GASTROINTESTINAL NURSING

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GASTROINTESTINAL NURSING

• Digestive Tract Disorders
• 2013

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Anatomy and Physiology of the Digestive Tract

• Mouth
• Where teeth, tongue, and salivary glands begin
  food digestion
• Pharynx
• Muscular structure shared by the digestive and
  respiratory tracts
• It joins the mouth and nasal passages to the
  esophagus
• Esophagus
• Long muscular tube that passes through the
  diaphragm into the stomach
• Stomach
• Churns and mixes food with gastric secretions
  until a semiliquid mass called chyme

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Anatomy and Physiology of the Digestive Tract

• Small intestine
• Chemical digestion and absorption of nutrients
  take place
• Approximately 20 feet long and consists of three
  sections the duodenum, the jejunum, and the
  ileum
• Liver and pancreatic secretions enter the
  digestive tract in the duodenum

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Anatomy and Physiology of the Digestive Tract

• Large intestine and anus
• The first section of the large intestine is the
  cecum
• Ascending colon goes up right side of the abdomen
  
• Transverse colon crosses abdomen just below waist
  
• Descending colon goes down left side of abdomen
• The last 6 to 8 inches of the large intestine is
  the rectum, which ends at the anus, where wastes
  leave the body

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Age-Related Changes

• Teeth are mechanically worn down with age
• The jaw may be affected by osteoarthritis
• A significant loss of taste buds with age
• Xerostomia (dry mouth) is common
• Walls of esophagus and stomach thin with aging,
  and secretions lessen
• Production of hydrochloric acid and digestive
  enzymes decreases
• Gastric motor activity slows
• Movement of contents through the colon is slower
  
• Anal sphincter tone and strength decrease

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Nursing Assessment and Health History

• ?? Common complaints of GI system
• Why is past medical history important??
• What family history might be relevant??
• What are some common questions you need to ask in
  your review of systems???

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Diagnostic Tests Procedures

• Gastrointestinal
• System

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Stool Specimens

• OP
• OB
• Fecal Fat
• C S

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RADIOGRAPHIC TESTS

• Most common tests
• 1) Barium swallow or UGI
• 2) Small Bowel series
• 3) Barium enema
• Others CTS,US abd. X-rays

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ENDOSCOPIC TESTS (for upper GI system)

• Esophagoscopy
• Gastroscopy
• Gastroduodenoscopy
• EGD
• ERCP

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ENDOSCOPIC TESTS ( for lower GI system)

• Colonoscopy
• Proctoscopy
• Sigmoidoscopy

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Laboratory Tests

• Gastric Analysis
• CBC
• PT (prothrombin time)
• INR
• PTT (partial thromboplastin time)

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• Bilirubin
• Blood proteins
• Alkaline Phosphatase
• LDH
• GGT

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• AST
• ALT
• Cholesterol Triglycerides
• Amylase
• CEA

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Abnormal Assessment Findings

• Distention
• Firmness
• Tenderness
• Altered bowel sounds

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Therapeutic Measures Related Nursing
Interventions

• With GI Patients

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Gavage or Enteral Nutrition (Tube Feedings)

• Provide nutritional support through a tube
• Short or long term
• In conditions that prohibit oral nourishment

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Gastric Decompression

• Types of tubes ( pg. 780 )
• What is the purpose of gastric decompression?
• ??Nursing Interventions??

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Types of Tubes

• Nasogastric - (NG)
• Gastrostomy (G-tube)
• Jejunal (J-tube)
• Percutaneous (PEG)

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Figure 38-6
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Total Parenteral Nutrition (TPN)

• Nutritionally complete
• Used when GI system not functioning
• Short or long term

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Figure 38-9
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Critical Thinking Exercise

• A 71 y.o. woman who underwent a bowel resection
  for the removal of a tumor is receiving TPN
  through a central venous catheter. The patients
  fingerstick blood glucose is 250 mg/dl, and the
  patients temp is 102 F and the nurse notes
  puralent drainage at the catheter insertion site.

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Pre-Op Nursing Interventions

• For GI surgery patients

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• GI tract cleansing
• Assess vital signs
• Liquids for 24 hrs. or NPO
• IV
• Antibiotics
• NGT insertion

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Post-Op Nursing Interventions

• For GI surgery patients

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• Relieve pain
• Detect complications
• Prevent gastric distention
• Replace lost fluids
• Maintain urine elimination

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Digestive Disorders
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Medical Anorexia

• Loss of Appetite Caused by
• Nausea, decreased sense of taste or smell, mouth
  disorders, and medications
• Emotional problems such as anxiety, depression,
  or disturbing thoughts

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Anorexia

• Medical diagnosis
• Physician assesses for malnutrition
• Weight may be monitored over several weeks
• Complete history and physical examination
• Serum hemoglobin, iron, total iron-binding
  capacity, transferrin, calcium, folate, B12, zinc
  
• Thyroid function tests

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Anorexia

• Assessment
• Record chronic and recent illnesses,
  hospitalizations, medications, and allergies
• Female patients obstetric history
• Symptoms pain, nausea, dyspnea, extreme fatigue
  
• The functional assessment reveals patterns of
  activity and rest, usual dietary patterns,
  current stressors, and coping strategiesall can
  affect appetite

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Anorexia

• Interventions
• Assist with oral hygiene before and after meals
• Teach proper oral hygiene refer for dental care
• Relieve nausea before presenting a meal tray
• Before serving meal tray, remove bedpans/emesis
  basins from sight, conceal drains and drainage
  collection devices, deodorize room if necessary
• Socialization during mealtime
• Respect food likes and dislikes
• Position patient comfortably with easy access to
  food

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Obesity

• 20 over ideal body wt.
• Morbid obesity 2X normal body wt.

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Complications

• CV disease
• Diabetes
• Respiratory difficulties
• Musculoskeletal problems
• Emotional and social isolation

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Causes

• Caloric intake gt expenditure
• Heredity
• Emotional stress/psychosocial factors
• Slowed metabolism

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Medical Management

• Weight reduction diet
• Exercise
• Medication
• Counseling

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Surgical Treatment

• RNYGBP
• VBG
• LBP
• Liposuction
• Dumping Syndrome

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Show what you know

• List 3 Nursing Diagnosis related Nursing
  Interventions for the
• OBESE PATIENT

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Disorders of the Mouth
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Dental Caries

• Destructive process of tooth decay
• Causes
• Bacteria
• Poor oral hygiene

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Prevention

• Frequent brushing and flossing
• Dentist visit 2X/yr
• Good nutrition
• Fluoride

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Treatment

• Removal of diseases portion of tooth and filling
• May need dentures
• If untreated, may lead to periodontal disease

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Stomatitis

• Inflammation of the oral mucosa
• Causes are???
• Treatment is ???
• What is Aphthous Stomatitis?

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Herpes Simplex

• HSV Type 1
• Vesicles around the mouth lips
• Tx is comfort not curative
• Zovarax ointment (antiviral)

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Candidiasis

• Fungal infection (Thrush)
• Candida Albicans
• White patches in mouth
• Immunosuppression
• Abx therapy

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DISORDERS OF THE

• TEETH GUMS

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Periodontal Disease

• Gingivitis(inflammation of gums and supporting
  tissues)
• Gums are red, swollen, painful and bleed easily
• Cause? poor oral hygiene nutrition

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SHOW WHAT YOU KNOW

• Assessment?
• Nursing Diagnosis.?
• Interventions.?

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Oral Cancer

• 2 types of malignant tumors
• Squamous and Basal cell
• Early s/s may be ignored
• Tongue irritation, loose teeth, pain in ear or in
  tongue

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Risk Factors

• Tobacco use
• Alcohol use
• Poor nutrition
• Chronic irritation
• http//www.oralcancerfoundation.org/dental/slide_s
  how.htm

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Treatment

• Chemo
• Radiation
• Surgery

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Post Op Care Radical Neck

• Impaired oral mucous membrane
• Ineffective breathing pattern
• Acute pain
• NGT, PEG, or TPN
• Disturbed Body Image

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Disorders of Esophagus
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Esophageal Cancer

• Not common, poor prognosis
• Middle or lower portion of esophagus
• No known cause

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Predisposing Factors

• Cigarette smoking
• Excessive alcohol intake
• Poor oral hygiene
• Eating spicy foods

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Signs and Symptoms

• Progressive dysphagia
• Weight loss may be dramatic
• TX ? Chemo or surgery
• Esophagectomy, Esophagogastrostomy, or
  Esophagogastrectomy

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Nursing Care of the patient with Esophageal CA

• Assessment.?
• Nursing Diagnosis.?
• Interventions.?
• Nutrition
• Anxiety
• Risk for infection, injury

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Esophageal Diverticulum

• Esophageal out-pouching
• Zenkers Diverticulum
• Bad breath due to accumulation of food in
  diverticulum

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http//en.wikipedia.org/wiki/Zenker's_diverticulum
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Treatment

• Bland diet
• Antacids
• Anti-emetics
• Surgery

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Pre-Op Nursing Measures

• Semi-fowlers
• Small meals
• Loose clothing

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Disorders Affecting Digestion

• And Absorption

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Hiatal Hernia

• Protrusion of the lower esophagus and stomach
  upward through the diaphragm
• Two types Sliding and Rolling

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Causes

• Weakness of muscles of diaphragm
• Exact cause is unknown
• Excessive intra-abdominal pressure

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Contributing Factors

• Obesity
• Pregnancy
• Abdominal tumors, ascites or repeated heavy
  lifting

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Signs and Symptoms

• Feeling of fullness
• Eructation
• Heartburn
• Dysphagia
• Regurgitation

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Medical Treatment

• Avoid increased intra-abdominal pressure
• HOB 6-12 inches?prevents nighttime reflux
• Drug Therapy
• Diet

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Surgical Treatment

• Nissen Fundoplication
• Angelchik Prosthesis
• Figure 38-14
• 38-15

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Nissen Fundoplication
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THINK !!

• Describe your Post-Op Nrsg Interventions for this
  patient?

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GERD

• Gastroesophageal Reflux Disease
• Backward flow of stomach contents into the
  espohagus
• Sometimes occurs with a sliding hiatal hernia

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• WHAT IS NERD ???

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Signs Symptoms

• Burning sensation that moves up and down,
  commonly after meals
• Intermittent dysphagia
• belching

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Diagnosis

• Based on symptoms
• Sx relief w/ PPI return when DCd
• Endoscopy
• Gastric analysis

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Med Treatment Nrsg Care

• Same as for hiatal hernia
• Drug therapy may include Zantac, Reglan,
  Prilosec antacids
• Fundoplication if required

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Patient Teaching

• Avoid ASA and NSAIDS
• Chew food well
• Avoid eating 2 hrs. before bedtime

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Gastritis

• Inflammation of the stomach mucosa/lining
• Several types same pathophysiology
• H-pylori? prime culprit NSAIDS, stress, ETOH

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Signs Symptoms

• N/V
• Abdominal pain
• Anorexia
• Feeling of fullness

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Treatment

• Meds
• Replacement of fluids after N,V diarrhea
  subsides
• Elimination of the cause
• Tx nrsg. Interventions same as for Ulcer Disease

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THINK..

• List 3 Nursing Diagnosis and related
  interventions when caring for the patient with
  gastritis
• What teaching would you do with this patient???

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Peptic Ulcer

• Lesion on either the mucosa of stomach or
  duodenum
• 80 are in duodenum
• May be acute or chronic
• Classified as gastric or duodenal
• See Table 38-4

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Causes

• Bacterium? H. pylori
• ASA, NSAIDS
• Physical trauma (shock,burns)
• Foods or conditions that cause excessive gastric
  acid secretions

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Comparison of Peptic Ulcers

• GASTRIC

• DUODENAL

• Incidence
• Ulcer depth
• S/S
• Complications

• Incidence
• Ulcer depth
• S/S
• Complications

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Very Important Patient Teaching

• 1) Limit milk products
• 2) No baking soda

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Complications of Peptic Ulcers

• Hemorrhage
• Perforation
• Peritonitis
• Obstruction

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Medical Treatment

• Drug therapy
• Diet therapy
• NGT ? hemorrhage
• Saline Lavage
• Surgical treatment options Table 38-6 Fig. 38-16

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Complications after Gastrectomy

• Dumping syndrome pg. 813
• Sx occur within 20 min of eating
• Bloating, flatulence, cramps diarrhea
• Diaphoresis, anxious, shaky
• Malabsorption--gt Malnutrition

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THINK

• What teaching would you provide to the patient
  experiencing Dumping Syndrome??

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Stomach Cancer

• Silent neoplasm
• Poor prognosis
• No early s/s
• Late s/s vomiting, ascites, abd. Mass, enlarged
  liver

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Risk Factors

• H-pylori infection
• Pernicious anemia
• Chronic gastritis
• Family history

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Treatment

• Chemo
• Radiation
• Surgery

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Health Promotion Considerations

• What are some things we can do and or teach
  others to do which might reduce the risk of
  developing several types of Cancer not just
  stomach Cancer???/

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AbSORPTION ELIMINATION

• Disorders Affecting

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Malabsorption

• Intestinal absorption of nutrients is reduced
• Two examples are
• Celiac sprue/disease
• Lactase deficiency

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Signs Symptoms

• Steatorrhea
• Malnutrition weight loss
• Abdominal pain, cramping
• Bloating
• diarrhea

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Treatment

• Sprue? diet and drug therapy, avoid foods w/
  gluten(wheat, barley, oats)
• Lactase ? avoid milk products take lactase
  enzyme ( Lactaid)

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Critical Thinking Question

• A nurse enters the room of a 72-year-old patient
  who is receiving a continuous tube feeding and
  finds the patient lying flat in bed. The nurse
  questions the nurse assistant and discovers that
  the patient requested to be placed flat. What is
  significant about this situation? Why? How should
  the nurse handle the situation?

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• THATS IT!!
• YOUR DONE
• WITH GI UNIT 1
• ON TO UNIT 2..