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Med/Surg II, Part 3 of 4 Digestion Disorders

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1 Med/Surg II, Part 3 of 4 Digestion Disorders
Malignant Oral and Laryngeal Tumors

2 Pre-Malignant Mouth Lesions
Leukoplakia: pre-malignant lesion, especially on tongue or lips; thickened, white, permanently attached patches, slightly raised, sharp edges Erythroplakia: pre-malignant lesion more likely to progress to malignancy than leukoplakia; red, velvety lesion found in floor of mouth, tongue, palate, mandible mucosa

3 Squamous Cell Mouth Carcinoma
Risk Factors Increased age Tobacco (chewing or smoking) Treatment Early detection is most important Local excision will be done if possible for biopsy and possible cure. Risk Factors Increased age Tobacco (chewing or smoking) potentiated by alcohol Treatment Early detection is most important. Encourage regular dental exams where a thorough examination of the mouth is done. Local excision will be done if possible for biopsy and possible cure. If the lesion is large or cannot be fully removed, a radical mouth or neck dissection will be done.

4 Diagnosis of Laryngeal Cancer
Direct laryngoscopy CT scan of the head and neck with contrast MRI of head and neck with contrast PET scan: Biopsies Endoscopic biopsy Fine needle aspiration (FNA) biopsy Diagnosis Direct laryngoscopy CT scan of the head and neck with contrast MRI of head and neck with contrast PET scan: Positron emission tomography (PET) uses glucose that contains a radioactive atom. Cancer cells in the body absorb large amounts of the radioactive sugar and a special camera can detect the radioactivity. Biopsies Endoscopic biopsy: Because the larynx and hypopharynx are located deep inside the neck, biopsies of these areas are not done in the doctor's office. Fine needle aspiration (FNA) biopsy: FNA biopsy (a thin needle placed into the mass so that cells can be withdrawn to check under a microscope) can determine if it is a benign lymph node that has grown in reaction to a nearby infection, (such as a sinus or tooth infection), a benign fluid-filled cyst that can be cured by surgery, or cancer.

5 Total Laryngectomy, Preoperative Care
Discuss the informed consent Explain that the procedure will likely be many hours Intensive care unit for airway protection - may be on a ventilator. Alternate forms of communication Prepare the patient for a feeding tube Explain pain control methods: PCA machine. Have the patient practice with one if possible. Tracheostomy will probably be performed - explain this to the patient. Preoperative care: Discuss the informed consent with the patient and family to make sure they understand. Explain that the procedure will likely be many hours long – family should expect the long wait. The patient will probably wake up in the intensive care unit for airway protection as well as the effects of long anesthesia time. The patient may even be on a ventilator. Explain alternate forms of communication for the immediate postoperative period & if they will be needed on a permanent basis (total laryngectomy). Discuss voice rehabilitation if there will be a partial laryngectomy. Prepare the patient for a feeding tube. Discuss the role of nutrition in wound healing. Explain pain control methods, especially use of the PCA machine. Have the patient practice with one if possible. Tracheostomy will probably be performed - explain this to the patient.

6 Postoperative Care Airway Maintenance
Flap and reconstructive tissue care Hemorrhage Wound breakdown Pain management Nutrition Speech rehabilitation Postoperative Care Immediate priorities: Patent airway, oxygenation, hemorrhage, pain management Ongoing nursing care: Airway maintenance and ventilation After the patient is weaned from the ventilator, make sure a mist collar is placed over the tracheostomy Encourage the patient to cough up secretions but suction if needed Tracheostomy: cleanse around the opening and clean the tube if it can be removed; inspect for crusting and remove Give the patient a Yankauer to suction his own mouth Flap and reconstructive tissue care A flap of tissue may be transplanted from another part of the body to cover wounds on the neck. Any flap needs to be checked hourly for the first 24 hours: color, warmth, Doppler pulses all should be evaluated Any changes must be reported to the surgeon immediately. This may be a plastic surgeon rather than the head and neck surgeon – make sure you call the right one! Hemorrhage Hemorrhage is uncommon with a simple laryngectomy. There will probably be a bulb-type drain that needs maintenance: empty as needed & measure, re-compress the bulb & make sure it stays compressed, “milk” the tubing leading from the wound to discourage clotting. If the drainage suddenly decreases, consider a blockage. This could cause a buildup of blood under the flap and may impair its circulation. Call the surgeon immediately Wound breakdown Wound healing is a common problem related to the patient’s possible underlying nutrition deficiencies. Keep the wound scrupulously clean and painted with antibiotic ointment as ordered. If there is wound breakdown around the carotid artery, it may rupture. Emergency treatment is direct pressure over the site & immediate transport to the operating room for repair. There is a high risk of stroke and death in these instances. Pain management A continuous morphine drip is used the first few days. There is a significantly high level of anxiety in these patients. They need to control their pain relief and should also have intermittent PCA morphine available Alcohol withdrawal also may be a problem. Be prepared with an order for Ativan IV prn agitation. Too much agitation, aside from scaring the patient, may block recovery. Nutrition A feeding tube will be inserted in the operating room – it may be sewn into the neck wound. The dietician will recommend the type and amount of feeding to be given. It may be continuous or bolus feedings. If the patient will be giving his own tube feedings at home, teach him how to do bolus feedings. The patient will need a swallowing evaluation before he is allowed to eat orally. He may require ongoing therapy to be consistently safe eating without aspiration Speech rehabilitation The speech therapist will discuss communication options with the patient The nursing staff will reinforce the patient’s selected method and encourage him as he re-learns how to speak. Options include esophageal speech and mechanical devices

7 Discharge Teaching Stoma Care
Avoid swimming, care with showering or shaving to protect stoma opening Lean slightly forward, cover stoma when coughing or sneezing Wear a stoma guard Clean the stoma with mild soap & water. Lubricate with non-oil-based ointment prn Increase humidity in airway with saline spray, humidifier in room Wear a Med-Alert bracelet & carry emergency care card Discharge Teaching: Self management at home requires preparation. The nurse will verify the patient understands the following: Stoma care Avoid swimming, be careful when showering or shaving to protect stoma opening Lean slightly forward, cover stoma when coughing or sneezing Wear a stoma guard: to filter the air entering the airway & to maintain humidity in the airway. Clean the stoma with mild soap & water. Lubricate with non-oil-based ointment prn Increase humidity in airway with saline spray, humidifier in room Wear a Med-Alert bracelet & carry emergency care card

8 Communication Verify the patient knows how to use his selected communication method Keep backup communication options available Card that explains the patient’s situation in an emergency: Communication Verify the patient knows how to use his selected communication method Ask patient to keep backup communication options available A card is available from the International Association of Laryngectomees that explains the patient’s situation in an emergency:

9 Smoking cessation support Speech therapy Dietician
Resources Smoking cessation support Speech therapy Dietician Laryngectomy support group Alcoholics Anonymous if needed Smoking cessation It is essential the patient stop smoking to promote wound healing & prevent recurrence of the cancer Support and reinforcement are available – make sure the patient knows how to contact and get that support: this is the web site of the American Lung Association. There is a section on smoking cessation at this site:

10 Psychosocial Preparation
A visit from a fellow laryngectomee Importance of returning to a normal lifestyle as much as possible Expect changes in smell & taste as well as communication Prepare for mucus with handkerchiefs, tissues or gauze Psychosocial preparation Many changes are occurring in this patient’s life. A visit from a fellow laryngectomee would be helpful. To find a support group: Stress the importance of returning to a normal lifestyle as much as possible, usually within 4-6 weeks. Tell the patient to expect changes in smell & taste as well as communication Be prepared for mucus with handkerchiefs, tissues or gauze Resources Make sure the patient has a written list of resources in the local community: Laryngectomee support group: see Lost Chord Club above Smoking cessation support Speech therapy Dietician Alcoholics Anonymous if needed

11 Gastroesophageal Reflux Disease (GERD) Esophageal Cancer
Esophageal Problems Gastroesophageal Reflux Disease (GERD) Esophageal Cancer

12 Clinical Manifestations of GERD
Pyrosis Dyspepsia - may mimic symptoms of a myocardial infarction Regurgitation of food particles or fluid – sour or bitter taste in mouth – high risk aspiration Dysphagia Hypersalivation Clinical Manifestations Pyrosis (burning sensation in esophagus) Dyspepsia (heartburn) - may mimic symptoms of a myocardial infarction Regurgitation of food particles or fluid – sour or bitter taste in mouth – high risk aspiration Dysphagia (difficulty swallowing) Hypersalivation (water brash)

13 Collaborative Management: Diet
Limit or eliminate chocolate, fat, mints, carbonated drinks Limit spicy and acidic foods when symptomatic Eat 4-6 small meals per day Avoid evening snacks, no food 3 hours before sleeping Collaborative Management Diet: Limit or eliminate chocolate, fat, mints, carbonated drinks Limit spicy and acidic foods when symptomatic Eat 4-6 small meals per day Avoid evening snacks, no food 3 hours before sleeping (reflux is most damaging at night when patient is supine)

14 Lifestyle Changes Elevate head of bed at least 6 inches to avoid reflux when sleeping Sleep in left lateral decubitus position Smoking and alcohol exacerbate reflux Weight reduction will decrease intra-abdominal pressure Avoid any activity that increases abdominal pressure Lifestyle changes: Elevate head of bed at least 6 inches to avoid reflux when sleeping Sleep in left lateral decubitus (side-lying) position Smoking and alcohol exacerbate reflux Weight reduction will decrease intra-abdominal pressure Avoid any activity that increases abdominal pressure: lifting heavy objects, stooping, constrictive clothing

15 Medication Antacids for occasional episodes raise gastric pH: Gaviscon, Maalox, Mylanta one hour before and 2-3 hours after a meal Histamine receptor antagonists reduce acid secretion: ranitidine (Zantac), famotidine (Pepcid) Proton pump inhibitors are the main treatment for GERD: omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), esomeprazole (Nexium) Medication: Antacids for occasional episodes raise gastric pH: Gaviscon, Maalox, Mylanta one hour before and 2-3 hours after a meal Histamine receptor antagonists reduce acid secretion: ranitidine (Zantac), famotidine (Pepcid) Proton pump inhibitors are the main treatment for GERD. They decrease gastric acid secretion and promote tissue healing: omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), esomeprazole (Nexium)

16 Esophageal Cancer Risk Factors: Chronic irritation: smoking, alcohol ingestion, GERD Manifestations: progressive and persistent dysphagia (most common), sense of mass in throat, painful swallowing (odynophagia), substernal pain or fullness, regurgitation with foul breath and hiccups and weight loss Risk Factors: Chronic irritation: smoking, alcohol ingestion, GERD Manifestations: progressive and persistent dysphagia (most common), sense of mass in throat, painful swallowing (odynophagia), substernal pain or fullness, regurgitation with foul breath and hiccups and weight loss (late).

17 Diagnosis Barium swallow with fluoroscopy
Esophagogastroduodenoscopy (EGD) with biopsies (definitive diagnosis) Image Source: National Cancer Society, Public Domain,

18 Esophageal Reconstruction Postoperative Nursing Care
Highest priority Stress deep breathing Incentive spirometer Early ambulation Semi-fowler’s position in bed Esophageal Reconstruction – Postoperative Nursing Care: Respiratory care: highest priority – stress deep breathing, incentive spirometer, early ambulation, semi-fowler’s position in bed

19 Cardiovascular Monitor closely for: Chest tube management if present
Hypotension from hypovolemia Pulmonary edema from fluid overload Chest tube management if present Cardiovascular: hypotension from hypovolemia or pulmonary edema from fluid overload – monitor closely for both. Chest tube management if present

20 Wound management Multiple incisions and drains
Support incision when moving to prevent dehiscence Infection from incision leak Watch for fever, increased fluid from drains, signs of local inflammation, tachycardia Wound management: Multiple incisions and drains. Support incision when moving to prevent dehiscence; infection from incision leak – watch for fever, increased fluid from drains, signs of local inflammation, tachycardia

21 Nasogastric tube Placed intraoperatively to decompress suture area
Do not irrigate or reposition. Drainage bloody early, green-yellow after 24 hours Nasogastric tube: placed intraoperatively to decompress suture area – do not irrigate or reposition. Drainage bloody early, green-yellow after 24 hours

22 Nutrition Jejunal tube placed intraoperatively
Start tube feeding after 24 hours, increase slowly When taking oral nutrition, start with liquids and advance slowly to accommodate decreased stomach capacity Teach: always eat in upright position – to protect against reflux Eat 6-8 small meals per day No liquids with meals to prevent diarrhea (dumping syndrome) Jejunal tube placed intraoperatively. Start tube feeding after 24 hours, increase slowly When taking oral nutrition, start with liquids and advance slowly to accommodate decreased stomach capacity Teach: always eat in upright position – to protect against reflux Eat 6-8 small meals per day No liquids with meals to prevent diarrhea (dumping syndrome)

23 Peptic Ulcer Disease (PUD) Gastric Carcinoma
Stomach Disorders Peptic Ulcer Disease (PUD) Gastric Carcinoma

24 Peptic Ulcer Disease (PUD)
Risk Factors Acute gastritis caused by: Helicobacter pylori, a gram-negative bacterium Medication side effect: Nonsteroidal anti-inflammatory drugs, alcohol, cytotoxic agents, caffeine, corticosteroids Risk Factors Acute gastritis caused by: Helicobacter pylori, a gram-negative bacterium Medication side effect: Nonsteroidal anti-inflammatory drugs, alcohol, cytotoxic agents, caffeine, corticosteroids

25 Prevention Avoid excess alcohol
Use caution with inflammatory medications Avoid excess caffeine Stop smoking Prevention Avoid excess alcohol Use caution with inflammatory medications Avoid excess caffeine Stop smoking

26 Manifestations Epigastric pain Anorexia, nausea or vomiting
Hematemesis Dyspepsia Intolerance of fatty and spicy foods Manifestations Epigastric pain Anorexia, nausea or vomiting Hematemesis Dyspepsia Intolerance of fatty and spicy foods

27 Collaborative Treatment
Teach: Stress reduction, avoid alcohol and tobacco Diet: Limit any foods or spices that cause symptoms Avoid bedtime snacks (stimulate acid secretion) Collaborative Treatment Teach: Stress reduction, avoid alcohol and tobacco Diet: Limit any foods or spices that cause symptoms: caffeine, decaffeinated coffee (contains peptides that stimulate acid release), chocolate, mustard, paprika, cloves, pepper, hot spices. Avoid bedtime snacks (stimulate acid secretion)

28 Drugs H. pylori: Treat with 2 antibiotics + bismuth compound (Pepto-Bismol) or proton pump inhibitor Antacids 2 hours after meals to buffer acid secretions. H2- receptor blockers to prevent acid secretions Drugs: Treat H. pylori with 2 antibiotics + bismuth compound (Pepto-Bismol) or proton pump inhibitor such as omeprazole (Prilosec) Antacids (aluminum and magnesium combination products such as Maalox or Mylanta) 2 hours after meals to buffer acid secretions. Tums is not recommended due to rebound acid secretion H2- receptor blockers to prevent acid secretions

29 Mucosal barrier, sucralfate (Carafate) Antisecretory agents
Drugs (continued) Mucosal barrier, sucralfate (Carafate) Antisecretory agents Prostaglandin analogues such as misoprostol (Cytotec) to decrease acid secretion and increase mucosal resistance Mucosal barrier, sucralfate (Carafate) Antisecretory agents: pantoprazole (Protonix), esomeprazole (Nexium). NOTE: if giving omeprazole (Prilosec) or lansoprazole (Prevacid) delayed release granules through a feeding tube, dissolve in a bicarbonate solution to protect from gastric acid Prostaglandin analogues such as misoprostol (Cytotec) to decrease acid secretion and increase mucosal resistance

30 Manage Complications Bleeding: Watch for coffee ground vomitus; black, tarry stools (melena) as well as bright red blood Monitor hemoglobin, hematocrit, coagulation studies Monitor vital signs for shock Manage Complications Bleeding: Watch! For coffee ground vomitus, black, tarry stools (melena) as well as bright red blood Monitor hemoglobin, hematocrit, coagulation studies Monitor vital signs for shock Nasogastric lavage: NOTE: use 0.9% saline NOT tap water Hypovolemia from bleeding: isotonic crystalloids (0.9% saline, Ringer’s lactate), blood products, electrolytes as indicated. Watch! for alkalosis due to acid loss from vomiting. Endoscopic therapy: Assist physician with EGD who will perform cautery, inject with epinephrine or use laser to close bleeding vessels Patient preparation: large-bore IV catheter for conscious sedation, blood products if needed; NPO for at least 6 hours, informed consent Post-procedure: monitor vital signs, oxygen

31 Manage Complications Nasogastric lavage:
NOTE: use 0.9% saline NOT tap water

32 Hypovolemia from Bleeding
Isotonic crystalloids (0.9% saline, Ringer’s lactate), blood products, electrolytes as indicated Watch! for metabolic alkalosis due to acid loss from vomiting.

33 Assist physician with EGD
Patient preparation: Large-bore IV catheter for conscious sedation Blood products if needed NPO for at least 6 hours, informed consent Post-procedure: monitor vital signs, oxygen

34 Surgical Management Vagotomy Pyloroplasty
Billroth I (gastroduodenostomy) Billroth II (gastrojejunostomy) Surgical Management Vagotomy: cutting the vagus nerve to the stomach eliminates the acid-secreting stimulus. Pyloroplasty: widens the exit of the pylorus, facilitates stomach emptying Billroth I procedure (gastroduodenostomy): distal stomach is removed, remainder is anastomosed to the duodenum. Billroth II procedure (gastrojejunostomy): lower stomach is removed, remainder is anastomosed to the jejunum Image Source: Royal College of Surgeons of Ireland, Creative Commons

35 Postoperative Management:
Nasogastric Tube: Attach securely to maintain position – do not change position without surgeon’s order Monitor drainage for color, volume of drainage NOTE: report more than scant bloody drainage or minimal drainage; do not irrigate. Postoperative Management: Nasogastric Tube: Attach securely to maintain position – do not change position without surgeon’s order ; monitor drainage for color, volume of drainage. NOTE: report more than scant bloody drainage or minimal drainage; do not irrigate.

36 Dumping Syndrome Early manifestations: vertigo, tachycardia, syncope, sweating, pallor, palpitations. Late (90 minutes to 3 hours after eating): excessive insulin release causes dizziness, palpitations, diaphoresis, confusion. Dumping Syndrome: rapid emptying of gastric contents into small intestine. Early manifestations: vertigo, tachycardia, syncope, sweating, pallor, palpitations. Late (90 minutes to 3 hours after eating): excessive insulin release causes dizziness, palpitations, diaphoresis, confusion.

37 Management: Dumping Syndrome
Eat small amounts Eliminate liquids at meals High-protein, high-fat, low-carbohydrate diet Powdered pectin may prevent symptoms Octreotide (Sandostatin) prescribed in severe cases to inhibit hormones that cause symptoms

38 Alkaline Reflux Gastropathy
Bile reflux in patients whose pylorus is bypassed or removed (Billroth procedures) Symptoms of early satiety, abdominal discomfort, vomiting. Alkaline reflux gastropathy: bile reflux in patients whose pylorus is bypassed or removed (Billroth procedures). Symptoms of early satiety, abdominal discomfort, vomiting.

39 Delayed Gastric Emptying
Often present after gastric surgery, usually resolves within one week. Continued nasogastric suction relieves symptoms until resolved. Delayed gastric emptying: often present after gastric surgery, usually resolves within one week. Continued nasogastric suction relieves symptoms until resolved.

40 Afferent Loop Syndrome
If duodenal loop is partially obstructed after a Billroth II, pancreatic and biliary secretions fill the loop, distending it. Monitor for abdominal bloating, pain minutes after eating followed by nausea and vomiting. Surgical correction is necessary. Afferent loop syndrome: if duodenal loop is partially obstructed after a Billroth II, pancreatic and biliary secretions fill the loop, distending it. Monitor for abdominal bloating, pain minutes after eating followed by nausea and vomiting. Surgical correction is necessary.

41 Nutrition Decreased absorption of calcium and vitamin D.
At risk for pernicious anemia. Give vitamin B12 injection May need folic or iron replacement. Deficiency in vitamin B12, folic acid, and iron; impaired calcium metabolism, decreased absorption of calcium and vitamin D. All caused by shortage of intrinsic factor. Patient at risk for pernicious anemia. Monitor complete blood count (CBC) for megaloblastic anemia (red blood cells are larger than normal) and leucopenia. Give vitamin B12 injection. May need folic or iron replacement.

42 Gastric Carcinoma: Risk Factors
H. pylori infection, untreated Pernicious anemia Gastric polyps Achlorhydria Chronic atrophic gastritis Cigarette smoking, alcohol consumption are controversial Gastric Carcinoma Risk Factors H. pylori infection, untreated Pernicious anemia, gastric polyps, achlorhydria (absence of hydrocholoric acid secretion) Chronic atrophic gastritis: Ingestion of pickled foods, salted fish, salted meat, nitrates from processed foods, high salt consumption lead to atrophic gastritis. Gastric surgery, especially Billroth II procedure, may lead to atrophic gastritis Cigarette smoking, alcohol consumption are controversial

43 Manifestations Early: Late: Indigestion
Abdominal discomfort, feeling of fullness Epigastric, back, or retrosternal pain Late: Nausea and vomiting Obstructive symptoms, enlarged lymph nodes Iron deficiency anemia Palpable epigastric mass Enlarged lymph nodes Progressive weight loss Manifestations Early: Many patients have no early symptoms. If present: Indigestion Abdominal discomfort Feeling of fullness Epigastric, back, or retrosternal pain Late, advanced gastric cancer: Nausea and vomitinig Obstructive symptoms Iron deficiency anemia Palpable epigastric mass Enlarged lymph nodes Progressive weight loss

44 Surgical Management Subtotal or total gastrectomy: stomach, or portion, is removed and duodenum, or remainder of stomach, is sutured to esophagus Surgical Management: Subtotal or total gastrectomy: stomach, or portion, is removed and duodenum, or remainder of stomach, is sutured to esophagus

45 Postoperative Care Decompress wound: maintain patency and suction from NG tube to keep pressure off sutures and prevent anastomosis leakage Notify surgeon if reposition or irrigation needed. Postoperative Care Decompress wound: maintain patency and suction from NG tube to keep pressure off sutures and prevent anastomosis leakage. Notify surgeon if reposition or irrigation needed.

46 Postoperative Care (continued)
Assess color, amount, odor of NG drainage: notify surgeon of any changes Color should change from dark red to green-yellow over the first 2-3 days Assess color, amount, odor of NG drainage: notify surgeon of any changes. Color should change from dark red to green-yellow over the first 2-3 days.

47 Postoperative Care (continued)
Replace fluids and electrolytes intravenously: At risk for dehydration, Imbalances of sodium, potassium, chloride Metabolic alkalosis. Replace fluids and electrolytes intravenously: at risk for dehydration, imbalances of sodium, potassium, chloride and metabolic alkalosis.

48 Postoperative Care (continued)
Anti-ulcer and antibiotic therapy: prevention of stress ulcers and prophylaxis against any gastric contamination of the abdominal cavity. Anti-ulcer and antibiotic therapy: prevention of stress ulcers and prophylaxis against any gastric contamination of the abdominal cavity.

49 Postoperative Care (continued)
Monitor abdomen: listen for bowel sounds, watch for distention – may be third spacing, obstruction or infection. Encourage ambulation to stimulate peristalsis. Monitor abdomen: listen for bowel sounds, watch for distention – may be third spacing, obstruction or infection. Encourage ambulation to stimulate peristalsis.

50 Nutrition Total parenteral nutrition (TPN)
Enteral feeding postoperatively Oral feedings: prevent regurgitation from overeating or eating too quickly. Watch for dumping syndrome. Treat anemia, vitamin B12, and folate deficiency. Teach: recurrence of cancer is common – need regular follow-up. Nutrition: May start total parenteral nutrition (TPN) preoperatively if weight loss. Enteral feeding postoperatively. Oral feedings: prevent regurgitation from overeating or eating too quickly. Watch for dumping syndrome. Eliminate milk and dairy products as well as teaching the diet to prevent dumping syndrome – many are lactose intolerant postoperatively. Treat anemia, vitamin B12, and folate deficiency. Teach: recurrence of cancer is common – need regular follow-up.

51 Disorders of the Intestine
Irritable Bowel syndrome (IBS) Hernias Colorectal Cancer

52 Irritable Bowel Syndrome (IBS)
Typical manifestations: Abdominal pain relieved by defecation or associated with changed stool frequency or consistency Abdominal distention Sensation of incomplete stool evacuation Mucus in stool Irritable Bowel syndrome (IBS) Spastic motility dysfunction of the small bowel and colon causing diarrhea, constipation, left lower quadrant abdominal pain after eating, and bloating. Manning Criteria (typical manifestations): Abdominal pain relieved by defecation or associated with changed stool frequency or consistency Abdominal distention Sensation of incomplete stool evacuation Mucus in stool

53 Collaborative Management
Identify food intolerances Add fiber to diet (bran) Avoid lactose, fructose or sorbitol (often cause problems) Avoid gas-forming foods Limit caffeinated drinks (GI stimulants) Evacuate promptly Stress and anxiety reduction Collaborative Management Education: Identify food intolerances Add fiber to diet (bran) Avoid lactose, fructose or sorbitol (often cause problems) Avoid gas-forming foods Limit caffeinated drinks (GI stimulants) Evacuate promptly Stress and anxiety reduction

54 Medications Constipation prominent: Diarrhea prominent:
GI prokinetics Bulk laxatives at meals with water Diarrhea prominent: loperamide (Imodium) or diphenoxylate (Lomotil) Abdominal pain prominent: Anticholinergic before meals to prevent spasm: dicyclomine (Antispas, Bentyl, Asacol) Medications are directed at major symptom: Constipation prominent: GI prokinetics: tegaserod (Zelnorm) stimulates peristalsis before meals Bulk laxatives at meals with water: Bran Calcium polycarbophil (Mitrolan) Psyllium (Metamucil) Diarrhea prominent: loperamide (Imodium) or diphenoxylate (Lomotil) inhibit intestinal motility Abdominal pain prominent: Anticholinergic before meals to prevent spasm: dicyclomine (Antispas, Bentyl)

55 Hiatal Hernia Clinical Manifestations Heartburn (reflux)
Dysphagia, belching Feeling of fullness or breathlessness after eating Feeling of suffocation Worsening of symptoms when lying down Clinical Manifestations Hiatal Hernia: Heartburn, reflux, dysphagia, belching, feeling of fullness or breathlessness after eating, feeling of suffocation; worsening of symptoms when lying down

56 Prevention Remain upright several hours after eating Avoid straining
Sleep with head elevated Weight loss to decrease abdominal pressure Prevention Remain upright several hours after eating Avoid straining Sleep with head elevated Weight loss to decrease abdominal pressure

57 Medical Management Frequent small feedings
No reclining for 1 hour after eating Control reflux Medical Management Frequent small feedings No reclining for 1 hour after eating Control reflux

58 Postoperative Nursing Care
NG placed in OR, no moving! Expect temporary dysphagia – gradual increase in diet Gas bloat syndrome – inability to belch – avoid gas producing foods, gum, drinking with straw Aerophagia (air swallowing) habit – retrain or use simethicone to reduce bloating Postoperative Nursing Care NG placed in OR, no moving! Expect temporary dysphagia – gradual increase in diet Gas bloat syndrome – inability to belch – avoid gas producing foods, gum, drinking with straw Aerophagia (air swallowing) habit – retrain or use simethicone to reduce bloating

59 Inguinal Hernia Bulge, lump or swelling in groin
Sharp pain or dull ache radiating to scrotum or vagina Mass felt with standing or straining Reducible Irreducible (incarcerated) Strangulated Bulge, lump or swelling in groin Sharp pain or dull ache radiating to scrotum or vagina. Mass felt with standing or straining Reducible: disappears when patient lies flat. Irreducible (incarcerated): cannot be pushed back into abdominal cavity; requires emergency surgery Strangulated: blood supply cut off to the herniated bowel segment: abdominal distention, nausea, vomiting, pain, fever, tachycardia; requires emergency surgery

60 Prevention Weight control Avoid heavy lifting and straining

61 Medical Management A truss is prescribed for inguinal hernias. A firm pad placed over hernia attached to a belt to keep intestine from protruding

62 Postoperative Nursing Care
Difficulty voiding Scrotal support Ice bags to scrotum or vaginal area Elevate scrotum on soft pillow Teach: avoid heavy lifting, straining for 3 weeks Difficulty voiding: stand, run water, increase fluid intake; may need I & O Catheterization Scrotal support Ice bags to scrotum or vaginal area Elevate scrotum on soft pillow Teach: avoid heavy lifting, straining for 3 weeks

63 Colorectal Cancer Cancer of the colon or rectum; two-thirds occur in recto-sigmoid area. Metastasizes via lymphatics or blood circulation, usually to the liver. Image Source: National Cancer Society, Public Domain,

64 Prevention Avoid fat or fatty foods, low-fiber foods, refined carbohydrates Consume fruits and vegetables, especially cabbage family; whole grains, adequate water, baked or poached fish and poultry Avoid chronic bowel inflammation Prevention Foods to avoid: fat or fatty foods, low-fiber foods, refined carbohydrates Foods to consume: fruits and vegetables, especially cabbage family; whole grains, adequate water, baked or poached fish and poultry Avoid chronic bowel inflammation

65 Early Detection Genetic testing for familial risk
Yearly occult blood testing of stool, -or- Flexible sigmoidoscopy every 5 years, -or- Double-contrast barium enema every 5 years, -or- Colonoscopy every 10 years Genetic testing for familial risk Yearly occult blood testing of stool, or: Flexible sigmoidoscopy every 5 years, or: Double-contrast barium enema every 5 years, or: Colonoscopy every 10 years

66 Manifestations Rectal bleeding (hematochezia) with anemia
Narrowing of stool, change in bowel habits Signs and symptoms of bowel obstruction: gas pain, cramping, incomplete evacuation, high-pitched tinkling bowel sounds in waves Dull abdominal pain

67 Colorectal Cancer Staging
Image Source: National Cancer Society, Public Domain,

68 Fiberoptic Colonoscopy
Colon preparation During procedure Conscious sedation Care after Procedure Watch! Bowel perforation Polyp removal Expect amnesia: written instructions, no driving! Diagnosis: Fiberoptic colonoscopy: direct visual inspection of the intestine for tissue biopsies, polyp removal. Colon preparation: laxative for two nights and cleansing enema the morning of the exam. Clear liquid diet the day before Watch for bloating, cramps, fluid and electrolyte imbalance, hypothermia During procedure: Provide intravenous analgesia and conscious sedation Monitor oxygen saturation, vital signs Monitor color, skin temperature, level of consciousness, abdominal distention, vagal response, pain After procedure: Watch for signs of bowel perforation: rectal bleeding, abdominal pain, rigidity or distention, fever If midazolam (Versed) used for sedation, explain amnesic effects Explain expected symptoms of feeling full, cramping and gas If polyp removed, expect small amount of blood in first stool – patient to report any excessive bleeding Give written instructions on discharge Patient cannot drive: transportation must be arranged before procedure Image Source: National Cancer Society, Public Domain,

69 Colostomy Surgical Treatment: Colostomy
Resection of the bowel involved with tumor may include a colostomy to excrete fecal material. Temporary to promote healing or permanent if distal colon and rectum are removed. Image Source: National Cancer Society, Public Domain,

70 Preoperative preparation
Clear liquids for 1-2 days Mechanical bowel cleansing Prophylactic antibiotics Colostomy placement Instruct in general principles of ostomy care Nasogastric tube Preoperative preparation: Clear liquids for 1-2 days Mechanical bowel cleansing: laxatives and enemas Prophylactic antibiotics Colostomy placement may be marked by enterostomal therapist Instruct in general principles of ostomy care Nasogastric tube

71 Postoperative care: Colostomy management
Assess stoma color, integrity, drainage Keep periostomal skin clean, dry Place close-fitting pouch over stoma - monitor for leakage Empty pouch frequently, remove gas buildup Postoperative care: Colostomy management Assess stoma color, integrity, drainage Keep periostomal skin clean, dry Place close-fitting pouch over stoma - monitor for leakage Empty pouch frequently, remove gas buildup Ascending – liquid Transverse – pasty Descending – solid

72 Perineal Wound Care Bulb suction drains: monitor amount, color, odor of drainage Absorbent dressing Rectal pain and itching Teach: use side-lying position, avoid long periods of sitting using soft pillow Do NOT use air ring or donut devices – will cut off circulation to wound Perineal wound care: Bulb suction drains: monitor amount, color, odor of drainage Absorbent dressing – change frequently for sero-sanguinous drainage – use close-fitting underwear to keep close to wound Rectal pain and itching: local benzocaine, sitz baths Teach: use side-lying position, avoid long periods of sitting using soft pillow Do NOT use air ring or donut devices – will cut off circulation to wound

73 Discharge Teaching Refer to local ostomy association. Ostomy supplies
Instruct Placing a drainage bag Assessing and cleansing the stoma, irrigation Signs of infection Nutrition: avoid odor and gas-causing foods Develop a plan: constipation or diarrhea Discharge Teaching: Refer patient and caregivers to local ostomy association. Locate through the United Ostomy Assocations of America at: Provide prescription for ostomy supplies and instruct patient/caregiver in placing a drainage bag, assessing and cleansing the stoma, irrigation (sigmoid ostomy), and signs of infection Nutrition: avoid odor and gas-causing foods (cabbage family, eggs, fish, beans, high-cellulose products) Develop a plan to prevent or treat constipation or diarrhea

74 Inflammatory Bowel Disease
Ulcerative Colitis Peritonitis Crohn’s Disease Diverticular Disease Appendicitis

75 Ulcerative Colitis Begins in rectum, proceeds toward cecum; affects only superficial layers Age & 55-65 10-20 liquid, bloody stools per day Stools occult blood positive Very ↓ hemoglobin, ↑ WBCs ↓ sodium, potassium, chloride, albumin Barium enema: incomplete filling, fine ulcerations Inflammatory Bowel Disease Ulcerative Colitis: Recurrent ulceration and inflammation of the colon and rectum Ulcerative Colitis begins in rectum, proceeds toward cecum; affects only superficial layers Age & 55-65 10-20 liquid, bloody stools per day Stools occult blood positive Very decreased hemoglobin Increased white blood cells Decreased sodium, potassium, chloride, hypoalbuminemia Barium enema: incomplete filling, fine ulcerations

76 Complications Hemorrhage Bowel perforation Fistulas
Nutritional deficiencies

77 Crohn’s Disease Mostly terminal ileum, patchy through all layers of the bowel Age 15-40 5-6 soft, loose stools per day, rarely bloody ↓ hemoglobin, ↑ WBCs, ↓ albumin Upper GI series: “string sign” of constricted terminal ileum Decreased folic acid, vitamins A, B complex, C Crohn’s Disease (Regional Enteritis): chronic inflammation through all layers of the distal ileum and sometimes the ascending colon. Crohn’s Disease Mostly terminal ileum, patchy through all layers of the bowel Age 15-40 5-6 soft, loose stools per day, rarely bloody Decreased hemoglobin Increased white blood cells Upper GI series: “string sign” of constricted terminal ileum Hypoalbuminemia Decreased folic acid, vitamins A, B complex, C

78 Complications Fistula Nutritional deficiencies

79 Collaborative Management
Medication: to rest the bowel Nutrition: Fluids, low-residue, high-protein, high-calorie diet Vitamin and iron supplements Avoid foods that cause diarrhea Avoid cold foods and smoking: increase intestinal motility Collaborative Management: Diarrhea during exacerbation Keep record of stool frequency, amount and color Monitor for tachycardia, tachypnea, fever = fluid deficit Weight daily – rapid weight loss = fluid deficit Bowel rest, anti-inflammatory and antidiarrheal medications Replace fluid losses intravenously Prevent skin breakdown in peri-anal area Medication: to rest the bowel Anti-inflammatories – sulfasalazine (Azulfidine), mesalamine (Asacol) Corticosteroids – methylprednisolone (Solu-Medrol), prednisone for acute episode Immunosuppressants – mercaptopurine (Purinethol), asathiprine (Imuran) Anti-diarrheals – loperamide (Imodium), diphenoxylate (Lomotil) Nutrition: Fluids, low-residue, high-protein, high-calorie diet Vitamin and iron supplements Avoid foods that cause diarrhea Avoid cold foods and smoking: increase intestinal motility

80 Colectomy Total colectomy with an ileal pouch-anal anastomosis (IPAA). A pouch is formed from the terminal ileum and connected to the anal canal. Continent (Kock’s) ileostomy. Colectomy: The surgery of choice for extensive ulcerative colitis is a total colectomy with an ileal pouch-anal anastomosis (IPAA). A pouch is formed from the terminal ileum and connected to the anal canal. A temporary ileostomy is usually performed to allow the anastomosis to heal. Another surgical option is the continent (Kock’s) ileostomy. Image Source: National Cancer Society, Public Domain,

81 Preoperative Care Similar to colostomy
Fluids, blood & protein if losses severe Low residue diet, frequent small feedings Antibiotics to treat inflammation, cleanse bowel Stoma right lower quadrant about 2 inches below waistline

82 Postoperative Care Apply a pouch with meticulous skin care
Assess stoma for bleeding, color Monitor stool production Empty pouch when no more than 1/3 full Emphasize fluid and salt intake High potassium, low-residue diet, avoid gas-producing or high fiber foods to prevent blockage Signs of blockage: abdominal cramps, swelling of stoma, no output over 4-6 hours Relieve blockage prn Postoperative Care: Apply a pouch over the stoma with meticulous skin care – stool will be liquid, irritating to surrounding skin Assess stoma for bleeding, color: should be pink or red, moist, protrude slightly from abdominal wall Monitor stool production: small amounts of blood at first, then dark green and viscous; gradually thickens and turns yellow-brown Empty pouch when no more than 1/3 full to keep sealed on skin Emphasize fluid and salt intake, especially in hot weather, to prevent dehydration High potassium, low-residue diet, avoid gas-producing or high fiber foods to prevent blockage Popcorn, corn, nuts, cucumbers, celery, fresh tomatoes, figs, strawberries, blackberries, caraway seeds Signs of blockage: abdominal cramps, swelling of stoma, no output over 4-6 hours Relieve blockage prn: Warm shower or tube bath to relax abdominal muscles Assume knee-chest position to decrease abdominal pressure Drink warm fluid or grape juice – cathartic effect Massage peristomal area Remove pouch if stoma is swollen, place pouch with larger opening Irrigate through stoma with normal saline if necessary

83 Irrigate continent ileostomy (Kock pouch)
Insert catheter into pouch, drain every 4-6 hours Irrigate once daily with normal saline. No external pouch is necessary Amount of stool will increase as pouch stretches.

84 Appendicitis Epigastric or peri-umbilical cramping
Nausea followed by vomiting Pain becomes more steady and severe, migrates to right lower quadrant (McBurney’s point) Rebound tenderness Signs of perforation Manifestations: Epigastric or peri-umbilical cramping Nausea followed by vomiting Pain becomes more steady and severe, migrates to right lower quadrant (McBurney’s point) Rebound tenderness: increased pain after deep pressure put on area away from pain and released Signs of perforation: Pain increased by coughing or movement, relieved by flexing right hip Photo Source: Wikimedia Commons, Creative Commons,

85 Peritonitis Rigid, board-like abdomen (classic)
Pain: general abdominal, may spread to shoulders or chest Distended abdomen Nausea, vomiting Decreased bowel sounds Rebound abdominal tenderness High fever, tachycardia Manifestations: Rigid, board-like abdomen (classic) Pain: general abdominal, may spread to shoulders or chest Distended abdomen Nausea, vomiting Decreased bowel sounds Rebound abdominal tenderness High fever, tachycardia

86 Collaborative Management
NPO with intravenous fluids Broad spectrum intravenous antibiotics Nasogastric tube to decompress stomach Oxygen Pain management Collaborative Management: NPO with intravenous fluids Broad spectrum intravenous antibiotics Nasogastric tube to decompress stomach Oxygen Pain management

87 Exploratory Laparotomy
Abdomen is flushed with saline and lavaged with antibiotic solution. Postoperative Care: Position Manage wound and drains If wound irrigation ordered, use sterile technique Replace lost fluids and electrolytes Exploratory laparotomy to find and remove source of infection. Abdomen is flushed with saline and lavaged with antibiotic solution. Postoperative Care: Position: semi-Fowler’s to promote drainage, allow deeper respirations Manage wound and drains: wound will probably be left open to heal by secondary intention If wound irrigation ordered – use sterile technique with catheter-tip syringe Replace lost fluids with intravenous therapy, add electrolytes based on lab results

88 Diverticular Disease Small outpouchings of the colon, 90% in the sigmoid colon, that can become infected resulting in diverticulitis, or rupture, resulting in peritonitis. Risk Factors: Diet: highly refined, fiber-deficient Decreased physical activity Poor bowel habits with constipation Diverticular Disease Small outpouchings of the colon, 90% in the sigmoid colon, that can become infected resulting in diverticulitis, or rupture, resulting in peritonitis. Risk Factors: Diet: highly refined, fiber-deficient Decreased physical activity Poor bowel habits with constipation

89 Manifestations Episodic left-sided abdominal cramping or steady pain
Constipation alternating with diarrhea Narrow stools with bright red blood Diverticulitis: if undigested food and bacteria collect in the diverticula, inflammation results Manifestations: Episodic left-sided abdominal cramping or steady pain Constipation alternating with diarrhea Narrow stools with bright red blood Diverticulitis: if undigested food and bacteria collect in the diverticula, inflammation results

90 Collaborative Management
Broad-spectrum antibiotics Pain relief: patient-controlled analgesia with opiate Bulk-forming products: psyllium seed (Metamucil) Bowel rest during acute episode Assess for decreased bowel sounds, abdominal distention, tenderness: peritonitis from bowel rupture Assess for lower GI bleeding Broad-spectrum antibiotics for acute diverticulitis: metronidazole (Flagyl) for anerobes Pain relief: patient-controlled analgesia with opiate Bulk-forming products: psyllium seed (Metamucil) Bowel rest during acute episode: NPO with intravenous fluids and/or parenteral nutrition, gradually resume diet Assess for decreased bowel sounds, abdominal distention, tenderness: peritonitis from bowel rupture Assess for lower GI bleeding

91 Teach Avoid laxatives Eat a high-fiber diet
Avoid: wheat and corn bran, vegetable and fruit skins, nuts, dry beans

92 Liver Disorders Cirrhosis Hepatitis

93 Cirrhosis Portal hypertension Ascites Esophageal varices
Coagulation defects Jaundice Encephalopathy Hepatorenal syndrome Spontaneous bacterial peritonitis Cirrhosis Gradual destruction of the liver with scarring and decreased function manifested by: Portal hypertension: persistent increased pressure in portal vein backing blood up into the spleen, esophagus, stomach, and intestines Ascites: free fluid in the peritoneal cavity rich in albumin, depleting plasma fluid and protein Bleeding esophageal varices: veins in esophagus distended from portal hypertension, hematenesis or melena result Coagulation defects: decreased vitamin K absorption leading to decreased production of factors II, VII, IX, and I. The enlarged spleen destroys platelets. Jaundice: liver cannot excrete bilirubin Encephalopathy: impaired thinking from elevated serum ammonia Hepatorenal syndrome: related to imbalanced blood flow to and from the kidneys Spontaneous bacterial peritonitis (SBP): low serum protein allows bacteria to leak into ascetic fluid

94 Clinical Manifestations
Massive ascites: distended abdomen with positive fluid wave, enlarged abdominal girth Hepatomegaly right costal border in early cirrhosis, later hard and small Fetor hepaticus: fruity or musty breath odor Asterixis (liver flap): coarse tremor of wrists and fingers Clinical Manifestations Massive ascites: distended abdomen with positive fluid wave, enlarged abdominal girth Hepatomegaly right costal border in early cirrhosis, later hard and small Fetor hepaticus: fruity or musty breath odor Asterixis (liver flap): coarse tremor of wrists and fingers

95 Laboratory Assessment
Prolonged prothrombin time and INR Serum elevation in: Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Lactate dehydrogenase (LDH) Indirect bilirubin, ammonia Creatinine (hepatorenal syndrome) Serum decrease in: Albumin, Platelet count, Hemoglobin and hematocrit White blood cell count Laboratory Assessment Prolonged prothrombin time and INR Serum elevation in: Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Lactate dehydrogenase (LDH) Indirect bilirubin Ammonia Creatinine (hepatorenal syndrome) Serum decrease in: Albumin Platelet count Hemoglobin and hematocrit White blood cell count

96 Diagnostic Procedures
Ultrasound Percutaneous biopsy Esophagogastro-duodenoscopy (EGD) Diagnostic Procedures Ultrasound of the liver: liver size, ascites, nodules, blood flow (with Doppler) Percutaneous liver biopsy: Pre-procedure: Labs: prothrombin time, complete blood count, platelet count May give fresh frozen plasma and/or platelets to enhance clotting Post-procedure: Apply gentle pressure to biopsy site, roll patient to his right side. Instruct him to remain there for 1 hour to prevent bleeding or bile leakage Hemoglobin and hematocrit – compare with pre-procedure Chest x-ray to rule out pneumothorax Ultrasound of liver to rule out hematoma Vital signs q 15 minutes x 4, q 30 minutes x 4: notify physician for hypotension, tachycardia, respiratory distress, change in level of consciousness Observe for and report: increased pain, abdominal girth, weakness or dizziness, bleeding

97 Liver Biopsy Pre-procedure:
Labs: prothrombin time, CBC, platelet count Fresh frozen plasma and/or platelets Post-procedure: Pressure to site, roll to right side for 1 hour Hemoglobin and hematocrit Chest x-ray to rule out pneumothorax Ultrasound of liver to rule out hematoma Report: ↓ BP, ↑ heart rate, respiratory distress, change in level of consciousness Report: increased pain, abdominal girth, weakness or dizziness, bleeding Pre-procedure: Labs: prothrombin time, complete blood count, platelet count May give fresh frozen plasma and/or platelets to enhance clotting Post-procedure: Apply gentle pressure to biopsy site, roll patient to his right side. Instruct him to remain there for 1 hour to prevent bleeding or bile leakage Hemoglobin and hematocrit – compare with pre-procedure Chest x-ray to rule out pneumothorax Ultrasound of liver to rule out hematoma Vital signs q 15 minutes x 4, q 30 minutes x 4: notify physician for hypotension, tachycardia, respiratory distress, change in level of consciousness Observe for and report: increased pain, abdominal girth, weakness or dizziness, bleeding

98 Esophagogastroduodenoscopy (EGD)
Pre-procedure: NPO for 6-8 hours IV access for conscious sedation Remove dentures, assess gag reflex Place in left lateral decubitus position Post-procedure: Frequent vital signs until conscious sedation worn off Keep patient NPO until gag reflex returns Monitor for: pain, bleeding, fever Esophagogastroduodenoscopy (EGD): to evaluate esophageal varices Pre-procedure: NPO for 6-8 hours IV access for conscious sedation Remove dentures, assess gag reflex Place in left lateral decubitus position (Sims’ or side-lying) Post-procedure: Frequent vital signs until conscious sedation worn off Keep patient NPO until gag reflex returns Monitor for: pain, bleeding, fever (signs of perforation)

99 Nutrition High calorie, moderate fat
Ascites/edema – Low sodium to control fluid retention, limit fluid intake if serum sodium is low High serum ammonia – limit protein Vitamins/minerals – thiamine, folate, multiple vitamins, fat-soluble vitamins (A,D,E,K), magnesium

100 Fluids/Electrolytes Monitor intake and output Weigh patient daily
Daily electrolytes, BUN, creatinine, protein, hematocrit Monitor for signs of fluid retention Give intravenous fluids and electrolytes as indicated

101 Medication Diuretics: Anti-infective agents: Alternative medications:
Spironolactone (Aldactone)Furosemide (Lasix) Laxatives: lactulose (Cephulac) Anti-infective agents: Neomycin sulfate (aminoglycoside) Metronidazole (Flagyl) Alternative medications: Silymarin (herb milk thistle), Adenosylmethione (SAM-e) Medication Diuretics: Spironolactone (Aldactone) To reduce ascites Potassium-sparing, weaker diuretic Furosemide (Lasix) Potassium excreting, strong diuretic - Monitor serum potassium, electrocardiogram, blood urea nitrogen (BUN), creatinine, intake and output Laxatives: Lactulose (Cephulac) To decrease serum ammonia - Monitor number of stools per day. Pull water into bowel, lowers colon pH (easier to convert ammonia), reduces ammonia-producing bacteria. Goal: 2-4/24 hours. May cause nausea. Anti-infective agents: Neomycin sulfate (aminoglycoside) Metronidazole (Flagyl) Both reduce intestinal bacteria, decrease ammonia production. Flagyl has less renal toxicity. Aminoglycoside precautions: hearing, renal, neurologic. Monitor intake and output, BUN, creatinine Alternative medications: Silymarin (herb milk thistle); Adenosylmethione (SAM-e). Anti-inflammatory, anti-oxidant. Ask patient about use of these alternative medications

102 Paracentesis Patient preparation: Informed consent Weigh patient
Assess vital signs Have patient void immediately prior to procedure Supine, seated at edge of bed or in chair with feet supported Obtain vacuum bottle, paracentesis tray May give 25% albumin intravenously Patient preparation: Informed consent Weigh patient Assess vital signs Have patient void immediately prior to procedure (avoids bladder puncture) Position supine, seated at edge of bed or in chair with feet supported Obtain vacuum bottle, paracentesis tray May give 25% albumin intravenously to maintain intravascular volume

103 Post-Paracentesis Bed rest Monitor blood pressure for hypotension
Place patient supine, legs elevated if hypotensive Send specimen to laboratory as ordered Place dry dressing over puncture site – expect some fluid leakage Weigh patient

104 Esophageal Varices Blood loss leading to shock occurs if these thin-walled varices burst. Teach patient to avoid any activity that increases abdominal pressure: stooping heavy lifting vigorous physical exercise Esophageal Varices: Resulting from portal hypertension in liver disease, esophageal varices can be a life-threatening emergency. Blood loss leading to shock occurs if these thin-walled varices burst. Teach patient with known varices to avoid any activity that increases abdominal pressure: stooping, heavy lifting, vigorous physical exercise

105 Balloon Tamponade Sengstaken-Blakemore tube
One larger balloon is inflated in the esophagus to press on the varices Smaller balloon is inflated in the stomach to keep traction on the esophageal balloon. A third lumen opens into the stomach to aspirate blood and stomach contents. Balloon tamponade: compression of varices with balloon such as Sengstaken-Blakemore tube with two balloons. One larger balloon is inflated in the esophagus to press on the varices; the other, smaller, balloon is inflated in the stomach to keep traction on the esophageal balloon. A third lumen opens into the stomach and is connected to suction to aspirate blood and stomach contents. Nursing precautions: prevent aspiration and airway occlusion: Aspiration prevention: Keep patient in semi-Fowler’s position, maintain patency of suction port Airway occlusion: if the patient becomes dyspneic, the balloon in the esophagus may have slipped and blocked the trachea – immediately cut the tube distal to the bifurcation points (to the two balloons) and remove the tube

106 Band Ligation Endoscopic band ligation of varices:
Small “O” bands placed by physician around base of varices to cut off blood supply. The nurse may give an infusion of octreotide before procedure to reduce blood flow

107 Sclerotherapy Injection of an agent into the varices to occlude their blood supply. Performed by an MD during EGD.

108 Transjugular intrahepatic portal-systemic shunt (TIPS)
enlargement of portal vein with balloon inflation and stent placed to maintain patency. Photo Source: Courtesy of the University of Michigan Health System,

109 Shunts Monitor patient for circulatory fluid overload: increased blood pressure, crackles in lung bases. Patient may need a diuretic. Expect decreased ascites: decreased abdominal girth, weight loss, increased urine output.

110 Hepatitis A (HAV) Cause: Ingestion of fecal contaminants: water, shellfish, food handlers, oral-anal sex Incubation: days Signs: Mild, similar to gastrointestinal illness Prevention: Wash hands, safe water supplies, vaccination; immune globulin after exposure Treatment: Bed rest, frequent small feedings of high-protein high-calorie foods, enteral feedings if unable to eat; avoid alcohol & substances that affect liver function Infectious hepatitis

111 Hepatitis B (HBV) Cause: Blood from unprotected sex, sharing needles, accidental needle sticks, unscreened blood transfusion, hemodialysis, maternal-fetal Incubation: days Signs: Fatigue, anorexia, nausea & vomiting, fever, RUQ pain, rash, dark urine, light stool, joint pain, jaundice Prevent: Screen donor blood, standard precautions with all blood samples, disposable needles, lancets, needle-less IV systems; vaccination of all newborns, high-risk persons Passive immunity: hepatitis B Immune Globulin (HBIG) after exposure (if not vaccinated); alpha interferon injections for chronic infection; gradually increase activity

112 Hepatitis C (HCV) Cause: Sharing needles (highest incidence), needle stick injury, tattoos with dirty equipment, intranasal cocaine sharing Incubation: days (average 7 weeks) Signs: gradual chronic inflammation of liver, eventual cirrhosis (leading cause of liver transplants in U.S.), liver cancer possible Prevent: Screen blood transfusions, sterile disposable intravenous equipment; sterilize equipment. No vaccine Treat: Interferon and ribavirin (Rebetol)

113 Pancreatitis Pancreatic Carcinoma
Pancreatic Disorders Pancreatitis Pancreatic Carcinoma

114 Pancreatitis Inflammation characterized by release of its enzymes into the pancreas causing hemorrhage and necrosis. Risk Factors Alcohol ingestion Cholelithiasis Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) complication

115 Manifestations Abdominal pain localized in epigastrium – most frequent symptom– relieved by fetal position or bending forward Nausea, vomiting, weight loss Generalized jaundice Gray-blue color around umbilicus (Cullen’s sign) Gray-blue color to the flanks (Turner’s sign) Respiratory compromise from abdominal pressure Decreased breath sounds, especially at bases Manifestations Abdominal pain localized in epigastrium – most frequent symptom – relieved by fetal position or bending forward Tenderness on abdominal palpation Rigidity of abdominal wall Nausea, vomiting, weight loss Decreased or absent bowel sounds Generalized jaundice Gray-blue color around umbilicus (Cullen’s sign) Gray-blue color to the flanks (Turner’s sign) Respiratory compromise from abdominal pressure: atelectasis, left lung pleural effusion Decreased breath sounds, especially at bases Dyspnea, orthopnea

116 Diagnosis - Lab Increased serum amylase (nonspecific): remains elevated for 3-4 days Increased lipase (more specific): remains elevated for 2 weeks Elevated trypsin (most accurate) Elevated bilirubin and alkaline phosphatase if concurrent biliary dysfunction Elevated alanine aminotransfersase (ALT) if biliary obstruction Elevated glucose Decreased calcium, magnesium if fat necrosis present Elevated white blood cell count Diagnosis Serum signs: Increased serum amylase (nonspecific): remains elevated for 3-4 days Increased lipase (more specific): remains elevated for 2 weeks Elevated trypsin (most accurate) Elevated bilirubin and alkaline phosphatase if concurrent biliary dysfunction Elevated alanine aminotransfersase (ALT) if biliary obstruction Elevated glucose: dysfunction of pancreatic endocrine function Decreased calcium, magnesium if fat necrosis present Elevated white blood cell count

117 Diagnosis: Radiography
Abdominal x-ray: gas-filled duodenum (obstruction) Chest x-ray: elevated left diaphragm, pleural effusion Computed tomography (CT) with contrast Abdominal ultrasound

118 Collaborative Management
NPO, nasogastric drainage if vomiting with ileus Pain relief Comfort: bed rest, assist to fetal position if pain acute Intravenous fluids and electrolytes Semi-fowlers position, frequent turning, incentive spirometer ERCP to remove gallstones and open sphincter of Oddi Collaborative Management Decrease GI tract activity to decrease pancreatic stimulation: NPO, nasogastric drainage if vomiting with ileus Pain relief: opioids via continuous infusion and bolus doses via patient-controlled analgesia (PCA) Comfort: bed rest, assist to fetal position if pain acute Intravenous fluids and electrolytes Semi-fowlers position, frequent turning, incentive spirometer: prevent respiratory complications ERCP to remove gallstones and open sphincter of Oddi

119 Monitor for complications:
Necrosis: sudden increase in pain Hemorrhagic shock Septic shock Respiratory failure

120 Pancreatic Carcinoma Pain: boring pain in mid-back unrelated to position or activity Progressive and severe More severe at night Accentuated when lying supine Relieved by sitting up and leaning forward Jaundice with clay-colored stools, dark urine Gastrointestinal: anorexia, nausea, vomiting, weight loss, flatulence, ascites, glucose intolerance Pancreatic Carcinoma Clinical Manifestations Epigastric pain + jaundice + weight loss = classic signs of pancreatic carcinoma but late in disease Pain: Boring pain in mid-back unrelated to position or activity Progressive and severe More severe at night Accentuated when lying supine Relieved by sitting up and leaning forward Jaundice with clay-colored stools, dark urine Gastrointestinal: Anorexia, nausea, vomiting Weight loss Flatulence Ascites Glucose intolerance

121 Diagnosis Elevated but nonspecific: amylase, lipase, alkaline phosphatase, bilirubin Elevated carcinoembryonic antigen (CEA) levels in 80%-90% Computed tomography (CT) confirms presence of tumor versus cyst ERCP with cystology of aspirate most definitive diagnosis

122 Collaborative Management
Pain: high dose opioids, usually morphine or hydromorphone (Dilaudid) Chemotherapy Radiation: shrinks tumor cells = pain relief Biliary stent: if biliary drainage system is obstructed Laparoscopic procedures to palliate, debulk or remove tumors Whipple procedure (radical pancreaticoduodenectomy) for extensive metastasis Collaborative Management Pain: high dose opioids, usually morphine or hydromorphone (Dilaudid) Chemotherapy: limited success with combination drugs Radiation: shrinks tumor cells, giving pain relief Biliary stent: if biliary drainage system is obstructed Laparoscopic procedures to palliate, debulk or remove tumors Whipple procedure (radical pancreaticoduodenectomy) for extensive metastasis

123 Whipple Procedure GI drainage Positioning Pain Fluids and electrolytes
Watch! Sudden increased pain may be anastomosis leak Fluids and electrolytes Nutrition GI drainage: Salem sump nasogastric tube, wound drainage to suction Keep NG at low suction to prevent fluid buildup around sutures, do not reposition tube If obstructed, instill air first, then irrigate gently with mL 0.9% saline if needed Monitor drainage for color, consistency, amount – should be serosanguinous. Any clear, bile-tinged or bloody drainage should be reported for possible fistula. Most common and most serious complication: fistula due to anastomosis breakdown causes chemical peritonitis Positioning: Semi-fowler’s position to decrease suture line and anastomosis stress, optimize lung expansion. Pain: Preoperative analgesic use may increase dosage needs postoperatively Watch! Sudden increased pain may indicate anastomosis leak or peritonitis Pain relief enhances pulmonary function, prevents atelectasis, pneumonia Monitor fluids and electrolytes: Significant fluid and blood losses due to long surgery, exposed intestine, loss from drainage tubes. Prone to third-spacing of fluids resulting in shock Monitor vital signs for hypotension, tachycardia, decreased urine output Watch for pitting edema of extremities, dependent edema in sacrum and back Intake exceeding output Nutrition: usually malnourished preoperatively, low albumin levels Total parenteral nutrition (TPN) Monitor glucose closely: new onset diabetes mellitus from pancreatic manipulation

124 Cholecystitis Cholelithiasis
Biliary Disorders Cholecystitis Cholelithiasis

125 Cholecystitis/Cholelithiasis
Risk Factors Excessive dietary cholesterol intake Obesity Increased age, female Type I diabetes mellitus Low-calorie or liquid protein diets Alcohol abuse Hemolytic blood disorders, such as Crohn’s disease After gastric bypass surgery Cholecystitis/Cholelithiasis Cholecystitis is inflammation of the gallbladder from blocked bile flow, usually from cholelithiasis (formation of stones, or calculi in the gallbladder or bile duct). Risk Factors Excessive dietary cholesterol intake Obesity, possibly due to impaired fat metabolism Increased age, female Type I diabetes mellitus: higher levels of fatty acids Low-calorie or liquid protein diets: increased cholesterol freed from tissues Alcohol abuse Hemolytic blood disorders, such as Crohn’s disease After gastric bypass surgery

126 Manifestations Biliary colic: pain in right upper quadrant of the abdomen, may radiate to back, right scapula, or shoulder Abrupt onset – triggered by high-fat or high-volume meal Severe and constant Lasts hours Aggravated by movement, breathing Anorexia, nausea, vomiting are common Fevers and possibly chills Jaundice & icterus Pruritis Clay-colored (light), fatty (steatorrhea) stools Urine is dark and foamy Manifestations Biliary colic: pain in right upper quadrant of the abdomen, may radiate to back, right scapula, or shoulder Abrupt onset – triggered by high-fat or high-volume meal Severe and constant Lasts hours Aggravated by movement, breathing Anorexia, nausea, vomiting are common Fevers and possibly chills Jaundice (skin yellowing) and icterus (scleral yellowing) from increased bilirubin in circulation Pruritis from excessive bile salts Clay-colored (light), fatty (steatorrhea) stools from excess unconverted bilirubin Urine is dark and foamy from presence of bilirubin

127 Diagnosis Rebound tenderness in right upper quadrant (Blumberg’s sign)
Pain increases with deep inspiration (Murphy’s sign) while examiner pushes over gallbladder area (right costal margin). Direct bilirubin rises Indirect bilirubin rises Ultrasonography shows edema of gallbladder wall surrounded by fluid. Diagnosis Rebound tenderness in right upper quadrant (Blumberg’s sign) Pain increases with deep inspiration (Murphy’s sign) while examiner pushes over gallbladder area (right costal margin). Direct bilirubin rises from impaired excreton from the gallbladder (cholelithiasis) Indirect bilirubin rises from red blood cell hemolysis (hemolytic disorders) Ultrasonography shows edema of gallbladder wall surrounded by fluid. If ultrasound is not diagnostic, an endoscopic retrograde cholangiopancreatography may be performed.

128 Endoscopic Retrograde Cholangiopancreatography (ERCP)
Contrast agent injected into the ducts and x-rays are taken to evaluate their caliber, length and course A special flexible tube (endoscope) is inserted through the mouth into the duodenum A catheter is advanced through the endoscope and inserted into the pancreatic or biliary ducts. A contrast agent is injected into these ducts and x-rays are taken to evaluate their caliber, length and course. Narrowing, stones, and tumors can be identified. Instruments can be placed through the scope and into the ducts to open the entry of the ducts into the bowel, stretch out narrow segments, remove or crush stones, take tissue samples, and drain obstructed areas.

129 Collaborative Management
Teach low-fat diet If calculi are causing obstruction, give fat-soluble vitamins Ursodol (Actigall) or chenodial (Chenix) Cholestyramine (Questran) for pruritis Opiate analgesics Watch! morphine may cause biliary spasm and constrict sphincter of Oddi (outlet). Antispasmodic Antibiotics if infection is suspected Biliary catheter (T-tube) Collaborative Management Diet Teach low-fat diet for prevention of biliary colic If calculi are causing obstruction, give fat-soluble vitamins (A, D, E, K) Medication Both ursodol (Actigall) and chenodial (Chenix) decrease cholesterol production in the liver Cholestyramine (Questran) for pruritis binds with bile salts so they can be excreted in stool Opiate analgesics: morphine may cause biliary spasm and constrict sphincter of Oddi (outlet). May give meperidine (Demerol) but it’s not safe in older adults Antispasmodice such as atropine and dicyclomine (Bentyl) Antibiotics if infection is suspected Biliary catheter (T-tube): under fluoroscopy, a catheter is inserted into bile duct so bile can flow

130 Laparoscopic Cholecystectomy
Small puncture at umbilicus, carbon dioxide instilled to lift abdominal wall. Laparoscope inserted, attached to a monitor, and abdominal organs are viewed. Several small punctures are made to allow forceps to manipulate the gallbladder, aspirate bile, crush stones and remove all through the umbilical port. Postoperative care: Pain from carbon dioxide retention: Teach early ambulation to promote absorption. Laparoscopic cholecystectomy: minimally invasive, the preferred surgical technique. Small puncture at umbilicus, carbon dioxide instilled to lift abdominal wall. A laparoscope is inserted, attached to a monitor, and abdominal organs are viewed. Several small punctures are made to allow forceps to manipulate the gallbladder, aspirate bile, crush stones and remove all through the umbilical port. Postoperative care: Pain from carbon dioxide retention: Teach early ambulation to promote absorption.

131 Open Cholecystectomy Postoperative nursing care
Pain relief via patient-control analgesia (may be meperidine instead of morphine if risk of sphincter of Oddi) spasm. Antiemetics – common postoperative nausea. Incision and drain care If drainage is large may give synthetic bile salts such as dehydrocholic acid (Decholin) via NG tube When patient is allowed to eat, clamp tube for 1-2 hours per surgeon’s order before and after meals Open cholecystectomy: less used but may be necessary to explore biliary ducts and insert drains to prevent fluid accumulation, requires an incision in right subcostal area. Longer procedure, more difficult and longer recovery, increased risk of complication. Postoperative nursing care: Pain relief via patient-control analgesia (may be meperidine instead of morphine if risk of sphincter of Oddi) spasm. Antiemetics – common postoperative nausea. Incision and drain care: Keep drainage system below gallbladder area Watch for foul odor and/or purulent drainage Expect bloody drainage changing to green-brown bile Output should be 400+ ml/day gradually decreasing If drainage is large may give synthetic bile salts such as dehydrocholic acid (Decholin) via NG tube When patient is allowed to eat, clamp tube for 1-2 hours per surgeon’s order before and after meals

132 Home Care of T-tube Report sudden increase in output
Inspect for signs of infection Report change in drainage, abdominal pain, nausea or vomiting Clean and change dressing daily Never irrigate, aspirate or clamp the drainage tube without surgeon’s order Prevent kinks, pulling tension or tangling of tubing– keep drainage bag below tubing Empty drainage bag If ordered, clamp tube for 1-2 hours before and after meals. Otherwise keep unclamped Watch stools Teach home care of T-tube: Report sudden increase in output (may occur 9-10 days postoperatively) Inspect for signs of infection – report to physician if present Report change in drainage, abdominal pain, nausea or vomiting Clean and change dressing daily Never irrigate, aspirate or clamp the drainage tube without surgeon’s order Prevent kinks, pulling tension or tangling of tubing by securing to abdomen with tape or Velcro – keep drainage bag below tubing Empty drainage bag at the same time each day through spout- do not disconnect tubing If ordered, clamp tube for 1-2 hours before and after meals. Otherwise keep unclamped Watch stools for return of brown color 7-10 days postoperatively

133 Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the Microsoft Office Clip Art Gallery.


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