Alterations of GI System

1. Alterations of GI System Nur 302 Unit I

2. Carcinoma of Oral Cavity • Predisposing factors: tobacco & alcohol • S/S: leukoplakia, erythroplakia, ulcer, sore or rough spot • Diagnosis: biopsy • Collaborative Care: surgery, radiation, chemo or combination • Health Promotion • Expected Outcomes

3. Mandibular Fracture • Rx: immobilization by wiring- 4-6 weeks • Pre-op teaching • Post-op Care: Airway, oral hygiene, communication, nutrition

4. Nausea & Vomiting • Problems- 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 emptying • IV and NG tube, begin diet with clear liquids.

5. GERDPredisposing Factors • Hiatal hernia • Incompetent lower esophageal sphincter • Decreased esophageal clearance • Decreased gastric emptying. • Esophagitis- trypsin & bile salts.

6. Hiatal Hernia Etiology • Weakening of diaphragm muscles, increased intraabdominal pressure, age, trauma, poor nutrition, recumbent position. • Types: Sliding & Paraesophageal or rolling. Complications: hemorrhage from erosion, stenosis, stomach ulceration, strangulation hernia, esophagitis. • Treatment : See GERD, elevate HOB on 4-6” blocks, lose weight.

7. GERD & Hiatal HerniaSigns & Symptoms • Heartburn • Wheezing, coughing, dyspnea • Hoarseness, sore throat • Post eating bloating • N/V, regurgitation • Hiatal hernia s/s mimic GB disease, angina, peptic ulcer

8. Barium swallow Esophagoscopy Biopsy Esophageal motility studies Check ph Diagnostic Studies

9. GERD & 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.

10. Hiatal Hernia Treatment • Surgery: valvuloplasties or antireflux procedures. • Post-op care: • Prevent respiratory complications maintain fluid & electrolyte balance prevent infection. • Chest tube • NG tube.

11. Barrett’s esophagus/syndrome. Etiology: smoking, alcohol, chronic trauma, poor oral hygiene, asbestos. S/S: progressive dysphagia, late s/s pain. Complication: hemorrhage, mets to liver and lung. Treatment: surgery, radiation, & chemo. Esophageal Cancer

12. Esophageal Cancers • Pre-op care: • high calorie, high P, liquid diet or TPN • oral care • teaching • Post-op care : • NG bloody 8-12 hours • semi-Fowler’s position • prevent resp. complication

13. Gastritis • Types: Acute or Chronic, Type A (Fundal) & Type B (Antral). • Etiology: breakdown in normal mucosa barrier • Corticosteroids, NSAIDS, ASA,spicy foods, alcohol • Presence of Helicobacter pylori

14. Gastritis Signs & Symptoms • Anorexia • N/V • Epigastric tenderness • Feeling of fullness • Hemorrhage

15. Diagnostic Studies • Endoscopic exam • CBC • Stool for occult blood • Cytologic exam

16. Gastritis • Treatment: 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.

17. Peptic 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

18. Peptic Ulcer Signs & Symptoms • May have no pain • Gastric ulcer pain • epigastric, burning, “gassy” • 1- 2 hrs after meals, stomach empty or when eat food • Duodenal ulcer pain • back or mid-epigastric, burning, cramp-like • 2-4 hrs after meals, antacids relieve pain

19. Peptic Ulcers • Complications: hemorrhage, perforation, gastric outlet obstruction. • Diagnostics: fiberoptic endoscopy, H.pylori tests, barium contrast studies, gastric analysis, CBC, urine analysis, liver enzymes studies, serum amylase, stool for occult blood. • Conservative therapy: (see gastritis).

20. Nursing 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.

21. Partial gastrectomy Billroth I – Gastroduodenostomy, removes distal 2/3 stomach & attaches to duodenum Billroth II – Gastrojejunostomy, removes distal 2/3 stomach & attaches to jejunum Vagotomy-eliminates stimulus for acid secretion Pyloroplasty –enlarges pyloric sphincter, increases gastric emptying Surgical Therapy

22. Post-op Care • Observe NG tube drainage • Red, decreasing in color 1st 24 hours • Observe for clogged NG tube • Do not irrigate without MD order, surgeon replaces NG if pt pulls out tube • Observe for decreased peristalsis • I&O, VS

23. Post-op Care • Observe for bleeding/ hemorrhage, NG & dressing • Pain management • What are the general post-op complications & nursing care? • If you do not have HCl, what disease are you at risk for?

24. 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 consent Take initial set VS Pick up blood from lab Assess IV site Start transfusion Verify pt ID, & blood compatability Case Scenario & Prioritization

25. Prioritization • Pre-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 transfusion • Save transfusion unit • Inform MD/RN • Save next voided specimen • Start 0.9NS • Take VS

26. Post-op complications • Dumping Syndrome • Postprandial hypoglycemia • Bile reflux gastritis

27. Dumping Syndrome • Large amount hyperosmolar chyme in intestine->fluid is drawn in->decrease of plasma volume • Bowel also becomes distended->increased motility • 15-30 minutes after eating->s/s last 1 hr • Weakness, sweating, dizzy, cramps, urge to have BM

28. Postprandial Hypoglycemia Like dumping syndrome 2 hours after eating Bolus of high CHO fluid into small intestine->bolus of insulin secretion->hypoglycemia What are the s/s of hypoglycemia?

29. Bile 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

30. Nutrition PostgastrectomyDumping Syndrome • Six small meals • Do not have fluids with meals • Fluids 45 minutes before or after meals • Dry foods low CHO, moderate protein & fats • Avoid concentrated sweets (jams, candy, etc) • Lie down after meals, short rest period

31. Ca of the stomach • Etiology: 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

32. Food Poisoning • S/S: n/v, diarrhea, colicky abdominal pain • Types: acute bacterial gastroenteritis- staph, clostridial, salmonella, botulism, escherichia coli, see table 42-27

33. Food PoisoningHealth Promotion • Correct food preparation • Cleanliness • Cooking • Refrigeration

34. Diarrhea • “Symptom”, acute or chronic • Etiology: decreased fluid absorption, increased fluid secretion, motility disturbance. • Dx studies: H&P, labs, endoscopy • Care: replace fluid & lytes, decrease # stools, treat cause, meds

35. Acute Infectious Diarrhea • Assessment: freq & duration, char & consistency, laxatives, antibiotics, diet travel, stress, family history, food prep • VS, ht & wt, skin turgor, skin breakdown BS, distention, abdominal tenderness • Nsg Care: hand washing, contact isolation, teach pt & family

36. Constipation • Etiology: insufficient dietary fiber, inadeq fluid intake, meds, little exercise • Complications: hemorrhoids, Valsalva’s maneuver, diverticulosis • Teaching: 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 girth • DX: H&P, preg test, rectal & pelvic exam, CBC, U/A, abd x-rays • Emergency management: table 43-13

38. “Acute Abdomen” • Assess: VS, inspect, palpate & auscultate abdomen, pain, n/v, change in bowel habits, vaginal discharge • Pre-op Care: CBC, type & cross match, clotting studies, cath, skin prep, NG • Post-op care of NG tube, mouth & nare care, control of n/v, abd distention & gas pains

39. Chronic Abdominal Pain • Irritable bowel syndrome, peptic ulcer , diverticulitis, chronic pancreatitis, hepatitis, cholecystitis, pelvic inflam. disease, vascular insuffic., psychogenic • Diagnosis & treatment: “critical thinking skills”

40. Abdominal 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 rupture • S/S: abd guarding & splinting, distended, hard abd, decr or absent BS, contusions, abrasions, bruising on abd, pain, shock, hematemesis or hematuria, Cullen’s sign

41. Abdominal 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 tenderness • Interventions: airway, control bleeding, cover protruding organs, IV, labs, foley, VS, LOC, see table 43-14

42. Appendicitis • S/S: periumbilical pain, then shifting to RLQ & localizing @ McBurrey’s point, tenderness, rebound tenderness, muscle guarding, Rovsing’s sign, anorexia, n/v, low grade fever • Complic: perforation, peritonitis, abscess • Dx: H&P, WBC, u/a • Nsg Care: NPO, no laxatives or heat to area, post-op: OOB next day & advance diet

43. Peritonitis • Etiology: rupture of an organ, trauma, pancreatitis, peritoneal dialysis • S/S: tenderness over area, rebound tenderness, muscle rigidity & spasms, abd distention, n/v, tachycardia, tachypnea, alt bowel habits • Complications: hypovolemic shock, septicemia, abscess, paralytic ileus, organ failure • DX: CBC, C&S perit. Fld, CT, x-ray

44. Nursing Care • Assess pain, BS, distention, guarding, temp, labs, s/s shock • VS, I&O, lytes, NPO, antiemetics, NG • Surgical site drains (penrose, Jackson Pratt, “open belly”) check color & amt drainage, I & O if irrigation of wound • Antibiotics, analgesics, maybe TPN

45. Gastroenteritis • S/S: n/v, diarrhea, fever abd cramps • Rx: NPO til stop vomiting, then flds with glucose & electrolytes (Pedialyte) • Complication: dehydration, loss of lytes • Strict handwashing & medical asepsis, rest & increased fld intake

46. Ulcerative Colitis • Inflammation, 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

47. Complications • Intestinal: hemorrhage, strictures, perforation, toxic megacolon, colonic dilatation, risk for colon cancer • Extraintestinal: due to malabsorbtion or problem with immune system – joints, skin, mouth & eyes • Dx: CBC, lytes, albumin, stool analysis, sigmoidascope & colonoscopy, barium enema

48. Nursing & Collaborative Care • Rest bowel • Control inflammation • Prevent / treat infection • Correct malnutrition • Meds to relieve s/s • Alleviate stress • See NCP 40-3

49. Meds • Sulfasalazine – maintenance & remission, for 1 year • 5-ASA – active disease, 4-ASA given as retention enemas • Corticosteroids :IV, enema, Prednisone • Cyclosporin • Sedatives, antibiotics, vitamins

50. Surgery • Total proctocolectomy with perm. ileostomy • Total protocolectomy with continent ileostomy called a Knock pouch • Total colectomy & ileal reservoir • Surgery “cures” disease • Post-op: stoma care, skin integrity, I&O, observe for hemorrhage, abscess, small bowel obstruction, electrolyte imbalance & dehydration, diet teaching & care of ileostomy