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NURSING II Kathleen C. Ashton


... tests: sigmoidoscopy, proctoscopy, anoscopy, colonoscopy (also used to remove polyps) Virtual colonoscopy (half the cost, quick, not yet covered by insurance) ... – PowerPoint PPT presentation

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Title: NURSING II Kathleen C. Ashton

NURSING IIKathleen C. Ashton
  • The Client With Alterations in Digestion

Nutritional Assessment
  • Digestion begins in mouth - mastecation
  • Should chew our food at least 25 times
  • Food Record used to determine type and amount
    over 3-7 days
  • Consider IBW and UBW. Need ht. and wt.
  • 24 hour recall - recalls previous days intake -
    measures total nutritive value of food compared
    with the RDA
  • Limitations
  • Previous day may not be typical (ask this
  • Depends on memory (problem with elderly)

Effects of Hospitalization
  • metabolic changes due to illness or change in
    activity level (low albumin denotes low protein
    stores and negative nitrogen balance)
  • necessity of NPO for diagnostic tests
  • use of IVs or tube feeding without regard for
    exact needs of client
  • institutional cooking vs. home cooking
  • lack of normal mealtime atmosphere family, table
    and chairs, toilet tissue
  • errors in delivery wrong person, wrong diet
  • elderly effects of medications, anorexia
  • antibiotics disturb normal flora, give yogurt
    when appropriate

Diagnostic Tests
  • Upper GI, Barium Swallow
  • odorless, tasteless, insoluble
  • NPO after midnight
  • no smoking
  • swallow barium under direct xray visualization
  • will have white stool
  • Gastric Analysis gives information on gastric
    acid secretion

Diagnostics (Continued)
  • Endoscopy
  • uses fiberoptics and laser technology.
  • can take color photos, biopsy, retrieve stones,
    reduce tumors (cannot remove them)
  • check for gag reflex after gastroscopy, before
    giving fluids. Returns in 1 - 2 hours
  • Lower GI, Barium Enema
  • Direct visualization (scopes used tests
    sigmoidoscopy, proctoscopy, anoscopy, colonoscopy
    (also used to remove polyps)
  • Virtual colonoscopy (half the cost, quick, not
    yet covered by insurance)
  • Stool exam for ova and parasites, occult blood
  • CAT scan, ultrasound, MRI (care with pacers)

Considerations for Adolescents
  • Calcium absorbed best during adolescence -
    negated by carbonated drinks high in phosphorous
  • Eating disorders begin with disturbed body images
    - anorexia nervosa, bulemia
  • Kate Moss type models send message that girls
    are fat
  • Anabolic steroid use and misuse an issue with

Considerations for the elderly
  • Tooth loss is not inevitable
  • We are keeping our teeth longer due to better
    nutrition. Not true across the nation -
  • Time magazine reports 48 of seniors in W.VA are
    toothless (highest in US)
  • 13.9 of seniors in Hawaii are toothless
  • Educate about careful fitting of dentures -
    should be refitted every 5 years or whenever
    there is a major change in weight
  • Weight issues may necessitate a change in timing
    or amounts of food intake
  • Eating six small meals starting with breakfast
    and ending before 7PM

Cancer of the oral cavity
  • Rare and carries a good prognosis if early
  • Risk factors
  • smoking snuff, chewing tobacco, pipes
  • alcohol
  • increased age
  • exposure to elements
  • affects more men than women
  • Begins as painless sore, progresses to lymph
  • Large tumors (4cm) tend to recur

Nursing Implications
  • Early screening
  • Body image is big issue
  • Support needed as chemo or radiation begins
  • Mouth care and fluids to prevent dryness
  • Combat anorexia
  • Address fears
  • Communication - use paper and pencil or computer
    to facilitate communication

Radical neck dissection
  • Indicated for certain cancers
  • Preoperative care is standard, main concern is
    airway maintenance and communication post
  • Wound care usually includes drains, may be
    connected to suction
  • TPN may be indicated to maintain a positive
    nitrogen balance
  • Diet orders later may include liquid, soft,
    puree or blenderized
  • Complications hemorrhage, nerve injury

Esophogeal conditions
  • Esophagoscope used to remove foreign bodies
  • Burns are common from accidental swallowing of
    caustic material
  • Esophagectomy - may have blood-tinged drainage
    for 8-12 hours post op
  • Surgery is difficult - esophagus lies behind
    trachea - thoracotomy needed

  • Highly acidic secretions escape from stomach into
    esophagus when LES relaxes
  • Risk factors DM, obesity, hiatal hernia, ETOH,
    COPD, smoking, peppermint, hi fat, citrus or
    tomato-based foods, caffeine
  • Can lead to Barretts esophagus, hemorrhaging,
    perforation, respiratory symptoms and cancer
  • Treated with lifestyle change, antacids, H2
    receptor antagonists, proton pump inhibitors,
    surgery (fundoplication) to wrap the stomach
    around the esophagus

Hiatal Hernia
  • Common in US
  • Types
  • Sliding type stomach herniates into esophagus
  • Paraesophogeal (less common) stomach herniates
    near esophagus
  • Mimics cardiac and gi burning and pain
  • Best advice maintain ideal weight, avoid
    activities that increase intra-abdominal pressure

Gastrointestinal tubes
  • Levin an orogastric or nasogastric single lumen
  • removes gas and fluid from stomach (use
    intermittent suction)
  • may be used to deliver feeding (short term)
  • measure using NEX method
  • check placement by 4 tests
  • Maintain patency
  • Salem sump double lumen tube with blue pigtail
  • reduces force of suction against gastric mucosa
  • uses continuous low suction to decompress stomach
  • Keep vent above head do not irrigate through it
  • Very common tube in hospitals

Sengstaken-Blakemore tube
  • Triple lumen tube to control bleeding esophageal
    varices (BEV)
  • 2 balloons, one in stomach one in esophagus
  • Third lumen for gastric lavage - monitors
  • Inflated balloons and iced saline used to stop
  • Minnesota tube permits suctioning, has 4 ports
  • May use football helmet to provide counter
    traction and stabilize position

Intestinal tubes
  • Most common are
  • Miller-Abbott
  • Harris
  • Cantor
  • Double lumen tubes - one for aspiration and one
    for inflation or weight (mercury used)
  • Inserted by physician, advanced by nurse or
    patient, usually one inch per hour
  • Used to relieve obstructions

Feeding tubes
  • Dobhoff, Moss, Nutriflex, Keofeed, Interflex
  • All are very flexible, may need stylet for
  • Irrigate q 4 hours, replace q 4 weeks
  • Careful placement and careful monitoring!
  • Provide oral and nasal care (intestinal tubes
    removed through the mouth)
  • Ice chips with caution
  • Irrigation 30-60cc NSS. Need MD order. Record
    carefully on IO.
  • Tape gently but securely. Use holder if
    available. May clamp intermittently.

  • Percutaneous endoscopic gastrostomy (PEG) used
    almost exclusively now. Mushroom catheter
    threaded through mouth and out abdominal wall.
    Bumper used to keep in place.
  • Flush bag between feedings to assure patency. Bag
    and tubing changed every 24 hours.
  • Skin care vital - gastric juices may leak. Daily
    soap and water wash. Vaseline or stomahesive may
    be used for irritation
  • Monitor for migration out of track

Hyperalimentation (HAL or CHALcentral)
  • May be the RN who first considers or suggests it
  • Total parenteral nutrition (TPN) supplies
    nutrients to the body
  • When protein intake less then protein use,
    negative nitrogen balance can occur (in as little
    as 24 hours)
  • Average post-op adult requires 1500 calories per
    day to spare body protein
  • Goals
  • 1. Improve nutritional status and promote weight
  • 2. Improve healing ability

  • Prescribed solution prepared by pharmacist
  • MD consults with pharmacist, nutritionist or CNS
    to determine best solution
  • Prepared under filtered-air, laminar flow hood
  • Basic solution is 25 glucose amino acids, ex.
    FreAmine provides 1000 cal 6 gm nitrogen/Liter
  • Electrolytes added according to serum needs
  • Commercial preparations Aminosol, Amigen
  • TPN is irritating (highly concentrated), must use
    central line and discontinue gradually

Administration of TPN
  • Hickman single or double lumen, tubing hangs out
  • Broviac pediatric use
  • Groshong less popular
  • Portacath placed under skin but must puncture
    skin with curved needle to gain access
  • Care is specific for each device

  • Inflammation of stomach mucosa
  • Caused by ingestion of infected or noxious food
    -sets up inflammatory process
  • May be related to radiation or systemic infection
  • Chronic gastritis - may be due to lack of
    intrinsic factor - Vitamin B12 not absorbed
  • Anxiety is biggest nursing focus, also avoid
    smoking, alcohol, spices. Bland diet helps. Watch
    for dehydration hemorrhage
  • Antacids (Peptobismol), anticholinergics
    (Donnatol) may provide relief

GI Bleeding
  • Frank red blood indicates active bleeding
  • Coffee ground emesis may indicate older bleeding
  • Melena - blood in stool - bleeding in lower GI
  • Stabilized with iced saline lavage via NG tube
  • Vasopressin used to provide constriction in GI
  • Can occur with excessive ASA ingestion
  • Treated with fluid replacement and blood

Peptic Ulcers
  • Helicobactor A pylori - becomes active in some
  • Risk factors
  • smoking
  • heredity (3X more have relative with ulcers)
  • blood type O
  • high anxiety, hurried lifestyle
  • eating too fast
  • affects more men then women
  • may be associated with infection, tumors
  • Duodenal ulcers more common than gastric

Manifestations and management
  • Worse in spring and fall
  • Dull, gnawing pain usually relieved by food
  • Heartburn, emesis, constipation, hemorrhage most
    common complication - also perforation
  • Drugs Histamine receptor antagonists, Carafate
  • Rest, reduce stress, no smoking or alcohol, avoid
    hot or cold foods, diet as tolerated, antibiotics
  • Curlings ulcers occur after an acute medical
    crisis or head injury, also known as gastric

Gastric cancer
  • Becoming less common each year
  • Poor prognosis - defies early detection. May
    appear as an ulcer
  • Progresses to indigestion, anorexia, pain, weight
    loss, anemia, NVD
  • Requires complete gi workup with CAT, bone and
    liver scans
  • Small frequent meals, may need B12, watch for
    obstruction, pain relief, emotional support.

Surgical Procedures
  • Gastrectomy removal of portion of stomach
  • may require gastrostomy and liquids for life
  • Whipple procedure removal of most of esophagus,
    stomach, intestines, pancreas.
  • Only palliative
  • Survival past 1 year is rare
  • Vagotomy vagal nerve cut to reduce acid
  • Complications hemorrhage - lavage is performed
    with replacement of blood

Dumping Syndrome
  • Occurs in 10 - 15 of those who have had gastric
    surgery or vagotomy
  • Rapid gastric emptying distends duodenum or
  • N,V, pain, explosive diarrhea, borborygmus,
    tachycardia, vertigo
  • Intervention
  • 6 small meals/day
  • low carbohydrate, high protein and fat
  • rest for 1/2 to 1 hour postprandially
  • drink between meals, not with meals