1. GI/ENDO-1

2. Anatomy & Physiology Review
Mouth
Pharynx
Esophagus
Stomach
Pyloric Sphicter
Small & large intestines
Anus
Pg. 731
REVIEW TRANSPARENCY
ASK WHAT THE FUNCTION OF EACH ORGAN IS.
Review Age-Related changes pg.732

3. Stool Specimens O&P OB C-diff C & S Take or send to lab ASAP
O & P  tests for parasite ova (eggs)
OB tests for blood not visible with naked eye. Treated with chemical after smearing on special paper. Color changes indicate presence of blood.
Fecal Fat
C&S tests for specific bacteria in stool
Q: What are some specific nursing interventions to remember when collecting stool specimens?
A: #1-5 pg 740
Looking for parasites, bacteria, hidden blood, and problems with fat digestion

4. RADIOGRAPHIC TESTS Most common tests: 1) Barium swallow or UGI
2) Small Bowel series
3) Barium enema
Pg. 735 ( See Table 736 for descriptions of radiographic tests )
Collaborative Learning Activity
Divide class into heterogenous groups of 5-6 students. Assign each group 5-6 studies and lab tests. Each student is to look up and report the following on 1 test/procedure:
Describe the test/What the test is for
Describe the procedure
Give the most important nursing implication before and after the test
Provide minutes for students to research the material and allow another minutes for each student to report on their findings. Remind students to take notes when classmates are presenting.
May want to exclude CT Scan, Ultrasound and Abdominal X-rays from this assigmenent as they are not in the book.

5. ENDOSCOPIC TESTS (for upper GI system)
Esophagoscopy
Gastroscopy
Gastroduodenoscopy
EGD
ERCP
Nursing..Always check…before eating or drinking?
Pg. 736 Table ( see highlighted in text )
THESE TESTS ARE FOR THE UPPER DISGESTIVE TRACT

6. Newest…
Capsule cam

7. ENDOSCOPIC TESTS ( for lower GI system)
Colonoscopy
Pg. 736 ( highlighted areas)
THESE TESTS ARE THE LOWER DIGESTIVE TRACT

8. Abnormal Assessment Findings
Distention
Firmness
Tenderness
Altered bowel sounds
Q- What do normal BS sound like?
A- pg. 734 highlighted areas…
Need to be able to recognize abnormal BS. Knowledge of the “normal” makes identifying abnormal sounds easier.

9. Gastrostomy – (G-tube) Jejunal – (J-tube) Percutaneous – (PEG)
Types of Tubes
Nasogastric - (NG)
Gastrostomy – (G-tube)
Jejunal – (J-tube)
Percutaneous – (PEG)
Review admin of tube feedings, review Key Points 1-11
Figure 38-6 PEG placement

10. Tube feeding HOB If too low they may aspirate.
Check Placement!! Always!!
2ways
Residual
Listen

11. Tube Flushing
Your facility will always have a protocol to follow. H2O, Sterile water, NS (Sodium Chloride)
30ml general rule
Can try changing positions of pt if still blocked

12. Total Parenteral Nutrition – (TPN)
Nutritionally complete
Used when GI system not functioning
Short or long term
NPO!!!!!!!
Pg. 743
TPN bypasses the GI system and delivers nutrition directly into the bloodstream. A catheter is inserted into a lg. vein such as the subclavian (fig. 38-9) PG The feeding passes into superior vena cava into the right atrium which allows for rapid diluation. Catheter is sutured to the skin, radiograph is taken to check placement before use. Regular IV’s only provide water, glucose, electrolytes, minerals and vitamins.
2 types of TPN can be used. TPN is concentrated and provides carbs, pro, fat, water, electrolytes vitamins and minerals. Lipid solutions are not mixed with TPN and may be given via a peripheral line.
Review important points 1-6 pg 744

13. Anorexia Lack of appetite Cause: physical or emotional Pg. 745
Physical  nausea, a decreased sense of taste or smell, mouth disorders and meds may decrease appetite.
Emotional anxiety, depression or unpleasant thoughts may cause anorexia. Unpleasant environment may influence appetite as well.

14. Contributing factors:
Special diet
Illness
Unpleasant odors
Social isolation
Decreased sense of taste or smell
Pureed diet, low salt, and low fate diets are unappetizing
Older people often report decreased appetite. May be attributed to diminished senses of taste, smell, drug effects, decreased activity and social isolation

15. Signs & Symptoms Glossitis cheilosis Muscle wasting Extreme fatigue
Lesions of the mouth
Pg. 670
Explore all factors that can affect appetite when assessing pt.ie chronic or recent illness, usualy dietary patterns, current stressors,, and coping strategies.
During the PE, be alert for signs of malnutrition ie: glossitis(inflam of the tongue) cheilosis (cracked lips) and muscle wasting. Evaluate the fit of dentures

16. Nursing Interventions
Oral hygiene, dentures
Pleasant environment for meals, socialization(Family)
Diet preferences, small servings
Pg 750
Provide good oral hygiene before meals, make sure dentures fit well. Treat nauseau, remove bedpans and emesis basins prior to meals arriving. Encourage family members to visit during meal times,bring food from home, consider dietary restrictions. Correctable causes of anorexia are treated but sometimes no physical cause is found. Nutritional supplements may be ordered. Oral route is preferred but in extremes may include TPN.
Anorexia usually temporary. Teach importance of adequate nutrition in meeting health goals. Most will make an effort to eat when they understand.

17. Obesity 20% over ideal body wt. Morbid obesity= 2X normal body wt.
Pg 774
The basic problem is that caloric intake exceeds metabolic demands.

18. Complications CV disease Diabetes Respiratory difficulties
Musculoskeletal problems
Emotional and social isolation
Pg 774
Others…endometrial cancer, polycythemia, cholelithiasis

19. Causes Caloric intake > expenditure Heredity
Emotional stress/psychosocial factors
Slowed metabolism
Excess food energy is converted to fat cells, which are capable of great expansion. When fat cells reach a certain size, they divide to form new fat cells. Fat cells decrease in size, but not in number, when a person loses weight.
Theories state that there may be a mechanism within the hypothalmus that regulates weight within a certain range. When a person’ nutrient intake falls below the level required to maintain the set wieght, the body conserves energy to maintain that weight. This may explain why some people always seem to return to a certain weight despite strict dieting and temporary weight loss.

20. Medical Management Weight reduction diet Exercise Medication
Counseling
Caloric allowance may be as low as 800 calories/day.
Amphetimines are effective but are not widely prescribed bec. They aggrevate cardiac disease and hypertension.
Drugs available are Didrex, Adkpost, Sanorex, Orlistat and Meridia. To be effective, drugs must be used in combination with diet and exercise. Wellbutrin is being studied for usefulness in weight loss.

21. Surgical Treatment RNYGBP VBG LBP Liposuction Post op: Pain management
TCDB…splinting with pillows
Pg. 775
RNYGBP Roux-en-y gastric bypass decreases the size of the stomach,into a pouch, connects to jejunum. Decreases the stomach’s capacity and bypasses most of the absorptive section of the GI tract. Primarily a restictive procedure.
VBG-> stomach is stapled to reduce its capacity leaving a sm. Opening for food . LBPIt is the newest procedure. Band placed around fundus of stomach, creates a small pouch
lipo removes adipose tissue using suction and lipectomy is the surgical excision of flabby folds of adipose tissue.
Dumping Syndrome is a common complication.

22. Dumping Syndrome S&S Prevent Diaphoretic Distension Diarrhea
Smaller meals
Slow down tube feeding

23. Constipation Drink H2O!! Stool Softners Laxatives Colace Surfak
Fiber..Metamucil
Miralax
Laxatives
Ducolax pills
Ducolax Supp
Need to be in BR in 20-30min

24. Diarrhea Treat the cause Replace lost fluid and electrolytes
Monitor electrolytes….Lab?
Watch for severe fatigue
Watch for Hypotension

25. Oral Cancer 2 types of malignant tumors Squamous and Basal cell
Early s/s may be ignored
Tongue irritation, loose teeth, pain in ear or in tongue
Need to tell people to check!
Pg.753
early s/s may be ignored
The most life-threatening disorder affecting the mouth is CA. Two types of malignant tumors develop in the mouth: squamous cell carcinoma and basal cell carcinoma.
Squamous cell occur on the lips, buccal mucosa, gums floor of mouth, tonsils and tongue. The most comon site for basal cell CA is the lip
Leukoplakia is considered a premalignant condition. Commonly seen as hard white patches in the mouth.
Malignant lesins may appear as ulcerations, thickened or rough areas, or sosre spots. The presence of hard, white pataches in the mouth are leukoplakia which is considered a premalignant conditon.

26. Risk Factors Tobacco use Alcohol use Poor nutrition Chronic irritation
Pt’s should be taught to report any oral or dental problems to their dentist because it may be an early sign of oral CA.
CA of the lip is assoc. with prolonged exposure to run,wind and pipe smoking. CA of the mouth is assoc. with tobacco and alcohol use.

27. Treatment Surgery- Radical Neck Must watch Nutrition
Monitor Wt and serum albumin levels(low)
Alteration in nutrition: less than….
Radiation
Chemo
Diagnosis- biopsy glossectomy=remove all of tongue
When a malignancy is confirmed the MD often orders endoscopic examinations and radiographs of the upper digestive and respiratory tracts to see whether there is evidence of metastases. Dependng on the extent of the CA, treatment may include surgery, radiation or chemo.
Small lesions may be exciseed and larger lesions that are more invasive may require more radical surgery.
Hemiglossectomy=remove part of tongue

28. Esophageal Cancer Not common, poor prognosis
Middle or lower portion of esophagus
No known cause
756

29. Excessive alcohol intake Poor oral hygiene Eating spicy foods
Predisposing Factors
Cigarette smoking
Excessive alcohol intake
Poor oral hygiene
Eating spicy foods
CA of the esophagus often has begun to metastasize by the time it is diagnosed. The liver and lung are comon sites of metastasis.
Higher incidence among African American males than among white males and is related to tobacco use and dietary.

30. Signs and Symptoms Progressive dysphagia** Weight loss may be dramatic
TX  Chemo or surgery
Esophagectomy, Esophagogastrostomy, or Esophagogastrectomy
Pallative….Dilation
Pg. 756
Progressive dysphagia is the primary symptom. First with meats, then with soft foods, followed by liquids.
Esophagectomy  removal of all or part of the esophagus and replacement of the resected part with a graft.
Esophagogastrostomy resection of the diseased part of the esoophagus and attachment of the remaining esophagus to the stomach Figure 38-12
Esophagogastrectomy replacement of the diseased part of the esophagus with the upper part of the stomach.
See figure Colon Interposition pg 757 esophagoenterostomy

31. GERD Gastroesophageal Reflux Disease
Backward flow of stomach contents into the espohagus
Pg. 763
A key finding is a relaxation of the LES ( lower esophageal sphincter)
Factors that contribute to the development of GERD include abnormalities around the LES , gastric or duodenal ulcer, gastric or esophageal surgery, prolonged vomiting and prolonged gastric intubation. The acidic stomach contents flow backwarads into the esophagus and eventually cause esophagitis (inflam. Of the esophagus)

32. Burning sensation that moves up and down, commonly after meals
Signs & Symptoms
Burning sensation that moves up and down, commonly after meals
Intermittent dysphagia
Belching (Eructation)
Onset of symptoms may be sudden or gradual
Acid regurgitation is common. Symptoms are likely to occur after activities that increase intra-abdominal pressure such as lifting, straining and lying supine.

33. Treatment H2 Receptor Antagonist inhibits acid secretion
Drug therapy may include: Zantac, Reglan, Prilosec & antacids (Calcium Carbonate)
No BiCarb (baking soda)…It’s a base…A/B balance
Question lifting practices..Too much?
Fundoplication if required
If medical drug therapy is unsuccessful, then fundoplication

34. Patient Teaching Avoid ASA and NSAIDS Chew food well
Avoid eating 2 hrs. before bedtime
Avoid irritating foods

35. Avoid caffeine, ETOH, nicotine
Supine with HOB ^ 30 degrees

36. Oooooo….Here it comes….

37. Mr Flussmushin
Mr Flussmushin is a 49 yo African American male who had Lap band surgery today. Mr. Flussmushin has been fighting his weight problem for many years and is currently 6’0, 382lbs. He has a history of HTN, NIDDM, and Hyperlipidemia. Allergies= PCN. He currently takes Norvasc 5mg po daily, Glucophage 500mg po daily, and Pravastatin 40mg po daily. He drinks heavily on occasion but not daily. Smokes rarely. Current vitals are 98.8, 100, 20, 162/92, 94% O2. He had a lab band placed this morning and is now in one of your rooms. He is complaining of some abdominal pain at a level 6. Dr. Myan ordered percocet 5mg po every 4 hours prn pain, give 1 dose of heparin SC at 80units/Kg (Comes 5000units per ml), Coumadin 5mg po today, PT/INR daily, CBC daily, BMP daily. Get up OOB every 2 hours. Continue home meds. Vitals every 4 hours. NPO except meds for today. NS at 100ml/hr IV. Dry drsg’s over incisions. May change PRN. Write a care plan for Mr Flussmshin and include correct dose of heparin to give.

38. Hiatal Hernia
Protrusion of the lower esophagus and stomach upward through the diaphragm
Pg. 760
Sliding  the gastroesophageal junction is above the hiatus. When the pt stands or sits up it slides back into place, when the pt lies down it slides above the diagraphm. Associated w/ GERD.
Rolling  protion of the stomach herniates up through the diaphragm through a secondary opening.

39. Causes Excessive intra-abdominal pressure Obesity Pregnancy
Abdominal tumors, ascites or repeated heavy lifting
Also long term bedrest in a reclining position may cause a hiatal hernia.

40. Signs and Symptoms Feeling of fullness Eructation Heartburn Dysphagia
Regurgitation
Pg 760
Many do not have any symptoms
Eructation is belching

41. Medical Treatment Avoid increased intra-abdominal pressure
HOB ^ 6-12 inchesprevents nighttime reflux
Drug Therapy
Diet…smaller meals
Stop eating before bedtime
Drug therapy Antacids. H2 blockers(Zantac), and proton pump inhibitors like Prilosec to reduce acid secretion, and urecholine may be ordered to increase the tone of the LES
Diet to avoid acid producers
Review patient teaching plan pg 762

42. Surgical Treatment Nissen Fundoplication Angelchik Prosthesis
See pic 762
Fundoplication = strengthens the LES by suturing the fundus of the stomach around the esophagus and anchoring it below the diaphragm
Angelchik Prosthesis = C-shaped silicone device tied around the distal esophagus, anchoring it below the diaphragm.

43. Gastritis
Inflammation of the stomach mucosa/lining
Causes:
Meds, spicy foods, alcohol, stress, H.pylori
Pg. 763
The muscosal barrier that normally protects the stomach from auto-digestion breaks down. Hydrochloric acied, histamine, and pepsin act to cause tissue edema, increased capillary permeability and possible hemorrhage.
There are many causes of gastritis, but the main culprit is thought to be Helicobacter pylori.
Review to highlighted areas in text.
Meds NSAIDS, other causes stress, ETOH

44. Signs & Symptoms N/V Abdominal pain Anorexia Feeling of fullness
Pg. 764
In people who abuse alcohol, hemorrhage may be the only symptom. Symptoms of chronic gastritis may be the same as acute gastritis. Some patients have only mild indigestion or no symptoms at all unless they developo pernicious anemia.
Chronic gasstritis changes the stomach lining and causes a decrease in both acid production and intrinsic factor. Intrinsic factor is needed for maturation of RBC’S. Without intrinsic factor, pernicious anemia can develop.

45. Treatment Meds..Phenergan*and Zofran
Careful with Phenergan
Replacement of fluids after N,V & diarrhea subsides
Elimination of the cause
Surgical intervention if all else fails
Pg. 764
Best means of diagnosing is with gastroscopy. Lab studies may be done to detect occult blood in feces, low blood hemoglobin . H-pylori can be detected by breath, urine or serum tests.
Meds Antacids and H2receptor blockers to reduce gastric acidity. Analgesics for pain relief and antibiotics for H. pylori. Usually Prilosec and amoxicillin and or clarithromycin for H. pylorii. Corticosteroids also may be used to reduce inflammation. Vitamin B12 must be given regularly to prevent long term complications espec in chronic gastritis.
Medical management focuses on elimination of the cause ( pylori, drugs, ETOH.)
With pts having an acute episode of gastric bleeding, MD may order IV, CBC, NGT and O2. Your 1st nrsg intervention would be to adm. Oxygen.
Goal is to return pt to their “normal” elimination patterns.

46. Ulcers Peptic (Same as duodenum Ulcers) Tx:
Often on mucosa wall of stomach or duodenum
Caused by H-Pylori (bacteria)
Stress…Burns, shock
Tx:
Smaller meals
H2 drugs and/or gastric pump inhibitors
AB if…

47. Gastric Tx Pain after a meal Bleeding Coffee ground emesis Tx
H2 drugs
Smaller meals, bites and chew up your food

48. Once either type of ulcer erodes deep enough it will hit blood vessels… Bad Bad
Hemorrhage
Black tarry stools
Coffee ground emesis

49. Worst case Scenario Subtotal Gastrectomy
They take out 2/3 to ¾ lower part of stomach,
the pyloric sphincter and part of the duodenum
They will leave part of the duodenum where the bile duct from the liver comes in

50. The End