Gastrointestinal Disorders N635 Medical Surgical - Disease Management II 02-23-10

1
Gastrointestinal DisordersN635 Medical Surgical
- Disease Management II02-23-10

• Presenters
• Maria M. Stone
• Alicia Talavera
• Amy Davidson
• Amanda Durazo
• Timothy Wong

2
Gastrointestinal Disorders Review at a Glance

• Barretts epithelium esophageal epithelial
  tissue that has undergone change as a result of
  repeated exposure to gastric juice and is more
  resistant to erosion, but is premalignant.
• Body mass index (BMI) estimates total body fat
  stores in relation to height and weight.
• Bulk-forming agents high-fiber supplements that
  increase fecal bulk.
• Cholecystitis and Choleithiasis
• Cholecystitis an acute inflammation of the
  gallbladder.
• Cholelithiasis The formation or presence of
  stones in the gallbladder.
• Cirrhosis Degeneration of liver tissue causing
  enlargement, fibrosis, and scarring.
• Crohns Disease (Regional Enteritis) Subacute,
  chronic inflammation extending throughout the
  entire intestinal mucosa (most frequently found
  in terminal ileum).
• Chyme stomach contents partially digested
  food mixed with gastric juice.

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Gastrointestinal Disorders Review at a Glance

• Colostomy surgical diversion of large intestine
  fecal contents to an external collection device.
• Diarrhea increase in frequency, amount or
  liquidity of stool that is a change from the
  individuals normal pattern.
• Diverticular Disease manifested in two clinical
  forms 1) Diverticulosis and 2) diverticulitis.
• Diverticulosis bulging pouches in the GI wall
  (diverticula) push the mucosa lining through the
  surrounding muscle.
• Diverticulitis inflamed diverticula, (may cause
  obstruction, infection, and/or hemorrhage.)
• Dumping syndrome complication of gastric
  resections where there is a rapid emptying of
  stomach contents into the jejunum causing
  physiologic manifestations.
• Esophagogastroduodenoscopy (EGD) direct
  visualization of esophagus, stomach, and duodenum
  through a fiberoptic endoscope and used to
  diagnose disorders of aforementioned structures.

4
Gastrointestinal Disorders Review at a Glance -
continued

• Esophagogastric tube also known as the
  Sengstaken-Blakemore and Minnesota tube,
  consisting of a tube with several lumens used to
  inflate a gastric balloon, esophageal balloon and
  drain stomach contents.
• Fistula abnormal pathway been structures or
  from an internal organ to an outside surface.
• Gastroesophageal reflux the backward flow of
  gastric contents into the lower portion of the
  esophagus.
• Gavage referring to intermittent feeding
  through a tube in the stomach or jejunum.
• Hepatitis Widespread inflammation of liver
  cells usually caused by a virus.
• Hernia referring to a protrusion of an organ
  through a weakness in muscle.
• Hiatal Hernia herniation of the stomach and
  other abdominal viscera through an enlarged
  esophageal opening in the diaphragm. Etiology
  unknown.

5
Gastrointestinal Disorders Review at a Glance -
continued

• Esophagogastroduodenoscopy (EGD) direct
  visualization of esophagus, stomach, and
  duodenum.
• Ileostomy surgical diversion of fecal contents
  at the level of the ileum to an external
  collection device.
• Inflammatory Bowel Diseases consists of Crohns
  disease and ulcerative colitis.
• Intestinal Obstruction Partial or complete
  blockage of the intestinal flow (fluids, feces,
  gas).
• Intestinal tube long tube, 6 to 10 feet in
  length, used to decompress the intestines.
• Lavage irrigation of the stomach using a tube
  inserted into the stomach.

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Gastrointestinal Disorders Review at a Glance -
continued

• Lower esophageal sphincter (LES) the sphincter
  located at the esophageal gastric junction.
• Nasogastric (NG) tube a tube inserted through
  the nose and into the stomach and used to drain
  contents or for feeding.
• Non-steroidal anti-inflammatory drugs (NSAIDs)
  medications usually used for analgesia and to
  reduce inflammation.
• Pancreatitis Nonbacterial inflammation of the
  pancreas.
• Peptic Ulcer Disease (PUD) ulceration which
  penetrates the mucosal wall of the GI tract.
• Ulcerative Colitis disease which affects the
  superficial mucosa of the colon, causing the
  bowel to eventually narrow, shorten, and thicken
  due to muscular hypertrophy. Occurs in the large
  bowel and rectum.
• Zollinger-Ellison syndrome disorder in which a
  pancreatic tumor secretes gastrin, which then
  stimulates secretion of acid and pepsin.

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Gastrointestinal Disorders Case Study

• MW, a 47-year-old female, is admitted to the
  hospital to rule out chronic gastro esophageal
  reflux disease (GERD) versus peptic ulcer disease
  (PUD). You are the nurse assigned to care for
  this client.
• What diagnostic tests should you anticipate being
  ordered to differentiate her diagnoses?

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Gastrointestinal Disorders Case Study Answer
and Rationale

• An upper-GI series will probably be ordered and
  can show lower esophageal sphincter (LES)
  function as well as ulceration. An
  esophagogastroduodenoscopy can be more diagnostic
  because it is a direct visualization of the
  tissue of the esophagus and can show
  inflammation. The gastric and duodenal mucosa
  are also visualized directly and ulcerations are
  evident. The advantage of endoscopy over an
  upper-GI series is that tissue samples can be
  obtained for determining the presence of cancer,
  Barretts epithelium, or H. pylori. Gastric
  analysis may also be used to determine the pH and
  acid output of the stomach.

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Gastrointestinal Disorders Case Study

• MW, a 47-year-old female, is admitted to the
  hospital to rule out chronic gastro esophageal
  reflux disease (GERT) versus peptic ulcer disease
  (PUD). You are the nurse assigned to care for
  this client.
• What are the priorities of care after these
  tests?

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Gastrointestinal Disorders Case Study Answer
and Rationale

• An upper-GI series usually involves the ingestion
  of barium, which is constipating. The client
  should be encouraged to drink fluids and
  ambulate. Aspiration of barium during the
  procedure is a possibility, so the nurse should
  assess lung sounds and monitor for signs of
  aspiration such as fever, cough, and dyspnea.
  For the client after esophagogastroduodenoscopy,
  it is extremely important to assess for return of
  swallowing and the gag reflex since the throat is
  anesthetized for the procedure, therefore,
  general safety measures should be instituted
  (side rails up, bed in low position).

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Gastrointestinal Disorders Case Study

• MW, a 47-year-old female, is admitted to the
  hospital to rule out chronic gastro esophageal
  reflux disease (GERT) versus peptic ulcer disease
  (PUD). You are the nurse assigned to care for
  this client.
• What instructions about lifestyle changes should
  you give MW if she has gastro esophageal reflux
  disease (GERD)?

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Gastrointestinal Disorders Case Study Answer
and Rationale

• Lifestyle and diet modifications are key to
  controlling GERD. The client should be
  instructed to avoid eating within 2 hours of
  bedtime and should remain in an upright position
  after eating. Tight clothing (belts, tight
  waistbands), straining (weight lifting, bending
  over, lifting heavy objects), and vigorous
  physical activity increase intra-abdominal
  pressure aggravate GERD and should be avoided. A
  reduction in dietary fat and an increase in
  complex carbohydrates encourage more rapid
  gastric emptying and reduction in symptoms of
  GERD. The client should be instructed to avoid
  substances that decrease LES tone such as
  caffeinated beverages, chocolate, peppermint,
  spearmint, smoking, and fried foods. The client
  should be encouraged to elevate the head of the
  bed about 12 inches to prevent reflux at night

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Gastrointestinal Disorders Case Study

• MW, a 47-year-old female, is admitted to the
  hospital to rule out chronic gastro esophageal
  reflux disease (GERT) versus peptic ulcer disease
  (PUD). You are the nurse assigned to care for
  this client.
• What instructions about signs and symptoms of
  complications of GERD and PUD should you provide
  to MW?

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Gastrointestinal Disorders Case Study Answer
and Rationale

• The complications of GERD are limited to the
  development of Barretts epithelium, cancer, and
  esophageal stricture. Symptoms include
  dysphagia, pain, and more systemic symptoms such
  as fatigue, dyspnea, and activity intolerance.
  Complications of PUD are perforation, hemorrhage,
  gastric cancer (gastric ulcer), and pyloric
  obstruction. The client should be instructed to
  report any of the following symptoms vomiting,
  hematemesis, black tarry stools, pain, rapid
  heart rate, abdominal rigidity, and fever as they
  may indicate a complication.

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Gastrointestinal Disorders Case Study

• MW, a 47-year-old female, is admitted to the
  hospital to rule out chronic gastro esophageal
  reflux disease (GERT) versus peptic ulcer disease
  (PUD). You are the nurse assigned to care for
  this client.
• If MW asks you about the possibility of
  developing cancer, how would you respond?

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Gastrointestinal Disorders Case Study Answer
and Rationale

• Clients with GERD may develop Barretts
  epithelium and be at a greater risk for cancer if
  GERD remains untreated, so it is important that
  the client follow the treatment regimen. If the
  client has a duodenal ulcer, the risk for
  developing cancer as a result are minimal
  however, there is an increased incidence of
  gastric cancer in people with gastric ulcers.
  Continued follow-up is therefore important in
  this population.

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Gastrointestinal Disorders HESI Hints

• A Fowlers or semi-Fowlers position is
  beneficial in reducing the amount of
  regurgitation as well as preventing the
  encroachment of the stomach tissue upward through
  the opening in the diaphragm.
• Stress can cause or exacerbate ulcers. Teach
  stress reduction methods and encourage those with
  a family history of ulcers to obtain medical
  surveillance for ulcer formation.
• Clinical manifestations of GI Bleeding
• Pallor conjunctival, mucous membranes, nail
  beds.
• Dark tarry stools
• Bright red or coffee-ground emesis.
• Abdominal mass or bruit.
• Decreased BP, rapid pulse, cool extremities
• The GI tract usually accounts for only 100 to
  200ml fluid loss per day, although it filters up
  to 8 liters per day. Large fluid losses can
  occur if vomiting and/or diarrhea exists.
• Opiate drugs tend to depress gastric motility.
  However, they should be given with care, and
  those receiving them should be closely monitored
  because distended intestinal wall accompanied by
  decreased muscle tone may lead to intestinal
  perforation.

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• ALICIA

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GI Hesi Review Question

• Which of the following assessments is essential
  for the nurse to make when caring for a client
  who has just had an esophagogastroduodenoscopy
  (EGD)?
• Auscultate bowel sounds
• Check gag reflex
• Monitor gastric pH
• Measure abdominal girth

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Answer

• Answer is 2.
• The posterior pharynx is anesthetized for easy
  passage of the endoscope into the esophagus. The
  return of the gag reflex indicates that normal
  function is returning and the client is able to
  swallow (option 2). Bowel sounds (option 1) and
  abdominal girth (option 4) are associated with
  caring for a client with a nasogastric tube in
  place. Gastric pH (option 3) is related to the
  client with peptic ulcer disease.

21
GI Hesi Review Question

• The client is admitted to the hospital with
  ulcerative colitis. The nurse should assess the
  client for which sign that indicates a
  complication of the disease?
• Low hemoglobin and hematocrit
• Low platelet count
• Epigastric or right-sided pain following a
  high-fat meal
• Presence of fat in the stools

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Answer

• Answer is 1.
• Hemorrhage and bleeding are a common feature of
  ulcerative colitis, and over time this can lead
  to significant loss of RBCs, the client should be
  assessed for possible anemia (option 1).
  Steatorrhea is seen in malabsorption syndrome
  (option 4). Thrombocytopenia may occur if the
  client is treated with immunosuppressants (option
  2) to control the disease. Signs of
  cholelithiasis are unrelated to ulcerative
  colitis (option 3).

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GI Hesi Review Question

• A client is admitted to the hospital with a bowel
  obstruction. Which of these findings by the
  nurse would indicate that the obstruction is in
  the early stages?
• High-pitched tinkling bowel sounds
• Low rumbling bowel sounds
• No bowel sounds auscultated
• Normal bowel sounds heard in all four quadrants

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Answer

• Answer is 1.
• Early in a bowel obstruction, the bowel attempts
  to move the contents past the obstruction, and
  this is heard as high-pitched tinkling bowel
  sounds (option 1). As the obstruction progresses,
  bowel sounds will diminish and may finally become
  absent (option 3). Bowel sounds in all four
  quadrants (option 4) and rumbling bowel sounds
  (option 2) are normal.

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GI Hesi Review Question

• A client with gastroesophageal reflux disease
  (GERD) is prescribed famotidine (Pepcid). In
  order to provide effective teaching, the nurse
  must include which information about the action
  of the drug?
• It improves motility
• It coats the distal potion of the esophagus
• It increases the gastric pH
• It decreases the secretion of gastric acid

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Answer

• Answer is 4.
• Famotidine is a histamine-2 receptor antagonist
  and reduces the secretion of gastric acid (option
  4). This class of drugs does not have a direct
  effect on reflux or GI motility. Metoclopramide
  improves GI motility (option 1). Sucralfate
  coasts the ulcer (option 2). Antacids neutralize
  the hydrochloric acid in the stomach (option 3).

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• AMY

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GI Hesi Review Question

• A 65-year old man presents to the Emergency
  Department complaining of recurring burning chest
  pain after eating. His history consists of
  obesity, type-II diabetes, sedentary behavior,
  and commonly takes TUMS on a regular basis. As
  his ED nurse, which nursing diagnosis would be
  suitable for this patient?
• At risk for severe pain related to an angina
  attack.
• At risk for hyperglycemic hyperosmolar nonketotic
  syndrome related to poorly controlled diabetes.
• Deficient knowledge related to GERD.
• Possible nutritional deficiency related to
  overuse of antacids.

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Answer

• Answer is 3.
• Chest pain only after eating is a common
  complaint of Gastroesophaegeal reflux disease
  (GERD). Chest pain before eating is related to
  Peptic Ulcer Disease. Commonly taking TUMS is
  another indication of acid reflux.

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GI Hesi Review Question

• Name the three causes of intestinal obstruction.
• Constipation, neurogenic, and vascular.
• Mechanical, neurogenic, and vascular.
• Mechanical, diverticulitis, and vascular.
• Mechanical, constipation, and diverticulitis.

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Answer

• Answer is 2
• The three main causes of intestinal obstruction
  are due to Mechanical (adhesions, hernias,
  volvulus twisting of the gut, intussusceptions,
  tumors), neurogenic (paralytic illeus, lesions on
  the spinal cord), and vascular causes (artery
  occlusions).

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GI Hesi Review Question

• A patient is being admitted to post-op recovery
  for a hip replacement. It is 12-hours post-op and
  she is complaining that she has not eaten in 24
  hours and wants some ice cream to soothe her
  irritated throat. What is the next nursing
  intervention for this patient?
• Give her the ice cream right away to soothe her
  irritated throat and document the amount on her
  IOs.
• Tell her she cannot have any liquids or food
  until she ambulates for the first time.
• Contact doctor to increase IV fluids because her
  output is decreasing.
• Ascultate for bowel sounds, if bowel sounds are
  heard, allow her to eat some ice cream.

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Answer

• Answer is 4
• After surgery, it is important to determine if
  the intestines have begun to move or are still
  paralytic. The nurse must determine, via
  auscultation of the abdomen, if bowel sounds have
  returned. If food and liquid is given too early,
  an intestinal obstruction may occur.

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GI Hesi Review Question

• A 45-year old woman presents in your outpatient
  facility concerned with her family history of
  colorectal cancer. What interventions would be
  suitable to suggest for this woman?
• Eat more cruciferous vegetables.
• Tell her that there is nothing she can do this
  type of cancer cannot be prevented.
• Decrease fiber intake, and increase more foods
  from animal sources.
• Begin colonoscopy examinations every year after
  50.

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Answer

• Answer is 1
• The only valid answer is to eat more cruciferous
  vegetables (broccoli, cauliflower, etc).
  Preventative screening is important. Rectal
  examinations should be given every year after age
  40, and colonoscopies/sigmoidoscopies should only
  be given every 3 -5 years after age 50. Fiber
  intake should increase, and foods from animal
  sources should decrease for preventive measures.

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• TIMOTHY

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GI Hesi Review Question

• A client is to receive gavage feeding through a
  nasogastric (NG) tube. Which of the following
  nursing actions should be performed to prevent
  complications?
• Flush with 20 mL of air
• Place client in high Fowlers position
• Advance tube 1 cm
• Plug the air vent during feeding

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Answer

• Answer is 2. Keeping the client in a high
  Fowlers position minimizes the risk of
  aspiration (option 2). Flushing with air (option
  1) will increase abdominal distention and
  increase discomfort and risk of aspiration.
  Advancing the tube (option 3) is only relevant if
  it is a nasoduodenal tube that has not advanced
  beyond the pylorus. Plugging the air vent
  (option 4) is unnecessary.
• Strategy The NG tube bypasses the oropharynx and
  the gag reflux, which concludes that the airway
  is compromised. Select the answer that protects
  the airway.

39
GI Hesi Review Question

• The nurse should question the client with
  gastroesophageal reflux disease (GERD) about the
  use of which type of medications that decrease
  lower esophageal sphincter (LES) tone?
• Antidepressants
• Calcium channel blockers
• Antiestrogen agents
• Alpha-adrenergic blocking agents

40
Answer

• Answer is 2. Many common substances contribute to
  decreased LES tone including fatty foods,
  caffeinated beverages, nicotine, beta-adrenergic
  blocking agents, calcium channel blockers (option
  2), nitrates, theophylline, alcohol, and
  anticholinergic drugs. Antidepressants,
  antiestrogen agents, and alpha adrenergic
  blockers have no effect on LES tone.
• Strategy Identify how the lower esophageal
  sphincter contributes to the symptoms of GERD and
  select the drug that increases that effect.

41
GI Hesi Review Question

• The client with irritable bowel syndrome (IBS)
  asks the nurse what causes the disease. Which of
  the following response by the nurse would be most
  appropriate?
• This is an inflammation of the bowel caused by
  eating too much roughage.
• IBS is caused by a stressful lifestyle
• The cause of this condition if unknown
• There is thinning of the intestinal mucosa caused
  by ingestion of gluten

42
Answer

• Answer is 3. There is no known cause of IBS, and
  diagnosis is made by excluding all other diseases
  that cause the symptoms (option 3). There is no
  inflammation of the bowel (option 1). Some
  factors exacerbate the symptoms (option 2),
  including anxiety, fear, stress, depression, some
  foods (options 1 and 4) and drugs, but these do
  not cause the disease.
• Strategy Know the different forms of
  inflammatory bowel disease and causative factors
  vs exacerbating factors.

43
GI Hesi Review Question

• A client with Crohns disease (regional
  enteritis) who is taking sulfasalazine
  (Azulfidine) asks the nurse why this medication
  is necessary. When information should the nurse
  include in her response.
• The drug decreases abdominal cramping by slowing
  peristalsis.
• The drug decreases prostaglandin production in
  the bowel so it decreases inflammation.
• The drug inhibits neurotransmission of pain
  impulses.
• The drug stimulates the release of endorphins so
  pain is relieved.

44
Answer

• Answer is 2. Sulfasalazine is a GI
  anti-inflammatory medication that exerts its
  action by decreasing prostaglandin production in
  the bower (option 2). Peristalsis is decreased
  by anticholinergic agents (option 1). Analgesics
  affect pain impulses (options 3 and 4).
• Strategy Review the goals of treatment for
  inflammatory bowel disease and select the answer
  that directly decreases the inflammatory response.

45

• Amanda

46
Question 1

• Colace works by?
• Stimulating muscles and nerves in the bowels to
  help move stool along
• Forming bulk that absorbs liquid to produce a
  soft bulky stool, stimulating bowel normally by
  the presence of the bulk
• Encouraging bowel movements by drawing water into
  the bowel from surrounding body tissues,
  providing soft stool mass and increased bowel
  action

47
Answer is 2

• Rationale Colace is a bulk-forming laxative.
• Nursing Intervention
• We should encourage our patients to increase
  their fluid intake during their use of Colace
  because water is being lost to the colon.

48
Question 2

• When a client has peptic ulcer disease, the nurse
  would expect a priority intervention to be?
• Assisting in inserting a Miller-Abbott tube
• Assisting in inserting an arterial pressure line
• Inserting a nasogastric tube
• Inserting an IV

49
Answer is 3

• Insert a NG tube
• Rationale
• NG tube needs to be inserted to determine the
  presence of active GI bleeding. A Miller-Abbott
  tube is a weighted, mercury-filled ballooned tube
  used to resolve bowel obstructions. There is no
  evidence of shock or fluid overload in the
  client therefore an arterial line is not
  indicated and an IV is optional.

50
Question 3

• A 55 year old patient with severe epigastric pain
  due to acute pancreatitis has been admitted to
  the hospital. The clients activity at this time
  should be?
• Ambulation as desired
• Bedrest in supine position
• Up ad lib and right side-lying position in bed
• Bedrest in Fowlers position

51
Answer is 4

• Bedrest in Fowlers position
• Rationale
• The pain of pancreatitis is made worse by
  walking and by laying in the supine position.
  The client is more comfortable sitting up and
  leaning forward.

52
Question 4

• A client has had a cystectomy and
  ureteroileostomy (ileal conduit). The nurse
  observes this client for complications in the
  postoperative period. Which of the following
  symptoms indicates an unexpected outcome and
  requries priority care?
• Edema of the stoma
• Mucus in the drainage appliance
• Reddness of the stoma
• Feces in the drainage applance

53
Answer is 4

• Feces in the drainage appliance
• Rationale
• The ileal conduit procedure incorporates
  implantation of the ureters into a portion of the
  ileum which has been resected from its anatomical
  position and now functions as a reservoir or
  conduit for urine. Feces should not be draining
  from the conduit. Edema a red color of the stoma
  are the expected outcomes in the immediate
  post-op period, as is mucus from the stoma.

54
Question 5

• Most cleft palates are repaired at what age?
• Immediately after birth
• 1 to 2 months
• 3 to 4 months
• 1 to 2 years

55
Answer is 4

• 1 to 2 years
• Rationale
• Most surgeons will correct the cleft at 1 to
  2 years old before faulty speech patterns develop
  to take advantage of palatal changes during
  infancy

56
Question 6

• To clear Dr. B out of the classroom as quickly as
  possible, so we can all go home, we should have
  all eaten which food for lunch?
• Beans
• Donuts
• Wine and cheese
• Pizza

57
Question 6 Answer

• Do you really need the answer and rationale?
• We are done people!
• Lets go home!
• Thank you for your participation!!
• The GI Group