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GASTROINTESTINAL PROCEDURES

DEAN NIO C. NOVENO, RN, MAN 1

GASTROINTESTINAL

PROCEDURES

NIO C. NOVENO, RN, MAN

nionoveno@yc GI PROCEDURES 2

Gastrointestinal (GI) Series

The introduction of barium, an opaque medium, into the upper GI tract via the mouth, gastrostomy tube, or nasogastric tube to visualize the area by x-ray methods

Nursing care

1. Explain procedure to client

2. Maintain the client NPO after midnight

3. Inform client that the stool will be white or pink for 24 to 72 hours after procedure

4. Encourage fluids and administer cathartics as ordered

5. Evaluate client's response to procedure


Barium Enema

A. The introduction of barium, an opaque medium, into the intestines for the purpose of x-ray visualization for pathologic changes


Barium EnemaNursing care

1. Explain procedure to the client

2. Prepare the client for the procedure by:a. Administering cathartics and/or enemas as

ordered to evacuate the bowel

b. Maintaining the client NPO for 8 to 10 hours prior to the test

3. Inspect stool after the procedure for the presence of barium

4. Administer enemas and/or cathartics as ordered if the stool does not return to normal

5. Encourage fluid intake





Colostomy Irrigation and Care

1. Instillation of fluid into the lower colon via a stoma on the abdominal wall to stimulate peristalsis and facilitate the expulsion of feces

2. Cleansing the colostomy stoma and collection of feces o sigmoid colon will tend to produce formed

stools

o transverse or ascending colostomy will produce less formed stools


Colostomy irrigation


Colostomy Irrigation and CareNursing care

1. Secure a physician's order

2. Irrigate the stoma at the same time each day to approximate normal bowel habits

3. Insert a well-lubricated catheter tip into the stoma o 7 to 10 cm in the direction of the remaining bowel

o as the solution is allowed to flow, the catheter may be advanced

4. Hold the irrigating container o height: 30.5 to 45.7 cm (12 to 18 inches)

o temperature: 105oF (40.5oC)

5. Clamp tubing or temporarily lower the container if the client complains of cramping


Colostomy Irrigation and CareNursing care

6. Provide privacy while waiting for fecal returns or permit the client to ambulate with the collection bag in place to further stimulate peristalsis

7. Clean the stomao if excoriation occurs, a soothing ointment may be

ordered

8. Apply a colostomy bag or gauze dressing

9. Teach the client to control odor when necessaryo place two aspirin tablets (or commercially available

deodorizers) in the colostomy bag

o take bismuth subcarbonate tablets orally to control odor





Colostomy bag

One-piece Two-piece


Endoscopy

The visualization of the esophagus, stomach, gallbladder, pancreas, colon, or rectum using a hollow tube with a lighted end

1. Gastroscopy: stomach

2. Esophagoscopy: esophagus

3. Sigmoidoscopy: sigmoid colon

4. Proctoscopy: rectum

5. Endoscopic retrograde cholangiopancreatography (ERCP)


Gastric endoscopy


Endoscopy




Sigmoidoscopy


Colonoscopy


Endoscopic retrograde

cholangiopancreatography (ERCP)


EndoscopyNursing care

1. Obtain an informed consent for the procedure

2. If rectal examination is indicated, administer cleansing enemas prior to the test

3. Restrict diet (NPO) prior to procedure

4. Following the procedure, observe for bleeding, changes in vital signs, or nausea

5. If the throat is anesthetized (as for a gastroscopy or esophagoscopy), check for the return of gag reflex before offering oral fluids





Enemas

1. Tap-water enema (TWE): introduction of water into the colon to stimulate evacuation

2. Soapsuds enema (SSE): introduction of soapy water into the colon to stimulate peristalsis by bowel irritationo contraindicated as a preparation for an

endoscopic procedure

• may alter the appearance of the mucosa

3. Hypertonic enema: commercially prepared small-volume enema that works on the principle of osmosis


Enemas


Enemas

4. Harris flush or drip: introduction of water into the colon as tolerated and subsequent repeated drainage of that water through the same tubing to facilitate passage of flatus

5. High colonic irrigation: introduction of water into the upper portion of the colon to facilitate complete fecal evacuation

6. Instillation: introduction of a liquid (usually mineral oil) into the colon to facilitate fecal activity through lubricating effect


EnemasNursing care


2. Provide privacyo place in side-lying position

3. Obtain the correct solution

4. Lubricate the tip of a rectal catheter with water-soluble jelly

5. Insert the catheter 10 to 15 cm (4 to 6 inches) into the rectum




EnemasNursing care

6. Allow the solution to enter slowlyo keep it no more than 30.5 to 45.7 cm (12 to

18 inches) above the rectum

o temporarily interrupt flow if cramps occur

7. Allow ample time for the client to expel the enema

8. Observe and record the amount and consistency of returns



Gastric Analysis

1. Analysis of stomach contents for the presence of abnormal constituents or lack of normal constituents such as hydrochloric acid, blood, acid-fast bacteria, and lactic acid

2. Acid content is elevated in ulcers, decreased in malignant conditions of the stomach, and absent in pernicious anemia


Gastric AnalysisNursing care


2. Maintain the client NPO prior to the test and have a nasogastric tube passed at time of procedure

3. Administer histamine or caffeine to stimulate hydrochloric acid secretion prior to the procedure if ordered

4. Obtain stomach contents, secure in an appropriate container, and send to laboratory



Gavage (Tube Feeding)

1. Nasogastric

a. Placement of a tube through the nose into the

stomach, securing it in place with tape

b. Prepared nutritional supplements are

introduced through this tube

2. Intestinal

a. Placement of a tube through the nose into the

small intestine, securing it in place with tape

b. There is less likelihood of aspiration because

the pyloric sphincter inhibits backflow





3. Surgically placed feeding tubesa. Cervical esophagostomy: tube is sutured directly

into the esophagus for clients who have had head and neck surgery

b. Gastrostomy: tube is placed directly into stomach through the abdominal wall and sutured in place• used for clients who require tube feeding on a

long-term basis

c. Jejunostomy: tube is inserted directly into the jejunum for clients with pathologic conditions of the upper GI tract



4. Percutaneous endoscopic gastrostomy (PEG)

a. Stomach is punctured during endoscopy procedure

b. Does not require general anesthesia or laparotomy

c. Dressing should be changed daily

d. Although associated with reduced risks, accidental removal and aspiration still may occur


Gavage (Tube Feeding)Nursing care

1. Verify placement of tube prior to feeding

a. Inject a small amount of air into the tube and, with a stethoscope placed over the epigastric area, listen for the passage of air into the stomach

b. Aspirate for presence of stomach contents; reinstill to avoid electrolyte imbalance

c. Test aspirate for acid pH

d. Small-bore tube placement must be verified by x-ray examination


Gavage (Tube Feeding)Nursing care

2. Aspirate contents of stomach prior to feeding to determine residual• reinstill to avoid electrolyte imbalance

• withhold feeding if the residual is greater than 150 ml





3. Intermittent feeding

a. Position the client so that the head is elevated

during and for 1 hour after the feeding

b. Appropriately verify placement of tube

c. Introduce a small amount of water (30 ml) first to

verify the patency of the tube

– the tube should not be allowed to empty during

feeding so that excess air is not forced into the

stomach



3. Intermittent feeding cont…

d. Slowly administer the feeding at room or body temperature

– observe and question the client to determine tolerance

– the higher the feeding container and the larger the lumen of the feeding tube, the more rapid the flow

e. Administer a small amount of water to clear the tube at the completion of the feeding

f. Clamp the tubing and clean the equipment

g. Place client in sitting position for 1 hour after feeding

– place infant in right side-lying position



4. Continuous feeding

a. Place prescribed feeding in gavage bag and prime

tubing to prevent excess air from entering stomach

b. Set rate of flow

– rate of flow can be manually regulated by setting

drops per minute or mechanically regulated by

using an electric pump

c. Position the client to keep the head elevated

throughout the feeding



4. Continuous feeding cont…

d. Appropriately verify placement of tube when adding additional fluid to a continuous feeding

e. Flush tube intermittently with water to prevent occlusion of tube with feeding

f. Monitor for gastric distention and aspiration

– gastric distention and subsequent aspiration are less frequent

g. Discard unused fluid that has been in gavage administration bag at room temperature for longer than 4 hours





5. Care common for all clients receiving

tube feedings

a. Monitor for abdominal distention

– changes in bowel sounds or diarrhea

b. Discontinue feeding if nausea and/or

vomiting occur

c. Provide oral hygiene



5. Care common for all clients receiving tube feedings cont…

d. When appropriate, encourage the client to chew foods that will stimulate gastric secretions while providing psychologic comfort– chewed food may not be swallowed

e. Provide special skin care– if the client has a gastrostomy tube sutured in place,

the skin may become irritated from gastrointestinal enzymes

– if the client has a nasogastric tube, the skin may become excoriated at point of entry because of irritation

f. Evaluate client's response to the procedure


Ileostomy Care

The physical care of the ileostomy stoma and surrounding skin

Nursing care

1. Protect the skin from irritation, since the feces will be liquid because of the anatomic location of the stoma

2. Explain procedure to the client and family and encourage selfcare

3. Do not irrigate the stoma

4. Affix an appliance with an adequate seal (e.g., karaya) to prevent accidental leakage around the stoma; the appliance is generally changed every 2 to 4 days but emptied every 6 hours



Ileostomy




Irrigation of Nasogastric

(Levin) Tube

1. The Levin tube is commonly used for gastric

decompression

2. Purposes of insertion of a nasogastric tube

include emptying the stomach, obtaining a

specimen for diagnostic purposes, or

providing a means for nourishment

3. Irrigation is the insertion and then removal of

fluid (usually normal saline) to maintain

patency


Gastric decompression: Levin


Irrigation of Nasogastric (Levin) Tube Nursing Care

1. Check that the order for irrigations has been written by the physician

2. Ascertain the patency of the Levin tube attached to intermittent suction by observing for drainage� nausea or abdominal discomfort may indicate

that the tube is occluded

3. Assemble equipment: 30-ml syringe or bulb syringe, irrigating solution, and basin for returning fluid

4. Verify placement


Irrigation of Nasogastric

(Levin) Tube

5. Instill approximately 30 ml of fluid into the tube

6. Gently withdraw the same volume of fluid as was instilledo if the client has undergone gastric surgery, the

physician will generally order instillationso irrigation fluid is instilled but not withdrawn

o the amount instilled must be subtracted from total gastric output

7. Chart the amount, color, and consistency of drainage





Paracentesis

The surgical puncture of the peritoneal

membrane of the abdominal cavity for

the purpose of removing fluid


ParacentesisNursing care

1. Explain the procedure; obtain consent

2. Have the client void prior to procedure

to avoid accidental trauma to the

bladder

3. Assist the client to a sitting position

4. Observe for signs of shock

• sudden fluid shifts can result in

hypotension


Paracentesis


ParacentesisNursing care

5. Chart the amount and characteristics

of fluid withdrawn

6. Apply a dry sterile dressing to the

puncture site

7. Properly label the specimen if required

and send to the laboratory

8. Evaluate client's response to the

procedure




Parenteral Replacement Therapy

Peripheral parenteral nutrition (PPN)

1. Administration of isotonic lipid and amino acid solutions through a peripheral vein

2. Amino acid content should not exceed 4%; dextrose content should not be greater than 10%

3. Assists in maintaining a positive nitrogen balance



Total Parenteral Nutrition (TPN)

1. Administration of carbohydrates, amino acids, vitamins, and minerals via a central vein (usually the superior vena cava)

2. High osmolality solutions (25% dextrose) are administered in conjunction with 5% to 10% amino acids, electrolytes, minerals, and vitamins

3. Assists in maintaining a positive nitrogen balance



Intralipid therapy

1. Infusion of 10% to 20% fat emulsion

that provides essential fatty acids

2. Provides increased caloric intake to

maintain positive nitrogen balance



Total nutrient admixture (TNA or "3 in 1")

1. Combination of dextrose, amino acids

and lipids in one container; vitamins

and minerals may be added

2. Administered through a central line

over 24 hours




Parenteral Replacement TherapyNursing care

1. Infuse fluid through a large vein such

as the subclavian because of the high

osmolarity of the solution used in TPN

2. Ensure proper placement of the tube

by chest x-ray examination after

insertion of a catheter; accidental

pneumothorax can occur during

insertion



3. Precisely regulate the fluid infusion rate; an intravenous pump should be used if available

a. Rapid infusion may result in movement of the fluid into the intravascular compartment• dehydration, circulatory overload, and

hyperglycemia can occur

b. Slow infusion may result in hypoglycemia, since the body adapts to the high osmolarity of this fluid by secreting more insulin• therapy is never terminated abruptly but is

gradually discontinued



4. Use aseptic technique when handling

the infusion or changing the dressing

(in many institutions, only nurses

specially prepared are allowed to

change the dressing because of the

high risk of infection)

5. Consult manufacturer's instructions

about tubing when administering lipids



6. Utilize a filter for TPN; filters cannot

be used for lipids

7. Use surgically aseptic technique when

changing tubing

8. Record daily weights, and monitor

urinary sugar and acetone or blood

glucose levels frequently





8. Check laboratory reports daily, especially glucose, creatine, BUN, and electrolytes• serum lipids and liver function studies if lipids are

administered

9. Monitor temperature every four hours since infection is the most common complication of TPN• if the client has a temperature elevation, order

cultures of blood, urine, and sputum to rule out other sources of infection



Stool Specimens

1. Stool for guaiac (occult blood): specimen or smear of stool on a commercially prepared card is analyzed for the presence of blood• positive results indicate the presence of blood in the

stool• peptic ulcer, gastritis, gastric or colonic carcinoma,

colitis, or diverticulitis

2. Stools for O and P (ova and parasites): must be sent to the laboratory while still warm for microscopic examination unless a preservative is available

3. Stool culture: specimen or swab of stool is sent in a sterile container for identification of abnormal bacterial growth


Guaic’s test


Stool SpecimensNursing care

1. Explain procedure to the client

2. Collect specimen in an appropriate

container

3. Label the container with the client's

name, identification number,

physician, and room number

4. Chart that the specimen was sent and

any unusual assessment of the stool



GASTROINTESTINAL

PROCEDURES

THANK YOU!THANK YOU!THANK YOU!THANK YOU!

NIO C. NOVENO, RN, MAN

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