Stressors of the Gastrointestinal System NUR240 Stressors of the Gastrointestinal System 1/09

Overview of the Gastrointestinal Tract Structure Function Nerve supply Blood supply Oral cavity Stomach Pancreas Liver and gallbladder Intestines Esophagus 1/09

Assessment Techniques History Demographic data Family history and genetic risk Personal history Diet history Anorexia Dyspepsia 1/09

Current Health Problems Pattern of bowel movements Color and consistency of the feces Occurrence of diarrhea or constipation Effective action taken to relieve diarrhea or constipation Presence of frank blood or tarry stools Presence of abdominal distention or gas 1/09

Skin Changes Related to Gastrointestinal Disorders Skin discolorations or rashes Itching Jaundice Increased susceptibility to bruising Increased tendency to bleed 1/09

Physical Assessment Mouth and pharynx Abdomen and extremities Inspection (Cullen’s sign) Auscultation, look for borborygmus Percussion Palpation 1/09

Laboratory Tests Complete blood count Clotting factors Electrolytes Assays of liver enzymes—aspartate and alanine aminotransferase Serum amylase and lipase Bilirubin: the primary pigment in bile (Continued) S&P 1/09

Laboratory Tests (Continued) Evaluation of oncofetal antigens CA 19-9 and CEA Urine tests—amylase, urine urobilinogen Stool tests—fecal occult blood test, ova parasites, Clostridium difficile infection Radiographic examinations 1/09

Upper Gastrointestinal Series and Small Bowel Series Before test: Maintain NPO for 8 hr. Withhold analgesics and anticholinergics for 24 hr. Client drinks 16 ounces of barium. Rotate examination table. After the test: Give plenty of fluids. Administer mild laxative or stool softener; stools may be chalky white for 24 to 72 hr. S&P 1/09

Barium Enema Barium enema enhances radiographic visualization of the large intestine. Only clear liquids are given 12 to 24 hr before the test; NPO the night before; bowel cleansing is done. After the test, expel the barium: drink plenty of fluids; stool is chalky white for 24 to 72 hr. 1/09

Percutaneous Transhepatic Cholangiography X-ray study of the biliary duct system Laxative before the procedure NPO for 12 hr before test Coagulation tests, intravenous infusion Bedrest for several hours after procedure Assessment of vital signs Client positioned on right side with a firm pillow or sandbag placed against the lower ribs and abdomen (Continued) S&P 1/09

Other Tests Computed tomography Endoscopy: direct visualization of the gastrointestinal tract by means of a flexible fiberoptic endoscope Ultrasonography Endoscopic ultrasonography Liver-spleen scan S&P 1/09

Esophagogastroduodenoscopy Visual examination of the esophagus, stomach, and duodenum NPO for 6 to 8 hr before the procedure Conscious sedation After the test, assessment of vital signs every 30 min NPO until gag reflex returns Throat discomfort possible for several days S&P 1/09

Endoscopic Retrograde Cholangiopancreatography (ERCP) Visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas NPO for 6 to 8 hr before test Access for intravenous sedation Return of gag reflex checked Assessment for pain, colicky abd pain 1/09

Small Bowel Capsule Enteroscopy Visualization of the small intestine (camera pill) Only water for 8 to 10 hr before test NPO for first 2 hr of the testing Application of belt with sensors 1/09

Colonoscopy Endoscopic examination of the entire large bowel Liquid diet for 12 to 24 hr before procedure, NPO for 6 to 8 hr before procedure Bowel cleansing routine Assessment of vital signs every 15 min If polypectomy or tissue biopsy, blood possible in stool S&P 1/09

Gastric Analysis Measurement of the hydrochloric acid and pepsin content for evaluation of aggressive gastric and duodenal disorders (Zollinger-Ellison syndrome) Basal gastric secretion and gastric acid stimulation test NPO for 12 hr before test Nasogastric tube insertion 1/09

Gastroesophageal Reflux Disease AKA GERD Occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus Reflux esophagitis characterized by acute symptoms of inflammation Esophageal reflux occurs when gastric volume or intra-abdominal pressure is elevated, the sphincter tone of the lower esophageal sphincter (LES) is decreased, or it is inappropriately relaxed. S&P 1/09

Gastroesophageal Reflux Disease Etiology: smoking, caffeine, alcohol Increased abdominal pressure from obesity, ascites, pregnancy, tight clothing Contributing factors: fatty foods, Ca channel blockers, nitrate, theophylline, peppermint, chocolate, anticholinergics 1/09

Clinical Manifestations Dyspepsia Regurgitation Hypersalivation Dysphagia Others manifestations: chronic cough, asthma, atypical chest pain, eructation (belching), flatulence, bloating, after eating, nausea and vomiting 1/09

Diagnostic Assessment 24-hr ambulatory pH monitoring Endoscopy Esophageal manometry 1/09

Nonsurgical Management Diet therapy- 4-6 small meals/day. Limit caffeine, tea, cola and chocolate Remain upright 1-2 hrs after meals Client education Lifestyle changes: elevate head of bed 6 in. for sleep, sleep in left lateral decubitus position; stop smoking and alcohol consumption; reduce weight; wear nonbinding clothing; refrain from lifting heavy objects, straining, or working in a bent-over posture 1/09

Drug Therapy Antacids neutralize excess acids, give 1-3hr pc and at hs Histamine receptor antagonists decrease acid production. Ex. Zantac, Pepcid, Axid, Tagamet Proton pump inhibitors provide effective, long-acting inhibition of gastric acid secretion. Ex. Protonix, Prilosec, Nexium, Prevacid Prokinetic drugs increase gastric emptying and improve LES pressure and esophageal peristalsis. Ex. Reglan Assess for SE and pt respoonse 1/09

Other Treatments Endoscopic therapies Surgical therapies For more info , check out these websites: www.ddnc.org www.gastro.org www.heartburnalliance.org 1/09

Hiatal Hernia Protrusion of the stomach through the esophageal hiatus of the diaphragm into the thorax S&P 1/09

Assessment Heartburn Regurgitation Pain Dysphagia Belching Worsening symptoms after eating or when in recumbent position S&P 1/09

Nonsurgical Management Drug therapy: antacids, histamine receptor antagonists Diet therapy: avoid eating in the late evening and avoid foods associated with reflux Weight reduction Elevate head of bed 6 in. for sleep, remain upright for several hours after eating, avoid straining and vigorous exercise, avoid nonbinding clothing. 1/09

Nursing Considerations Imbalanced nutrition Risk for aspiration Acute pain 1/09

Surgical Management Hiatal Hernia Repair Preoperative care Operative procedures Postoperative care Respiratory care Nasogastric tube management Nutritional care for complications of surgery including gas bloat syndrome and aerophagia (air swallowing) 1/09

Diverticula A pouchlike herniation through the muscular wall of a tubular organ. May occur in the stomach, SI, or most commonly, the colon. Zenker’s diverticulum most common Diet therapy : size and frequency of meals Surgical management Both sexes are equally affected Incidence increases with age Diet high in refined sugars S&P 1/09

Diverticulosis Indicates the presence of diverticula Symptoms: cramping, narrow stools, constipation, weakness and fatigue Complications: hemorrhage, diverticulitis 1/09

Diverticulitis Inflammation around the divericular sac Undigested food and bacteria collect in the sacs Primarily in individuals older than 50 S&S: localized pain (LLQ), fever, elevated WBCs Dx: colonscopy, BE, CT Scan Complications: perforation, hemorrhage, obstruction, abscess 1/09

Treatment Broad spectrum antibiotics Pain relief Diet- hi fiber Avoid seeds, popcorn, figs, berries, seeds, etc. Sx: if peritonitis or abscess, segment is resected with temp colostomy Anti-anxiety measures 1/09

Inflammatory Bowel Disease Etiology: uncertain, may be a genetic predisposition, may be autoimmune Umbrella term for ulcerative colitis and Crohn’s disease Manifestations: diarrhea- up to 20/day with exacerbations crampy abdominal pain exacerbations/ remissions Definitive dx by colonoscopy 1/09

Ulcerative Colitis Edematous, inflamed mucosa with multiple abscesses beginning in the rectum and moving up through the LI Inflammation, microscopic hemorrhages and abscesses develop- becomes ulcerated Primarily affects large bowel distal to proximal, mucosal to submucosal involvement Affects younger people (age 15-25) More common in females 1/09

Crohn’s Disease Any part of the intestine, most commonly in terminal ileum and ascending colon Patchy lesions (shallow ulcers), inflammation, edema and formation of fistulastransmural (entire bowel wall) Etiology: Dx: Manifestations: Complications: 1/09

Acute tx for all disorders Fluids and bowel rest Medications Potential surgery: Colectomy Colostomy Long Term- low-fiber, low, residue diet Cure for UC- 505 eventually need colostomy Only palliative for Crohn’s (70-80%) eventually need colostomy 1/09

Assessments WBC, Hgb, Electrolytes, ESR Ulcerative Colitis: Bloody diarrhea with mucus and cramping, abd pain Crohn’s Disease: Non-bloody diarrhea, crampy abd pain, insidious weight loss, fatigue, LGT Bowel sounds F&E balance S&S infection 1/09

Acute exacerbation Keep pt NPO with an IV and promote bowel rest Correct malnutrition Pain control Administer prescribed meds Provide high calorie, high protein, low fat, low fiber diet with instructions Provide nutritional supplements 1/09

Complications and Nursing Implications Fluid and electrolyte imbalance, malnutrition Bowel obstruction or perforation Ulcerative Colitis Toxic megacolon Increased risk for colon Ca Crohn’s Disease Fistulas Massive or repeated bowel resections Risk for cholelithiasis and pancreatitis 1/09

Medications 5-aminosalicylic acid drugs- anti-inflammatory effects sulfasalazine (Azulfidine) mesalamine (Asacol) Corticosteroids Immunosuppressive agents azathioprine (Imuran) Antibiotics and antidiarrheal drugs if applicable 1/09

Irritable Bowel Syndrome (IBS) AKA spastic bowel or functional colitis Motility disorder of GI tract Intermittent constipation/diarrhea patterns No inflammation 1/09

IBS Manifestations Abdominal pain, may be relieved by defecation Intermittent colicky abdominal pain Altered bowel elimination Abdominal bloating, flatulence Possible nausea and vomiting 1/09

IBS Dx Stool- occult blood, O& P CBC and ESR Sigmoidoscopy or colonoscopy Upper GI or small bowel series 1/09

IBS Tx Bulk forming laxatives Anticholinergics- Antispas, Bentyl Immodium, lomotil for diarrhea Antidepressants and SSRIs may relieve abd pain High fiber diet Avoid gas forming foods-if excess gas is problem Avoid caffeine Stress and anxiety reduction 1/09

Peptic Ulcer Disease (PUD) Mucosal lesion of the gastric mucosa or duodenum Gastric ulcers, duodenal ulcers, stress ulcers Mucosal defenses are impaired, edema, degenerative changes of superficial epithelium Causes: Helicobacter pylori infection – up to 90%, infection is cause NSAID use Severe stress Hypersecretory states 1/09

PUD S&S Dyspepsia Pain Orthostatic changes Gastric Ulcer Pain Duodenal Ulcer Pain 30-60 min pc 1.5-3hr pc Rarely occurs at night Often occurs at night Pain worse with eating Pain relieved by eating 1/09

PUD: Dx Procedures Helicobacter pylori testing Gastric sampling Urea breath test, IgG testing EGD-Esophagogastroduodenoscopy-definitive test for PUD Stool samples for occult blood 1/09

Treatment Triple Therapy: Bismuth or Proton Pump Inhibitors 2 Antibiotics- Flagyl + tetracycline, clarithromycin, amoxicillin Antacids Sucralfate (Carafate) Avoid substances that increase gastric secretion Avoid foods that cause discomfort Smaller meals 1/09

Complications and Nsg Implications Assess for perforation/peritonitis Assess for GI Bleeding What to look for?? What to do? 1/09

Intestinal Obstruction May be from mechanical (90% of all) or nonmechanical causes (paralytic ileus) Symptoms vary according to location Bowel sounds hyperactive above obstruction and hypoactive below Tx focuses on F&E balance, decompressing the bowel and relief/removal of obstruction 1/09

Dx Procedures CBC Acid-base balance assessment Electrolytes- hypokalemia Xray- F&U abd xrays look for free air and gas Endoscopy and BE Cat Scan 1/09

Nursing Interventions NPO with bowel rest NGT IVF and electerolytes Pain management Ambulation Possible preop the patient 1/09

Complications and Nsg Implications Dehydration Electrolyte Imbalance Perforation Ischemic or Strangulated Bowel Peritonitis Shock Metabolic Alkalosis- UGI Obstruction Metabolic Acidosis- LGI Obstruction 1/09

Gastric and Colorectal Cancer Early gastric (malignant neoplasms in stomach) Ca- manifestations: Indigestion, loss appetite, bloating Weight loss, fatigue, abdominal discomfort Many clients have no clinical manifestations. Advanced Ca- Vomiting, occult blood in stool, Iron deficiency anemia, palpable mass, enlarged lymph nodes, pallor 1/09

Gastric Ca Gastric Ca- Interventions : Relieve pain- analgesics, position for comfort, NG tube initially. Monitor for complications- hemorrhage. To maintain nutrition- may need TPN Patient and family education regarding diet, supplements, medication. 1/09

Gastric Ca- Tx Drug – 5FU Fluorouracil, FAM protocol Adriamycin and mitomycin C combined. Surgical management- In early Ca- surgery is usually curative, palliative resection for Advanced Ca. Standard post op care . 1/09

Colorectal Ca Diagnostic tests- CBC, fecal occult blood, CEA, colonoscopy, CT, C-Xray, biopsy. ACS Recommendation for Early Colorectal Ca Detection: FOBT every year Flexible sigmoidoscopy every 5 years FOBT every year plus flexible sigmoidoscopy every 5 years Double contrast BE every 5 years Colonoscopy every 10 years Staging of CA, 0-4. 0= CA in situ, 4=distant mets. Ostomy surgery Radiation Chemo 1/09

Colorectal Ca Ileostomy- stoma formed from ileum Colostomy- stoma formed from colon Reasons-colorectal CA, colitis, Crohn’s, diverticulitits Temporary or permanent colostomy. 1/09

Colorectal Ca Most tumors in rectum or sigmoid colon Manifestations- Bleeding, change in bowel habits, pain, anorexia and weight loss with advanced disease. Complications- Obstruction, perforation and extension (metastasis) of disease. 1/09

Colorectal Surgery NPO- until peristalsis returns, clears to advance, low residue, high calorie diet. Cough and deep breathe PCA for pain Inspect stoma- color- pink, red. Patient teaching- stoma will shrink over 3 months, appliance fitted IV, I and O, Foley Monitor electrolytes 1/09

Colorectal Surgery Life style- sexuality, self esteem, body image, enterostomal therapy nurse, support groups. Assess educational needs of client, learning disabilities, hand dexterity, vision. Educate patient and family- regarding care. Teach assessment of stoma, clean skin and stoma gently, assess for irritation. Skin barriers to protect skin. http://www.colorectal-cancer.net/ http://www.ostomy.50megs.com/ostomies.html 1/09

The nurse should explain that a diet for a peptic ulcer will most likely consist of which of the following? 1. Bland foods 2. High protein foods 3. Any foods that are tolerated. 4. Large amounts of milk. 1/09

Interventions for Clients with Morbid Obesity 1/09

Nutritional Standards to Promote Health Dietary recommendations, food guide pyramids for adequate nutrition Nutritional assessment includes: Diet history Anthropometric measurements Measurement of height and weight Assessment of body fat (body mass index) 1/09

Laboratory Assessment Hematology Protein studies Serum cholesterol Other laboratory tests 1/09

Obesity Overweight: increase in body weight for height compared to standard Obesity: at least 20% above upper limit of normal range for ideal body weight Morbid obesity: severe negative effect on health 1/09

Obesity Complications Diabetes mellitus Hypertension Hyperlipidemia CAD Obstructive sleep apnea Obesity hypoventilation syndrome Depression and other mental health/behavioral health problems ( 1/09

Obesity Complications Urinary incontinence Cholelithiasis Chronic back pain Early osteoarthritis Decreased wound healing Increased susceptibility to infection 1/09

Obesity and Health Promotion Health promotion/illness prevention Teach the potential consequences and complications. Teach the importance of eating a healthy diet. Teach that foods eaten away from home tend to be higher in fat, cholesterol, and salt, and lower in calcium. 1/09

Obesity and Health Promotion Reinforce need for regular moderate activity for at least 30 min per day. Educate regarding diet and activity for children and adolescents, and continuing throughout adulthood. 1/09

Nonsurgical Management Very low-calorie diets of 200 to 800 calories per day Balanced and unbalanced low-energy diets Novelty diets Diet therapy Exercise program Drug therapy Complementary and alternative therapies and treatments 1/09

Surgical Management Liposuction Panniculectomy Bariatric surgery Indications-Morbid obesity with co-morbidities and weight control measures that have failed. Liposuction Panniculectomy Bariatric surgery Preoperative care 1/09

Operative Procedures Vertical banded gastroplasty Circumgastric banding Gastric bypass Roux-en-Y gastric bypass Gastric bypass- create a small stomach which empties directly into jejunum. Gastric banding- laparoscopic- adjustable band around upper part of stomach. Vertical banded Gastroplasty- “stomach stapling”. 1/09

Postoperative Care Analgesia Skin care Nasogastric tube placement Diet Prevention of postoperative complications – Upper GI with gastrograffin Observe dumping syndrome signs such as tachycardia, nausea, diarrhea, and abdominal cramping To avoid dumping syndrome, avoids sweets, candies, fruit juices, ice cream, milk shakes and other foods with a high sugar content. Some people have this experince with greasy foods as well due to GI enzymes. Suggest that client lie down after eating to delay emptying of gastric contents. 1/09

Summary of Bariatric Sx Multidisciplinary team should evaluate and educate potential surgical candidates Life altering way of eating, surgery will limit amt of food one is able to eat Teach how to prevent dumping syndrome Prevent postop complications, infections, monitor wound healing, nutrition, body image 1/09