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

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Title: 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.

3
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.

6
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.

7
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?

8
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.

9
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?

10
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).

11
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)?

12
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

13
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?

14
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.

15
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?

16
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.

17
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.

18
  • ALICIA

19
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

20
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

22
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).

23
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

24
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.

25
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

26
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).

27
  • AMY

28
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.

29
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.

30
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.

31
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).

32
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.

33
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.

34
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.

35
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.

36
  • TIMOTHY

37
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

38
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
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