NUR240

1. NUR240 Stressors of the Gastrointestinal System

2. Overview of the Gastrointestinal Tract • Structure • Function • Nerve supply • Blood supply • Oral cavity • Stomach • Pancreas • Liver and gallbladder • Intestines • Esophagus

3. Assessment Techniques • History • Demographic data • Family history and genetic risk • Personal history • Diet history • Anorexia • Dyspepsia

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

5. Skin Changes Related to Gastrointestinal Disorders • Skin discolorations or rashes • Itching • Jaundice • Increased susceptibility to bruising • Increased tendency to bleed

6. Physical Assessment • Mouth and pharynx • Abdomen and extremities • Inspection (Cullen’s sign) • Auscultation, look for borborygmus • Percussion • Palpation

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)

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

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.

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.

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)

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

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

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

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

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

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

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.

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

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

21. Diagnostic Assessment • 24-hr ambulatory pH monitoring • Endoscopy • Esophageal manometry

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

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

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

25. Hiatal Hernia • Protrusion of the stomach through the esophageal hiatus of the diaphragm into the thorax

26. Assessment • Heartburn • Regurgitation • Pain • Dysphagia • Belching • Worsening symptoms after eating or when in recumbent position

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.

28. Nursing Considerations • Imbalanced nutrition • Risk for aspiration • Acute pain

29. Surgical ManagementHiatal 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)

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

31. Diverticulosis • Indicates the presence of diverticula • Symptoms: cramping, narrow stools, constipation, weakness and fatigue • Complications: hemorrhage, diverticulitis

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

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

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

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

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:

37. Acute tx for all disorders • Fluids and bowel rest • Medications • Potential surgery: Colectomy Colostomy Long Term- low-fiber, low, residue diet

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

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

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

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

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

43. IBS Manifestations • Abdominal pain, may be relieved by defecation • Intermittent colicky abdominal pain • Altered bowel elimination • Abdominal bloating, flatulence • Possible nausea and vomiting

44. IBS Dx • Stool- occult blood, O& P • CBC and ESR • Sigmoidoscopy or colonoscopy • Upper GI or small bowel series

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

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

47. PUD S&S • Dyspepsia • Pain • Orthostatic changes

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

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

50. Complications and Nsg Implications • Assess for perforation/peritonitis • Assess for GI Bleeding What to look for?? What to do?