Presentation on theme: "Alterations of GI System Nur 302 Unit I. Carcinoma of Oral Cavity Predisposing factors: tobacco & alcohol S/S: leukoplakia, erythroplakia, ulcer, sore."— Presentation transcript:
Alterations of GI System Nur 302 Unit I
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
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.
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.
Gastritis Treatment: eval. & eliminate the specific cause, double & triple antibiotic combinations for H. pylori, no smoking, bland diet. Assessment: dehydration, vomiting, hemorrhage. Teaching: stress close medical follow- up, diet, meds.
Peptic Ulcers Types: acute or chronic, gastric or duodenal (80%). Person with a gastric ulcer has normal to less than normal gastric acidity compared with a person with a duodenal ulcer. Etiology: H.pylori disrupted mucosal barrier, increased vagal nerve stimulation (eg. emotions), genetic, medications
Peptic Ulcer Signs & Symptoms May have no 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
Nursing Care Acute care: NPO, NG, IV fluid,v/s qh till stable Hemorrhage: assess color of hematemesis, s/s shock. Perforation: assess for sudden severe pain to abd. & shoulder, rigid abdomen, decreased or absent B.S.
Surgical Therapy Partial gastrectomy Billroth I – Gastroduodenostomy, removes distal 2/3 stomach & attaches to duodenum Billroth II – Gastrojejunostomy, removes distal 2/3 stomach & attaches to jejunum Vagotomy-eliminates stimulus for acid secretion Pyloroplasty –enlarges pyloric sphincter, increases gastric emptying
Post-op Care Observe NG tube drainage Red, decreasing in color 1 st 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
Post-op Care Observe for bleeding/ hemorrhage, NG & dressing Pain management What are the general post-op complications & nursing care? If you do not have HCl, what disease are you at risk for?
Case Scenario & Prioritization BK is post-op Bilroth I and is to receive 2 units of blood. As you get out of report, lab calls and says the first unit of blood is ready. Prioritize: Verify order to transfuse blood and consent Take initial set VS Pick up blood from lab Assess IV site Start transfusion Verify pt ID, & blood compatability
Prioritization Pre-transfusion T98.6, P80, R18, BP136/78. Transfusion started, slow …..15 minutes later- T98.2, P90, R22, BP 130/70, no itching, rate increased 100/h……20 minutes later- skin flushed, p 120, R32, BP100/60, c/o chest pain & chills. Priority problem??? What do you do first? Prioritize: Stop transfusion Save transfusion unit Inform MD/RN Save next voided specimen Start 0.9NS Take VS
Post-op complications Dumping Syndrome Postprandial hypoglycemia Bile reflux gastritis
Dumping Syndrome Large amount hyperosmolar chyme in intestine->fluid is drawn in->decrease of plasma volume Bowel also becomes distended- >increased motility minutes after eating->s/s last 1 hr Weakness, sweating, dizzy, cramps, urge to have BM
Postprandial Hypoglycemia Like dumping syndrome 2 hours after eating Bolus of high CHO fluid into small intestine->bolus of insulin secretion- >hypoglycemia What are the s/s of hypoglycemia?
Bile Reflux Gastritis Alkaline gastritis from bile salts Continuous epigastric s/s which increase after meals & relieved by vomiting (temporarily) Treatment – Questran ac or pc, Aluminum hydroxide antacids
Nutrition 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
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
Constipation Etiology: insufficient dietary fiber, inadeq fluid intake, meds, little exercise Complications: hemorrhoids, Valsalva’s maneuver, diverticulosis Teaching: 20 – 30 g of fiber/day, drink 3 qts/day, exercise 3X/week, avoid laxatives/enemas, record elimination pattern, do not delay defecation & establish a pattern
“Acute Abdomen” Etiology: see table 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
“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
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
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
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
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
Nursing Care Assess pain, BS, distention, guarding, temp, labs, s/s shock VS, I&O, lytes, NPO, antiemetics, NG Surgical site drains (penrose, Jackson Pratt, “open belly”) check color & amt drainage, I & O if irrigation of wound Antibiotics, analgesics, maybe TPN
Gastroenteritis S/S: n/v, diarrhea, fever abd cramps Rx: NPO til stop vomiting, then flds with glucose & electrolytes (Pedialyte) Complication: dehydration, loss of lytes Strict handwashing & medical asepsis, rest & increased fld intake
Ulcerative Colitis Inflammation, abscesses in mucosa break into submucosa & ulcerate, decreased area for absorption, granulation tissue forms & mucosa becomes thick & short. S/S: bloody diarrhea & abd pain - acute or chronic, mild or severe exacerbations. Fever, malaise, anorexia, wt loss, dehydration, anemia, tachycardia
Complications Intestinal: hemorrhage, strictures, perforation, toxic megacolon, colonic dilatation, risk for colon cancer Extraintestinal: due to malabsorbtion or problem with immune system – joints, skin, mouth & eyes Dx: CBC, lytes, albumin, stool analysis, sigmoidascope & colonoscopy, barium enema
Nursing & Collaborative Care Rest bowel Control inflammation Prevent / treat infection Correct malnutrition Meds to relieve s/s Alleviate stress See NCP 40-3
Meds Sulfasalazine – maintenance & remission, for 1 year 5-ASA – active disease, 4-ASA given as retention enemas Corticosteroids :IV, enema, Prednisone Cyclosporin Sedatives, antibiotics, vitamins
Surgery Total proctocolectomy with perm. 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
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
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
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
Surgery Indications: fistulas, abscess, intestinal obstruction, perforation, ? Carcinoma, hemorrhage, no response to therapy Surgery is not a cure, high recurrence Procedure – intestinal resection with anastomosis
Nursing Care Patient & family teaching regarding nature of disease & limitations of 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
Intestinal Obstruction Mechanical: adhesions, neoplasms, hernias Nonmechanical: paralytic ileus, pseudoobstructions, vascular Pathophysiology: feces, fld & gas collect proximal to obstruction, distention, collapse distal bowel, decr absorption of fld, incr pressure, flds & lytes into peritoneal cavity. Edema, necrosis, congestion from decr bld supply, possible bowel rupture & shock
Intestinal Obstruction Obstructions: simple, closed loop, strangulated, incarcerated S/S: n/v, pain, distention, inability to pass gas, hi pitched BS above area of obstruction Dx: H&P, abd x-rays, barium enema, sigmoidoscopy, colonoscopy, CBC, lytes, BUN, amylase, WBC, guiac stool Tx: decompress intestine, surgery
Nursing Care Assessment: pain, s/s, BS, dehydration, labs Insertion & care NG tube Intestinal tubes: Harris tube, Miller- Abbott tube, Cantor tube
Colon & Rectal Cancer Risk factors Adenomatous polyps->adenocarcinoma Spread thru walls of intestine -> lymph system, metastasis to liver-> portal vein S/S: L lesions- rectal blding, alt constipation & diarrhea, ribbon like stools, sensation of incomplete evacuation, s/s obstruction. R lesions- vague abd pain, weakness & fatigue from anemia
Colon & Rectal Cancer Dx: H&P, rectal exam, sigmoidoscopy, air contrast barium enema, CT scan colonoscopy, CBC, clotting studies, liver enzymes, CEA Staging: primary tumor, regional lymph node involvement, distant metastasis Surgery: R or L hemicolectomy, abdominal perineal resection Chemo & radiation: post-op or palliative
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
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.
Home Care Psychological support Pain/discomfort management Nutrition Care of perineal wound Home health nurse – assessment & teaching of pt & family Community Services
Ostomy Surgery Temporary or permanent Stoma Ileostomy, knock pouch, ileoanal reservoir Cecostomy Colostomy, loop & double barrel Ostomy Care: assess stoma, skin care, select pouch/bag, psychol support & adaptation to stoma, sexual dysfunction
Diverticular Disease Lack of fiber, retention of stool & bacteria, fecalith-> inflammation, small perforations, edema, abscess, peritonitis S/S diverticulosis: none or LLQ crampy abd pain, alt constipation & diarrhea. Diverticulitis: localized pain, tender LLQ mass, fever, chills, n/v, anorexia, leukocytosis, elderly-afebrile, little tenderness
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
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
Short Bowel Syndrome Excessive resection of small intestine. Rapid intestinal transit, impaired digestion & absorption, fld & lyte loss S/S: diarrhea & steatorrhea, malnutrition &vit & mineral deficiencies, wt loss, lactase def, bacterial overgrowth, kidney stones Tx: antidiarrheal meds, TPN-> hi CHO, low F diet, 6 meals/day
Anorectal Problems 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