4Nausea & VomitingProblems- 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 emptyingIV and NG tube, begin diet with clear liquids.
9GERD & 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.
16GastritisTreatment: 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.
17Peptic 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
18Peptic Ulcer Signs & Symptoms May have no painGastric ulcer painepigastric, burning, “gassy”1- 2 hrs after meals, stomach empty or when eat foodDuodenal ulcer painback or mid-epigastric, burning, cramp-like2-4 hrs after meals, antacids relieve pain
20Nursing 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.
21Surgical Therapy Partial gastrectomy Billroth I – Gastroduodenostomy, removes distal 2/3 stomach & attaches to duodenumBillroth II – Gastrojejunostomy, removes distal 2/3 stomach & attaches to jejunumVagotomy-eliminates stimulus for acid secretionPyloroplasty –enlarges pyloric sphincter, increases gastric emptying
22Post-op Care Observe NG tube drainage Red, decreasing in color 1st 24 hoursObserve for clogged NG tubeDo not irrigate without MD order, surgeon replaces NG if pt pulls out tubeObserve for decreased peristalsisI&O, VS
23Post-op Care Observe for bleeding/ hemorrhage, NG & dressing Pain managementWhat are the general post-op complications & nursing care?If you do not have HCl, what disease are you at risk for?
24Case 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 consentTake initial set VSPick up blood from labAssess IV siteStart transfusionVerify pt ID, & blood compatability
25PrioritizationPre-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 transfusionSave transfusion unitInform MD/RNSave next voided specimenStart 0.9NSTake VS
27Dumping SyndromeLarge amount hyperosmolar chyme in intestine->fluid is drawn in->decrease of plasma volumeBowel also becomes distended->increased motility15-30 minutes after eating->s/s last 1 hrWeakness, sweating, dizzy, cramps, urge to have BM
28Postprandial Hypoglycemia Like dumping syndrome2 hours after eatingBolus of high CHO fluid into small intestine->bolus of insulin secretion->hypoglycemiaWhat are the s/s of hypoglycemia?
29Bile 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
30Nutrition Postgastrectomy Dumping Syndrome Six small mealsDo not have fluids with mealsFluids 45 minutes before or after mealsDry foods low CHO, moderate protein & fatsAvoid concentrated sweets (jams, candy, etc)Lie down after meals, short rest period
31Ca of the stomachEtiology: 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
36ConstipationEtiology: insufficient dietary fiber, inadeq fluid intake, meds, little exerciseComplications: hemorrhoids, Valsalva’s maneuver, diverticulosisTeaching: 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 girthDX: H&P, preg test, rectal & pelvic exam, CBC, U/A, abd x-raysEmergency management: table 43-13
38“Acute Abdomen”Assess: VS, inspect, palpate & auscultate abdomen, pain, n/v, change in bowel habits, vaginal dischargePre-op Care: CBC, type & cross match, clotting studies, cath, skin prep, NGPost-op care of NG tube, mouth & nare care, control of n/v, abd distention & gas pains
40Abdominal 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 ruptureS/S: abd guarding & splinting, distended, hard abd, decr or absent BS, contusions, abrasions, bruising on abd, pain, shock, hematemesis or hematuria, Cullen’s sign
41Abdominal 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 tendernessInterventions: airway, control bleeding, cover protruding organs, IV, labs, foley, VS, LOC, see table 43-14
42AppendicitisS/S: periumbilical pain, then shifting to RLQ & McBurrey’s point, tenderness, rebound tenderness, muscle guarding, Rovsing’s sign, anorexia, n/v, low grade feverComplic: perforation, peritonitis, abscessDx: H&P, WBC, u/aNsg Care: NPO, no laxatives or heat to area, post-op: OOB next day & advance diet
43PeritonitisEtiology: rupture of an organ, trauma, pancreatitis, peritoneal dialysisS/S: tenderness over area, rebound tenderness, muscle rigidity & spasms, abd distention, n/v, tachycardia, tachypnea, alt bowel habitsComplications: hypovolemic shock, septicemia, abscess, paralytic ileus, organ failureDX: CBC, C&S perit. Fld, CT, x-ray
44Nursing CareAssess pain, BS, distention, guarding, temp, labs, s/s shockVS, I&O, lytes, NPO, antiemetics, NGSurgical site drains (penrose, Jackson Pratt, “open belly”) check color & amt drainage, I & O if irrigation of woundAntibiotics, analgesics, maybe TPN
45Gastroenteritis S/S: n/v, diarrhea, fever abd cramps Rx: NPO til stop vomiting, then flds with glucose & electrolytes (Pedialyte)Complication: dehydration, loss of lytesStrict handwashing & medical asepsis, rest & increased fld intake
46Ulcerative ColitisInflammation, 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
47ComplicationsIntestinal: hemorrhage, strictures, perforation, toxic megacolon, colonic dilatation, risk for colon cancerExtraintestinal: due to malabsorbtion or problem with immune system – joints, skin, mouth & eyesDx: CBC, lytes, albumin, stool analysis, sigmoidascope & colonoscopy, barium enema
48Nursing & Collaborative Care Rest bowelControl inflammationPrevent / treat infectionCorrect malnutritionMeds to relieve s/sAlleviate stressSee NCP 40-3
49Meds Sulfasalazine – maintenance & remission, for 1 year 5-ASA – active disease, 4-ASA given as retention enemasCorticosteroids :IV, enema, PrednisoneCyclosporinSedatives, antibiotics, vitamins
50Surgery Total proctocolectomy with perm. ileostomy Total protocolectomy with continent ileostomy called a Knock pouchTotal colectomy & ileal reservoirSurgery “cures” diseasePost-op: stoma care, skin integrity, I&O, observe for hemorrhage, abscess, small bowel obstruction, electrolyte imbalance & dehydration, diet teaching & care of ileostomy
51Crohn’s DiseaseInflammation of segments GI tract esp ileum,jejunum, colon & involves all layers of bowel wallClassic “cobblestone” appearance, normal bowel between diseased, longitudinal, deep ulcerated partsThickening bowel wall & stricturesAbscesses & fistulas with bladder, vagina, bowel
52Crohn’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 & umbilicusComplications: fistulas, malabsorption of A,D,E,K, gluten intolerance, arthritis, liver disease, cholelithiasis, nephrolithiasis, uveitisDx: same as ulcerative colitis
53Collaborative Care Sulfasalazine – large intestine involvement Corticosteroids – taper off when s/s subsideImmunosuppressive meds if steroids ineffectiveFlagyl – perianal areaFish oil, B-12 IM,Balloon dilation of stricturesElement diet- hi calorie, hi Nitrogen no fat; OR lo residue & roughage, hi calorie & P, possibly lactate free diet
54SurgeryIndications: fistulas, abscess, intestinal obstruction, perforation, ? Carcinoma, hemorrhage, no response to therapySurgery is not a cure, high recurrenceProcedure – intestinal resection with anastomosis
55Nursing CarePatient & family teaching regarding nature of disease & limitations of txTeach: diet, importance of rest, meds, when to seek medical care, reduce stress, perianal carePost-op: ulcerative colitis NCP 43-3Skin care, referral to wound care nurse for abscess / fistulas
56Intestinal Obstruction Mechanical: adhesions, neoplasms, herniasNonmechanical: paralytic ileus, pseudoobstructions, vascularPathophysiology: 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
57Intestinal Obstruction Obstructions: simple, closed loop, strangulated, incarceratedS/S: n/v, pain, distention, inability to pass gas, hi pitched BS above area of obstructionDx: H&P, abd x-rays, barium enema, sigmoidoscopy, colonoscopy, CBC, lytes, BUN, amylase, WBC, guiac stoolTx: decompress intestine, surgery
58Nursing Care Assessment: pain, s/s, BS, dehydration, labs Insertion & care NG tubeIntestinal tubes: Harris tube, Miller-Abbott tube, Cantor tube
59Colon & Rectal Cancer Risk factors Adenomatous polyps->adenocarcinoma Spread thru walls of intestine -> lymph system, metastasis to liver-> portal veinS/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
60Colon & Rectal CancerDx: H&P, rectal exam, sigmoidoscopy, air contrast barium enema, CT scan colonoscopy, CBC, clotting studies, liver enzymes, CEAStaging: primary tumor, regional lymph node involvement, distant metastasisSurgery: R or L hemicolectomy, abdominal perineal resectionChemo & radiation: post-op or palliative
61Health 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 riskBarriers: lack of info & fear of dxResearch: use of anti-inflammatory drugs or long term use of ASADiet
62Nursing Care Abd-Perineal Resection Teach extent of surgery for abdom-perineal resection, positioning for comfort & sitz bath, ostomy questionsAbd wound, perineal wound, stomaProfuse 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.
63Home Care Psychological support Pain/discomfort management Nutrition Care of perineal woundHome health nurse – assessment & teaching of pt & familyCommunity Services
64Ostomy Surgery Temporary or permanent Stoma Ileostomy, knock pouch, ileoanal reservoirCecostomyColostomy, loop & double barrelOstomy Care: assess stoma, skin care, select pouch/bag, psychol support & adaptation to stoma, sexual dysfunction
65Diverticular DiseaseLack of fiber, retention of stool & bacteria, fecalith-> inflammation, small perforations, edema, abscess, peritonitisS/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
67Hernias Protrusion of viscous thru wall of cavity. Reducible, irreducible or incarcerated, strangulatedTypes: inguinal, femoral, ventral or incisionalS/S: bulge, discomfort, pain->strangulatedTx: herniorrhaphy, hernioplasty, trussPost-op: check voiding, scrotal support, ice pack, no coughing, splint incision with mouth open if sneeze, no lifting 6-8 weeks
68Malabsorption Syndrome Causes: biochemical or enzyme deficiency, bacterial profileration, disruption sm intestine mucosa, disturbed lymph or vascular circulation,surface area lossLactose intolerance, inflam bowel disease, celiac, tropical sprue, cystic fibrosisS/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
69Short Bowel Syndrome Excessive resection of small intestine. Rapid intestinal transit, impaired digestion & absorption, fld & lyte lossS/S: diarrhea & steatorrhea, malnutrition &vit & mineral deficiencies, wt loss, lactase def, bacterial overgrowth, kidney stonesTx: antidiarrheal meds, TPN-> hi CHO, low F diet, 6 meals/day
71Anorectal ProblemsAnal fissure –crack or skin ulcer in anal wall, associated with constipationAnorectal abscess- perirectal infection E. coli, staph or strep, foul smell, sepsisSurgically drained, packed q day with petroleum jelly gauze, keep clean, heal by granulation, sitz bath, lo residue dietPilonidal cyst- sacrcoccyx, congenital, lined with epithelium & hair, abscess formsTx- I&D