nursing management: gastrointestinal problems

1. Nursing Management: Gastrointestinal Problems George Ann Daniels, MS. RN

2. Tobacco-cigarettes, pipes, cigars, chewing tobacco, and snuff Malnutrition- r/t alcohol Sun exposure fair complexion Squamous cell- most common lips of menTobacco-cigarettes, pipes, cigars, chewing tobacco, and snuff Malnutrition- r/t alcohol Sun exposure fair complexion Squamous cell- most common lips of men

3. Assessment Leukoplakia White nodular, patchy areas on the mucosa Smokers patch Erthroplasia Red velvety patch Blister Non-healing sore> 3 weeks Crusts and bleeds Painless hard fixed mass ulcerations Areas of constant irritation Erthroplasia- 90% chance of becoming malignantErthroplasia- 90% chance of becoming malignant

4. Mouth and tongue White or yellowish ulcerated lesions Early stage- red or white and asymptomatic Feels like rough area Pain Hot/spicy foods Impaired speech Slurred Difficulty swallowing Increased salivation Blood tinged sputum Often found during routine dental examinationOften found during routine dental examination

5. Diagnostic test Oral exfoliative cytology Scrapping from lesion Examined microscopically Surgery treatment Small lesions Simple surgical excision with radiation Large tumors Total glossectomy Laryngectomy Mandibulectomy Hemiglassectomy Radial Neck Most common Followed with radiation and chemotherapy Mandibulectomy removal of mandible Hemi- removal of � tongueMandibulectomy removal of mandible Hemi- removal of � tongue

6. Pre-operative Nursing Care Assessment Nutritional, fluid, and electrolyte status Weight loss Respiratory status Teach Disfigurement Impairment of speaking, swallowing, and eating Review Oral suctioning Surgery Preparation NPO Cleanse mouth prior to surgery Soreness and difficulty swallowing Respiratory- trauma and swelling post surgery Reconstructive surgery Soreness and difficulty swallowing Respiratory- trauma and swelling post surgery Reconstructive surgery

7. Post Operative Nursing Care Removal or parotid gland Assess for Cranial Nerve VI function Pain management Nutritional IV for 24-48 hours R/t edema May have NG or gastrostomy tube for tube feeding Ability to handle food/fluids Psychologic Withdraw from people Non-adaptive response Anxiety about resuming personal responsibilities CN 6- rise/lower eyebrows, frown, smile, show teeth, pucker lips, CN 6- rise/lower eyebrows, frown, smile, show teeth, pucker lips,

8. Nursing Process Risk for ineffective airway clearance R/T edema, difficulty swallowing, increased secretions Pain R/T surgical tissue trauma Altered nutrition: Less than body requirements R/t inability to ingest foods and fluids orally Impaired verbal communication R/T postoperative restriction on mouth movement Risk for body image disturbance R/T changes in appearance secondary to surgery. Risk for infection R/T location of surgical site

9. Mandibular Fraacture Fracture of the mandible from trauma to the face or jaws Surgery Immobilization Wiring the jaws, cross wires, or rubber bands 4-6 weeks

10. Pre-operative Care Teach Disfigurement Will be able to breathe, speak, and swallow liquids May have N/G tube to prevent vomiting May also be used as feeding tube

11. Post-Operatively Focus on airway Respiratory distress emergency Cut wires and bands Tape wire cutter and scissors to bed Surgeon outlines which wires to cut Trach and/or endotrach suction on hand Aspiration Place on side Elevate HOB Suction Diet Liquid diet Straw Gas and fatigue Oral hygiene Warm saline swishes after meals and snacks Keep corners of mouth moist Oral Communication Discharged with wires Patient concerns Oral care, handling secretions, diet, facing people

12. Nausea/Vomiting Nausea is the feeling to vomit Diaphoresis, increased salivation, pallor, tachycardia, dizziness and faintness Vomiting is the expulsion of gastric contents Reverse peristalsis and relaxation of the esophageal sphincter Types: Projectile, retching (dry heaves) Assessment of vomit Condition associated with N/V Amount, odor Content- undigested food, mucus, parasites, foreign bodies Color- Green, red, coffee ground, black, brown Color: green- bile from the duodenum, brown -feces large intestines, black or coffee ground- old blood, red - blood Color: green- bile from the duodenum, brown -feces large intestines, black or coffee ground- old blood, red - blood

13. Hospital NPO then IV�s with electrolyte replacement NG tube Keeps stomach empty Decreases the urge to vomit Bowel obstruction Paralytic Illus Drugs Antiemetic Prevention Start with water first Clear liquids, warm cola, increase in amounts if no vomiting Dry toast, crackers, bland foods Avoid foods that stimulate peristalsis High fat foods, orange juice, caffeine, high fiber foods.extremely hot or cold fluids Bland foods- pasta, rice, chicken Include foods high in potassium- tea, bananas, cheese, whole milk Bland foods- pasta, rice, chicken Include foods high in potassium- tea, bananas, cheese, whole milk

14. Geriatric consideration Major problem with electrolyte imbalance Decreased level of consciousness Increased risk of aspirations May need to alter doses of antimetics Confusion Reduce for fragile adults

15. Constipation Passage of hard, dry stool, less than the patient�s normal pattern Factors Inadequate dietary fiber, inadequate fluid intake, lack of exercise, irregular bowel habits, medications (iron).

16. Assessment Feeling of fullness, back pain, headache, anorexia, and malaise, absence of stool, abdominal distention, decreased frequency, rectal pressure, straining, tenesmus, increase flatus, nausea, palpable mass, stools with blood, dizzy, and urinary retention Time of day , events associated with defecation: smoking, coffee, eating, diet exercise medications (laxatives), BS, percussion for abdominal distention, check for hemorrhoids, fissures, or irritation. Long periods between movements fecal impaction

17. Pediatric Considerations Newborn 1st stool meconium 24-36 hours old No stool red flag Meconium plug Atresia Hirschsprung Hypothyroidism Infancy Relates to diet Usually no constipation seen in Breastfed infant Change to cow�s milk or formula fed infants Childhood Environmental Delaying urge Playing School age Embarassment Stress and change in toileting patterns Lack of privacy Busy schedule

18. Pharmacology Laxative types Bulk formers- Metamucil Absorbs H20 and increases bulk Surfactants ( stool softeners) Colace, pericolace Lubricates intestines and softens feces Contact Laxatives Dulcolax, Exlax stimulates peristalsis Saline Laxatives- Milk of Mag Retention of fluid causing an osmotic effect

19. Prevention Increase fluid 3 quarts/3000mL per day Water, fruit juice Avoid caffeine Stimulates fluid loss-hard stools Increase dietary fiber 20-20 grams Softens stool, adds bulk, promotes evacuation Bran, fruits, grains Infants- increase cereal, add vegetables and fruits Increase exercise Walking, swimming, bike 3 times a week Promote normal environment Regular times to defecate Do not delay Avoid depending on laxatives or enemas Can actually cause constipation Normal motility of bowel is interupted BM slows or stops passage

20. Diarrhea Passage of liquid stool more frequent than normal bowel habit Abdominal cramping, presence of mucus, blood, or fat, urgency, tenesmus, perianal discomfort, feeling not completely empty Pharmacology Lomotil, Imodium

21. Nursing DX Diarrhea Well ventilated room, easy access to bathroom or bedpan, Stress free environment, Antidirrahea medications, NPO for 4 hours, then weak tea, bouillon, Jell-O, thin cooked cereal then to low residue diet: tender beef, veal, chicken, boiled or steamed rice, hard boiled eggs. Avoid cold liquids, caffeine, and concentrated sweets Risk for Impaired tissue integrity use soft toilet paper, gently wash with gentle soap and warm h20, pat dry. Protective salve. Sitz baths for 10 minutes TID. Witch hazel soaked pads (Tucks)

22. Fluid Volume deficit IV, I & O, measure all liquid stool and count in output. Weight daily, monitor lab values for electrolyte imbalance.

23. Pediatric Diarrhea Most acute diarrhea is infectious Self limiting Less than 14 days in duration Chronic diarrhea Greater than 14 days Intractable diarrhea of infancy Fist few months Greater than 2 weeks Chronic nonspecific diarrhea (CNSD) Irritable bowel of childhood and toddlers Ages 6-54 months

24. Assessment data Mild diarrhea Few stools/day without evidence of illness Moderate diarrhea Several loose or watery stools/day Normal or elevated temperature Vomiting Fretful and irritable

25. Severe diarrhea Numerous to continuous stools Evident signs of dehydration Cry lacks vigor, often whining and high pitched Irritable Seeks comfort and attention Displays purposeless movements Inappropriate response to people/familiar things Lethargic, comatose, or moribund (near death)

26. Goals in Management of diarrhea Assessment of fluid and electrolyte imbalance Re-hydration Maintenance of fluid therapy Re-introduction of adequate diet

27. Oral Hydrating Solutions ORS�s Mild to moderate diarrhea 60-80 mL/kg over 2 hours Older children 1:1 replacement ( stool amount: replacement fluids) 10 mL/kg or � to 1 cup ORS for each diarrhea stool

28. Pediatric Considerations Dehydration Total output of fluid exceeds the total intake, regardless of the underlying cause Fluid loss Insensible loss Skin and respirations Renal excretions GI tract Diabetes Ketoacidosis Extensive burns

29. Extent of Dehydration Know the moderate and severe signs and symptoms located in table 24-1 on page 882 of Wong

30. Pediatric Fluid Requirements Daily maintenance fluid requirements Calculate weigh of child in kilograms Allow 100 mL per kilogram for first 10 kg Allow 50 mL per kilogram for second 10 kg Allow 20 mL for remainder of weight in kilograms Total the amounts Divide total amount by 24 hours to obtain rate in mL�s per hour 25 lbs= 11 kg 100 for first 10 kg 50 for second 10 kg Total 150 divide by 24=6.25 cc per hour25 lbs= 11 kg 100 for first 10 kg 50 for second 10 kg Total 150 divide by 24=6.25 cc per hour

31. Nursing Management Monitor I & O Assess change in condition Very rapid VS, Skin, Mucous Membranes, Body Weight, Fontanels, Sensory alterations Interventions are specialized to specific disorder Diabetes, renal, etc. Diapers-weigh 1 g wet diaper =1 mL of urineDiapers-weigh 1 g wet diaper =1 mL of urine

32. Manage diarrhea with ORS AVOID Fruit juices, carbonated drinks and gelatin Avoid high carbohydrate content low electrolyte high osmolality AVOID Caffeinated soda high in caffeine=diuretic AVOID BRAT diet No longer used r/t little nutritional value ( low in energy and protein) high in carbohydrate and low in electrolytes

33. Hiatal Hernia Herniation of a portion of the stomach into the esophagus S & S Heartburn Regurgitation Chest pain Dysphagia

34. Types Sliding Most common Gastroesophageal sphincter is displaced into the thoracic cavity

35. Paraesophgeal (rolling)Hiatal Hernia Stomach fundus rolls into the thorax

36. Complications Erosion Hemorrhage Stenosis Strangulation Regurgitation Aspiration

37. Nursing Management Bland diet in small feedings Semi-fowlers position after eating-promotes movement of ingested foods Pain management Antacids Pyrosis Histimine- Blocking agents Tagamet Pepcid No citrus fruits or tomatoes products No citrus fruits or tomatoes products

38. Surgical Treatment Fundoplication Wrapping the fundus of the stomach around the lower portion of the stomach Creates a one-way valve Post op NPO until peristalsis returns IV until peristalsis returns Patent N/G tube irrigate

39. Esophagitis/GERD Inflammation of the esophagus Most common GERD Reflux of gastric secretions in the esophagus Incompetent LES

40. Triggers Smoking Intake of alcohol or spicy foods Ingestion of caustic agents Lye/ammonia Reflux (GERD) Friction movement of sliding hiatal hernia Prolonged gastric intubations Bacterial/viral invasion

41. Assessment Heartburn Pyrosis Retrosternal Burning Painful swallowing Radiate to arms, neck, back, jaw Regurgitation belching Diet Produces Heartburn Feels like lump in the throat Food stoppage Dysphagia Solid foods Respiratory difficulty Aspiration of gastric content Heartburn- irritation of esophagus by gastric acid Regurgitation- hot,bitter, sour liquid in throat or mouth Dysphagia- difficulty swallowing Heartburn- irritation of esophagus by gastric acid Regurgitation- hot,bitter, sour liquid in throat or mouth Dysphagia- difficulty swallowing

42. Complications Local effects of gastric secretion irritation on the esophageal mucosa Formation of fibrosis scar tissue Ulcerations bleeding

43. Management of Mild Esophagitis Goal- eliminate cause and promote healing Nutritional Bland diet Restrict spicy/acid foods Weight reduction

44. Prevent reflux Small frequent meals Sleep with HOB elevated Blocks 4-6 inches Do not lie down 2-3 hours post eating Avoid tight fitting clothing around waist Avoid bending over after meals Diet High protein, low fat Avoid Alcohol Smoking Caffeine Late night eating Avoid fatty foods, chocolate, peppermint, spearmint, alcohol, tea, coffee

45. Medications Antacids Coats stomach lining that help decrease gastric secretions Between meals and HS 1-3 hours Cholinergic drugs Increases pressure at the LES=increased gastric emptying Reglan Histamine Antagonist Reduces gastric secretions Cimetidine (tagamet) Famotidine (Pepcid) Ranitidine (Zantac) Proton-pump inhibitors Lanosprazole ( Prevacid) Omprazole (Prilosec Know side effects , Client instructions, contraindications Know side effects , Client instructions, contraindications

46. Pediatric Considerations Assessment: Spitting up Vomiting Weight loss Gagging Chocking at the end of the feeding Respiratory problems Hematemesis Melena Anemia Heartburn Irritability Medication Tagment, Zantac, Pepcid, Prilosec Nursing Care 30 degree angle Elevate head of crib with extra bedding, wood, or metal frame, or wedge constructed from cardboard.

47. Gastritis Inflammation of the gastric mucosa Factors Break down in the gastric mucosa Chronic alcohol abuse Excessive ingestion of ASA/NSAIDS Reflux of duodenal contests post gastric surgery Radiation Helicobacter pylori Staph Salmonella Smoking Stress Renal failure Spicy, irritating foods Trauma NG suction Hiatal hernia Endoscopic procedures

48. Types Type A Autoimmune disease Eats away the mucosa Type B Presence of Helicobacter pylori

49. Manifestations Anorexia N/V Epigastric tenderness Feeling of fullness Hemorrhage Alcohol abuse

50. Management Bland diet Six small meals a day Antacid after meals

51. Achalasia Peristalsis of the lower 2/3 of the esophagus is absent Food and fluid accumulate in the lower esophagus Results in dilation of the lower esophagus

52. Assessment Dysphagia More frequent with fluids Substernal pain After meals Halitosis Inability to erucate Regurgiation of sour-tasting food and liquids Horisontal position Weight Loss Erucate-belchErucate-belch

53. Treatment Dilation Dilation of the esophagus Pneumatic dilation of the LES Balloon tipped dilator passed orally Surgery Esophagomyotomy Division of muscle fibers in the esophagus Allows pouch to form Swallowing with out obstruction Medications Anticholinergics, calcium channel blockers, long acting nitrates

54. Abdominal Trauma Blunt MVA Penetrating Gunshot wounds or stab wounds Lacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears, diaphragmatic rupture, urinary bladder rupture, great vessel tears, renal injury, and stomach or intestinal rupture May result in massive blood loss and hypovolemic shockMay result in massive blood loss and hypovolemic shock

55. Manifestations Guarding and splinting of the abdominal wall Hard, distended abdomen Intraabdominal bleeding Decreased or absent bowel sounds Contusions, abrasions, or bruising Abdominal pain Pain over scapula Hematemesis/hematuria Hypovolemic shock Cullen�s sign Scapula- irritation of the phrenic nerve from free blood into the abd Cullen�s ecchymotic discoloration around the umbilicusScapula- irritation of the phrenic nerve from free blood into the abd Cullen�s ecchymotic discoloration around the umbilicus

56. Nursing management

57. Hirschsprung Disease Obstruction caused by inadequate motility of parts of the large intestines Failure of ganglion cells to migrate along the GI tract during gestation Aganglionic segments of the proximal portion of the large intestines and rectum Absence of peristalsis in a segment of the large intestines Accmulation of intestinal contents Megacolon Rectal sphincter cannot relax preventing defecationRectal sphincter cannot relax preventing defecation

58. Diagnostic Evaluation Based on clinical manifestations Barium Enema Anorectal biopsy with histological examination for absence of ganglion cells

59. Clinical Manifestation Newborn Period Failure to pass meconium within 24-48 hours after birth Spitting up Poor feeding Visible bowel loops Bile-stained vomitus Abdominal distention Infancy Failure to thrive Constipation Abdominal distention Diarrhea and vomiting Explosive watery stools Fever Severe prostration

60. Childhood Symptoms more chronic Constipation Ribbon like foul smelling stools Abdominal distention Palpable fecal masses Poorly nourished Prognosis Good with corrective surgery Temporary colostomy

61. Nursing Care Pre-op Improving nutritional status Low fiber, high calorie, high protein TPN Enemas Sterilizing colon Saline enemas with antibiotic solutions Oral antibiotics Psychological preparation for possible colostomy Parent and child Stress colostomy is temporary Post-op Stoma Care Diaper pinned below dressing to prevent contamination Possible foley Discharge teaching Colostomy care High fiber diet Post operatiPost operati