1. Stressors of the Gastrointestinal System
NUR240
Stressors of the Gastrointestinal System
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2. Overview of the Gastrointestinal Tract
Structure
Function
Nerve supply
Blood supply
Oral cavity
Stomach
Pancreas
Liver and gallbladder
Intestines
Esophagus
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3. Assessment Techniques
History
Demographic data
Family history and genetic risk
Personal history
Diet history
Anorexia
Dyspepsia
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4. 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
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5. Skin Changes Related to Gastrointestinal Disorders
Skin discolorations or rashes
Itching
Jaundice
Increased susceptibility to bruising
Increased tendency to bleed
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6. Physical Assessment Mouth and pharynx Abdomen and extremities
Inspection (Cullen’s sign)
Auscultation, look for borborygmus
Percussion
Palpation
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7. 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
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8. 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
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9. 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
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10. 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.
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11. 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
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12. 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
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13. 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
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14. 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
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15. 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
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16. 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
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17. 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
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18. 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

19. 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
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20. Clinical Manifestations
Dyspepsia
Regurgitation
Hypersalivation
Dysphagia
Others manifestations: chronic cough, asthma, atypical chest pain, eructation (belching), flatulence, bloating, after eating, nausea and vomiting
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21. Diagnostic Assessment
24-hr ambulatory pH monitoring
Endoscopy
Esophageal manometry
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22. 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
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23. 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
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24. Other Treatments Endoscopic therapies Surgical therapies
For more info , check out these websites:
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25. Hiatal Hernia
Protrusion of the stomach through the esophageal hiatus of the diaphragm into the thorax
S&P
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26. Assessment Heartburn Regurgitation Pain Dysphagia Belching
Worsening symptoms after eating or when in recumbent position
S&P
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27. 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.
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28. Nursing Considerations
Imbalanced nutrition
Risk for aspiration
Acute pain
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29. 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)
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30. 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
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31. Diverticulosis Indicates the presence of diverticula
Symptoms: cramping, narrow stools, constipation, weakness and fatigue
Complications: hemorrhage, diverticulitis
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32. 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
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33. 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
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34. 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
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35. 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
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36. 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:
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37. 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
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38. 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
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39. 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
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40. 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
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41. Medications 5-aminosalicylic acid drugs- anti-inflammatory effects
sulfasalazine (Azulfidine)
mesalamine (Asacol)
Corticosteroids
Immunosuppressive agents
azathioprine (Imuran)
Antibiotics and antidiarrheal drugs if applicable
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42. Irritable Bowel Syndrome (IBS)
AKA spastic bowel or functional colitis
Motility disorder of GI tract
Intermittent constipation/diarrhea patterns
No inflammation
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43. IBS Manifestations Abdominal pain, may be relieved by defecation
Intermittent colicky abdominal pain
Altered bowel elimination
Abdominal bloating, flatulence
Possible nausea and vomiting
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44. IBS Dx Stool- occult blood, O& P CBC and ESR
Sigmoidoscopy or colonoscopy
Upper GI or small bowel series
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45. 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
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46. 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
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47. 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
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48. PUD: Dx Procedures Helicobacter pylori testing Gastric sampling
Urea breath test, IgG testing
EGD-Esophagogastroduodenoscopy-definitive test for PUD
Stool samples for occult blood
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49. 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
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50. Complications and Nsg Implications
Assess for perforation/peritonitis
Assess for GI Bleeding
What to look for??
What to do?
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51. 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
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52. 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
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53. Nursing Interventions
NPO with bowel rest NGT IVF and electerolytes Pain management Ambulation Possible preop the patient
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54. Complications and Nsg Implications
Dehydration Electrolyte Imbalance Perforation Ischemic or Strangulated Bowel Peritonitis Shock Metabolic Alkalosis- UGI Obstruction Metabolic Acidosis- LGI Obstruction
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55. 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
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56. 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.
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57. 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 .
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58. 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, = CA in situ, 4=distant mets.
Ostomy surgery
Radiation
Chemo
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59. Colorectal Ca Ileostomy- stoma formed from ileum
Colostomy- stoma formed from colon
Reasons-colorectal CA, colitis, Crohn’s, diverticulitits
Temporary or permanent colostomy.
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60. 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.
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61. 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
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62. 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.
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63. 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.
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64. Interventions for Clients with Morbid Obesity
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65. 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)
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66. Laboratory Assessment
Hematology
Protein studies
Serum cholesterol
Other laboratory tests
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67. 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
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68. Obesity Complications
Diabetes mellitus
Hypertension
Hyperlipidemia
CAD
Obstructive sleep apnea
Obesity hypoventilation syndrome
Depression and other mental health/behavioral health problems (
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69. Obesity Complications
Urinary incontinence
Cholelithiasis
Chronic back pain
Early osteoarthritis
Decreased wound healing
Increased susceptibility to infection
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70. 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.
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71. 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.
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72. 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
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73. 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
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74. 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”.
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75. 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.
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76. 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