis causes capsule to pass in bowel movement.
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y Barium swallowo More thorough barium contrast study of esophagus provided
by most UGI exam
o Defects in luminal filling and narrowing of barium columnindicate tumors, scarred stricture or esophageal varices
o Allows easy recognition of anatomical abnormalitieso Left atrial dilation, aortic aneurysm, and para-esophageal
tumor may cause extrinsic compression of barium column
within esophagus.
o If barium leaks from GI tract, its not absorbed and can causecomplications.
y Gastrografin studieso Gastrografin:
water soluble and rapidly absorbedo Preferable when perforation is suspectedo It facilitates imaging through radiographso If product escapes from GI tract it is absorbed by the
surrounding tissue
y Diatrizoateo Use in place of bariumo Interventions
Maintain NPO after midnight Explain importance of rectally expelling barium Stools will be light colored until complete expelling
occurs
Increase fluid intake Give MOM after barium swallow exam unless
contraindicated.
y Esophageal function testo Acid perfusion test, attempt to reproduce symptoms of
gastroesophageal reflux
o Helps differentiate esophageal pain from angina pectoriso If pt suffers pain within instillation of hydrochloric acid into
esophagus, test is positive and indicates reflux esophagitis
o Interventions Avoid sedating pt
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NPO for 8 hrs prior exam Withhold antacid and analgesics
y Stool for occult blood, guaiac, hemoccult, hematest!o Stool specimen free from tissue and urineo Diet free from organ mean 24-48 hrs before test
y Sigmoidoscopyo Lower segment of large intestine!o Nursing care
NPO Admin enema night before Consent Observe for signs of bowel perforation
Abd pain Bleeding Tenderness Distention
y Barium enema studyo AKA lower GI serieso Consists of series of xrays of colono Used to diagnose presence of :
polyps , tumors, diverticula, positional abnormalitieso Can be used to detect intussusceptions in childreno Nursing care
Administer cathartics such as magnesium citrate Cleansing enema evening before MOM evacuation of barium NPO Retained barium equals hard stools!
y Colonoscopyo Requires sedationo Camera to view entire colono GOLYTELY night beforeo More accurateo Requires bowel preparation night before
y Virtual colonoscopyo Uses MRI or CT to take pictures of entire colon
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o Needs sedation but no consent less invasiveo Same prep as conventional colono Needs GOLYTELY night beforeo GOLYTELY bowel prep (pg 183 box 5-2 AHN)
y Stool cultureo Exam of stool for presence of bacteria, ova, parasiteso Many physicians may order stool for ova and parasites (o&P)o Usually done to detect enteropathogens aka, shigella, c diff.o Usually 3 stool series are collected on subsequent days.o Nursing interventions
If enema ordered use only saline or tap water Soap suds enema could affect viability of organisms
collected
Stool samples obtained before barium exam instruct ptnot to mix specimen with feces
Don gloves , make sure specimen taken to lab within 30min
y Obstruction serieso AKA flat plate abd
y Group of xray series performed on abdomen for pts who havesuspected bowel obstruction , perforated viscus, paralytic ilius, or
abdabcessy Consists of at least 2 radiographic studiesy First shot is erect abdxray that allows visualization of diaphragmy Radiographs are examined for evidence of free air under the
diaphragm- which is pathognomonic sign of obstruction
y Detects air fluid levels within intestiney Nursing care
o Ensure study is scheduled before barium studies for adequatevisualization.
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GI Pharm. 4/25/2011 2:11:00 PM
Pharmacology Notes 4/15/11-For Test 4 Pharmacology
Hydrochloric acid production
Stomach-acid production
Rugae-big folds in the stomach
Gastric pits-smaller folds in the stomach where we find the parietal cellsParietal cells
Hydrochloric acid
Parietal cells--> HCL
Potassium goes out, Hydrogen goes in produces Hydrochloric acid
H2 Blockers (dine)
y Ranitidine (Zantac) works in less than 1 hour (Long acting)y Cimetidine (Tagament)y Decrease acid in stomach
PPI Proton Pump Inhibitors -(ZOLE)
y Reduce acid secretions of the stomachy Esomeprazole (Nexium)y Omeprazole -Long acting (Starts in 1-3 hours but lasts 24 hours)
Short Acting- Antacids
y Aluminum Hydroxide (Amphojel)y Side effects fecal impaction, intestinal obstructiony Maalox-short acting
Vomiting
y Nausea and vomiting-defense of the GI system and are signs ofaltered body function
y Nausea-unpleasant sensation of the need to vomity Vomiting-(emesis) the forcing of the stomach contents up through
the espophagus and out to the mouth
y Phases of vomitingo Nauseao Retches (gagging)o Vomiting
y Vestibular system-when balance is or sense of position is upset,vomiting occurs
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y Receptors in the GI tract mechanoreceptors and chemoreceptorso Mechanoreceptors-distention and contraction in bowel
obstruction, vomiting occurs
o Chemoreceptor-sensory verve cells in response to chemicalstimuli such as poisonous substances in the intestines
y Vomiting Center of the brain-located in the medulla is responsiblefor initiating the vomiting reflex.
y It combines the input from the GI tract, vestibular apparatus andhigher brain pressure centers for activation.
y Once activated, the vomiting center causes vomiting by stimulatingthe salivary and respiratory centers and the throat (pharyngeal), GI
and abdominal muscles
y Causes of nausea and vomitingo Unpleasant sights, smells, memories, side effects of
chemotherapy, medical disorders
o Drug or treatment induced---agents antibiotics, cancerchemo, opiate drugs, radiation therapy
o Labyrinth disorders-----menier's disease, motiono Endocrine system infection---pregnancy, gastroenteritis, viral
laybrinthitis
o Increased intracranial pressure-hemorrhage, meningitiso Postoperative-analgesics, anesthetics, proceduralo Central Nervous System---Anticipatory, bulimia nervosa,
migraine
Antiemetic Drugs -
y Intended responses for antiemetic agents:y -vomiting reflex inhibitedy -vomiting reflex pathways are interruptedy -Pt is sedatedy -Nausea is relievedy -Vomiting is preventedy Nursing Diagnosis:
o Risk for fluid & electrolyte imbalanceo Nausea r/t distention & contraction in the intestinal tracto Nausea r/t poisonous substance in the stomach
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y Common side effects of antiemetic drugs vary with the prescribeddrug.
Anticholinergics-
y Primary antimuscarinic (anti-parkinson) agents that act by bindingto and blocking acetylcholine receptors
o thus, preventing the nauseous stimuli from being transmittedy -limits the stimulation of the emetic center from the vestibular
system.
y -has minimal effect on vestibular stimulation (vestibular andserotonin)
y Scopolamine Hcl (transderm-Scop, scopace, maldemar)Antihistamines-
y it inhibits the same pathways as anticholinergic drugs and depressinner ear excitability, reducing vestibular stimulation
y -Decreases allergic response by blocking histaminey -also acts on chemoreceptor trigger zone to decrease vomitingy -increases CNS stimulation, has anticholinergic responsey -because of this it inhibits one or more of the vomiting reflex
pathways
y -sedating effects help control the sensation of nauseaPromethazine (phenergan)
Dipenhydramine (benadryl)
Meclizine (bonamine, antivert)
Cyclizine (Marezine)
5HT3-Receptor Antagonist/serotonin blockers-
y Blocks serotonin receptors in the GI tract and the chemotriggerzone in the brain
y -by blocking the receptors in both of these sites at least twopathways of the v omiting reflex are interrupted
y - most commonly used agents to prevent and treat nausea andvomiting associated with chemotherapy
Serotonin Blockers
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y Dolasetronmesylatey Granisetron HCLy Ordansetron HCLy Palonosetron HCL
Dopamine receptor antagonist or neuroleptic agents-
y Directly block dopamine from binding to the receptors in thechemotrigger zone and the intestinal tract
y -foods in the intestinal tract moves along more quickly and is lesslikely to stimulate responses that trigger the vomiting reflex, used
after surgery to promote peristalsis, prevents nausea and vomiting
Dopamine Receptor Antagonist Agents
y Metoclopromide (Reglan, Emex, Maxeran)y Chlorpromazine (Thorazine)y Perphenaziney Prochlorperazine (Compazine)y Trimethobenzamide (Tigan)
Drugs Common Side Effects
y Cyclizineo drowsiness, dry mouth, hypotension-Antihistamine
y Meclizine (Antivert)o Drowsiness-Antihistamine
y Prochlorperazineo blurred vision, constipation, dizziness, involuntary msucle
spasms, jitteriness, mouth puckering-Domamine receptor
y Metochlopromide (reglan)o drowsiness, fatigue, increased depression, restlessness-
antiemetic, (dopamine receptor antagonist)
y Promethazine (phenergan)o confusion, disorientation, dizziness, dry mouth, nausea,
vomiting rash, sedation-antihistamine
y Ondansetrono abdominal pain, constipation, fatigue, headache-Serotonin
y Granisetron
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o headache, constipation loss of energy-Serotoniny Scopolamine (L-Hyoscine)
o Blurred vision, constipation, dilated pupils, dizziness,drowsiness, dry mouth, light-headedness, rash, urinary
retention-anticholinergicy Trimethobenzamide (Tigan)
o blurred vision, diarrhea, drowsiness, muscle cramps,headache, hypotension, rectal irritation-Dopamine Receptor
Antagonist
Adverse Effects
y Also varies with the prescribed drugsy Prochlorperaziney promethazine (phenergen)y Metochlopromide (reglan)-cause tardive dyskinesiay Neuroleptic malignant syndrome-rare and life threatening side
effects in which dangerously high body temperature
y Trimethobenzamide-may cause coma, seizure
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GASTROINTESTINAL DISORDERS4/25/2011 2:11:00 PM
GASTROESOPHAGEAL REFLUXDISEASE (GERD)
y DESCRIPTIONo The backflow of gastric and duodenal contents into the
esophagus
y Caused by an incompetent lower esophageal sphincter, pyloricstenosis, or a motility disorder
y Symptoms may mimic those of a heart attacky ASSESSMENT
o Pyrosiso Dyspepsiao Regurgitationo Pain and difficulty with swallowingo Hypersalivation
y IMPLEMENTATIONo Instruct the client to avoid factors that decrease lower
esophageal sphincter pressure or cause esophageal irritation
o Instruct the client to eat a low-fat, high-fiber diet; avoidcaffeine, tobacco, and carbonated beverages; avoid eating
and drinking 2 hours before bedtime; avoid wearing tight
clothes; and to elevate the head of the bed on 6- to 8- inch
blocks
o Avoid the use of anticholinergics, which delay stomachemptying
o Instruct the client regarding prescribed medications, such asantacids, histamine H2-receptor antagonists, or gastric acid
pump inhibitors
o Instruct the client regarding the administration of prokineticmedications if prescribed, which accelerate gastric emptying
o If medical management is unsuccessful, surgery may berequired and involves a fundoplication (wrapping a portion of
the gastric fundus around the sphincter area of the
esophagus); may be performed by laparoscopy
HIATAL HERNIA
y DESCRIPTIONo Also known as esophageal or diaphragmatic hernia
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o A portion of the stomach herniates through the diaphragmand into the thorax
y It results from weakening of the muscles of the diaphragm and isaggravated by factors that increase abdominal pressure such as
pregnancy, ascites, obesity, tumors, and heavy liftingy Complications include:
o ulceration, hemorrhage, regurgitation and aspiration ofstomach contents, strangulation, and incarceration of the
stomach in the chest with possible necrosis, peritonitis, and
mediastinitis
y ASSESSMENTo Heartburno Regurgitation or vomitingo Dysphagiao Feeling of fullness
y IMPLEMENTATIONo Medical and surgical management is similar to that for GERo Provide small, frequent meals and minimize the amount of
liquids
o Advise the client not to recline for 1 hour after eatingo Avoid anticholinergics, which delay stomach emptying
GASTRITISy DESCRIPTION
o Inflammation of the stomach or gastric mucosay Can be acute or chronicy ACUTE
o Caused by the ingestion of food contaminated with disease-causing microorganisms or food that is irritating or too highly
seasoned, the overuse of aspirin or other
nonsteroidalantiinflammatory drugs (NSAIDs), excessive
alcohol intake, bile reflux, or radiation therapy
o ASSESSMENT Abdominal discomfort Headache Anorexia, nausea, and vomiting Hiccuping
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y CHRONICo Caused by benign or malignant ulcers, or by the bacteria
Helicobacter pylori; may also be caused by autoimmune
diseases, dietary factors, medications, alcohol, smoking, or
refluxo ASSESSMENT
Anorexia, nausea, and vomiting Heartburn after eating Belching Sour taste in the mouth Vitamin B12 deficiency ACUTEEROSIVE GASTRITIS
o IMPLEMENTATION Acute: Food and fluids may be withheld until symptoms
subside; then ice chips followed by clear liquids and
then solid food is introduced
Monitor for signs of hemorrhagic gastritis such ashematemesis, tachycardia, and hypotension, and notify
the physician if these signs occur
Instruct the client to avoid irritating foods, fluids, andother substances such as spicy and highly seasoned
foods, caffeine, alcohol, and nicotine Instruct the client in the use of prescribed medications,
such as antibiotics and bismuth salts (Pepto-Bismol)
Provide the client with information about theimportance of vitamin B12 injections, if a deficiency is
present
PEPTICULCERDISEASE
y DESCRIPTIONo An ulceration in the mucosal wall of the stomach, pylorus,
duodenum, or esophagus, in portions that are accessible to
gastric secretions; erosion may extend through the muscle
y May be referred to as gastric, duodenal, or esophageal ulcerdepending on location
y The most common peptic ulcers are gastric ulcers and duodenalulcers
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GASTRICULCERS
y DESCRIPTIONo Involves ulceration of the mucosal lining that extends to the
submucosal layer of the stomach
y Predisposing factors include stress, smoking, the use ofcorticosteroids, nonsteroidalantiinflammatory drugs (NSAIDs),
alcohol, a history of gastritis, a family history of gastric ulcers, or
infection with Helicobacter pylori
y Complications include:o hemorrhage, perforation, and pyloric obstruction
y ASSESSMENTo Gnawing, sharp pain in or left of the midepigastric region 1 to
2 hours after eating
o Nausea and vomitingo Hematemesis
y IMPLEMENTATIONo Monitor vital signs and for signs of bleedingo Administer small, frequent, bland feedings during the active
phase
o Administer histamine H2-receptor antagonists as prescribed todecrease the secretion of gastric acid
o Administer antacids as prescribed to neutralize gastricsecretions
o Administer anticholinergics as prescribed to reduce gastricmotility
o Administer mucosal barrier protectants as prescribed 1 hourbefore each meal
o Administer prostaglandins as prescribed for their protectiveand antisecretory actions
y CLIENT EDUCATIONo Avoid consuming alcohol and substances that contain caffeine
or chocolate
o Avoid smokingo Avoid aspirin or NSAIDso Obtain adequate rest and reduce stress
y IMPLEMENTATION: ACTIVEBLEEDING
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o Monitor vital signs closelyo Assess for signs of dehydration, hypovolemic shock, sepsis,
and respiratory insufficiency
o Maintain NPO status and administer IV fluid replacement asprescribed; monitor I&O
o Monitor hemoglobin and hematocritGASTRICULCERS
y IMPLEMENTATION: ACTIVEBLEEDINGo Administer blood transfusions as prescribedo Assist with the insertion of a nasogastric (NG) tube for
decompression and for lavage access
o Assist with normal saline or tap water lavage at roomtemperature to reduce active bleeding
o Prepare to assist with administering vasopressin (Pitressin) byIV as prescribed to induce vasoconstriction and reduce
bleeding
y SURGICAL IMPLEMENTATIONo TOTAL GASTRECTOMY
Also called esophagojejunostomy Removal of the stomach with attachment of the
esophagus to the jejunum or duodenum
o VAGOTOMY Surgical division of the vagus nerve to eliminate the
vagal impulses that stimulate hydrochloric acid
secretion in the stomach
GASTRICRESECTION
Also called antrectomy
Involves removal of the lower half of the stomach and usually includes a
vagotomy
GASTRICULCERS
SURGICAL IMPLEMENTATION
BILLROTH I
Also called gastroduodenostomy; partial gastrectomy, with remaining
segment anastomosed to duodenum
BILLROTH II
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Also called gastrojejunostomy; partial gastrectomy, with remaining segment
anastomosed to jejunum
PYLOROPLASTY
Enlarges the pylorus to prevent or decrease pyloric obstruction, thereby
enhancing gastric emptyingTOTAL GASTRECTOMY
TYPESOFVAGOTOMIES
BILLROTH I
BILLROTH II
PYLOROPLASTY
GASTRICULCERS
POSTOPERATIVE IMPLEMENTATION
Monitor vital signs
Position in Fowler's for comfort and to promote drainage
Administer fluids and electrolyte replacements by IV as prescribed; monitor
I&O
Assess bowel sounds
Monitor NG suction as prescribed
GASTRICULCERS
POSTOPERATIVE IMPLEMENTATION
Do not irrigate or remove the NG tube; assist the physician with irrigation or
removalMaintain NPO status as prescribed for 1 to 3 days until peristalsis returns
Progress the diet from NPO to sips of clear water to 6 small, bland meals a
day as prescribed when bowel sounds return
Monitor for postoperative complications of hemorrhage, dumping syndrome,
diarrhea, hypoglycemia, and vitamin B12 deficiency
DUODENAL ULCERS
DESCRIPTION
A break in the mucosa of the duodenum
Risk factors and causes include alcohol intake, smoking, stress, caffeine, the
use of aspirin, corticosteroids, and NSAIDs, and infection with Helicobacter
pylori
Complications include bleeding, perforation, gastric outlet obstruction, and
intractable disease
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Surgery is performed only if the ulcer is unresponsive to medications or if
hemorrhage, obstruction, or perforation occurs
DEVELOPMENT OFADUODENAL ULCER
DUODENAL ULCERS
PERFORATIONOFADUODENAL ULCERDUODENAL ULCERS
ASSESSMENT
Burning pain in the midepigastric area 2 to 4 hours after eating and during
the night
Pain that is often relieved by eating
Melena
DUODENAL ULCERS
IMPLEMENTATION
Monitor vital signs
Perform abdominal assessment
Instruct the client in a bland diet with small, frequent meals
Provide for adequate rest
Encourage the cessation of smoking
DUODENAL ULCERS
IMPLEMENTATION
Instruct the client to avoid alcohol intake, caffeine, the use of aspirin,
corticosteroids, and NSAIDsAdminister antacids as prescribed to neutralize acid secretions
Administer histamine H2-receptor antagonists as prescribed to block the
secretion of acid
DUMPING SYNDROME
DESCRIPTION
Rapid emptying of the gastric contents into the small intestine
Occurs following gastric resection
DUMPING SYNDROME
ASSESSMENT
Symptoms occurring 30 minutes after eating
Nausea and vomiting
Feelings of abdominal fullness and abdominal cramping
Diarrhea
Palpitations and tachycardia
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Perspiration
Weakness and dizziness
Borborygmi
DUMPING SYNDROME
CLIENT EDUCATIONEat a high-protein, high-fat, low-carbohydrate diet
Eat small meals and avoid consuming fluids with meals
Avoid sugar and salt
Lie down after meals
Take antispasmodic medications as prescribed to delay gastric emptying
VITAMINB12DEFICIENCY
DESCRIPTION
Results from either an inadequate intake of vitamin B12 or a lack of
absorption of ingested vitamin B12 from the intestinal tract
Pernicious anemia results from a deficiency of intrinsic factor, which is
necessary for intestinal absorption of vitamin B12
VITAMINB12DEFICIENCY
ASSESSMENT
Severe pallor
Fatigue
Weight loss
Smooth, beefy, red tongueSlight jaundice
Paresthesias of the hands and feet
Disturbances with gait and balance
VITAMINB12DEFICIENCY
IMPLEMENTATION
Increase dietary intake of foods rich in vitamin B12 if the anemia is the result
of a dietary deficiency
Administer vitamin B12 injections as prescribed on a weekly basis initially,
and then monthly for maintenance (lifelong) if the anemia is the result of a
deficiency of the intrinsic factor
ESOPHAGEAL VARICES
DESCRIPTION
Dilated and tortuous veins in the submucosa of the esophagus
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Caused by portal hypertension, often associated with liver cirrhosis, and high
risk for rupture if portal circulation pressure rises
Bleeding varices is an emergency
The goal of treatment is to control bleeding, prevent complications, and
prevent the reoccurrence of bleedingESOPHAGEAL VARICES
ESOPHAGEAL VARICES
ASSESSMENT
Hematemesis
Tarry stools, melena
Ascites
Jaundice
Hepatomegaly and splenomegaly
Dilated abdominal veins
Hemorrhoids
Signs of shock
ESOPHAGEAL VARICES
IMPLEMENTATION
Monitor vital signs
Elevate the head of the bed
Monitor for orthostatic hypotension
Monitor lung sounds and for the presence of respiratory distressAdminister oxygen as prescribed to prevent tissue hypoxia
Monitor level of consciousness (LOC)
ESOPHAGEAL VARICES
IMPLEMENTATION
Maintain NPO status
Administer IV fluids as prescribed to restore fluid volume and correct
electrolyte imbalances; monitor I&O
Monitor hemoglobin, hematocrit, and coagulation factors
Administer blood transfusions or clotting factors as prescribed
ESOPHAGEAL VARICES
IMPLEMENTATION
Assist in inserting an NG tube or a balloon tamponade as prescribed
Assist with the administration of iced saline irrigations to achieve
vasoconstriction of the varices
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Prepare to assist with administering vasopressin (Pitressin) by IV or intra-
arterial infusion as prescribed to induce vasoconstriction and reduce bleeding
ESOPHAGEAL VARICES
IMPLEMENTATION
Prepare to assist with administering nitroglycerin (Tridil) with vasopressin(Pitressin) to prevent vasoconstriction of the coronary arteries
Instruct the client to avoid activities that will initiate vasovagal responses
Prepare the client for endoscopic procedures or surgical procedures as
prescribed
ESOPHAGEAL VARICES
ENDOSCOPIC INJECTION (SCLEROTHERAPY)
Injection of a sclerosing agent into and around bleeding varices
Complications include chest pain, pleural effusion, aspiration pneumonia,
esophageal stricture, and perforation of the esophagus
INJECTIONSCLEROTHERAPY
ESOPHAGEAL VARICES
ENDOSCOPICVARICEAL LIGATION
Ligation of the varices with an elastic rubber band
Sloughing, followed by superficial ulceration, occurs in the area of ligation
within 3 to 7 days
ESOPHAGEAL VARICES
SURGICAL SHUNT PROCEDURESSPLENORENAL
Involves splenectomy, with anastomosis of the splenic vein to the left renal
vein
PORTACAVAL
Shunting of the blood from the portal vein to the inferior vena cava
MESOCAVAL
Involves a side anastomosis of the superior mesenteric vein to the proximal
end of the inferior vena cava
SHUNTING PROCEDURES
ESOPHAGEAL VARICES
SURGICAL SHUNT PROCEDURES
TRANSJUGULAR INTRAHEPATIC PORTAL/SYSTEMIC
Uses the normal vascular anatomy of the liver to create a shunt with the use
of a metallic stent
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The shunt is between the portal and systemic venous system within the liver
and is aimed at relieving portal hypertension
ULCERATIVECOLITIS
DESCRIPTION
Ulcerative and inflammatory disease of the bowel that results in poorabsorption of nutrients
Commonly begins in the rectum and spreads upward toward the cecum
Characterized by various periods of remissions and exacerbations
The colon becomes edematous and may develop bleeding lesions and ulcers;
the ulcers may lead to perforation
ULCERATIVECOLITIS
DESCRIPTION
Scar tissue develops and causes loss of elasticity and loss of ability to absorb
nutrients
Acute ulcerative colitis results in vascular congestion, hemorrhage, edema,
and ulceration of the bowel mucosa
Chronic ulcerative colitis causes muscular hypertrophy; fat deposits; and
fibrous tissue with bowel thickening, shortening, and narrowing
ULCERATIVECOLITIS
DESCRIPTION
Surgical intervention involves creation of an ostomy; the ostomy can be
created within the ileum or at various sites within the large bowelAn ileostomy is the surgical creation of an opening into the ileum or small
intestine that allows for drainage of fecal matter from the ileum to the
outside of the body
A colostomy is the surgical creation of an opening into the colon that allows
for drainage of fecal matter from the colon to the outside of the body
ULCERATIVECOLITIS
ACUTEULCERATIVECOLITIS
ULCERATIVECOLITIS
ASSESSMENT
Anorexia
Weight loss
Malaise
Abdominal tenderness and cramping
Severe diarrhea that may contain blood and mucus
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Dehydration and electrolyte imbalances
Anemia
Vitamin K deficiency
ULCERATIVECOLITIS
IMPLEMENTATIONAcute phase: Maintain NPO status, administer IVs and electrolytes, or total
parenteral nutrition (TPN) as prescribed
Restrict the clients activity to reduce intestinal activity
Monitor bowel sounds and for abdominal tenderness and cramping
Monitor stools, noting color, consistency, and the presence or absence of
blood
ULCERATIVECOLITIS
IMPLEMENTATION
Monitor for perforation, peritonitis, and hemorrhage
Following the acute phase, the diet progresses from clear liquids to low-
residue as tolerated
Instruct client to consume a low-residue, high-protein diet; vitamins and iron
supplements may be prescribed
Instruct client to avoid gas-forming foods and milk products and foods such
as whole-wheat breads, nuts, raw fruits and vegetables, pepper, alcohol,
and caffeine-containing products
ULCERATIVECOLITISIMPLEMENTATION
Instruct the client to avoid smoking
Administer bulk-forming agents such as bran, psyllium, or methylcellulose,
to decrease diarrhea and relieve symptoms
Administer antimicrobial, corticosteroids, and immunosuppressants as
prescribed to prevent infection and reduce inflammation
ULCERATIVECOLITIS
SURGICAL IMPLEMENTATION
TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY
Curative and involves the removal of the entire colon (colon, rectum, and
anus with anal closure)
The end of the terminal ileum forms the stoma, which is located in the right
lower quadrant
TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY
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ULCERATIVECOLITIS
SURGICAL IMPLEMENTATION
KOCK ILEOSTOMY (CONTINENT ILEOSTOMY)
An intra-abdominal pouch (stores the feces) is constructed from the terminal
ileumThe pouch is connected to the stoma with a nipple-like valve constructed
from a portion of the ileum; the stoma is flush with the skin
A catheter is used to empty the pouch, and a small dressing or adhesive
bandage is worn over the stoma between emptyings
KOCK ILEOSTOMY (CONTINENT ILEOSTOMY)
ULCERATIVECOLITIS
SURGICAL IMPLEMENTATION
ILEOANAL RESERVOIR
A two-stage procedure that involves the excision of the rectal mucosa, an
abdominal colectomy, construction of a reservoir to the anal canal, and a
temporary loop ileostomy
The ileostomy is closed in approximately 3 to 4 months after the capacity of
the reservoir is increased
CREATIONOFAN ILEOANAL RESERVOIR
ULCERATIVECOLITIS
SURGICAL IMPLEMENTATION
ILEOANAL ANASTOMOSIS (ILEORECTOSTOMY)Does not require an ileostomy
A 12- to 15-cm rectal stump is left after the colon is removed and the small
intestine is inserted into this rectal sleeve and anastomosed
Requires a large, compliant rectum
ILEOANAL ANASTOMOSIS
ULCERATIVECOLITIS
PREOPERATIVECOLOSTOMY AND ILEOSTOMY
Consult with enterostomal therapist to assist in identifying optimal
placement of the ostomy
Instruct the client to eat a low-residue diet for a day or two prior to surgery
as prescribed
Administer intestinal antiseptics and antibiotics as prescribed to cleanse the
bowel and to decrease the bacterial content of the colon
Administer laxatives and enemas as prescribed
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ULCERATIVECOLITIS
POSTOPERATIVECOLOSTOMY
Place a petrolatum gauze over the stoma as prescribed to keep it moist,
followed by a dry sterile dressing if a pouch (external) system is not in place
Place a pouch system on the stoma as soon as possibleMonitor the stoma for size, unusual bleeding, or necrotic tissue
ULCERATIVECOLITIS
POSTOPERATIVECOLOSTOMY
Monitor for color changes in the stoma
The normal stoma color is pink to bright red and shiny, indicating high
vascularity
A pale pink stoma indicates low hemoglobin and hematocrit levels
A purple-black stoma indicates compromised circulation, requiring physician
notification
ULCERATIVECOLITIS
POSTOPERATIVECOLOSTOMY
Assess the functioning of the colostomy
Expect that stool is liquid in the immediate postoperative period, but
becomes more solid depending on the area of the colostomy
Ascending colon - liquid
Transverse colon - loose to semi-formed
Descending colon - close to normalLOCATIONSOFCOLOSTOMIES
ULCERATIVECOLITIS
POSTOPERATIVECOLOSTOMY
Monitor the pouch system for proper fit and signs of leakage
Empty the pouch when it is one-third full
Fecal matter should not be allowed to remain on the skin
Administer analgesics and antibiotics as prescribed