1. Alterations of GI System
Nur 302 Unit I

2. Carcinoma of Oral Cavity
Predisposing factors: tobacco & alcohol
S/S: leukoplakia, erythroplakia, ulcer, sore or rough spot
Diagnosis: biopsy
Collaborative Care: surgery, radiation, chemo or combination
Health Promotion
Expected Outcomes

3. Mandibular Fracture Rx: immobilization by wiring- 4-6 weeks
Pre-op teaching
Post-op Care: Airway, oral hygiene, communication, nutrition

4. 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 emptying
IV and NG tube, begin diet with clear liquids.

5. GERD Predisposing Factors
Hiatal hernia
Incompetent lower esophageal sphincter
Decreased esophageal clearance
Decreased gastric emptying.
Esophagitis- trypsin & bile salts.

6. 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.

7. GERD & Hiatal Hernia Signs & Symptoms
Heartburn
Wheezing, coughing, dyspnea
Hoarseness, sore throat
Post eating bloating
N/V, regurgitation
Hiatal hernia s/s mimic GB disease, angina, peptic ulcer

8. Diagnostic Studies Barium swallow Esophagoscopy Biopsy
Esophageal motility studies
Check ph

9. 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.

10. Hiatal Hernia Treatment
Surgery: valvuloplasties or antireflux procedures.
Post-op care:
Prevent respiratory complications maintain fluid & electrolyte balance prevent infection.
Chest tube
NG tube.

11. 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.

12. Esophageal Cancers Pre-op care: Post-op care :
high calorie, high P, liquid diet or TPN
oral care
teaching
Post-op care :
NG bloody 8-12 hours
semi-Fowler’s position
prevent resp. complication

13. Gastritis Types: Acute or Chronic, Type A (Fundal) & Type B (Antral).
Etiology: breakdown in normal mucosa barrier
Corticosteroids, NSAIDS, ASA,spicy foods, alcohol
Presence of Helicobacter pylori

14. Gastritis Signs & Symptoms
Anorexia
N/V
Epigastric tenderness
Feeling of fullness
Hemorrhage

15. Diagnostic Studies Endoscopic exam CBC Stool for occult blood
Cytologic exam

16. 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.

17. 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

18. Peptic Ulcer Signs & Symptoms
May have no pain
Gastric 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

19. 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).

20. 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.

21. 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

22. Post-op Care Observe NG tube drainage
Red, decreasing in color 1st 24 hours
Observe for clogged NG tube
Do not irrigate without MD order, surgeon replaces NG if pt pulls out tube
Observe for decreased peristalsis
I&O, VS

23. 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?

24. 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 consent
Take initial set VS
Pick up blood from lab
Assess IV site
Start transfusion
Verify pt ID, & blood compatability

25. 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 transfusion
Save transfusion unit
Inform MD/RN
Save next voided specimen
Start 0.9NS
Take VS

26. Post-op complications
Dumping Syndrome
Postprandial hypoglycemia
Bile reflux gastritis

27. Dumping Syndrome
Large amount hyperosmolar chyme in intestine->fluid is drawn in->decrease of plasma volume
Bowel also becomes distended->increased motility
15-30 minutes after eating->s/s last 1 hr
Weakness, sweating, dizzy, cramps, urge to have BM

28. 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?

29. 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

30. Nutrition Postgastrectomy Dumping Syndrome
Six small meals
Do not have fluids with meals
Fluids 45 minutes before or after meals
Dry foods low CHO, moderate protein & fats
Avoid concentrated sweets (jams, candy, etc)
Lie down after meals, short rest period

31. 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

32. Food Poisoning S/S: n/v, diarrhea, colicky abdominal pain
Types: acute bacterial gastroenteritis- staph, clostridial, salmonella, botulism, escherichia coli, see table 42-27

33. Food Poisoning Health Promotion
Correct food preparation
Cleanliness
Cooking
Refrigeration

34. 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

35. 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

36. 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

37. “Acute Abdomen” Etiology: see table 43-12
S/S: PAIN, abd tenderness, vomiting, diarrhea, abd tenderness, constipation, flatulence, fatigue, fever, increased abd girth
DX: H&P, preg test, rectal & pelvic exam, CBC, U/A, abd x-rays
Emergency management: table 43-13

38. “Acute Abdomen”
Assess: VS, inspect, palpate & auscultate abdomen, pain, n/v, change in bowel habits, vaginal discharge
Pre-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

39. Chronic Abdominal Pain
Irritable bowel syndrome, peptic ulcer , diverticulitis, chronic pancreatitis, hepatitis, cholecystitis, pelvic inflam. disease, vascular insuffic., psychogenic
Diagnosis & treatment: “critical thinking skills”

40. Abdominal Trauma Etiology: blunt trauma or penetrating injuries
Lacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears, diaphragmatic rupture, urinary bladder rupture, great vessel tears, renal injury, stomach or intestinal rupture
S/S: abd guarding & splinting, distended, hard abd, decr or absent BS, contusions, abrasions, bruising on abd, pain, shock, hematemesis or hematuria, Cullen’s sign

41. Abdominal Trauma Dx: CBC, u/a, abd cat, x-rays, periton. lavage
Assessment: 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 tenderness
Interventions: airway, control bleeding, cover protruding organs, IV, labs, foley, VS, LOC, see table 43-14

42. Appendicitis
S/S: periumbilical pain, then shifting to RLQ & 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

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

44. 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

45. 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

46. 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

47. Complications
Intestinal: hemorrhage, strictures, perforation, toxic megacolon, colonic dilatation, risk for colon cancer
Extraintestinal: due to malabsorbtion or problem with immune system – joints, skin, mouth & eyes
Dx: CBC, lytes, albumin, stool analysis, sigmoidascope & colonoscopy, barium enema

48. Nursing & Collaborative Care
Rest bowel
Control inflammation
Prevent / treat infection
Correct malnutrition
Meds to relieve s/s
Alleviate stress
See NCP 40-3

49. 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

50. Surgery Total proctocolectomy with perm. ileostomy
Total protocolectomy with continent ileostomy called a Knock pouch
Total colectomy & ileal reservoir
Surgery “cures” disease
Post-op: stoma care, skin integrity, I&O, observe for hemorrhage, abscess, small bowel obstruction, electrolyte imbalance & dehydration, diet teaching & care of ileostomy

51. Crohn’s Disease
Inflammation of segments GI tract esp ileum,jejunum, colon & involves all layers of bowel wall
Classic “cobblestone” appearance, normal bowel between diseased, longitudinal, deep ulcerated parts
Thickening bowel wall & strictures
Abscesses & fistulas with bladder, vagina, bowel

52. 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, uveitis
Dx: same as ulcerative colitis

53. Collaborative Care Sulfasalazine – large intestine involvement
Corticosteroids – taper off when s/s subside
Immunosuppressive meds if steroids ineffective
Flagyl – perianal area
Fish 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

54. 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

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

56. 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

57. 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

58. Nursing Care Assessment: pain, s/s, BS, dehydration, labs
Insertion & care NG tube
Intestinal tubes: Harris tube, Miller-Abbott tube, Cantor tube

59. 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

60. Colon & Rectal Cancer
Dx: H&P, rectal exam, sigmoidoscopy, air contrast barium enema, CT scan colonoscopy, CBC, clotting studies, liver enzymes, CEA
Staging: primary tumor, regional lymph node involvement, distant metastasis
Surgery: R or L hemicolectomy, abdominal perineal resection
Chemo & radiation: post-op or palliative

61. Health Promotion Assess risk factors
American Ca Society recommends 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 risk
Barriers: lack of info & fear of dx
Research: use of anti-inflammatory drugs or long term use of ASA
Diet

62. Nursing Care Abd-Perineal Resection
Teach extent of surgery for abdom-perineal resection, positioning for comfort & sitz bath, ostomy questions
Abd wound, perineal wound, stoma
Profuse 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.

63. Home Care Psychological support Pain/discomfort management Nutrition
Care of perineal wound
Home health nurse – assessment & teaching of pt & family
Community Services

64. 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

65. 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

66. 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 stool
Diverticulitis: rest bowel- NPO, IV, BR,NG, antibiotics, complications->surgery

67. Hernias Protrusion of viscous thru wall of cavity.
Reducible, irreducible or incarcerated, strangulated
Types: inguinal, femoral, ventral or incisional
S/S: bulge, discomfort, pain->strangulated
Tx: herniorrhaphy, hernioplasty, truss
Post-op: check voiding, scrotal support, ice pack, no coughing, splint incision with mouth open if sneeze, no lifting 6-8 weeks

68. Malabsorption Syndrome
Causes: biochemical or enzyme deficiency, bacterial profileration, disruption sm intestine mucosa, disturbed lymph or vascular circulation,surface area loss
Lactose intolerance, inflam bowel disease, celiac, tropical sprue, cystic fibrosis
S/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

69. 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

70. 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

71. Anorectal Problems
Anal fissure –crack or skin ulcer in anal wall, associated with constipation
Anorectal abscess- perirectal infection E. coli, staph or strep, foul smell, sepsis
Surgically drained, packed q day with petroleum jelly gauze, keep clean, heal by granulation, sitz bath, lo residue diet
Pilonidal cyst- sacrcoccyx, congenital, lined with epithelium & hair, abscess forms
Tx- I&D