Nursing Care of Patient With Digestive Index

NURSING CARE OF PATIENT WITH DISTURBANCES IN METABOLISM

MAJOR FUNCTIONS OF THE GI SYSTEM Secretion Digestion Motility Absorption Elimination

ASSESSMENTNUTRITIONAL PROBLEMSASSESS CHARACTERISTICS

Typical 24-hour diet recall Usual weight Weight loss or gain Appetite

ASSESS ASSOCIATED FACTORS Food preferences Family or individual routines associated with eating Cultural and religious values Psychological factors Physical factors Access/transportation to grocery stores Eating habits, self-imposed dietary restrictions Body image Nutritional knowledge Finances

ASSESS ASSOCIATED FACTORS Other symptoms: fever, nausea, vomiting, diarrhea, constipation,

anorexia, weight loss, dyspepsiaASSESS HISTORY

Family history of GI cancer, ulcer disease, inflammatory bowel diseases

Previous history of tumors, malignancy, or ulcers

INDIGESTION (DYSPEPSIA)ASSESS CHARACTERISTICS

Associated Symptoms: feeling of fullness, heartburn, excessive belching, flatus, nausea, bad taste, mild or severe pain

Appetite Pain or tenderness and location Pain radiation Precipitating factors of pain Alleviating or aggravating factors Symptoms association with food intake If associated with food, describe the amount and type of food

ASSESS ASSOCIATED FACTORS Presence of nausea, vomiting, blood in bowel movements or

diarrhea History of alcohol, non-steroidal anti-inflammatory drugs (NSAIDs) or

aspirin useASSESS HISTORY

Cancer, inflammatory bowel disease Bowel obstruction Previous abdominal surgeries

NAUSEA AND VOMITINGASSESS CHARACTERISTICS

Stimuli such as specific foods, odors, activity or a certain time of the day

Occurence: before or after food intake How many times per day? Specific foods/fluids tolerated when vomiting occurs Amount, color and consistency of vomitus

ASSESS ASSOCIATED FACTORS Fever, headache, dizziness, weakness or diarrhea Missed menstrual period Weight loss

ASSESS HISTORY Gallbladder disease Ulcer disease GI cancer Unprotected intercourse

NATURE OF VOMITUS

CHARACTER POSSIBLE SOURCE

Yellowish or GreenishMay contain bileMedication e.g. Senna

Bright red (arterial) Hemorrhage or peptic ulcer

Dark red (venous)HemorrhageEsophageal or gastric varices

Coffee groundsDigested blood from slowlybleeding gastric or duodenal ulcer

Undigested foodGastric tumourUlcer, obstruction

Bitter Taste Bile

Sour or Acid Gastric contents

Fecal components Intestinal obstruction

DIARRHEAASSESS CHARACTERISTICS

Duration Frequency, consistency, color, quantity, and odor of stools Presence of blood, mucus, food particles in the stools Change in bowel habits Nocturnal diarrhea Aggravating or alleviating factors Weight loss

ASSESS ASSOCIATED FACTORS Fever, nausea, vomiting, abdominal pain, abdominal distention,

flatus, cramping, urgency with straining Use of antibiotics Recent travel to foreign countries with highest risk of traveler’s

diarrhea (Mexico, South America, Africa, and Asia) Emotional stress or anxiety

ASSESS HISTORY Colon cancer, ulcerative colitis, Crohn’s disease or malabasorption

syndrome Use of ginger as antiemetic (known to cause heartburn)

Use of licorice root for upset stomach and ulcers (known to cause sodium and water retention and loss of potassium)

POSSIBLE CAUSES OF DIARRHEA Infectious agents Food poisoning Medications Fecal impaction Bowel diseases Malabsorption syndromes Short bowel syndrome Malignant syndromes e.g. Zollinger-Ellison syndrome

CONSTIPATIONASSESS CHARACTERISTICS

Frequency, consistency, color of the stools Change in bowel habits Gradual or sudden Size of the stools Dietary changes Presence of blood or mucus Use of laxatives

ASSESS ASSOCIATED FACTORS Periods of diarrhea Abdominal pain or distention Stress Changes in activity level Regular time for defecation Use of antacids containing calcium or anticholinergics

ASSESS HISTORY Family history of colorectal cancer Depression or metabolic disorders such as hypothyroidism or

hypercalcemiaPOSSIBLE CAUSES OF CONSTIPATION

Inadequate fluid intake Psychological factors Electrolyte imbalances Hormonal abnormalities Mechanical bowel obstruction Medications Loss of innervation e.g. Hirschprung’s disease Neurological disorders

Anorectal disordersDYSPHAGIAASSESS CHARACTERISTICS

Onset: acute or gradual Problem with swallowing: intermittent or continuous Association with solid foods, liquids or both

ASSESS ASSOCIATED FACTORS Presence of regurgitation, heartburn, chest or back pain, weight loss Any hoarseness, voice change, or sore throat

ASSESS HISTORY Family history of esophageal cancer Stroke, palsy or any other neurologic conditions Alcohol or tobacco intake

Physical ExaminationASSESSMENTTECHNIQUES FOR PHYSICAL ASSESSMENTI – Inspection A – Auscultation P – Percussion P – Palpation

SIGNIFICANT FINDINGSFINDINGS SIGNIFICANCE/IMPLICATIONTenting of the skin DehydrationAbnormal body weight Obesity, anorexia nervosa or malignancyPalpable mass Enlarged organ, inflammation,

malignancy or herniaRebound tenderness, guarding

Appendicitis, cholecystitis, peritonitis, pancreatitis, duodenal ulcer

Protuberant or bulging abdomen

Ascites (may be confirmed by test for SHIFTING DULLNESS and FLUID WAVE)

Distention and absence of bowel sounds

Intestinal obstruction

Shifting Dullness Test1. The patient is examined in the supine position.2. Direct percussion is done over the abdomen, from the umbilicus to the flanks.3. The location of the transition from tympany to dullness is noted.4. Positive test: Percussion note is tympanitic over the umbilicus and dull over the lateral abdomen and flank areas.

Fluid Wave Test

STOOL CHARACTERISTICS AND IMPLICATIONSCHARACTERISTIC IMPLICATION/SIGNIFICANCE

Tarry black (MELENA) Upper GI bleeding

Bright red Lower GI bleeding

Blood streaked Lower rectal or anal bleeding

fatty, bulky, foamy, grayish stool (STEATORRHEA)

Liver problem or hepatitis

Clay-colored (NO BILE) Biliary obstruction

With mucus or pus Ulcerative colitis or shigellosis

Small, dry, rocky-hard Constipation, obstruction

Currant jelly Intussusception

Ribbon-like Hirschprung’s disease

Marble-sized stool pellets Spastic colon syndrome

Laboratory Tests:HEMOCCULT OR GUAIAC TEST (FECAL OCCULT BLOOD)

test to CHECK PRESENCE OF BLOOD in stoolINDICATION

detects presence of GASTROINTESTINAL BLEEDING and COLORECTAL CANCER

PATIENT INSTRUCTIONS BEFORE THE PROCEDURE (should be observed by the patient 3 DAYS BEFORE THE TEST)

Consume a HIGH-FIBER diet Avoid RED MEAT in the diet Avoid foods with HIGH PEROXIDASE content such as TURNIPS,

CAULIFLOWER, BROCCOLI, HORSERADISH AND MELON Avoid IRON PREPARATIONS, IODIDES, BROMIDES, ASPIRIN,

NSAIDS, VITAMIN C supplements greater than 250 mg/day Avoid ENEMA OR LAXATIVE before stool collection

INSTRUCTIONS ON COLLECTION OF SPECIMEN Stool must not be contaminated with TOILET PAPER OR TISSUE Specimen should be submitted for laboratory exam WITHIN 6 DAYS

FECALYSIS examination of stool AMOUNT, CONSISTENCY AND COLOUR

INDICATION detects presence of PARASITES, PUS, BLOOD CELLS and other

abnormal findings suggestive of pathologyPATIENT INSTRUCTIONS

avoid drugs such as CASTOR OIL AND LAXATIVES avoid drugs that interfere with results such as MINERAL OIL,

NEOMYCIN AND POTASSIUM CHLORIDE Eat HIGH-FAT DIET and refrain from ALCOHOL FOR 3 DAYS before

the test and during the collection (if the patient is for STOOL EXAM FOR LIPIDS)

Submit stool within 30 MINUTES TO 1 HOUR after collection

HYDROGEN BREATH TEST

Test used to EVALUATE CARBOHYDRATE ABSORPTION A radioactive substance is ingested, and, after a certain period of

time, exhaled gases are measuredINDICATION

Detects presence SHORT BOWEL SYNDROME LACTOSE INTOLERANCE Bacterial overgrowth of the intestine like in CROHN’S DISEASE

NURSING AND PATIENT CARE CONSIDERATIONS NPO 12 HOURS before the procedure AVOID SMOKING after midnight before the test AVOID ANTIBIOTICS AND LAXATIVES OR ENEMAS 1 WEEK before

the test

HELICOBACTER PYLORI TESTING1. SERUM IMMUNOGLOBULIN G ANTIBODY TEST

POSITIVE ANTIBODY TEST may not differentiate between active and inactive disease

A NEGATIVE TEST mean no antibodies or antibodies are presentINDICATION

Detects GASTRITIS and PEPTIC ULCER DISEASE caused by helicobacter pylori

NURSING AND PATIENT CARE CONSIDERATIONS Stop treatment 2 weeks before the test to prevent false-negative test Negative tests may require second test for confirmation

2. PY test H. PYLORI BREATH TEST Client take a 14C urea capsules Waits approximately 10 minutes & blows up a balloon. Air balloon is the transferred to a special vial for analysis Presence of gastric urease - the client most likely has H.pylori

infection 90% accurate

Nursing considerations Avoid antibiotic or bismuth for 1 month Avoid proton pump inhibitors for 2 weeks NPO for 6 hours before the test Advice client to swallow the capsule intact

GASTRIC ANALYSIS Analysis of gastric fluids Assists in determining problems with secretory activity of the gastric

mucosa

NURSING AND PATIENT CARE CONSIDERATIONS NPO for 8-12 hours before the test Content are aspirated every 15 minutes for at least 1 hour Analyze for Acidity ( pH ),volume and cytology

Radiology And Imaging Studies BARIUM SWALLOW (UPPER GI SERIES)

Fluoroscopic X-ray examinations of the ESOPHAGUS, STOMACH AND SMALL INTESTINE after ingestion of BARIUM SULFATE

INDICATION detects presence of strictures, ulcers, tumors, polyps, hiatal hernias

and motility problemsPATIENT PREPARATION BEFORE THE TEST

Maintain on LOW-RESIDUE DIET for 2-3 days No smoking, chewing gum, and mints Place on NPO after midnight before the test Instruct to avoid SMOKING Withhold OPIOIDS and ANTICHOLINERGICS 24 hours before the test

CARE OF THE PATIENT AFTER THE PROCEDURE Administer LAXATIVE to help expel the barium and prevent fecal

impaction Assess abdomen for distention and bowel sounds Observe stool for presence of barium Check the color of stool (initially whitish but should be brown within

72 hours) Check for barium impaction (manifested by constipation with

distended abdomen)

BARIUM ENEMA (LOWER GI SERIES) Flouroscopic X-ray examination of the large intestine after enema

with barium sulfate Air may be introduced after barium to provide a double contrast

study Procedure usually takes about 15 to 30 minutes INDICATION Detects structural changes such as tumors, polyps, diverticula,

fistula, obstructions, and ulcerative colitisCLIENT PREPARATION

maintain on low-residue, low-fat or clear liquid diet for 2 days prior to the test

Administer laxative a day before the test Place on NPO after midnight Perform enema on the morning before the examination Instruct client that barium sulfate will be given per rectum

PATIENT CARE AFTER THE PROCEDURE Administer laxative or perform enema after the test to prevent barium

impaction Instruct client to increase fluid intake to prevent fecal impaction Check color of stool (stools are white for 24-72 hours after the test) Instruct the client to report pain, bloating, absence of stool, or

bleeding (may indicate BARIUM IMPACTION)

ULTRASONOGRAPHY (ULTRASOUND) Non-invasive test using high-frequency sound waves to obtain image

of the abdominal organsINDICATION

Detects small abdominal masses, fluid-filled cysts, gallstones, dilated bile ducts, ascites and vascular abnormalities

CLIENT PREPARATION Maintain patient on a special diet, laxative, or other medication to

cleanse the bowel and decrease gas Place patient on NPO 8-12 hours before the test

COMPUTED TOMOGRAPHY SCAN (CT SCAN) An X-ray technique that provides excellent anatomic definition May be used with ultrasound to perform guided needle aspiration of

fluid or cells from lesions anywhere in the abdomenINDICATION

Detects tumors, cysts and abscesses Detects dilated bile ducts, pancreatic inflammation, gallstones Detects changes in intestinal wall thickness

CLIENT PREPARATION Place patient on NPO after midnight ENEMA or administer LAXATIVES to cleanse the bowel Check for allergy to IODINE and SEAFOODS if a contrast will be used Inform the client that the procedure is PAINLESS Instruct the client to REMAIN STILL during the procedure Withhold the procedure if patient is PREGNANT

REPORT ITCHING OR SHORTNESS OF BREATH after administration of contrast medium (may INDICATE ALLERGIC REACTION)

PARACENTESIS Procedure in which a needle or catheter is inserted into the

peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes

ENDOSCOPIC PROCEDURESENDOSCOPY

Use of flexible (fiberoptic endoscope) tube to visualize the GI tract and perform certain diagnostic and therapeutic procedures

Images are produces through a video screen or telescopic eyepiece It may be inserted through the rectum or mouth

TYPES 1) Capsule endoscopy 2) Esophagogastroduodenoscopy 3) Proctosigmoidoscopy and Colonoscopy

CAPSULE ENDOSCOPY Involves swallowing a capsule (camera device) which passes

through the GI tract After 8 hours, the capsule is excreted and connected to computer to

the download the imagesINDICATION

Detects abnormalities of the small bowel such as ACTIVE BLEEDING, POLYPS, ULCERATIONS, TUMORS, CAUSES OF DIARRHEA and NUTRITIONAL MALABSORPTION

CONTRAINDICATIONS Small bowel obstruction Dysphagia Fistula Severe delayed gastric emptying Gastrectomy with gastrojejunostomy GI stricture Pacemakers or implanted defibrillators

CLIENT PREPARATION Discontinue IRON PREPARATIONS AND CARAFATE 5 days before to

prevent mucosal staining

Discontinue ANTISPASMODICS, PEPTO-BISMOL AND ANTI-DIARRHEALS 24 HOURS before procedure

Instruct to STOP SMOKING 24 HOURS before the test to prevent mucosal staining

Maintain on CLEAR LIQUID DIET A DAY BEFORE the procedure NPO AFTER MIDNIGHT or 10 hours before SHAVE AREA ABOVE AND BELOW UMBILICUS before attaching

sensor array leads Instruct patient to AVOID STRENUOUS ACTIVITY, HEAVY LIFTING,

BENDING OR STOOPING, OR IMMERSION IN WATER while wearing leads and recorder

After ingesting the capsule, instruct the patient NOT TO EAT OR DRINK FOR AT LEAST 2 HOURS, then can advance to CLEAR LIQUID DIET

Instruct patient to avoid RADIO EQUIPMENT which may interfere with capsule’s signal

Tell patient that capsule is excreted after1-3 DAYS Watch out for signs of CAPSULE OBSTRUCTION such as

ABDOMINAL PAIN, CHEST PAIN, NAUSEA AND VOMITING, STRIKING SENSATION OR FEVER

ESOPHAGOGASTRODUODENOSCOPY (UPPER GI ENDOSCOPY)

Visualization of the ESOPHAGUS, STOMACH AND DUODENUM May also be used to perform biopsy, remove polyps, foreign bodies,

control bleeding, or open strictures INDICATION

Detects acute or chronic upper GI bleeding, esophageal or gastric varices, polyps, malignancy, ulcers, gastritis, esophagitis, gastroesophageal reflux

CLIENT PREPARATION NPO 8 HOURS before the test Remove DENTURES and BRIDGES to prevent airway obstruction Administer medications as prescribed ANTICHOLINERGICS (ATROPINE SULFATE) SEDATIVES, NARCOTICS OR TRANQUILIZERS (DIAZEPAM,

MEPERIDINE HCL) * LOCAL SPRAY ANESTHETIC to the posterior pharynx.

PATIENT CARE AFTER THE PROCEDURE Maintain patient in LATERAL POSITION to prevent aspiration Maintain NPO until gag reflex returns (2-4 hours) Offer LOZENGES or NORMAL SALINE GARGLES for throat irritation

or hoarseness Assess for SIGNS OF PERFORATION (abdominal or chest pain,

dyspnea, tachycardia, lightheadedness, distended abdomen, bleeding, fever, and dysphagia)

Instruct to AVOID DRIVING FOR 12 HOURS if sedative was used

PROCTOSIGMOIDOSCOPY AND COLONOSCOPY(LOWER GI ENDOSCOPY)

PROCTOSIGMOIDOSCOPY – visualization of the ANAL CANAL, RECTUM, AND SIGMOID COLON through a fiber optic sigmoidoscope

COLONOSCOPY – visualization of the ENTIRE LARGE INTESTINE, SIGMOID COLON, RECTUM AND ANAL CANAL

INDICATION detects malignancy, polyps, inflammation, or strictures

COLONOSCOPY is used for surveillance in patients with history of chronic ulcerative colitis, previous colon cancer or colon polypsCLIENT PREPARATION

Withhold ASPIRIN or ASPIRIN-CONTAINING products or IRON SUPPLEMENTS 7 days before the test

Maintain on CLEAR LIQUID DIET 24 HOURS before the test Administer CASTOR OIL or LAXATIVE to clear bowel Perform CLEANSING ENEMA Place patient in KNEE-CHEST, LATERAL OR SIM’S POSITION

CLEAR LIQUID DIET

FOOD GROUP FOODS INCLUDED

Fruit juices All clear or strained fruit juices

Soup Clear broth

DessertsClear flavored gelatin, ice pops,fruit-flavored ices, hard candy

BeveragesCoffee, tea, carbonated beverages, beverages, such as Kool-aid, Gatorade

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY Visualization of the common bile duct, the pancreatic , hepatic ducts

through the ampula of vater in the duodenum Uses the endoscope in combination with xray techniques. Uses contrast material (dye)

CLIENT PREPARATION Place on NPO 8 HOURS before the test Remove DENTURES and BRIDGES to prevent airway obstruction Administer medications as prescribed ANTICHOLINERGICS (ATROPINE SULFATE) SEDATIVES, NARCOTICS OR TRANQUILIZERS (DIAZEPAM,

MEPERIDINE HCL) * LOCAL SPRAY ANESTHETIC to the posterior pharynx Assess for allergy to dye

Disorders of the MouthSTOMATITIS

Inflammation of the oral cavityTYPES OF STOMATITIS1) Primary

APHTHOUS STOMATITIS or canker sores – MOST COMMON TYPE herpes simplex virus I and II

2) Secondary candidiasis or oral thrush may be due to overgrowth of normal flora

ETIOLOGY Infection Allergy to coffee, potatoes, cheese, nuts, citrus fruits, and gluten Vitamin deficiency Systemic disease Irritants Chemotherapy Radiation

Clinical Manifestations CANKER SORES – whitish gray center and erythematous ring Whitish plaque-like lesion, appears red and sore when wiped away –

COMMON IF WITH CANDIDIASIS Dysphagia Dry or hot sensation on area of lesions Elevation of temperature – RARE

Nursing diagnosis Pain r/t inflammation of oral mucous membrane. Imbalanced nutrition, less than body requirements r/t difficulty

swallowingLABORATORY ASSESSMENT

COMPLETE BLOOD COUNT – may reveal INFECTION CYTOLOGIC CULTURE and GRAM STAIN TESTING – to identify the

CAUSATIVE MICROORGANISM

NURSING CARE Provide ORAL CARE EVERY 2 HOURS and twice at night Use SOFT-BRISTLED TOOTHBRUSH OR FOAM SWABS Use SODIUM BICARBONATE solution (baking soda), WARM SALINE

or HYDROGEN PEROXIDE in rinsing the mouth Avoid COMMERCIAL MOUTHWASHES Provide SOFT, BLAND and NONACIDIC foods Apply TOPICAL ANALGESICS or ANESTHETICS as prescribed

DRUG THERAPYTYPE OF STOMATITIS

DRUG CONSIDERATIONS

General Tetracycline Syrup

USUAL DOSE:

250 mg/10 ml for 10 days

INSTRUCTION: rinse for 2 minutes then swallow

Herpes Simplex Acyclovir (Zovirax)

USUAL DOSE:

5 mg/kg for 1 hour IV

INSTRUCTION: make sure client has no renal problem

Fungal

Nystatin

(Mycostatin)

USUAL DOSE: 600,000 units QID oral suspension

ANTI-INFLAMMATORY AGENTS AND IMMUNE MODULATORS Triamcinolone in Benzocaine Dexamethasone Levamisole Amlexanox

ThalidomideSYMPTOMATIC TOPICAL AGENTS FOR PAIN

Benzocaine Camphor phenol 15 ml 2% viscous Lidocaine gargle of mouthwash every 3 hours

(maximum of 8 doses per day)

Disorders of the EsophagusGASTROESOPHAGEAL REFLUX DISEASE (GERD)

BACKWARD FLOW (reflux) of gastrointestinal contents into the esophagus

MOST COMMON upper GI disorder Common in PEOPLE OVER AGE 45

CAUSE Inappropriate relaxation of lower esophageal sphincter

PREDISPOSING FACTORS Ingestion of LARGE MEALS Conditions associated with DECREASED GASTRIC EMPTYING Recumbent or SUPINE positioning Insertion of nasogastric tube (NGT) INCREASED INTRAABDOMINAL and INTRAGASTRIC PRESSURE

FACTORS THAT RELAX LOWER ESOPHAGEAL SPHINCTER TONE Fatty foods Caffeinated beverages Chocolate Citrus fruits, tomatoes and tomato products Nicotine in cigarette smoke Medications e.g. calcium channel blockers, anticholinergic drugs Peppermint, spearmint Alcohol High levels of estrogen and progesterone

ASSESSMENT HEARTBURN or PYROSIS – suggests reflux DYSPHAGIA – suggests narrowing of lumen Dyspepsia – MOST COMMON SYMPTOM; occurs 30-60 minutes after

meals and with reclining position Regurgitation – with sour or bitter taste Hypersalivation (water brash) Odynophagia Chronic cough Eructation (belching)

DIAGNOSTIC TESTS 24-hour ambulatory pH monitoring – most accurate method

Endoscopy Esophageal manometry

Nursing diagnosis Imbalanced nutrition less than body requirements, r/t difficulty

swallowing Risk for for aspiration r/t difficulty swallowing Acute pain r/t difficulty swallowing Deficient knowledge

MANAGEMENTDIET THERAPY Avoid CAFFEINATED AND CARBONATED foods Avoid SPICY and ACIDIC FOODS SMALL FREQUENT FEEDINGS (4-6 small meals) Avoid foods 3 hours before going to bedLIFESTYLE CHANGES ELEVATE HEAD OF THE BED 6-8 inches for sleep DO NOT LIE DOWN 3-4 hours after eating Avoid NICOTINE and ALCOHOL LOSE WEIGHT – if the patient is obese Avoid CONSTRICTIVE CLOTHING, STRAINING or BENDING OVER

DRUG THERAPY ANTACIDS

Aluminum or Magnesium Hydroxide Maalox, Mylanta INDICATION: management of heartburn ACTION: elevates gastric pH and deactivates pepsin SIDE EFFECTS: constipation and diarrhea CLIENT INSTRUCTIONS: take the antacid 1 hour before and 2-3

hours after mealsHISTAMINE RECEPTOR ANTAGONISTS

famotidine (Pepcid) ranitidine (Zantac) cimetidine (Tagamet) nizatidine (Axid) INDICATION: management of heartburn ACTION: lowers the acidity of the gastric mucosa DRUG INTERACTION: CIMETIDINE may have significant interactions

with WARFARIN, THEOPHYLLINE, PHENYTOIN, NIFEDIPINE and PROPANOLOL

PROTON PUMP INHIBITORS Omeprazole (Priolosec)

Lansoprazole (Prevacid) Rabeprazole (Aciphex) Pantoprazole (Protonix) Esomeprazole (Nexium) INDICATION: management of heartburn ACTION: inhibits production of gastric acid secretion CLIENT INSTRUCTIONS: should be taken 30-60 minutes before

meals OTHER DRUGS

ANTI-EMETIC Metoclopramide (Plasil) ACTION – increase rate of gastric emptying ADVERSE EFFECTS – fatigue, anxiety, ataxia and hallucinations

SURGICAL MANAGEMENT LAPAROSCOPIC NISSEN FUNDOPLICATION (LNF) GOLD STANDARD for surgical management of GERD WRAPPING and ANCHORING a portion of the stomach fundus

around the lower esophageal sphincterNURSING CARE AFTER SURGERY

Elevate head of the bed at least 30 degrees to lower the diaphragm and facilitate lung expansion

Facilitate insertion of NGT to prevent excessive tightening of the fundoplication

Monitor drainage of NGT (should be normal yellowish green after within first 8 hours after surgery)

Check placement every 4-8 hours Avoid alcohol, caffeinated and carbonated foods Monitor for dysphagia (sign that fundoplication is too tight) Monitor for gas bloat syndrome Administer Simethicone 80 mg QID for excessive gas

ENDOSCOPIC THERAPIESSTRETTA PROCEDURE to INHIBIT THE ACTIVITY of the vagus nerve

use of radiofrequency energy through needles to induce THERMAL BURN in the gastroesophageal junction

ENTERYX PROCEDURE to TIGHTEN the lower esophageal sphincter

INJECTION OF SOFT, SPONGY PERMANENT IMPLANT made of liquid polymeric material into the LES muscle

PATIENT CARE AFTER ENDOSCOPIC THERAPIES Maintain on CLEAR LIQUIDS for 24 hours

After the DAY 1 – shift to SOFT DIET such as custard, pureed vegetables, mashed potatoes

Avoid NSAIDs and ASPIRIN for 10 days Give LIQUID MEDICATIONS as much as possible Avoid NGT INSERTION for at least 1 month Watch out for CHEST or ABDOMINAL PAIN, BLEEDING, DYPHAGIA,

SHORTNESS OF BREATH, NAUSEA or VOMITING

HIATAL HERNIA The opening of the diaphragm through which the esophagus passes

becomes enlarged. Part of the stomach tends to move into the lower portion of the

thorax TYPES

Sliding Hiatal Hernia Upper stomach and the gastroesophageal junction are

displaced upward and slide in and out of the thorax Paraesophageal Hiatal Hernia

All part of the stomach pushes through the diaphragm beside the esophagus

Clinical Manifestation Heartburn Regurgitation Dysphagia Sense of fulness after eating or chest pain

Diagnostic Procedure Xray Barium swallow Fluoroscopy

Management Same pharmacological management w/ GERD Small frequent feeding Advised not to recline 1 hour after eating Elevate HOB Surgery is indicated in about 15% of patients

Surgical Management Nissen Fundoplication

NISSEN FUNDOPLICATION(to treat GERD and hiatal hernia)

Disorders of the Stomach and Small IntestineGASTRITIS

Inflammation of the stomach mucosaCLASSIFICATION

A. Acute Gastritis – includes erosive gastritis and stress ulcersB. Chronic Gastritis – includes non-erosive gastritis

TYPES OF CHRONIC GASTRITIS1. Type A – inflammation of the glands in the

fundus and body2. Type B – inflammation of the glands from fundus to antrum3. Atrophic – diffuse inflammation and destruction of deeply located

glandsETIOLOGY

Acute Gastritis Local irritants (drug, alcohol, corrosive subs.) Bacterial invasion by salmonella, E. Coli and H. Pylori)Chronic Gastritis Atrophy of the gastric glands and achlorydria May occur due to bile acid reflux (complication of gastrojejunal

surgery or peptic ulcer disease) Chronic use of irritants

PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONACUTE GASTRITIS

rapid onset of epigastric pain Pain not relieved by food Dyspepsia hematemesis gastric haemorrhage

CHRONIC GASTRITIS vague epigastric pain pain relieved by food

intolerance of fatty or spicy foods pernicious anemia

SIMILARITIES ANOREXIA Nausea and Vomiting

DIAGNOSTIC TEST Esophagogastroduodenoscopy with biopsy

DRUG THERAPY H2 Receptor Antagonists Antacids Proton Pump Inhibitors Vitamin B12 (if there is pernicious anemia)

Triple Therapy (if there is H. Pylori in biopsy)1) 1 Bismuth subsalicylates or proton pump inhibitor (omeprazole)2) 1 Antibiotic (metronidazole)3) 1 Antibiotic (tetracycline, clarithromycin, amoxicillin) DRUGS TO AVOID – aspirin, ibuprofen

DIET THERAPY Instruct client to limit intake of foods and spices that cause distress Instruct client to avoid alcohol and tobacco Give soft, bland diet and smaller, more frequent meals

STRESS REDUCTION Progressive muscle relaxation Cutaneous stimulation Guided imagery Distraction

SURGICAL MANAGEMENT Partial gastrectomy Pyloroplasty Vagotomy Total gastrectomy

PEPTIC ULCER DISEASE ulceration of the gastric mucosa, duodenum and rarely the lower

esophagus and jejunumTYPES1. Gastric Ulcers

2. Duodenal Ulcers3. Stress Ulcers (Curling Ulcer)

Parameter Gastric Ulcer Duodenal Ulcer

Age Usually 50 years or olderUsually 50 years or older

Gender Male:Female 1:1 Male: Female 1:1

Blood group No differentiation Most often type O

General Nourishment May be malnourished Usually well nourished

Stomach acid production

Normal secretion or hyposecretion

Hypersecretion

OccurrenceMucosa exposed to acid-pepsin secretion

Mucosa exposed to acid-pepsin secretion

Clinical course Healing and recurrenceHealing and recurrence

PainOccurs 30-60 minutes after meal; at night rarely

Occurs 1-3 hours after a meal;at night 1-2 am

Pain QualityAccentuated by ingestion of food

Relieved byingestion of food

Response to treatmentHealing with appropriate therapy

Healing with appropriate therapy

Hemorrhage Hematemesis more common than melena

Melena more common that hematemesis

Malignant change Perhaps in less than 10% Rare

RecurrenceTends to heal and recurs often in the same location

60% recurrence in the same year

Surrounding mucosa Atrophic gastritis No gastritis

PREDISPOSING FACTORS Stress Irregular hurried meals Smoking and alcoholism Caffeinated, fatty, spicy, acidic foods Ulcerogenic medications – Aspirin, NSAIDs, Steroids GI disorders – Gastritis, Zolliger-Ellison Syndrome Type A personality Type O blood

COMPLICATIONS Hemorrhage Perforation Pyloric Obstruction Intractable Disease

ASSESSMENT

HISTORY Alcohol and tobacco use Use of corticosteroids, aspirin and NSAIDs

CLINICAL MANIFESTATIONS Epigastric tenderness Rigid, boardlike abdomen with rebound tenderness Diminishing hyperactive bowel sounds Dyspepsia Vomiting

DIAGNOSTIC TESTS Low hemoglobin and hematocrit Positive fecal occult blood test Barium examination Esophagogastroduodenoscopy (most accurate) Elevated Immunoglobulin G antibodies (suggest H. Pylori infection) Fecalysis

DRUG THERAPYTRIPLE THERAPY (most successful regimen)

1. Bismuth compound or proton-pump inhibitor (omeprazole) 2. Metronidazole 3. Tetracyline or Clarithromycin and Amoxicillin

HYPOSECRETORY DRUGS1) Histamine Receptor Antagonists2) Proton Pump Inhibitors3) Prostaglandin Analogues

MISOPROSTOL (CYTOTEC) ↓gastric secretion and ↑resistance of mucosa to injury CONTRAINDICATION: pregnancy MUCOSAL BARRIER FORTIFIERS SUCRALFATE (CARAFATE) ACTION: binds bile and pepsin to reduce mucosal injury INSTRUCTION: take 1 hour before meals and at bedtime SIDE EFFECT: constipation

DIET THERAPY Bland diet Small frequent feedings (6 small meals/day) Avoid caffeine-containing foods Avoid tobacco and alcohol

MANAGEMENT FOR HYPOVOLEMIA

Monitor VS, I/O Monitor serum electrolytes to determine need for replacement Administer ISOTONIC SOLUTIONS (NSS or lactated Ringer’s) Perform BLOOD TRANSFUSION as prescribed to expand blood

volume If there is active bleeding, administer FRESH FROZEN PLASMA

MANAGEMENT FOR BLEEDING Monitor for the following: signs of SHOCK (hypotension, chills, palpitations, diaphoresis, weak

thready pulse) Occult blood hematocrit, hemoglobin and coagulation studies Perform GASTRIC DECOMPRESSION OR LAVAGE AVOID NSAIDS to minimize GI bleeding

ENDOSCOPIC THERAPYGOAL: promote blood clot formation METHODS OF ENDOSCOPIC THERAPY

(1) THERMAL CONTACT – heater probe or multi electrocoagulation

(2) Inject bleeding site with diluted EPINEPHRINE(3) Laser therapy(4) Mechanical clip

CLIENT PREPARATION Administer SEDATIVES e.g. midazolam and meperidine Place on NPO 6 hours prior the procedure

CARE AFTER THE PROCEDURE Resume diet once gag reflex is present

MANAGEMENT FOR PERFORATION Replace lost fluids, blood and electrolytes* Administer of antibiotics Place on NPO Gastric lavage or decompression Monitor for signs of septic shock (fever, pain, tachycardia, lethargy

or anxietySURGICAL MANAGEMENT FOR OBSTRUCTION

Gastroduodenostomy (Billroth I) Gastrojejunostomy (Billroth II) Partial Gastrectomy Pyloroplasty

CLIENT PREPARATION Insert NGT connected to suction to remove secretions and empty the

stomachPOST-OPERATIVE CARE

Monitor placement, patency and drainage of NGT Monitor for DUMPING SYNDROME

Gastric Dumping Syndrome  Rapid gastric emptying is a condition where ingested foods bypass the stomach too

rapidly and enter the small intestine largely undigested.EARLY SIGNS OF DUMPING SYNDROME (within 30 minutes after feeding)

Vertigo Tachycardia Syncope Sweating Pallor Desire to lie down

LATE SIGNS OF DUMPING SYNDROME(90 minutes-3 hours after feeding)

Dizziness Light-headedness Palpitations Diaphoresis Confusion

MANAGEMENT FOR DUMPING SYNDROME Small frequent feeding Do not take fluids with meals Advise high-protein, high-fat, low-to-moderate carbohydrate

diet Administer pectin to prevent the syndrome

GASTROENTERITIS Inflammation of the mucous membranes of the stomach and the

intestinal tractCLASSIC MANIFESTATION

increase in the frequency and water content of the stools or vomitingTYPES

o VIRAL – caused by norwalk virus or rotavirus

o BACTERIAL – caused by E. Coli, campylobacter enteritis or shigellosis

PATHOPHYSIOLOGY

ASSESSMENT Nausea and vomiting (first 2 days of illness) Diarrhea Myalgia Headache Malaise Abdominal tenderness

SIGNS OF DEHYDRATION Poor skin turgor

Dry mucous membranes Hypotension Oliguria

ViralCampylobacter

E. Coli Shigella

Duration of Diarrhea

24-48 hours20-30 defecation for 7 days

10 days 5 days

Stool WateryWateryFoul-smellingSome blood

Watery Some bloodSome mucus

WaterySome bloodSome mucus

WBCs None None None Yes

RBCs None Yes None None

MANAGEMENT FLUID REPLACEMENT

Monitor vital signs, I and O and weight (1 kg weight loss is equivalent to 1 L loss)

Administer HYPOTONIC IV FLUIDS (0.45% NaCl) Oral Rehydration Salts (Oresol) If with HYPOKALEMIA – Incorporate potassium supplements Observe standard precautions

DIET THERAPY IF NOT ACTIVELY VOMITING – clear liquids with electrolytes IF VOMITING – NPO IF TREATED – saltine crackers, toast and jelly IF IMPROVING – bland diet AVOID caffeine

DRUG THERAPY LOPERAMIDE (IMODIUM) – to inhibit peristalsis BISMUTH SUBSALICYLATES (PEPTO-BISMUL) – to reduce watery

volume of stool ANTIBIOTICS NORFLOXACIN OR CIPROFLOXACIN – If caused by bacteria TRIMETHOPRIM OR SULFAMETHOXAZOLE (BACTRIM) – if caused

by If shigellosis is the cause.SKIN CARE

Avoid toilet paper and harsh soap

Use warm water and absorbent cotton Apply cream, oil or gel to excoriated skin Provide witch hazel compress and sitz bath

Disorders of the Lower GI TractINFLAMMATORY BOWEL DISEASESULCERATIVE COLITIS

chronic inflammatory process affecting the mucosa and submucosa of the COLON and RECTUM

CROHN’S DISEASE (REGIONAL ENTERITIS) chronic inflammatory bowel disease affecting segmental areas along

the ENTIRE WALL OF THE GI TRACT; most commonly noted at within the TERMINAL ILEUM

PARAMETER ULCERATIVE COLITIS CROHN’S DISEASEOther Name None Regional Enteritis

Location Rectum/lower colonIleum/ascendingcolon

Cause

Unknown Familial JewishEmotional stress

Unknown Jewish raceEnvironmental

Age 15-40 y.o20-30 y.o40-60 y.o

Bleeding Severe Stool with pus, mucus and blood

moderateStool with pus and mucus

Perianal Involvement Mild SevereRectal Involvement 100% 20%Diarrhea 20-30 watery stool/day 5-6 soft stool/dayAbdominal pain Yes yesWeight loss Yes Yes

Intervention

TPNSteroidsAzulfidine Ileostomy or Proctosigmoidoscopy

TPNAzulfidineIleostomy or Colectomy

PATHOPHYSIOLOGY OF ULCERATIVE COLITIS AND CROHN’S DISEASECLINICAL MANIFESTATIONS

PARAMETERULCERATIVE COLITIS

CROHN’S DISEASE

FEVER Low-grade Low-grade

FOOD INTOLERANCE

Intolerance to dairy, spicy and greasy foods

none

WEIGHT LOSS Yes Yes FREQUENCY OF BM

10-20/day 5-6/day

STOOL Bloody Loose ABDOMINAL PAIN Cramping Periumbilical

OTHER SIGNSTenesmus AnorexiaFatigue

Perianal ulceration

Tenesmus - the feeling of constantly needing to pass stools, even though bowels are already empty.

DIAGNOSTIC ASSESSMENTPARAMETER ULCERATIVE COLITIS CROHN’S DISEASEHEMOGLOBIN Low LowHEMATOCRIT Low LowWBC High NormalALBUMIN Low Low ESR High HighSODIUM Low Normal POTASSIUM Low Low CHLORIDE Low Normal MAGNESIUM Normal Low FOLIC ACID Normal LowCOBALAMIN Normal Low PYURIA None YesOCCULT BLOOD Yes NoneOTHER TESTS Barium Enema ProctosigmoidoscopyDRUG THERAPYSALICYLATE COMPOUNDS

Sulfasalazine (Azulfidine) Indication – Management of ulcerative colitis Action – inhibit prostaglandin synthesis to reduce inflammation Adverse effects – leukopenia and anemia take the drug with a full glass of water take the drug after meal to prevent GI discomfort

ORAL OR INTRAVENOUS CORTICOSTEROIDS Prednisone Indication – to reduce inflammation Adverse Effects – hyperglycemia, osteoporosis, peptic ulcer disease,

increased risk for infectionIMMUNOSUPPRESIVE DRUGS

Should be given in combination with steroids to be effective

Drug Name – cyclosporine, mercaptopurine Indication – to reduce inflammation Adverse Effects – thrombocytopenia, leukopenia, anemia, renal

failure, infection, headache, stomatitis, hepatotoxicityANTI-DIARRHEAL DRUGS

diphenoxylate HCl, atropine sulfate (lomotil), loperamide (imodium)

INFLIXIMAB (REMICADE) for refractory disease or for toxic megacolon an immunoglobulin G that neutralizes activity of tumour necrosis

factorDIET THERAPYIf client has severe symptoms:

NPO Total Parenteral Nutrition (TPN) If client has slightly less severe symptoms: Elemental formula e.g. Vivonex If client has less severe symptoms: Low-fiber (low-residue) diet

Foods to avoid: Whole-wheat grains Nuts fresh fruits and vegetables lactose containing foods caffeinated beverages Pepper Alcohol Smoking

COMPLEMENTARY AND ALTERNATIVE THERAPIES Vitamin C Biofeedback Hypnosis Yoga Acupuncture

SURGICAL MANAGEMENTINDICATIONS FOR SURGERY

Bowel perforation Toxic megacolon Hemorrhage

Colon cancer Failure of conventional treatment

TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY Terminal ileum is pulled through the abdominal wall and forms a

stoma or ostomy PRE-OPERATIVE CARE

Administer oral or parenteral antibiotic such as neomycin sulfate (Mycifradin) as a bowel antiseptic

Administer laxative or enemaPOST-OPERATIVE CARE

Monitor color, odor, consistency of ileostomy output (effluent) Instruct client to report any foul or unpleasant odor (it may indicate

intestinal blockage or infection) Instruct the client to wear pouch system at all times Apply skin barrier (gelatin, pectin) to prevent irritation and injury to

the skinTOTAL COLECTOMY WITH CONTINENT ILEOSTOMY

Alternative to traditional ileostomy with external pouch Creation of an internal reservoir called a Kock’s ileostomy or ileal

reservoir to be drained periodicallyPost-Operative Care

Monitor character and quality of effluent Teach the client to drain stoma when sensation of fullness is felt Apply a small dressing to keep stoma moist

TOTAL COLECTOMY WITH ILEOANAL ANASTOMOSIS Removal of the colon and rectum with anastomosis of the ileum and

the anal canalDISCHARGE INSTRUCTIONS FOR CLIENTS WITH ILEOSTOM

o SKIN CARE Use pectin-based skin barrier to protect skin from irritation Use skin sealants and ostomy skin creams Monitor skin for irritation

o POUCH CARE Empty pouch when it is 1/3 full Change pouch at intervals such as before meals, before

bedtime, before walking at morning, 2-4 hours after meals

Change pouch system every 3-7 daysDIET

Chew food thoroughly

Be cautious in taking high-fiber and high-cellulose foods such as popcorn, peanuts, coconut, string beans, shrimp and lobster, rice, skinned vegetables (tomatoes, corn and peas)

MEDICATIONS Avoid taking enteric-coated and capsule medications Do not take laxative or enema Contact physician if no stool has passed in 6-12 hours

DANGER SIGNS Drastic increase or decrease in effluent Stomal swelling, abdominal cramping, distention, and absence of

drainageINTERVENTIONS FOR DANGER SIGNS

Remove pouch Lie down and assume knee-chest position Begin abdominal massage Apply moist towels to the abdomen Drink hot tea Contact health care provider

IRRITABLE BOWEL SYNDROME Also known as SPASTIC BOWEL OR MUCUS COLITIS Different from ulcerative colitis because there is no inflammation or

ulceration presentRISK FACTORS

Emotional stress or anxiety Diverticulitis Intolerance to gastric stimulants such as caffeine or spicy foods or

lactoseINCIDENCE

Common among women, Caucasians and Jewish population

PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS

NURSING INTERVENTIONS Administer antidiarreals, antispasmodics, bulk-forming laxatives as

ordered Encourage high-fiber diet and avoid fatty and gas forming foods

(carbonated beverages, cauliflower or beans) Instruct client to avoid alcohol and tobacco Encourage to increase oral fluids intake Instruct on lifestyle changes (regular exercise, adequate rest

periods, stress management)

TWO FORMS OF DIVERTICULAR DISEASE

1. DIVERTICULOSIS – asymptomatic multiple out-pouching of the intestinal mucosa WITHOUT INFLAMMATION

2. DIVERTICULITIS – symptomatic multiple out-pouching of the intestinal mucosa WITH INFLAMMATION; causes retention of hardened stool

INCIDENCE More common in older adults More prevalent in men

PREDISPOSING FACTORS Diet low in fiber Diet high in refined carbohydrates

COMPLICATIONS Bowel perforation and peritonitis

Bowel obstruction Hemorrhage

ASSESSMENT Crampy abdominal pain in the left lower quadrant Abdominal distention Low-grade fever Chronic constipation Occult bleeding Nausea and vomiting Leucocytosis

DIAGNOSTIC TESTS Barium enema and colonoscopy (contraindicated if there is

diverticulitis) Complete blood count Urinalysis

NURSING INTERVENTIONS Instruct client to eat high-fiber foods Encourage to increase fluids Administer bulk laxatives and anticholinergics as prescribed Encourage client to lose weight and avoid activities that increase

intra-abdominal pressure SURGICAL MANAGEMENT

Colon resection with temporary colostomy

APPENDICITIS Inflammation of the vermiform appendix More common in males 10-30 years of age

ETIOLOGY Obstruction by fecal impaction, kinking of the appendix, parasites or

infections Low fiber diet High intake of refined carbohydrates

PATHOPHYSIOLOGY

ASSESSMENT Acute abdominal pain at RLQ or McBurney’s point (halfway between

the umbilicus and the anterior iliac crest) Anorexia, nausea and vomiting Rigid and guarded abdomen Blumberg sign (rebound tenderness)

Fever (temperature of 38-38.5 °C) Psoas Sign (lateral position with right hip flexion) Decreased or absent bowel sounds

DIAGNOSTIC TESTS WBC Count Leukocytosis: WBC above10,000/mm3 Perforation: suggested if WBC is above 20,000/mm3 Ultrasound may reveal enlarged appendix Barium Enema or CT Scan Ordered if symptoms are recurrent or prolonged May reveal presence of fecalith

MANAGEMENT Maintain patient on NPO for possible admission Administer IV fluids as prescribed to prevent fluids and electrolyets

imbalance Maintain patient in semi-Fowler’s position to prevent upward spread

of infection DO NOT GIVE LAXATIVE NOR ENEMA to prevent perforation of the

appendix DO NOT APPLY LOCAL HEAT to prevent inflammation and

perforation; instead apply COLD HEATSURGICAL MANAGEMENT

LAPAROSCOPY A small incision in the umbilicus is made and a small

endoscope is used to visualize the appendix If diagnosis is not definitive

LAPAROTOMY An open approach in which large abdominal incision is made

APPENDECTOMY Removal of the inflamed appendix Guided with laparoscopy Done with spinal anesthesia

NURSING CARE AFTER APPENDECTOMY Maintain client flat on bed for 6-8 hours Monitor for return of sensation in the lower extremities Maintain on NPO until peristalsis returns Instruct client to ambulate after 24 hours Tell the client that he can resume normal activities within 2-4

week

PERITONITIS

Inflammation of the peritoneumTYPES OF PERITONITIS

1. PRIMARY PERITONITIS acute bacterial infection resulting from contamination of the

peritoneum through the vascular system May occur from tuberculosis, cirrhosis and ascites

2. SECONDARY PERITONITIS bacterial invasion resulting from acute bacterial abdominal

disorder May occur from gangrenous bowel, visceral perforation, bile

leakage, blunt or penetrating trauma

PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONS RIGID, BOARDLIKE ABDOMEN (CLASSIC SIGN) Abdominal pain (localized, may refer to shoulder or thorax) Distended abdomen Nausea, anorexia and vomiting Diminishing bowel sounds Inability to pass flatus or feces Rebound tenderness in the abdomen

High fever Dehydration Oliguria Hiccups

DIAGNOSTIC ASSESSMENT ELEVATED WBC: 20,000/MM3 Abdominal x-ray may show dilation, edema, inflammation of the

small and large intestine Peritoneal Lavage may reveal the following WBC: 500/ml RBC: 50,000/ml Gram stain: (+) bacteria

MANAGEMENT Administration of the following as prescribed IV fluids to replace lost fluids Broad spectrum antibiotics Oxygen if there is dyspnea due to ascites Monitor daily weight, I/O to monitor fluid status NGT insertion to decompress the stomach and intestine Maintain client on NPO

SURGICAL MANAGEMENT 1. Abdominal surgery guided by exploratory laparotomy2. Appendectomy if there is appendicitis3. Colon resection with or without colostomy if there is bowel

perforationNURSING CARE AFTER SURGERY

Maintain patient in SEMI-FOWLER’S POSITION to promote drainage of peritoneal contents and allow adequate lung expansion

Perform PERITONEAL IRRIGATION as prescribed Check for presence of abdominal distention or pain (suggetive of

irrigant retention) Instruct client to AVOID LIFTING for at least 6 weeks

HEMORRHOIDS dilated and painful veins in the rectum

CLASSIFICATIONS Internal – hemorrhoids ABOVE the anal sphincter External – hemorrhoids BELOW the anal sphincter

RISK FACTORS Familial tendency Straining at stool

Prolonged sitting or standing Pregnancy Obesity Portal hypertension Anal intercourse Colon malignancy

ASSESSMENT Bleeding with defecation and pain (suggestive of internal

hemorrhage)DIAGNOSTIC TESTS

Digital rectal examination Sigmoidoscopy

NURSING INTERVENTIONS Instruct client on the importance of HIGH-FIBER DIET and

INCREASED FLUID INTAKE Instruct client to take STOOL SOFTENERS and use ointments such

as dibucaine, anti-inflammatories, or astringents Apply ICE PACKS for several hours followed by warm packs

SURGICAL MANAGEMENTHEMMORHOIDECTOMY

Laser surgery Atomising Cryosurgery Sclerotherapy (5% phenol in oil) Rubber band ligation

PREOPERATIVE CARE Advise low residue diet Administer stool softeners

NURSING CARE AFTER HEMORRHOIDECTOMY Watch out for bleeding Place the client in PRONE OR SIDE-LYING POSITION Administer analgesics as prescribed Administer stool softeners Offer warm Sitz baths 3-4 times a day

Disorders Involving the Accessory OrgansCHOLELITHIASIS

STONE FORMATION in the in the gallbladder and accessory ductsCHOLECYSTITIS

INFLAMMATION of the gallbladder

RISK FACTORS: 5F’s1. Female gender2. Fat (Obesity)3. Fair (Caucasian)4. Forty (age)5. Fertile (multigravida; use of contraceptive pills)

PATHOPHYSIOLOGY

CAUSE EFFECTS/MANIFESTATIONS

↓ fat emulsificationFat intoleranceAnorexia

Nausea and vomitingWeight lossGaseous eructationFlatulenceSteatorrhea

InflammationPain (Right Upper Quadrant)FeverLeukocytosis

↓ bile flow to colonAcholic stool↓ vitamin K absorption

↑ serum bilirubinJaundicePruritusTea-colored urine

DIAGNOSTIC TESTS Ultrasonography Oral cholecystogram IV cholangiogram Liver function tests Complete blood count

ORAL CHOLECYSTOGRAPHY – radiographic examination of the gallbladderPURPOSES OF ORAL CHOLECYSTOGRAPHY

To detect gallstones Assess the ability of the gallbladder to fill, concentrate its contents, contract and empty

NURSING CONSIDERATIONS ASSESS FOR ALLERGIES to iodine, seafood, or contrast media Administer contrast medium 10-12 hours before x-ray study Instruct patient to remain NPO AFTER TAKING THE CONTRAST

medium to prevent contraction and emptying of the gallbladder DEFER THE PROCEDURE IF PATIENT IS JAUNDICED!!!

TYPES OF CHOLECYSTOGRAPHY1) ORAL – done 10 HOURS after administration of contrast medium2) INTRAVENOUS – done 10 MINUTES after administration of contrast

mediumPREPARING A PATIENT FOR CHOLECYSTOGRAPHY

Instruct to have FAT FREE DINNER Place patient on NPO 2 HOURS BEFORE the test

PREPARING A PATIENT FOR CHOLANGIOGRAPHY ASSESS FOR ALLERGY TO IODINE!!! Instruct to drink ample amount of fluids after administration of dye

NURSING CARE AFTER CHOLANGIOGRAPHY Check for HYPERSENSITIVITY REACTION Instruct client that excretion of dye would cause BURNING

SENSATION during urinationNURSING INTERVENTIONS

Administer MEPERIDINE HCL (drug of choice) as prescribed for pain relief

AVOID ADMINISTERING MORPHINE!!! – it may cause spasm of the sphincter of Oddi

Use BAKING SODA or CALAMINE-CONTAINING LOTIONS for pruritus

Encourage LOW-FAT DIET Administer BILE SALTS such as Chenodeoxycholic acid or

Ursodioxycholic acid (UDCA)SURGICAL MANAGEMENT

CholecystectomyPREOPERATIVE NURSING CARE

Administer IV fluids to replace electrolytes Administer vitamin K injection, especially if prothrombin time is

prolongedPOSTOPERATIVE NURSING CARE

Place patient in SEMI-FOWLER’S POSITION to promote lung expansion

NGT DECOMPRESSION to prevent gastric distention LOW-FAT DIET for 2-3 months Encourage ambulation after 24 hours Encourage to resume normal activities within 2-3 days Monitor T-Tube if common bile duct exploration was done

T-TUBE INSERTION to DRAIN BILE

Drainage Characteristics It should be BROWNISH RED for the first 24 hours It should be 300-500 ML for the first 24 hours

Nursing Responsibilities Place drainage bottle AT THE LEVEL OF THE INCISION

PANCREATITIS Inflammation of the pancreas

TYPES

1. Acute Pancreatitis2. Chronic Pancreatitis

RISK FACTORS Alcohol abuse MEDICATIONS: Antihypertensives, diuretics, antimicrobials,

immunosuppresives, oral contraceptives GI DISORDERS: Biliary obstruction and intestinal diseases

PATHOPHYSIOLOGY

ASSESSMENTACUTE PANCREATITIS

SEVERE, CONTINUOUS left upper quadrant pain radiating to the back

Pain aggravated by eating Pain not relieved by vomiting Flexion of the spine Low-grade fever and leukocytosis

CHRONIC PANCREATITIS

HEAVY, GNAWING, OCCASIONAL BURNING OR CRAMPY L.U.Q abdominal pain

malabsorption and weight loss mild jaundice with dark urine and steatorrhea diabetes mellitus

DIAGNOSTIC TESTS Elevated serum and urinary amylase serum lipase serum bilirubin alkaline phosphatase sedimentation rate White blood cell count Fecal fat determinations Blood and urine glucose

NURSING INTERVENTIONS Administer MEPERIDINE HCL (DEMEROL) as ordered MORPHINE SULFATE PAIN MEDICATION OF CHOICE Place client on NPO DURING ACUTE PHASE bland, LOW-FAT DIET; avoid alcohol NGT DECOMPRESSION insertion to remove gastrin and prevent

further stimulation of the pancreas Administer CALCIUM SUPPLEMENTS (WITH VITAMIN D) if there is

hypocalcemia Administer INSULIN as ordered if there is hyperglycemia

LIVER CIRRHOSIS Irreversible chronic inflammatory disease characterized by massive

degeneration and destruction of hepatocytes resulting in a disorganized lobular pattern of regeneration

TYPES/CAUSES1. LAENNEC’S - caused by ALCOHOLISM or hepatotoxic drugs2. POST-NECROTIC- caused by viral HEPATITIS or industrial

hepatotoxins3. BILIARY - caused by BILIARY PROBLEMS4. CARDIAC - caused by CHF

PATHOPHYSIOLOGY

ASSESSMENT

↓ vitamin K absorption → bleeding tendencies ↓ glycogen stores → hypoglycemia ↓ serum albumin → ↓ hydrostatic pressure → edema and ascites ↓ bilirubin metabolism → hyperbilirubinemia → jaundice Portal hypertension → esophageal varices, hepatomegaly ↑ ADH → hyponatremia ↑ serum ammonia → hepatic encephalopathy

Portal hypertension - an increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver). The increase in pressure is caused by a blockage in the blood flow through the liver. Increased pressure in the portal vein causes large veins (varices) to develop across the esophagus and

stomach to bypass the blockage. The varices become fragile and can bleed easily.

DIAGNOSTIC TESTS LIVER BIOPSY (definitive test) Abdominal x-ray Ct scan Endoscopy Elevated Aspartate Aminotrasferase (AST), Alanine Aminotrasferase

(ALT), bilirubin Prolonged prothrombin time (PT) Decreased serum albumin CBC reveals anemia

PREPARING A PATIENT FOR ULTRASOUND OF THE LIVER NPO 8-12 hours before the procedure Administer laxative a night before the test Maintain adequate hydration

PREPARING A PATIENT FOR LIVER BIOPSY Place patient on NPO 2-4 hours prior ADMINISTER VITAMIN K Monitor prothrombin time Position patient in LEFT LATERAL POSITION with pillow under right

shoulder Instruct to HOLD BREATH 5-10 seconds during needle insertion

NURSING CARE AFTER LIVER BIOPSY Turn the patient to sides q4 hours Place on bed rest for 24 hours Monitor for signs of bleeding

NURSING INTERVENTIONS Place client on BED REST with bathroom privileges Offer LOW-PROTEIN, HIGH CARBOHYDRATES and vitamins (ADEK,

B-complex), LOW SODIUM RESTRICT AMOUNT OF ORAL FLUIDS and eliminate alcohol intake Provide meticulous skin care Monitor weight, I/O and ABDOMINAL GIRTH Assist in paracentesis if necessary Monitor for bleeding of esophageal varices Perform tap water or NSS enema Avoid giving aspirin (causes bleeding) and sedatives (hepatotoxic)

MEDICATIONS FOR A PATIENT WITH CIRRHOSIS ANTACID – to prevent GI bleeding SPIRONOLACTONE (Potassium-sparing diuretic) – diuretic of choice

to manage ascites; does not cause hypokalemia

FUROSEMIDE – diuretic given if patient has hyperkalemia after prolonged use of spironolactone

VITAMIN K – prevents bleeding tendencies INTRAVENOUS ALBUMIN – to manage ascites and edema DUPHALAC (Lactulose) – reduces levels of ammonia NEOMYCIN SULFATE – reduce colonic bacteria responsible for

ammonia formationPREVENTION OF BLEEDING OF ESOPHAGEAL VARICES

Avoid Valsalva maneuver Avoid bending or stooping Avoid hot spicy foods Avoid lifting heavy objects

INTERVENTIONS FOR BLEEDING ESOPHAGEAL VARICES Place patient in SEMI-FOWLER’S POSITION to prevent aspiration Suction the mouth Perform gastric lavage with tap water Insert SENGSTAKEN-BLAKEMORE TUBE Administer IV fluids, blood transfusion as ordered Administer VASOPRESSIN to constrict splanchnic arteries

PREPARING A PATIENT FOR PARACENTESIS Ask to empty bladder to prevent puncture Check serum protein studies Place patient in sitting or upright position

NURSING CARE AFTER PARACENTESIS Check urine output Watch out for board-like abdomen (sign of PERITONITIS) Monitor for signs of hypovolemic shock